Case Scenario: Crossmatch Is Positive, What to do?
Case Study: 40 y/o Female (Ankita) with ESRD and on dialysis for 1 month with unknown etiology, with her husband as donor. Rest of her workup is normal. Immunological workup is below.
| Sensitization History | 2 Pregnancies | |||||
| HLA Typing | A | B | C | DR | DQB1 | DQA1 |
| Donor | 02:11, 24:07 | 08:01, 52:01 | 03:01, 10:01 | 02:01, 05:01 | 01:01, 01:01/04 | |
| Recipient | 11:01, 24:02 | 35:03, 51:01 | 04:04, 13:01 | 03:02, 06:03 | 01:03, 03:01 | |
| XM | T cells | B Cells | ||||
| CDC XM | Positive | Positive | ||||
| Flow XM | Positive | Positive | ||||
| Single Antigen Bead SAB Report 1 – Click to view |
Class I : Multiple anti HLA Abs | Class II: Multiple Anti HLA Abs. |
Questions & Answers
Q1. Why are the CDC and Flow XM positive?
Ans: Due to Anti- HLA antibodies which are donor specific.
Q2. What options are there for this recipient?
Ans: Desensitization, alternate donor, swap, deceased donor. – discuss difficulties with each of these.
Q3. Which of these options would be your first choice?
Ans: Low PRA: alternate donor or swap.
Q4. Would this option change if the SAB report is SAB Report 2 – Click to View?
Ans: High PRA: look for siblings with 2 haplomatched, else 1 haplomatched parents as children likely to be positive. But can be surprised, see question below.
Q5. How would you compare the risks of HLA incompatibility vs ABO incompatibility in these patients.?
Ans: For high PRA, finding a low HLA risk is going to be almost impossible, and in such a situation a 2 haploidentical sibling even if ABO-I would be better and lower risk (10% rejection vs 40-50% AMR) and have likely longer graft survival than HLA incompatible.
