Cardiothoracic transplants in India: why adequate immunogenetic workup for potential recipients is a must
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Cardiothoracic transplants in India: why adequate immunogenetic workup for potential recipients is a must Mahendra Narain Mishra 1 Received: 4 August 2020 / Revised: 14 August 2020 / Accepted: 19 August 2020 # Indian Association of Cardiovascular-Thoracic Surgeons 2020
To The Editor This is in reference to the article by Shroff et al. which discusses the positive aspects of deceased donation in the country with special reference to cardiac transplants [1]. In India, the pretransplant immunological workup for potential cardiac transplant recipients and other deceased donations is inadequate. Airan et al. mention that the incidence of grade II or higher acute rejection was 25% (n = 10) in a small cohort of 25 patients, but do not mention anything about their sensitization status or anti-human leukocyte antigen (HLA) antibodies and extent of recipient-donor HLA mismatch [2]. According to the British Society of Histocompatibility and Immunogenetics/ British Transplant Society (BSHI/BTS) guidelines, up to 40% of United Kingdom (UK) thoracic recipients are sensitized on the basis of assessment by Luminex–X Map technology, which is far more sensitive and specific for detection of HLA antibodies and defining donor-specific antibodies (DSA) compared with complement-dependent cytotoxicity (CDC) crossmatch [3]. Complement-binding DSA of immunoglobulin G isotype (IgG1 and IgG3) are associated with the highest risk for acute rejection (both cellular and humoral), poor allograft survival, and chronic rejection. Two studies have reported the incidence of cellular rejection as 20–40% and of antibodymediated rejection as 10–20% respectively [3, 4]. Additionally, preformed antibodies which are detected only by solid phase assays can rarely lead to catastrophic hyperacute rejection. Therefore, adequate immunological pretransplant workup of all potential recipients is necessary. In addition to nine (a–i) recommendations made by the authors, National Organ and Tissue Transplantation (NOTTO) must ensure that adequate pretransplant immunological workup
* Mahendra Narain Mishra [email protected] 1
Department of Pathology, Baptist Christian Hospital, Tezpur, Assam, India
for all patients on deceased donor waitlist is carried out by the hospitals performing deceased organ transplants. There is a need to emulate Organ Donation and Transplantation (ODT), United Kingdom and Eurotransplant, for regulation of deceased donation including information of recipients on waiting list, their sensitization status, and HLA type of recipient and donor. Although the cold ischemia time for the heart is relatively short (4–5 h), it is sufficient to perform 11 loci HLA typing by realtime polymerase chain reaction (PCR) in 90 min with minimum hands on time. HLA typing of the donor is carried out at the hospital, where the donor organs have originated, and also in the receiving hospital. The latter also performs crossmatch, which may be virtual or physical; and the HLA typing and crossmatch reports are shared with ODT before proceeding wi
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