e1 References 1 Walters S, Porter C, Brophy PD Dialysis and pediatric acute kidney injury choice of renal support modality Pediatr Nephrol 2009;24(1) 37 48 2 Kaddourah A, Basu RK, Bagshaw SM, Goldstei[.]
e1 References Walters S, Porter C, Brophy PD Dialysis and pediatric acute kidney injury: choice of renal support modality Pediatr Nephrol 2009;24(1):37-48 Kaddourah A, Basu RK, Bagshaw SM, Goldstein SL, Investigators A Epidemiology of acute kidney injury in critically ill children and young adults N Engl J Med 2017;376(1):11-20 Jetton JG, Boohaker LJ, Sethi SK, et al Incidence and outcomes of neonatal acute kidney injury (AWAKEN): a multicentre, multinational, observational cohort study Lancet Child Adolesc Health 2017;1(3):184-194 Price JF, Mott AR, Dickerson HA, et al Worsening renal function in children hospitalized with decompensated heart failure: evidence for a pediatric cardiorenal syndrome? Pediatr Crit Care Med 2008;9(3):279-284 Akcan-Arikan A, Zappitelli M, Loftis LL, Washburn KK, Jefferson LS, Goldstein SL Modified RIFLE criteria in critically ill children with acute kidney injury Kidney Int 2007;71(10):1028-1035 Plotz FB, Bouma AB, van Wijk JA, Kneyber MC, Bokenkamp A Pediatric acute kidney injury in the ICU: an independent evaluation of pRIFLE criteria Intensive Care Med 2008;34(9):1713-1717 Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW Acute kidney injury, mortality, length of stay, and costs in hospitalized patients J Am Soc Nephrol 2005;16(11):3365-3370 Goldstein SL, Somers MJ, Baum MA, et al Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy Kidney Int 2005;67(2):653-658 Gillespie RS, Seidel K, Symons JM Effect of fluid overload and dose of replacement fluid on survival in hemofiltration Pediatr Nephrol 2004;19(12):1394-1399 10 Foland JA, Fortenberry JD, Warshaw BL, et al Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis Crit Care Med 2004;32(8):1771-1776 11 Hayes LW, Oster RA, Tofil NM, Tolwani AJ Outcomes of critically ill children requiring continuous renal replacement therapy J Crit Care 2009;24(3):394-400 12 Sutherland SM, Zappitelli M, Alexander SR, et al Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry Am J Kidney Dis 2010;55(2):316-325 13 Karvellas CJ, Farhat MR, Sajjad I, et al A comparison of early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury: a systematic review and meta-analysis Crit Care 2011;15(1):R72 14 Wang X, Jie Yuan W Timing of initiation of renal replacement therapy in acute kidney injury: a systematic review and meta-analysis Ren Fail 2012;34(3):396-402 15 Modem V, Thompson M, Gollhofer D, Dhar AV, Quigley R Timing of continuous renal replacement therapy and mortality in critically ill children Crit Care Med 2014;42(4):943-953 16 Augustine JJ, Sandy D, Seifert TH, Paganini EP A randomized controlled trial comparing intermittent with continuous dialysis in patients with ARF Am J Kidney Dis 2004;44(6):1000-1007 17 Rabindranath K, Adams J, Macleod AM, Muirhead N Intermittent versus continuous renal replacement therapy for acute renal failure in adults Cochrane Database Syst Rev 2007(3):CD003773 18 Pannu N, Klarenbach S, Wiebe N, Manns B, Tonelli M, Alberta Kidney Disease Network Renal replacement therapy in patients with acute renal failure: a systematic review JAMA 2008;299(7):793-805 19 Bagshaw SM, Berthiaume LR, Delaney A, Bellomo R Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: a meta-analysis Crit Care Med 2008;36(2):610-617 20 Schneider AG, Bellomo R, Bagshaw SM, et al Choice of renal replacement therapy modality and dialysis dependence after acute kidney injury: a systematic review and meta-analysis Intensive Care Med 2013;39(6):987-997 21 Sun Z, Ye H, Shen X, Chao H, Wu X, Yang J Continuous venovenous hemofiltration versus extended daily hemofiltration in patients with septic acute kidney injury: a retrospective cohort study Crit Care 2014;18(2):R70 22 Frank HA, Seligman AM, Fine J Treatment of uremia after acute renal failure by peritoneal irrigation J Am Med Assoc 1946;130: 703-706 23 Basso F, Ricci Z, Cruz D, Ronco C International survey on the management of acute kidney injury in critically ill patients: year 2007 Blood Purif 2010;30(3):214-220 24 Bunchman TE, McBryde KD, Mottes TE, Gardner JJ, Maxvold NJ, Brophy PD Pediatric acute renal failure: outcome by modality and disease Pediatr Nephrol 2001;16(12):1067-1071 25 Flynn JT, Kershaw DB, Smoyer WE, Brophy PD, McBryde KD, Bunchman TE Peritoneal dialysis for management of pediatric acute renal failure Perit Dial Int 2001;21(4):390-394 26 Chionh CY, Soni SS, Finkelstein FO, Ronco C, Cruz DN Use of peritoneal dialysis in AKI: a systematic review Clin J Am Soc Nephrol 2013;8(10):1649-1660 27 Mishra OP, Gupta AK, Pooniya V, Prasad R, Tiwary NK, Schaefer F Peritoneal dialysis in children with acute kidney injury: a developing country experience Perit Dial Int 2012;32(4):431-436 28 Kwiatkowski DM, Menon S, Krawczeski CD, et al Improved outcomes with peritoneal dialysis catheter placement after cardiopulmonary bypass in infants J Thoracic Cardiovasc Surg 2015;149(1):230-236 29 Bojan M, Gioanni S, Vouhe PR, Journois D, Pouard P Early initiation of peritoneal dialysis in neonates and infants with acute kidney injury following cardiac surgery is associated with a significant decrease in mortality Kidney Int 2012;82(4):474-481 30 Santos CR, Branco PQ, Gaspar A, et al Use of peritoneal dialysis after surgery for congenital heart disease in children Perit Dial Int 2012;32(3):273-279 31 Chadha V, Warady BA, Blowey DL, Simckes AM, Alon US Tenckhoff catheters prove superior to cook catheters in pediatric acute peritoneal dialysis Am J Kidney Dis 2000;35(6):1111-1116 32 Cullis B, Abdelraheem M, Abrahams G, et al Peritoneal dialysis for acute kidney injury Perit Dial Int 2014;34(5):494-517 33 Nash MA, Russo JC Neonatal lactic acidosis and renal failure: the role of peritoneal dialysis J Pediatr 1977;91(1):101-105 34 Verrina E Peritoneal Dialysis In: Avner E, Harmon W, Niaudet P, Yoshikawa N, eds Pediatric Nephrology 6th ed Berlin Heidelberg: Springer-Verlag; 2009:1785-1816 35 Raaijmakers R, Schroder CH, Gajjar P, Argent A, Nourse P Continuous flow peritoneal dialysis: first experience in children with acute renal failure Clin J Am Soc Nephrol 2011;6(2):311-318 36 Amerling R, DeSimone L, Inciong-Reyes R, et al Clinical experience with continuous flow and flow-through peritoneal dialysis Semin Dial 2001;14(5):388-390 37 Warady BA, Bakkaloglu S, Newland J, et al Consensus guidelines for the prevention and treatment of catheter-related infections and peritonitis in pediatric patients receiving peritoneal dialysis: 2012 update Perit Dial Int 2012;32(suppl 2):S32-S86 38 Huber R, Fuchshuber A, Huber P Acute peritoneal dialysis in preterm newborns and small infants: surgical management J Pediatr Surg 1994;29(3):400-402 39 Shea M, Hmiel SP, Beck AM Use of tissue plasminogen activator for thrombolysis in occluded peritoneal dialysis catheters in children Adv Perit Dial 2001;17:249-252 40 Sakarcan A, Stallworth JR Tissue plasminogen activator for occluded peritoneal dialysis catheter Pediatr Nephrol 2002;17(3): 155-156 41 Krishnan RG, Moghal NE Tissue plasminogen activator for blocked peritoneal dialysis catheters Pediatr Nephrol 2006;21(2):300 42 Leblanc M, Ouimet D, Pichette V Dialysate leaks in peritoneal dialysis Semin Dial 2001;14(1):50-54 43 Fischbach M, Terzic J, Menouer S, Provot E, Bergere V Hemodialysis in children: principles and practice Semin Nephrol 2001;21(5): 470-479 e2 44 Elshihabi I, Brzowski A, Kaye C, Kearon P Efficiency of hemodialysis therapy for a urea cycle defect in a neonate Clin Nephrol 1995;43(3):208-209 45 Brophy PD, Tenenbein M, Gardner J, Bunchman TE, Smoyer WE Childhood diethylene glycol poisoning treated with alcohol dehydrogenase inhibitor fomepizole and hemodialysis Am J Kidney Dis 2000;35(5):958-962 46 Brown MJ, Shannon MW, Woolf A, Boyer EW Childhood methanol ingestion treated with fomepizole and hemodialysis Pediatrics 2001;108(4):E77 47 Gitomer JJ, Khan AM, Ferris ME Treatment of severe theophylline toxicity with hemodialysis in a preterm neonate Pediatr Nephrol 2001;16(10):784-786 48 Michael M, Brewer ED, Goldstein SL Blood volume monitoring to achieve target weight in pediatric hemodialysis patients Pediatr Nephrol 2004;19(4):432-437 49 Sakarcan A, Quigley R Hyperphosphatemia in tumor lysis syndrome: the role of hemodialysis and continuous veno-venous hemofiltration Pediatr Nephrol 1994;8(3):351-353 50 Jaing TH, Hsueh C, Tain YL, Hung IJ, Hsia SH, Kao CC Tumor lysis syndrome in an infant with Langerhans cell histiocytosis successfully treated using continuous arteriovenous hemofiltration J Pediatr Hematol Oncol 2001;23(2):142-144 51 Hackbarth R, Bunchman TE, Chua AN, et al The effect of vascular access location and size on circuit survival in pediatric continuous renal replacement therapy: a report from the PPCRRT registry Int J Artif Organs 2007;30(12):1116-1121 52 Warady BA, Bunchman T Dialysis therapy for children with acute renal failure: survey results Pediatr Nephrol 2000;15(1-2):11-13 53 Davenport A Alternatives to standard unfractionated heparin for pediatric hemodialysis treatments Pediatr Nephrol 2012;27(10): 1869-1879 54 Hanevold C, Lu S, Yonekawa K Utility of citrate dialysate in management of acute kidney injury in children Hemodial Int 2010;14(suppl 1):S2-S6 55 Symons JM, Brophy PD, Gregory MJ, et al Continuous renal replacement therapy in children up to 10 kg Am J Kidney Dis 2003;41(5):984-989 56 Symons JM, Chua AN, Somers MJ, et al Demographic characteristics of pediatric continuous renal replacement therapy: a report of the prospective pediatric continuous renal replacement therapy registry Clin J Am Soc Nephrol 2007;2(4):732-738 57 McBryde KD, Kershaw DB, Bunchman TE, et al Renal replacement therapy in the treatment of confirmed or suspected inborn errors of metabolism J Pediatr 2006;148(6):770-778 58 Mehta RL, McDonald BR, Aguilar MM, Ward DM Regional citrate anticoagulation for continuous arteriovenous hemodialysis in critically ill patients Kidney Int 1990;38(5):976-981 59 Bunchman TE, Maxvold NJ, Barnett J, Hutchings A, Benfield MR Pediatric hemofiltration: Normocarb dialysate solution with citrate anticoagulation Pediatr Nephrol 2002;17(3):150-154 60 Tolwani AJ, Campbell RC, Schenk MB, Allon M, Warnock DG Simplified citrate anticoagulation for continuous renal replacement therapy Kidney Int 2001;60(1):370-374 61 Tolwani AJ, Prendergast MB, Speer RR, Stofan BS, Wille KM A practical citrate anticoagulation continuous venovenous hemodiafiltration protocol for metabolic control and high solute clearance Clin J Am Soc Nephrol 2006;1(1):79-87 62 Brophy PD, Somers MJ, Baum MA, et al Multi-centre evaluation of anticoagulation in patients receiving continuous renal replacement therapy (CRRT) Nephrol Dial Transplant 2005;20(7):14161421 63 Brophy PD, Mottes TA, Kudelka TL, et al AN-69 membrane reactions are pH-dependent and preventable Am J Kidney Dis 2001;38(1):173-178 64 Pasko DA, Mottes TA, Mueller BA Pre dialysis of blood prime in continuous hemodialysis normalizes pH and electrolytes Pediatr Nephrol 2003;18(11):1177-1183 65 Hackbarth RM, Eding D, Gianoli Smith C, Koch A, Sanfilippo DJ, Bunchman TE Zero balance ultrafiltration (Z-BUF) in bloodprimed CRRT circuits achieves electrolyte and acid-base homeostasis prior to patient connection Pediatr Nephrol 2005;20(9):13281333 66 Barletta JF, Barletta GM, Brophy PD, Maxvold NJ, Hackbarth RM, Bunchman TE Medication errors and patient complications with continuous renal replacement therapy Pediatr Nephrol 2006;21(6):842-845 67 Ronco C, Bellomo R, Homel P, et al Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial Lancet 2000;356(9223):26-30 68 Palevsky PM, Zhang JH, O’Connor TZ, et al Intensity of renal support in critically ill patients with acute kidney injury N Engl J Med 2008;359(1):7-20 69 Bellomo R, Cass A, Cole L, et al Intensity of continuous renalreplacement therapy in critically ill patients N Engl J Med 2009;361(17):1627-1638 70 Meier-Kriesche HU, Gitomer J, Finkel K, DuBose T Increased total to ionized calcium ratio during continuous venovenous hemodialysis with regional citrate anticoagulation Crit Care Med 2001;29(4): 748-752 71 Maxvold NJ, Smoyer WE, Custer JR, Bunchman TE Amino acid loss and nitrogen balance in critically ill children with acute renal failure: a prospective comparison between classic hemofiltration and hemofiltration with dialysis Crit Care Med 2000;28(4):1161-1165 72 Zappitelli M, Goldstein SL, Symons JM, et al Protein and calorie prescription for children and young adults receiving continuous renal replacement therapy: a report from the Prospective Pediatric Continuous Renal Replacement Therapy Registry Group Crit Care Med 2008;36(12):3239-3245 73 Tolwani AJ, Wheeler TS, Wille KM Sustained low-efficiency dialysis Contrib Nephrol 2007;156:320-324 74 Goldstein SL, Currier H, Graf C, Cosio CC, Brewer ED, Sachdeva R Outcome in children receiving continuous venovenous hemofiltration Pediatrics 2001;107(6):1309-1312 75 Flores FX, Brophy PD, Symons JM, et al Continuous renal replacement therapy (CRRT) after stem cell transplantation A report from the prospective pediatric CRRT Registry Group Pediatr Nephrol 2008;23(4):625-630 76 Ronco C, Garzotto F, Brendolan A, et al Continuous renal replacement therapy in neonates and small infants: development and firstin-human use of a miniaturised machine (CARPEDIEM) Lancet 2014;383(9931):1807-1813 77 Coulthard MG, Crosier J, Griffiths C, et al Haemodialysing babies weighing ,8 kg with the Newcastle infant dialysis and ultrafiltration system (Nidus): comparison with peritoneal and conventional haemodialysis Pediatr Nephrol 2014;29(10):1873-1881 e3 Abstract: Renal replacement therapy (RRT) has an established role in pediatric critical care Indications for RRT include volume overload, azotemia, electrolyte and metabolic imbalance, intoxication, or inability to provide adequate nutrition due to renal compromise Peritoneal dialysis remains an excellent form of acute pediatric RRT Hemodialysis is the modality of choice for rapid correction of fluid or metabolic imbalance Continuous renal replacement therapy (CRRT) can establish and maintain fluid and metabolic control in unstable patients Patients receiving RRT require careful monitoring of volume status, biochemical balance, and nutritional needs Coordination between the critical care and nephrology staff is essential for success Key Words: Dialysis, renal replacement therapy, CRRT, acute kidney injury, AKI 76 Pediatric Renal Transplantation JODI M SMITH, ANDRÉ A.S DICK, AND RUTH MCDONALD • Kidney transplantation is the treatment of choice for children with end-stage renal disease; children have high priority in the deceased donor allocation policy Upon arrival in the pediatric intensive care unit, key goals regarding blood pressure, central venous pressure (CVP), and urine output for the initial 24 to 48 hours are important to guide care Awareness of the child’s pretransplantation blood pressure and antihypertensive regimens and native urine output is important to help guide posttransplantation management Urine output is a critical marker of renal function; any drop in urine output should be addressed immediately The first step in Transplantation is the treatment of choice in children with endstage renal disease (ESRD) due to the beneficial impact on growth and development and quality of life Significant progress has been made in pediatric kidney transplantation Advances in immunosuppression have dramatically decreased rates of acute rejection, leading to improved short-term graft survival, but similar improvements in long-term graft survival remain elusive.1 Changes in allocation policy provide the pediatric population with timely access to transplant grafts, but there remains concern about the impact of less human leukocyte antigen (HLA) matching and a decrease in living donors.2 There are between 700 and 800 pediatric kidney transplants performed each year in the United States.3 The majority of transplantations (58%) occur in children between the ages of 11 and 17 years and in males (58%).3 Congenital anomalies of the kidney and urinary tract are the leading cause of kidney disease (35%), followed by focal segmental glomerulosclerosis (FSGS) and glomerulonephritis3 related to chronic renal failure and need for kidney transplantation Donor Source: Living Donor Versus Deceased Donor Living Donor Transplantation Living donor kidney transplantation is well established as the optimal treatment for children and adults with ESRD due to superior graft and patient survival.3,4 Despite these advantages, rates of living kidney donation are declining In the United States, only 930 • • • • PEARLS addressing low urine output is to assess the patient’s intravascular volume status (CVP, blood pressure), in addition to ensuring patency of the Foley catheter The most common reason for a decrease in urinary output is volume depletion The most catastrophic reason for a decrease in urine output is vascular thrombosis, which is assessed by a renal Doppler ultrasound Hypotension and underperfusion of the adult-sized kidney in the pediatric patient is associated with delay in renal recovery The treatment of choice for hypotension posttransplantation is volume expansion with crystalloid and/or colloid 36% of pediatric kidney transplants were from living donors in 2018.3 Potential reasons for this decline in living donation in the United States include deterioration in the health of the general population, changing ethnic/racial characteristics, financial barriers, more stringent living donor criteria, and misconceptions about living donation.5,6 In addition, differences in activity level of deceased donor transplantation programs in the region or country, cultural variations, and the manner in which parents are solicited for donation may contribute Deceased Donor Transplantation If no living donor is available, a child is placed on the deceased donor waiting list Children have long been recognized as a deserving priority in kidney allocation Candidates listed before their 18th birthday are considered pediatric until they undergo transplantation or are otherwise removed from the waiting list In 1993, the Organ Procurement and Transplantation Network/ United Network for Organ Sharing (OPTN/UNOS) formed an Ad Hoc Pediatric Advisory Committee The committee prepared a white paper summarizing evidence of the detrimental effects of ESRD and dialysis on growth and development and describing technical problems with dialysis in pediatric patients Congress passed the Children’s Health Act of 2000, which was incorporated as an amendment to the National Organ Transplant Act (NOTA) This Act specifies that organ allocation policy is to recognize the differences in health and organ transplant issues between children and adults throughout the system, and adopt criteria, policies, and procedures that address the unique healthcare needs of children CHAPTER 76 Pediatric Renal Transplantation A new kidney allocation policy (KAS) was implemented in 2015.2 The new allocation policy risk stratifies deceased donors using the kidney donor profile index (KDPI) The KDPI takes into account donor age, height, weight, ethnicity, history of hypertension and diabetes, cause of death, serum creatinine level, hepatitis C status, and donation after circulatory death status Lower KDPI kidneys are associated with better posttransplantation survival Similarly, transplantation candidates on the waiting list are risk stratified based on estimated posttransplant survival (EPTS), which considers candidate age, dialysis duration, prior solid organ transplant, and diabetes status Generally, older age, longer dialysis duration, prior solid organ transplantation, and presence of diabetes are associated with higher EPTS scores and shorter expected posttransplantation survival The new allocation policy prioritizes candidates in the top 20th EPTS percentile to receive kidneys with a KDPI of 0.20 or less Children receive priority for kidneys with KDPI scores less than 0.35 Deceased donors are categorized into two groups: donation after brain death (DBD) and donation after circulatory death (DCD) DCD, previously referred to as donation after cardiac death or non-heart-beating organ donation, refers to the retrieval of organs for the purpose of transplantation from patients whose death is diagnosed and confirmed using cardiorespiratory criteria (see also Chapter 20) There are two principal types of DCD: controlled and uncontrolled Uncontrolled DCD refers to organ retrieval after a cardiac arrest that is unexpected and from which the patient cannot or should not be resuscitated In contrast, controlled DCD takes place after death that follows the planned withdrawal of life-sustaining treatments that have been considered to be of no overall benefit to a critically ill patient in the intensive care unit (ICU) or emergency department DCD kidneys were used in 4% of pediatric kidney transplant recipients from 2015 to 2017 in contrast to 20% of adult kidney transplant recipients.3 Another category of donor is the Public Health Service (PHS) Increased Risk Donor The transplant center receives notification from the Organ Procurement Organization that the donor organ meets criteria for PHS increased risk The phrase increased risk refers to the donor characteristics that could place the potential recipient at increased risk of disease transmission A potential organ donor may be labeled as increased risk for a variety of different exposures, which carry different risks of transmitting recent infection with human immunodeficiency virus, hepatitis B virus, or hepatitis C virus The phrase is not a reference to organ quality, nor should it be interpreted to be a predictor of graft survival At the time of the organ offer, if a donor is identified as being at increased risk, the transplantation team should include this risk information in the informed consent discussion with the transplantation candidate or medical decision-maker Timing of Transplantation In the United States, adult candidates can be placed on and accrue wait time on the deceased donor wait list when the glomerular filtration rate (GFR) is 20 mL/min or less or when they are receiving chronic dialysis therapy In contrast, there is no GFR cutoff for listing the pediatric candidate Once the estimated GFR declines to less than 30 mL/min per 1.73 m2, it is generally time to start preparing the child and the family for renal replacement therapy Although there have been many advances in conservative renal replacement therapy, renal transplantation is the best treatment for children with ESRD The majority of children in the 931 United States have been on dialysis prior to transplantation, 22% for less than year and 30% for to years.3 Preemptive transplantation refers to transplantation in a patient who has not been on dialysis, which occurred in 30% of pediatric kidney transplant recipients in 2018.3 Histocompatibility ABO Blood Group Considerations The ABO blood group consists of four common categories (A, B, AB, and O), with types A and O most frequently found in the US population Antigen is expressed on red blood cells, lymphocytes, and platelets, as well as epithelial and endothelial cells Formation of blood-group isoantibodies occurs against those antigens not native to the host Thus, antibodies to both A and B are found in an individual with blood type O, while an individual with blood type AB has no antibodies to A or B antigens Blood group A consists of two subtypes, A1 and A2 Approximately 80% of individuals in the United States with blood group A express A1 The antigenic expression of A2 is quantitatively and qualitatively less than that of A1, and the overall immunogenic risk based on antigen expression alone is A1 B A2 Given the lower immunogenic risk of the A2 antigen, donor A2 kidneys can generally be successfully transplanted into recipients with low pretransplantation anti-A titers without the use of desensitization It is important to understand that a blood type O donor is a universal donor, and a blood type AB recipient is a universal recipient In general, ABO-incompatible transplantation is rare in kidney transplantation, occurring in less than 1% of the pediatric population.3 HLA Matching Traditionally, it has been shown that the greater the HLA mismatch, the greater the risk for acute and chronic rejection Over time with newer immunosuppressive agents, HLA mismatching has been found to have less impact on the development of acute rejection and on early graft loss However, it is still well established that better matching results in a better long-term outcome following renal transplantation and that mismatch is a factor that contributes to the development of chronic allograft rejection Thus, the advantage of a perfect match is longer graft survival following renal transplantation The disadvantage of perfect matching is the potential that it will be more difficult to achieve, as waiting for an appropriate donor will be longer Pretransplantation Crossmatch Testing Pretransplant crossmatch between T cells and B cells is related to the presence of circulating anti-HLA class I and anti-HLA class II antibodies In general, B-cell crossmatches not impact transplant rejection However, T-cell crossmatches Once an antibody binds to a T cell, it is generally an indication that this antibody is an anti-HLA class II alloantibody It also suggests that this antibody has high potential to be pathologic and result in hyperacute rejection For this reason, a positive T-cell crossmatch is a contraindication to transplantation Newer techniques and studies have been developed such as Luminex to further define this alloantibody, and new therapeutic protocols may enable patients to be desensitized such that a transplantation can be performed in the future ... indication that this antibody is an anti-HLA class II alloantibody It also suggests that this antibody has high potential to be pathologic and result in hyperacute rejection For this reason, a... Act of 2000, which was incorporated as an amendment to the National Organ Transplant Act (NOTA) This Act specifies that organ allocation policy is to recognize the differences in health and organ... offer, if a donor is identified as being at increased risk, the transplantation team should include this risk information in the informed consent discussion with the transplantation candidate or medical