J Korean Soc Transplant.  2018 Jun;32(2):13-25. 10.4285/jkstn.2018.32.2.13.

Results of Questionnaire Survey of Current Immune Monitoring Practice of Transplant Clinicians and Clinical Pathologists in Korea: Basis for Establishment of Harmonized Immune Monitoring Guidelines

• Kang ES
• Choi SI
• Park YH
• Park GB
• Jang HR

• KMID: 2414444
• DOI: http://doi.org/10.4285/jkstn.2018.32.2.13

Abstract

Detection of significant alloimmune response, which affects graft function and survival by effective immune monitoring, is critical for treatment decision making. However, there is no consensus regarding immune monitoring (IM) for kidney transplantation (flow KT) in Korea. The IM protocol may be affected by the level of immunological risk, the methods of desensitization and the availabilities of resources such as laboratory support and cost of tests. Questionnaire surveys designed to identify the current practices regarding immune monitoring of KT among transplant clinicians and clinical pathologists in Korea and eventually provide a basis for the establishment of harmonized immune monitoring guidelines in KT were administered as part of a Korean Society for Transplantation Sponsored Research Project. The survey results revealed significant variations in IM protocols and interpretation of tests affecting treatment decisions between institutes. Moreover, the results revealed a need to expand the histocompatibility tests into high resolution HLA typing in multiple loci and non-HLA antibody tests that facilitate the epitope analysis and eventually virtual crossmatching. The results of the questionnaire survey from clinical pathologists are addressing the urgent need for the standardization of interpretation and harmonization of results reporting in single antigen bead based HLA antibody identification. Finally, communication between clinicians and clinical pathologists to meet the clinical expectations regarding various immune monitoring tests is needed.

Keyword

Kidney transplantation; Immunologic monitoring; Questionnaire survey

MeSH Terms

Academies and Institutes
Consensus
Decision Making
Histocompatibility
Histocompatibility Testing
Kidney Transplantation
Korea*
Monitoring, Immunologic*
Transplants

Figure

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  Fig. 1. Proportions of transplant clinicians responded in questionnaire surveys according to (A) specialties and (B) number of clinicians per single institute.

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  Fig. 2. The number of kidney transplantation performed per year in institutes where the transplant clinicians responded to questionnaire survey. Abbreviation: KT, kidney transplantation.

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  Fig. 3. Status of performing protocol biopsies after kidney transplantation. Responses of 32 clinicians from 25 institutes.

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  Fig. 4. Status of performing protocol biopsies depending on the level of immunological risk after kidney transplantation. The protocol biopsies are being performed in recipients with high immunological risk or regardless of immunological risk in different time points. Two clinicians responded that protocol biopsies are necessary on 1∼2 week and 12 week posttransplant. Responses of 32 clinicians from 25 institutes.

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  Fig. 5. Status of performing HLA antibody tests in (A) pre- and (B) post-kidney transplantation. Responses of 32 clinicians from 25 institutes. Abbreviation: SA ID, single antigen identification.

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  Fig. 6. Status of performing HLA antibody tests depending on the level of immunological risk after kidney transplantation. (A) HLA antibody screening test, (B) HLA antibody phenotyping test, and (C) HLA antibody single antigen identification test. Abbreviation: HLA, human leukocyte antigen.

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  Fig. 7. Suggested time points of HLA antibody monitoring test in patients waiting for kidney transplantation. Abbreviation: HLA, human leukocyte antigen.

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  Fig. 8. Indications of HLA antibody tests after kidney transplantation. Abbreviations: HLA, human leukocyte antigen; AMR, antibody mediated rejection.

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  Fig. 9. The threshold of %PRA to define high immunological risk in patients responded from 26 clinicians of 20 institutes. Abbreviation: PRA, percent reactive antibodies.

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  Fig. 10. Clinicians opinions about the need of further tests on histocompatibility. Abbreviation: HLA, human leukocyte antigen.

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  Fig. 11. Clinicians opinions about the need of further immune monitoring tests. Abbreviations: IGRA, interferon gamma releasing assay; CMV, cytomegalovirus; eGFR, estimated glomerular filtration rate.

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  Fig. 12. Clinicians opinions in areas which needs to be improved. Abbreviations: HLA, human leukocyte antigen; IM, immune monitoring.

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  Fig. 13. The principles of methods for HLA typing for kidney transplantation in responded laboratories according to the number of kidney transplantation performed per year in institutes. The data of three institutes referring HLA typing to outside labs are not included (∗) and the data of one institute of each performing HLA typing using two different methods are included (∗∗). Abbreviations: SSP, sequence-specific polymerase chain reaction; rSSOP, reverse sequence-specific oligonucleotide probe hybridization.

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  Fig. 14. HLA loci tested for kidney transplantation in responding laboratories. Abbreviation: HLA, human leukocyte antigen.

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  Fig. 15. The status of performing HLA antibody tests in responded laboratories according to the number of kidney transplantation performed per year in institutes. (A) Screening test, (B) Phenotyping, (C) Single antigen bead identification. Abbreviation: HLA, human leukocyte antigen.

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  Fig. 16. Clinical pathologist opinions on current shortcomings in laboratory practices.

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