PEDIATRIC RENAL TRANSPLANTATION USING FLOWCYTOMETRY CROSSMATCH AND HLA IMMUNOFENOTYPING

BASED ON DNA FOR SCREENING TEST: A CASE REPORT

Rudy Eka A Putra*, Besut Daryanto**, Kurnia Penta Seputra**, Paksi Satyagraha**, Atma Gunawan***, Hani Susianti****

*) Urology Resident at Urology Department Medical Faculty Brawijaya University – Saiful Anwar General Hospital Malang
**) Urology Staff at Urology Department Medical Faculty Brawijaya University – Saiful Anwar General Hospital Malang
***) Internal Medicine Staff at Internal Medicine Department Medical Faculty Brawijaya University – Saiful Anwar General Hospital Malang
****) Clinical Patologic Staff at Clinical Patologic Department Medical Faculty Brawijaya University – Saiful Anwar General Hospital Malang

INTRODUCTION
Renal transplantation is the most successful treatment option for children with kidney failure. Patient survival at 1, 5 and 10 years was respectively 99%, 97% and 96%. Successful renal transplantation can almost
restore a child’s normal life. Renal transplantation has beneficial effect both in economic and physiologic aspects. During this time we use the CM CDC and serological HLA immunofenotyping for renal transplant
screening, risk of rejection between donors and recipients as high. Therefore for this case used the technique of FXCM and HLA based on DNA immunofenotyping to reduce the risk of high rejection that are useful to
increase the number of success of renal transplantion. We report the experience of a kidney transplant surgery in children using the screening – flowcytometry cross matching and HLA immunofenotyping based on
DNA to predict graft rejection between the recipient and the donor at dr Saiful Anwar Hospital in Malang were the first conducted in Indonesia.
CASE REPORT
A 15-years old female adolescent with chronic kidney disease end stage was presented with hypertension, anemia, albuminuria, and renal azotemia.. She underwent hemodyalisis for 3 months and planned for renal
transplantation.
PHYSICAL EXAMINATION
On the physical examination of the recipients, it was obtained general status in which the general condition was sufficient. Moreover, she had awareness compos mentis with blood pressure of 130/90 mm Hg, pulse
of 88 beats per minute, respiration of 20 times per minute and temperature of 37,80C axilla. From her head neck examination, it was revealed that she had anemis conjunctiva condition.
LABORATORY – RADIOLOGY EXAMINATION
Based on the complete blood test results, it was known that she had anemia of which hemoglobin was 7.3 g / dL, leukocytes was 4750 / mm 3 and platelets was 174,000 / mm3, blood urea nitrogen (BUN) kidney
function was 16.3 mg / dL and serum creatinine was 4.21 mg / dL. She had reactive AntiCMV IgG too. After a complete urine examination had been conducted, it was found that her albuminuria was (2+). On the
recipient radiological examination, the thorax photo was within the normal limits and so was the plain abdominal photo. The abdominal ultrasound result was bilateral chronic parenchymatous renal disease. Based on
the recipients MRI angiography it was known that she had parenchymatous Chronic Kidney Disease and ascites in the pelvic cavity and iliaca communis D / S artery, the internal iliaca artery, and the normal external
artery iliaca externa was not obtained on the photo of thrombus / stenosis
Screening was done by using HLA ABDR method and flowcytometry crossmatch based on DNA. The result of the HLA A,B,DR screening results indicated that 3/6 typing missmatch and flowcytometry of T
lymphocytes and B lymphocytes was negative in result.

T lymphocytes examination results flowcytometry

Examination Result: negative

Negative control
Positive control
Donor recipient

B lymphocytes flowcytometry examination results

Examination Result: negative

Negative control

Positive control

Donor recipient
TREATMENT
A kidney organ from her mother transplanted at donor using end to end anastomose method. Tension occurs in during operation and the recipient kidney donors was installed mesh to increase vascularization of the
kidney . After transplantation procedure, she got immunosuppressive treatment. A 4 month follow up showed no graft rejection and normal daily activity, but there is increasing renal function test at 4 month and the
results of the re-evaluation in the recipient is ureteral stenosis , then we performed ureterorenoscopy with Holmium laser and inserted of DJ stent in a patient .
FOLLOW UP
Post-op kidney transplantation, the patient was given immunosuppressant drugs which were CellCept 2x500mg and prograft 2x5 mg. After 2 weeks of hospitalization in RSSA Malang, the response given by the
patient to the immunosuppressant drugs was good and there was no rejection reaction The first month until the fourth month after such treatment, the patient was given follow up action and it was revealed that the
patient was able to do several activities normally, the patient got fresher for doing such activities compared to the condition before the patient underwent kidney transplantation. One month later the patient came back
to the hospital to control the release of DJ stent, at the third month, when the patient came back to underwent control at month 4, the level of the patient’s creatinine increased at around 4.9 g / dl. The patient then
underwent evaluation surgery and it was found that the right ureteral stenosis occurred before undergoing ureterorenoscopy with Holmium Laser and DJ stent insertion. The last USG evaluation was conducted on
July 27, 2015 showing the following results : the size of transplant ren was 10.1 x 5.6 cm, normal echocortex, widening system pelviocalyceal (hydronephrosis grade I), DJ stent inserted, good medulla cortex
boundary, absence of widening ureter, and Doppler parameters within normal limit. The patient was still required to maintain the diet and kept controlling her condition to the hospital for following-up the patient’s
development.

DISCUSSION

Figure 2. The installation of mesh in the recipient and Doppler ultrasound results.
 Figure 3. The results of USG evaluation after DJ stent installation.

Conclusion:.
Flowcytometry crossmatch immunofenotyping analysis can be used to predict graft rejection between the recipient and the donor. No graft rejection reaction happening between the recipient and the donor in
terms of the preparation crossmatch of the kidney transplants. Modalities of therapy for chronic renal failure are dialysis and transplantation. Kidney transplantation is a better management for children suffering from
kidney failure than dialysis in terms of cost effectiveness, survival and quality of life. Transplantation of kidneys in children by using flocytometry shows results that can be applied to other recipients.