Does HLA matching matter in the modern era of renal transplantation?

Abstract

Children with end-stage kidney disease should be offered the best chance for future survival which ideally would be a wellmatched pre-emptive kidney transplant. Paediatric and adult practice varies around the world depending on geography, transplant allocation schemes and different emphases on living (versus deceased) donor renal transplantation. Internationally, paediatric patients often have priority in allocation schemes and younger donors are preferentially allocated to paediatric recipients. HLA matching can be difficult and may result in longer waiting times. Additionally, with improved surgical techniques and modern immunosuppressive regimens, how important is the contribution of HLA matching to graft longevity? In this review, we discuss the relative importance of HLA matching compared with donor quality; and long-term patient outcomes including retransplantation rates. We share empirical evidence that will be useful for clinicians and families to make decisions about best donor options. We discuss why living donation still provides the best allograft survival outcomes and what to do in the scenario of a highly mismatched living donor.

Outcomes of living unrelated donor kidney transplants in children: An Organ Procurement and Transplant Network database analysis

“…Our data demonstrate a substantial benefit afforded by living donor Tx in children compared to DD Tx (which had the poorest graft survival). Other predictors of graft loss found in our study are all previously well‐established factors and included pre‐Tx hypoalbuminemia, 7 need for pre‐Tx dialysis, 8 younger recipient age (in the first post‐Tx year), 9 black ethnicity, 10 female recipient sex, 3 FSGS as a cause of CKD 11 and number of HLA mismatches 12 . It is therefore heartening to note that there has been a progressive increase in the number of LURD Tx across the US over the years and that each OPTN region has centers that are accepting LURD for pediatric patients.…”

“…Other predictors of graft loss found in our study are all previously well-established factors and included pre-Tx hypoalbuminemia, 7 need for pre-Tx dialysis, 8 younger recipient age (in the first post-Tx year), 9 black ethnicity, 10 female recipient sex, 3 FSGS as a cause of CKD 11 and number of HLA mismatches. 12 It is therefore heartening to note that there has been a progressive increase in the number of LURD Tx across the US over the years and that each OPTN region has centers that are accepting LURD for pediatric patients. There are many biomedical reasons as to why living donor Tx recipients have a substantial survival benefit over recipients of DD Tx, a well-recognized observation.…”

Predictors of Short-Term Outcomes in Living Donor Renal Allograft Recipients: A Prospective Study From a Tertiary Care Center in North India

“…HLA typing and donor-specific antibodies (DSAs) were done pre-transplant in only a minority of patients in view of financial constraints. However, in the era of potent immunosuppressants, the role of HLA mismatches on graft outcomes is controversial [ 34 ]. With a paucity of donor organs and the growing epidemic of end-stage kidney disease, rejecting a donor based on the number of HLA mismatches is not justified.…”

Growth hormone treatment in the pre-transplant period is associated with superior outcome after pediatric kidney transplantation

“…Other important factors known to affect post-transplant growth including allograft function and steroid exposure need to be considered as well. Long-term transplant function in pediatric kidney allograft recipients is influenced by the quality of the transplant itself, with better results with living related donors, recipient-related factors such as HLA-matching and HLA-immunization and the immunosuppressive regimen [ 1 , 34 , 35 ]. In the present study, the frequency of living related KT was lower in the rhGH group compared to the non-prior rhGH group.…”