Society of Asian Academic SurgeonsTransplantation/ImmunologyHuman Leukocyte Antigen Class I Antibodies and Response to Platelet Transfusion in Patients Undergoing Liver Transplantation
Introduction
Allogeneic blood transfusion introduces a multitude of foreign antigens and cells into the recipient, who mounts an immune response to the donor antigens (i.e., alloimmunization). Various clinical consequences may arise specific to the blood cells and antigens involved. The antigens most commonly implicated are classified as (1) human leukocyte antigens (HLA), divided into class I shared by platelets and most nucleated cells including leukocytes and class II present on antigen-presenting cells; (2) granulocyte-specific antigens; (3) human platelet antigens; and (4) red blood cell antigens.1, 2, 3, 4
Thrombocytopenia, defined as a platelet count <100 × 109/L, is a common complication in patients with end-stage liver disease (ESLD). Although the risk for clinically significant spontaneous bleeding because of thrombocytopenia is generally low in healthy individuals with a platelet count >20 × 109/L, ESLD patients exhibit increased risk for spontaneous hemorrhage and for iatrogenic bleeding from indicated invasive procedures (e.g., endoscopy, liver biopsy, paracentesis, etc.). As such, patients with ESLD frequently receive transfusions of platelet concentrates and other blood products to minimize their risk of hemorrhage. Alloimmunization against platelets may occur in up to 45% of patients receiving PLT and platelet refractoriness or inadequate response of the platelet count to transfusion, resulting from alloimmunization in 13%.5 Patients may develop platelet antibodies as early as 4 d after blood transfusion.6 Platelet refractoriness in ESLD patients undergoing liver transplantation (LT) increases patients’ risk for peri- and intra-operative hemorrhage, additional transfusion, and complications.7, 8, 9 Data on the incidence of platelet refractoriness because of HLA alloimmunization in LT patients and its impact on posttransplant outcomes remain limited. We sought to examine the effect of HLA class I (HLA-I) antibodies on refractoriness to PLT and short-term outcomes after LT.
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Data collection
Using a prospectively collected transplantation database, we conducted a retrospective review of all patients aged ≥18 y who underwent LT or simultaneous liver–kidney (SLK) transplantation at the Froedtert and the Medical College of Wisconsin Transplant Center from October 2012 to September 2017. Patients were excluded if they (1) did not have HLA-I calculated panel-reactive antibody (cPRA) testing within 2 wk before or after transplantation, (2) suffered primary nonfunction of their hepatic
Patient characteristics
Of a total 145 LT and SLK transplantations performed during the study period, 72 patients met inclusion criteria and formed the study cohort. The mean age was 55.6 y. The most common etiologies of liver disease were hepatitis C and alcohol. Among the 26 female patients (36% of the study cohort), 19 patients (73%) had a history of pregnancy. Alloimmunization was observed in a total of 28 patients (39%) in the study cohort. The most commonly identified HLA-I antibody specificities in the study
Discussion
Although the impact of alloimmunization on platelet refractoriness has been well-described in hematology–oncology patients,5,14 the data on its clinical implications in solid organ transplantation remain limited. Our study reported the relationship between HLA-I alloimmunization and refractoriness to PLT in liver and SLK transplantation. We observed relatively high rates of both HLA-I alloimmunization, 39%, and refractoriness to PLT, 56%, in our cohort of LT and SLK transplantation patients. SE
Acknowledgment
The authors gratefully acknowledge Karen L. Pierce, B.S. C.H.S., and Lori A. Eggert, B.A., of the Versiti BloodCenter of Wisconsin Histocompatibility Laboratory for their help with coordinating the data collection.
This work was supported in part by The Kevin T. Cottrell Memorial Fund for Organ Transplantation Research.
Authors’ contributions: All authors contributed to study conception and design and analyzed the data. M.W., R.N., M.S., and A.P. contributed to acquisition of data. Drafting of
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