Abstract
The weight of human leukocyte antigen (HLA) matching in kidney allocation algorithms, especially in the United States, has been devalued in a stepwise manner, supported by the introduction of modern immunosuppression. The intent was further to reduce the observed ethnic/racial disparity, as data emerged associating HLA matching with decreased access to transplantation for African American patients. In recent years, it has been increasingly recognized that a leading cause of graft loss is chronic antibody-mediated rejection, attributed to the development of de novo antibodies against mismatched donor HLA expressed on the graft. These antibodies are most frequently against donor HLA-DQ molecules. Beyond their impact on graft survival, generation of de novo donor-specific HLA antibodies also leads to increased sensitization, as measured by panel-reactive antibody metrics. Consequently, access to transplantation for patients returning to the waitlist in need of a second transplant is compromised. Herein, we address the implications of reduced HLA matching policies in kidney allocation. We highlight the observed diminished outcome data, the significant financial burden, the long-term health consequences, and, more important, the unintended consequences. We further provide recommendations to examine the impact of donor-recipient HLA class II and specifically HLA-DQα1β1 mismatching, focusing on collection of appropriate data, application of creative simulation approaches, and reconsideration of best practices to reduce inequalities while optimizing patient outcomes.
Original language | English (US) |
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Pages (from-to) | 1012-1022 |
Number of pages | 11 |
Journal | Kidney international |
Volume | 100 |
Issue number | 5 |
DOIs | |
State | Published - Nov 2021 |
Funding
ART is a Paul I. Terasaki Scholar. VK acknowledges funding from an National Institute of Health Research (NIHR) Fellowship (PDF-2016-09-065) and from a P.I. Terasaki Scholarship. RBM is the chair of the Policy and Advocacy Committee of the American Society of Nephrology, but this article represents personal, not societal, views. PN is a Paul I. Terasaki Scholar. MN is senior clinical investigator of The Research Foundation Flanders (F.W.O.; 1844019N). ART is a Paul I. Terasaki Scholar. VK acknowledges funding from a National Institute of Health Research (NIHR) Fellowship (PDF-2016-09-065) and from a P.I. Terasaki Scholarship. RBM is the chair of the Policy and Advocacy Committee of the American Society of Nephrology, but this article represents personal, not societal, views. PN is a Paul I. Terasaki Scholar. MN is senior clinical investigator of The Research Foundation Flanders (F.W.O.; 1844019N).
Keywords
- HLA matching
- HLA-DQ
- antibody-mediated rejection
- kidney transplantation
ASJC Scopus subject areas
- Nephrology