title: Combined liver-kidney transplants: allosensitization and recipient outcomes.
abstract: BACKGROUND
  A pretransplant positive crossmatch in combined liver kidney transplants (CLK) is not considered a contraindication based on the reported immunoprotection conferred by the liver allograft. However, antibody-mediated rejection of the kidney in CLK has been reported recently. This prompted our study to investigate the impact of presensitization on CLK recipient outcomes.
  
  
  METHODS
  We examined kidney allograft and patient survival by indication of sensitization using Scientific Registry of Transplant Recipients data on CLK performed from 1995 to 2008. We defined sensitization as panel reactive antibody (PRA) more than 10% or a positive T-cell crossmatch (TXM).
  
  
  RESULTS
  Among 2484 CLK recipients with available PRA or TXM information, 30% had positive TXM or PRA more than 10%. Among those with TXM information, 12% had a positive crossmatch (n=234). In univariate analyses, patient (P=0.002) and overall kidney graft survival (P=0.015) were significantly diminished among sensitized patients. Differences in patient survival translated to estimated half-lives of 10.3 years among nonsensitized recipients versus 7.8 years among sensitized recipients, In multivariable Cox models, allosensitization was independently associated with patient death (adjusted hazard ratio=1.22, 95% CI, 1.04-1.43) and overall kidney graft loss (adjusted hazard ratio=1.16, 95% CI, 1.00-1.36).
  
  
  CONCLUSIONS
  These results suggest a negative impact of presensitization on patient and overall renal allograft survival in CLK. Accordingly, presensitization may need to be considered in risk stratification and clinical management of CLK.
authors.affiliation: Transplant Center, Cleveland Clinic, Cleveland, OH, USA. askarm@ccf.org
authors.forename: Medhat
authors.initials: M
authors.lastname: Askar
authors.forename: Jesse D
authors.initials: JD
authors.lastname: Schold
authors.forename: Bijan
authors.initials: B
authors.lastname: Eghtesad
authors.forename: Stuart M
authors.initials: SM
authors.lastname: Flechner
authors.forename: Bruce
authors.initials: B
authors.lastname: Kaplan
authors.forename: Lynne
authors.initials: L
authors.lastname: Klingman
authors.forename: Nizar N
authors.initials: NN
authors.lastname: Zein
authors.forename: John
authors.initials: J
authors.lastname: Fung
authors.forename: Titte R
authors.initials: TR
authors.lastname: Srinivas
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006085:Graft Survival; D006680:HLA Antigens / Q000276:immunology*; D006650:Histocompatibility Testing; D006801:Humans; D007165:Immunosuppression Therapy; D007518:Isoantibodies / Q000097:blood; D016030:Kidney Transplantation / Q000276:immunology / Q000401:mortality; D016031:Liver Transplantation / Q000276:immunology / Q000401:mortality; D008297:Male; D008875:Middle Aged; D014184:Transplantation, Homologous; D016896:Treatment Outcome
chemical_list: D006680:HLA Antigens; D007518:Isoantibodies