Clinical Significance of De Novo Donor Specific Antibody Based on the Type of Kidney Transplantation

BackgroundPreemptive living donor kidney transplantation (P-LDKT) has shown a better prognosis than nonpreemptive living donor KT (NP-LDKT) or deceased donor KT (DDKT). However, association between KT type and de novo donor specific antibody (dnDSA) is uncertain.MaterialsWe retrospectively analyzed 1114 patients who underwent KT between 1994 and 2020. We investigated the clinical significance of dnDSA based on KT type.ResultsMean follow-up duration was 131.5 ± 89.5 months. Mean age of recipients, mismatched number of human leukocyte antigens and incidence of delayed graft function were significantly higher in DDKT group than P-LDKT and NP-LDKT groups. There were no significant differences of incidence of dnDSA and acute rejection within 1 year among them. Death-censored graft survival rate was significantly lower in all groups with dnDSA than without dnDSA, respectively. In positive dnDSA, NP-LDKT and DDKT groups tended to be lower in the death-censored graft survival compared to P-LDKT and there was a significant interaction between type of KT and dnDSA (P = .010). Independent risk factors were acute rejection within 1 year (hazard ratio [HR], 4.341; 95% CI, 1.758-10.720; P = .001), dnDSA positivity (HR, 3.170; 95% CI, 1.364-7.371; P = .007), and eGFR at 12 months after KT (HR, 3.701; 95% CI 2.049-6.686; P < .001).ConclusionsThere was no significant difference of incidence of dnDSA based on KT type, but allograft survival was poor in all recipients with dnDSA. NP-LDKT and DDKT with dnDSA showed poor prognosis compared to P-LDKT with dnDSA. Therefore, continuous and rigorous surveillance of DSA needs among NP-LDKT and DDKT.     

Prevalence and Impact of Reformed and De Novo Anti-HLA Donor-Specific Antibodies in Liver Transplantation

Introduction

The prevalence and impact of pre-existing and de novo anti-HLA donor-specific antibodies (DSAs) after orthotopic liver transplantation (OLT) is still controversial. We investigated the prevalence of DSAs and their implication in the development of allograft dysfunction after OLT.

Long-Term Outcomes of Everolimus Therapy in De Novo Liver Transplantation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BackgroundRisk of nephrotoxicity in liver transplant patients on calcineurin inhibitors (CnIs) is a concern. Several controlled trials reported benefit of everolimus (EVR) in minimizing this risk when combined with a reduced CnI dose.BackgroundTo systematically review the efficacy and safety of EVR, alone or with reduced CnI dose, as compared to CnI alone post-liver transplantation.MethodsWe searched MEDLINE, Scopus, and the Cochrane Library for randomized controlled trials comparing EVR- and CnI-based regimens post-liver transplantation. Assessment of studies and data extraction were undertaken independently.ResultsEight studies were selected, describing 769 patients. Cockcroft-Gault GFR was higher at one (P = .05), 3, and 5 years (P = .030) in patients on EVR compared to those receiving CnI therapy. The composite endpoint of efficacy failure was similar between the 2 arms after 1, 3, and 5 years of study. More patients discontinued EVR due to adverse effects in 1 year; however, no difference was noted after 3 or 5 years. A higher rates of proteinuria, peripheral edema, and incisional hernia occurred in patients on EVR.ConclusionsThe analysis confirms noninferiority of EVR and reduced CnI combination. Combination regimen resulted in better renal function compared to standard CnI therapy.     

The Impact of Time-Zero Biopsy on Early Graft Outcomes After Living Donor Kidney Transplantation

Background

In contrast with deceased donor transplantation, the clinical significance of pathologic findings in time-zero biopsies after living donor kidney transplantation are rarely reported, due to the expectation that histologic findings and renal function are normal. The aim of this study was to identify subclinical pathologic findings in living donors and examine the effect on early graft renal function.

Methods

Between December 2006 and July 2011, 146 living-donor kidney transplant recipients were enrolled in this study. We retrospectively analyzed donor and recipient-related clinical parameters, and post-transplant 6 months and 1 year estimated glomerular filtration rate (eGFR) as early graft renal function. Time-zero biopsies were evaluated using the 2007 Banff criteria.

Results

Most abnormal histologic findings were of mild degree as determined by Banff scores. Global glomerulosclerosis (GS, 35.6%), tubular atrophy (CT, 36.3%), interstitial fibrosis (CI, 20.5%), vascular fibrous intimal thickening (CV, 4.1%), arteriolar hyaline thickening (AH, 14.4%), interstitial inflammation (I, 3.4%) were pathologic findings in time-zero biopsies. The univariate analysis revealed that donor age and gender were significantly associated with eGFR at post-transplant 6 months and at 1 year (P < .05). Furthermore, GS and CT were significantly associated with early graft renal function (P < .05). However, multivariate linear regression analysis showed only donor age was significantly associated with early graft renal function (P = .001).

Conclusion

A mild degree of subclinical, pathologic findings on time-zero biopsy did not affect early graft renal function in living-donor kidney transplantation.     

De Novo Malignancy After Adult-to-Adult Living Donor Liver Transplantation: A Single-Center Long-Term Experience

BackgroundThe incidence of de novo malignancy (DNM) after liver transplantation (LT) is reported to be 3.1% to 14.4%. It is a known cause of death in long-term recipients. This study aimed to clarify the clinical features and risk factors of DNM.MethodsRecipients who underwent adult-to-adult living-donor LT (LDLT) and survived for >6 months were investigated. The medical records were retrospectively reviewed. This study was approved by the institutional review board.ResultsIn total, 180 patients were included. The indications for LDLT were hepatocellular disease (n = 62), metabolic liver disease (n = 50), cholestatic disease (n = 46), acute liver failure (n = 12), and others (n = 10). The median age at LDLT was 48 (18-71) years, and the follow-up period was 15 (0-29) years. De novo malignancy was diagnosed in 24 recipients (28 sites), including the digestive tract (n = 9), genitourinary (n = 5), gynecologic (n = 5), lung (n = 4), hematological (n = 3), and others (n = 2). The median duration from LDLT to DNM was 7 (0-19) years. Four patients were lost to follow-up due to advanced-stage cancer. R0 (curative treatment) for non-hematological DNM was achieved in 19 lesions (95%). The 10- and 20-year DNM incidence rates were 11% and 20%, respectively. The 20-year survival rates of DNM (59.6%) and non-DNM (59.9%) patients were not significantly different. De novo malignancy was significantly higher in patients with primary sclerosing cholangitis than in others (P < .05).ConclusionsEven in DNM recipients, early detection of malignancy and R0 treatment promises long-term outcomes comparable to those of non-DNM recipients.     

Outcomes Following De Novo CNI-Free Immunosuppression After Heart Transplantation: A Single-Center Experience

Renal impairment at the time of heart transplantation complicates the choice of subsequent immunosuppressive therapy. Calcineurin (CNI)-free regimens utilizing proliferation signal inhibitors (PSI) may mitigate against nephrotoxicity in this group; however, their effectiveness remains unclear.
We present our 7-year experience with de novo CNI-free, PSI-based immunosuppression after heart transplantation. Of the 152 patients transplanted between July 1999 and July 2006, de novo immunosuppression regimens were 49 CNI-free, PSI-based, 88 CNI, 15 combination of CNI+PSI.
Pretransplant creatinine clearance improved within 6 months in the PSI group (0.69 ± 0.34 mL/s vs. 1.00 ± 0.54 mL/s, p < 0.05) but not the CNI (1.32 ± 0.54 mL/s vs. 1.36 ± 0.53 mL/s, p = ns) or CNI+PSI (1.20 ± 0.24 mL/s vs. 1.20 ± 0.41 mL/s, p = ns) groups. The PSI group had more episodes of early (≤6 months) acute rejection, bacterial or fungal infections and pleural effusions but less CMV infection (p < 0.05 for all comparisons). Early CNI addition occurred in 37% of the PSI group for acute rejection. 33% of the entire cohort changed immunosuppression regimens over 3.6 ± 2.2 years follow-up.
De novo CNI-free, PSI-based immunosuppression in patients with significant renal dysfunction allowed significant posttransplantation renal recovery but with increased early acute rejection, bacterial and fungal infections and pleural effusions.     

Impact of Recipient Age on Outcomes After Pancreas Transplantation

BackgroundFew reports have provided the ages of pancreas transplant recipients. The aim of this study was to determine whether recipient age affects survival of pancreatic grafts after transplantation.MethodsWe analyzed 73 patients who had undergone pancreas transplantation at our institution from August 2001 to March 2020 and assessed the effects of recipient age on pancreas graft survival within 5 years after pancreas transplantation.ResultsThe cutoff value for recipient age established by receiver operating characteristic curve was 35 years. The pancreas graft survival rate of recipients aged 35 years or younger (1, 3, and 5 years: 72.9%, 41.7%, and 41.7%, respectively) was significantly lower than that of recipients aged over 35 years (1, 3, and 5 years: 93.2%, 88.4%, and 88.4%, respectively). Multivariate Cox hazard regression analysis showed that recipient age 35 years or younger (hazard ratio = 3.60; 95% confidence interval, 1.04-12.50; P = .044) and solitary pancreas transplantation (hazard ratio = 10.72; 95% confidence interval, 2.72-42.28; P < .001) were significant risk factors for pancreas graft loss within 5 years.ConclusionOur data suggest that younger recipient age is a risk factor for pancreas graft loss after transplantation.     

Appointment Nonadherence and Graft Outcomes in Living Donor Kidney Transplantation

BackgroundMedication nonadherence is associated with worse graft outcomes but is hard to recognize in clinical settings due to its self-reporting nature. We hypothesized that appointment nonadherence might be associated with worse graft outcomes in living donor kidney transplantation.MethodsWe included 167 adult living-donor kidney transplants whose grafts survived >2 years from April 2011 to May 2020. Thirty-two cases of appointment nonadherence were identified and compared with the controls (n = 135).ResultsYounger age, male sex, higher body weight, and parent donor were significantly observed in the appointment nonadherence group. The appointment nonadherence group was significantly associated with worse graft survival (5 years: 82.3% vs 98.9%, P < .001, 10 years: 67.2% vs 89.6%, P < .001), de novo donor-specific antibody production, acute rejection, as well as the decline of graft function. Furthermore, appointment nonadherence had a 4-fold higher risk of graft loss after an adjustment with recipient age, sex, body weight, and donor type (adjusted hazard ratio: 3.93, 95% CI: 1.15-13.42, P = .029).ConclusionsAppointment nonadherence might be an alternative predictor for worse graft outcomes after living donor kidney transplantation.     

De Novo Donor HLA‐Specific Antibodies after Heart Transplantation Are an Independent Predictor of Poor Patient Survival

Preformed donor HLA‐specific antibodies are a known indicator for poor patient survival after cardiac transplantation. The role of de novo donor‐specific antibodies (DSA) formed after cardiac transplantation is less clear. Here we have retrospectively analyzed 243 cardiac transplant recipients, measuring HLA antibody production every year after transplantation up to 13 years post‐transplant. Production of de novo DSA was analyzed in patients who had been negative for DSA prior to their transplant. DSA including transient antibodies were associated with poor patient survival (p = 0.0018, HR = 3.198). However, de novo and persistent DSA was strongly associated with poor patient survival (p = 0.0001 HR = 4.351). Although complement fixing persistent DSA correlated with poor patient survival, this was not increased compared to noncomplement fixing persistent DSA. Multivariable analysis indicated de novo persistent DSA to be an independent predictor of poor patient survival along with HLA‐DR mismatch and donor age. Only increasing donor age was found to be an independent risk factor for earlier development of CAV. In conclusion, patients who are transplanted in the absence of pre‐existing DSA make de novo DSA after transplantation which are associated with poor survival. Early and regular monitoring of post‐transplant DSA is required to identify patients at risk of allograft failure.     

Rates and Determinants of Progression to Graft Failure in Kidney Allograft Recipients With De Novo Donor‐Specific Antibody

Understanding rates and determinants of clinical pathologic progression for recipients with de novo donor‐specific antibody (dnDSA), especially subclinical dnDSA, may identify surrogate endpoints and inform clinical trial design. A consecutive cohort of 508 renal transplant recipients (n = 64 with dnDSA) was studied. Recipients (n = 388) without dnDSA or dysfunction had an eGFR decline of ?0.65 mL/min/1.73 m²/year. In recipients with dnDSA, the rate eGFR decline was significantly increased prior to dnDSA onset (?2.89 vs. ?0.65 mL/min/1.73 m²/year, p < 0.0001) and accelerated post‐dnDSA (?3.63 vs. ?2.89 mL/min/1.73 m²/year, p < 0.0001), suggesting that dnDSA is both a marker and contributor to ongoing alloimmunity. Time to 50% post‐dnDSA graft loss was longer in recipients with subclinical versus a clinical dnDSA phenotype (8.3 vs. 3.3 years, p < 0.0001). Analysis of 1091 allograft biopsies found that dnDSA and time independently predicted chronic glomerulopathy (cg), but not interstitial fibrosis and tubular atrophy (IFTA). Early T cell–mediated rejection, nonadherence, and time were multivariate predictors of IFTA. Independent risk factors for post‐dnDSA graft survival available prior to, or at the time of, dnDSA detection were delayed graft function, nonadherence, dnDSA mean fluorescence intensity sum score, tubulitis, and cg. Ultimately, dnDSA is part of a continuum of mixed alloimmune‐mediated injury, which requires solutions targeting T and B cells.

     

The Impact of Donor Obesity on Outcomes after Cadaver Pancreas Transplants

We examined the impact of donor obesity on surgical complications and graft function after pancreas transplants. From January 1994 through December 2001, we performed 711 cadaver pancreas transplants. We analyzed outcomes for three groups based on donor body mass index (BMI): <25 kg/m2 (n=434), 25-30 (n=196), and >30 (n=81). Donor characteristics were similar between the three groups except for donor cause of death. Cerebrovascular deaths were more common in the BMI >30 group (p=0.002), while trauma deaths were more common in the BMI <25 group (p=0.02). In the BMI >30 group, surgical complications, most notably surgical infections and thrombosis, were significantly more common; in addition, technical failure rates were higher and short-term graft survival was inferior. The incidence of technical failure was 9.7% in the BMI <25 group, 16.3% in the BMI 25-30 group, and 21.0% in the BMI >30 group (p=0.04). However, when we looked at only technically successful transplants, we found minimal differences in the three groups with regard to graft survival at 1 and 3 years posttransplant. Donor obesity increased the incidence of surgical complications in our pancreas recipients, but did not affect initial graft function posttransplant. Technically successful transplants using obese donors results in good graft function at 1 and 3 years posttransplant.     

De Novo Malignancy Following Adult-to-Adult Living Donor Liver Transplantation Focusing on Posttransplantation Lymphoproliferative Disorder

Objective

In patients with living donor liver transplantation (LDLT), late-onset complications sometimes develop because of long-term use of immunosuppressive drugs. One of the immunosuppressive drug-related complications is de novo malignancies resulting in reduced survival.

Preformed and De Novo Donor Specific Antibodies in Visceral Transplantation: Long‐Term Outcome With Special Reference to the Liver

Despite improvement in early outcome, rejection particularly chronic allograft enteropathy continues to be a major barrier to long‐term visceral engraftment. The potential role of donor specific antibodies (DSA) was examined in 194 primary adult recipients. All underwent complement‐dependent lymphocytotoxic crossmatch (CDC‐XM) with pre‐ and posttransplant solid phase HLA–DSA assay in 156 (80%). Grafts were ABO‐identical with random HLA‐match. Liver was included in 71 (37%) allografts. Immunosuppression was tacrolimus‐based with antilymphocyte recipient pretreatment in 150 (77%). CDC‐XM was positive in 55 (28%). HLA–DSA was detectable before transplant in 49 (31%) recipients with 19 continuing to have circulating antibodies. Another 19 (18%) developed de novo DSA. Ninety percent of patients with preformed DSA harbored HLA Class‐I whereas 74% of recipients with de novo antibodies had Class‐II. Gender, age, ABO blood‐type, cold ischemia, splenectomy and allograft type were significant DSA predictors. Preformed DSA significantly (p < 0.05) increased risk of acute rejection. Persistent and de novo HLA–DSA significantly (p < 0.001) increased risk of chronic rejection and associated graft loss. Inclusion of the liver was a significant predictor of better outcome (p = 0.004, HR = 0.347) with significant clearance of preformed antibodies (p = 0.04, OR = 56) and lower induction of de novo DSA (p = 0.07, OR = 24). Innovative multifaceted anti‐DSA strategies are required to further improve long‐term survival particularly of liver‐free allografts.     

Impact of Donor Dopamine on Immediate Graft Function after Kidney Transplantation

Optimizing medical donor management may have a considerable impact on transplantation outcome. This study investigated the effect of donor dopamine on initial graft function in renal allograft recipients, involving 254 consecutive recipients of a cadaver kidney, aged 18-74 years, transplanted between 1990 and 2003. Immunosuppression was based on cyclosporine. Patients were grouped according to donor use of dopamine during intensive care. Delayed graft function (DGF), and serial creatinine concentrations were compared between the groups. Dopamine-treated and -untreated donors were very similar regarding hemodynamics and renal function. Delayed graft function occurred in 47/158 treated and 48/96 untreated kidneys (p = 0.001). Donor dopamine was associated with a more rapid decrease of s-creatinine, which became obvious on the first postoperative day. Of patients in the treated and untreated group, respectively, 81.9% and 65.8% reached a s-creatinine level less than 2 mg/dL during the first month (p = 0.005). Donor dopamine remained predictive of a normalized s-creatinine level [HR 1.71; 95% CI 1.22-2.41] after controlling for confounding factors by multivariate Cox regression. Donor dopamine is associated with improvements of initial graft function after kidney transplantation. The beneficial effect of dopamine is achievable without side-effects for the recipients, and correlates with superior long-term graft survival.     

Class II HLA Epitope Matching—A Strategy to Minimize De Novo Donor‐Specific Antibody Development and Improve Outcomes

De novo donor‐specific antibody (dnDSA) develops in 15–25% of renal transplant recipients within 5 years of transplantation and is associated with 40% lower graft survival at 10 years. HLA epitope matching is a novel strategy that may minimize dnDSA development. HLAMatchmaker software was used to characterize epitope mismatches at 395 potential HLA‐DR/DQ/DP conformational epitopes for 286 donor–recipient pairs. Epitope specificities were assigned using single antigen HLA bead analysis and correlated with known monoclonal alloantibody epitope targets. Locus‐specific epitope mismatches were more numerous in patients who developed HLA‐DR dnDSA alone (21.4 vs. 13.2, p < 0.02) or HLA‐DQ dnDSA alone (27.5 vs. 17.3, p < 0.001). An optimal threshold for epitope mismatches (10 for HLA‐DR, 17 for HLA‐DQ) was defined that was associated with minimal development of Class II dnDSA. Applying these thresholds, zero and 2.7% of patients developed dnDSA against HLA‐DR and HLA‐DQ, respectively, after a median of 6.9 years. Epitope specificity analysis revealed that 3 HLA‐DR and 3 HLA‐DQ epitopes were independent multivariate predictors of Class II dnDSA. HLA‐DR and DQ epitope matching outperforms traditional low‐resolution antigen‐based matching and has the potential to minimize the risk of de novo Class II DSA development, thereby improving long‐term graft outcome.     

Impact of Cytomegalovirus Infection and Disease on Graft Loss After Pancreas Transplantation: A Single-Institution Study in Japan

BackgroundCytomegalovirus (CMV) is one of the most frequent infections after pancreas transplantation (PTx), and it is unclear whether CMV infection is associated with pancreas graft loss. A limited number of studies about the relationship between CMV infection and pancreas graft loss have been reported from Western countries, but there have been no reports from Japan. This study investigated the relationship between CMV infection and pancreas graft loss after PTx in a single Japanese institution.MethodsThis study included 58 patients who underwent PTx from deceased donors from April 2000 to March 2021 in our institution. We assessed pancreas graft loss based on CMV infection and disease and investigated the causes of graft loss, the time of onset of CMV disease, and the time of graft loss for each case.ResultsThe numbers of patients in the 4 categories of donor (D) and recipient (R) pretransplant anti-CMV antibody status were as follows: 4 (6.9%) in the D−/R− group, 6 (10.3%) in the D−/R+ group, 34 (58.6%) in the D+/R+ group, and 14 (24.1%) in the D+/R− group. Of the 58 patients, 74.1% and 44.1% received diagnoses of CMV infection and disease after PTx, respectively. There were no significant differences in the survival rates of pancreas graft loss stratified by CMV infection (P = .1809) or disease (P = .6241).ConclusionsThis study suggests that CMV infection and disease had no significant influence on pancreas graft loss in this Japanese institution.     

De Novo Donor‐Specific HLA Antibodies Are Associated With Rapid Loss of Graft Function Following Islet Transplantation in Type 1 Diabetes

Outcomes after islet transplantation continue to improve but etiology of graft failure remains unclear. De novo donor‐specific human leukocyte antigen (HLA) antibodies (DSA) posttransplant are increasingly recognized as a negative prognostic marker. Specific temporal associations between DSA and graft function remain undefined particularly in programs undertaking multiple sequential transplants. Impact of de novo DSA on graft function over 12 months following first islet transplant was determined prospectively in consecutive recipients taking tacrolimus/mycophenolate immunosuppression at a single center. Mixed‐meal tolerance test was undertaken in parallel with HLA antibody assessment pretransplant and 1–3 months posttransplant. Sixteen participants received a total of 26 islet transplants. Five (19%) grafts were associated with de novo DSA. Five (31%) recipients were affected: three post–first transplant; two post–second transplant. DSA developed within 4 weeks of all sensitizing grafts and were associated with decreased stimulated C‐peptide (median [interquartile range]) at 3 months posttransplant (DSA negative: 613(300–1090); DSA positive 106(34–235) pmol/L [p = 0.004]). De novo DSA directed against most recent islet transplant were absolutely associated with loss of graft function despite maintained immunosuppression at 12 months in the absence of a rescue nonsensitizing transplant. Alemtuzumab induction immunosuppression was associated with reduced incidence of de novo DSA formation (p = 0.03).     

Impact of Monosegment Graft Use for Infants in Pediatric Living Donor Liver Transplantation

BackgroundLeft lateral segment grafts are generally used for very young pediatric patients undergoing living donor liver transplantation (LDLT). Recently, graft reduction techniques were developed for LDLT. Monosegment grafting has been used in newborns. The aim of this study was to determine the usefulness of monosegment grafting for infants.MethodsRecipients <2 years of age who underwent LDLT with a monosegment graft between 2010 and 2020 were gathered. Parents comprised all LDLT donors. A segment 2 monosegment graft was resected as a graft from the donor. Standard liver volume (SLV) was estimated using Urata's equation. Graft type, graft weight (GW), and native liver weight were assessed.ResultsEight patients were included in the study. Original diseases consisted of biliary atresia (n = 6) and fulminant hepatitis (n = 2). Final graft type included monosegment (n = 5) and reduced monosegment (n = 3). Median final GW/body weight after reduction was 3% (range, 2%-3.4%). Median native liver weight/SLV was 134% except in patients with fulminant hepatitis. Median pre-reduction graft volume (GV)/estimated GV was 113% (range, 60%-208%). Median pre-reduction GV/SLV of monosegment grafts that required reduction (n = 3) was 109% (range, 106%-121%). Median final reduced graft GV/SLV was 80% (range, 74%-91%). Complications due to large-for-size grafts were not observed. One case of bile leakage due to graft reduction occurred as a complication. Grafts were functioning well with the exception of one graft loss due to antibody-mediated rejection.ConclusionEstimated GV in infants varies widely. Monosegment grafting can be useful for infants as well as newborns.     

Donor-Specific Anti-HLA Antibodies After Bone-Graft Transplantation. Impact on a Subsequent Renal Transplantation: A Case Report

Immunological evaluation by panel-reactive antibody (PRA) and determination of anti-HLA specificity are important phases in the evaluation of patients awaiting kidney transplantation. The main causes of immunization are previous solid organ transplantation, hemotransfusion, and pregnancy. It is also possible that immunogenicity can be triggered by vascularized tissue grafts. Immune induction by cryopreserved bone prostheses is not yet understood. A 19-year-old patient with osteosarcoma had undergone resection of the left proximal tibia with reconstruction using human bone in 1997. The donor HLA typing was as follows: A3, A29 (19); B44 (12), Bw4; DR13 (6), DR7, DR52, DR53. The patient was subsequently enrolled onto the waiting list for cadaveric donor kidney transplantation due to chronic kidney failure caused by cisplatin toxicity. Pretransplantation immunological screening using the complement-dependent cytotoxicity (CDC) technique revealed a PRA of 63%. IgG antibody specificities were detected against class I and class II donor antigens, specifically anti-A3, B44, DR7 antibodies, using flow cytometry (Tepnel Luminex). Further immunological studies using single HLA specificity analysis (LSA Class I°-II°, Tepnel-Luminex) showed direct antibodies against all donor antigen specificities. This case showed immune induction after the implantation of bone prosthesis in a kidney transplant candidate, underlining the importance of the availability of HLA typing data of donors of a human prosthesis.