Reflections and Future Directions HLA Testing in Transplantation
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1 Reflections and Future Directions HLA Testing in Transplantation Dr. Robert Liwski, MD, PhD, FRCPC Medical Director, HLA Typing Laboratory Division of Hematopathology Professor, Department of Pathology Dalhousie University, Halifax Medical Director, HLA Laboratory, CBS, Ottawa
2 Disclosure Nothing significant to disclose
3 Disclosure Nothing significant to disclose
4 HLA class I and class II antigens Monomer with noncovalently associated subunit (b2m) Presents antigenic peptides to CD8+ T cells Expressed by all nucleated cells including endothelium Heterodimer Presents antigenic peptides to CD4+ T cells Restricted expression on antigen presenting cells (dendritic cells, B cells, macrophages) Inducible on other cells (endothelium and epithelium)
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6 Polymorphism of the Major Histocompatibility Complex in humans - Human Leukocyte Antigen (HLA) Common alleles Effective polymorphism
7 Class II Class I DP DQ DR B C A b 1 a 1 b 1 a 1 b 3,4,5 b 1 a maternal DP DQ DR B C A paternal
8 HLA inheritance A C B DR DQ Mother Father Patient Sib 1 Sib 2 Sib 3 Sib 4 Approximately 25-30% chance of having an HLA matched sibling
9 Polymorphic residues on Class I HLA molecules (polymorphisms are concentrated around peptide binding groove) Top view Side view HLA-A Alpha chain conserved aa HLA-B Alpha chain polymorphic aa Peptide b2 microglobulin HLA-C
10 Your ( self ) HLA HLA antibody development
11 HLA antibody development Your ( self ) HLA Donor ( allo ) HLA
12 HLA antibody development Your ( self ) HLA Donor ( allo ) HLA
13 HLA antibody development Your ( self ) HLA Donor ( allo ) HLA Sensitizing events: Pregnancy Transplantation Transfusion
14 Strategies used to avoid/minimize transplant rejection HLA typing and matching of recipient/donor pairs Detection of donor specific HLA antibodies.
15 Evolution of HLA testing Past (2010) HLA typing Serology CDC HLA antibody screening Lymphocyte panel CDC Lymphocyte crossmatching CDC Present HLA typing Molecular methods IR SSOP, allele level HLA antibody ID Solid Phase Assay Virtual crossmatch Lymphocyte crossmatching Flow cytometry
16 3-Color Flow Cytometric Crossmatch Recipient serum Donor lymphocytes T cell B cell Bray, Lebeck and Gebel. Transplantation 48: , 1989.
17 3-Color Flow Cytometric Crossmatch T cell B cell Bray, Lebeck and Gebel. Transplantation 48: , 1989.
18 3-Color Flow Cytometric Crossmatch T cell B cell Bray, Lebeck and Gebel. Transplantation 48: , 1989.
19 3-Color Flow Cytometric Crossmatch FITC-a-IgG T cell B cell Bray, Lebeck and Gebel. Transplantation 48: , 1989.
20 3-Color Flow Cytometric Crossmatch FITC-a-IgG FITC-a-IgG T cell B cell Bray, Lebeck and Gebel. Transplantation 48: , 1989.
21 3-Color Flow Cytometric Crossmatch FITC-a-IgG PerCP-a-CD3 PE-a-CD19 FITC-a-IgG T cell B cell Bray, Lebeck and Gebel. Transplantation 48: , 1989.
22 3-Color Flow Cytometric Crossmatch FITC-a-IgG FITC-a-IgG PerCP-a-CD3 T cell PE-a-CD19 B cell Detect fluorescent labels by flow cytometry Bray, Lebeck and Gebel. Transplantation 48: , 1989.
23 3-Color Flow Cytometric Crossmatch Gating strategy T cell X-match B cell X-match Negative Weak positive Strong positive FITC-a-IgG FITC-a-IgG
24 HLA antibody identification by LABScreen Single Antigen Luminex Assay 100 different types of beads Each bead type coded with different red/infrared dye combination Each bead type is coated with different recombinant HLA antigen 2 lasers Reporter laser (532nm) Tells the instrument how much PE dye is bound to the bead Detection with anti-igg-pe Classification laser (635nm) Tells the instrument which bead is being examined
25 HLA antibody identification by LABScreen Single Antigen Luminex Assay
26 HLA antibody identification by LABScreen Single Antigen Luminex Assay A1 A2 A3 A11 A23 A24 A25 A26 A29 A30
27 HLA antibody identification by LABScreen Single Antigen Luminex Assay 8 A26 10 A30 1 A1 5 9 A29 6 A24 2 A2 4 A11 1 A1 7 A25 8 A A23 9 A A30 A23 2 A2 3 A3 7 A25 A3 4 A11 A24
28 HLA antibody identification by LABScreen Single Antigen Luminex Assay 8 A26 10 A30 1 A1 5 9 A29 6 A24 2 A2 4 A11 1 A1 7 A25 8 A A23 9 A A30 A23 2 A2 3 A3 7 A25 A3 4 A11 A24
29 HLA antibody identification by LABScreen Single Antigen Luminex Assay 8 A26 10 A30 1 A1 5 9 A29 6 A24 2 A2 4 A11 1 A1 7 A25 8 A A23 9 A A30 A23 2 A2 3 A3 7 A25 A3 4 A11 A24
30 HLA antibody identification by LABScreen Single Antigen Luminex Assay 8 A26 10 A30 1 A1 5 9 A29 6 A24 2 A2 4 A11 1 A1 7 A25 8 A A23 9 A A30 A23 2 A2 3 A3 7 A25 A3 4 A11 A24
31 HLA antibody identification by LABScreen Single Antigen Luminex Assay PE-a-IgG 8 A26 10 A30 1 A1 5 9 A29 6 A24 2 A2 4 A11 1 A1 7 A25 8 A A23 9 A A30 A23 2 A2 3 A3 7 A25 A3 4 A11 A24
32 HLA antibody identification by LABScreen Single Antigen Luminex Assay 8 A26 10 A30 1 A1 5 9 A29 6 A24 2 A2 4 A11 1 A1 7 A25 8 A A23 9 A A30 A23 2 A2 3 A3 7 A25 A3 4 A11 A24
33 HLA Class I antibody analysis Patient A3,31 B7,60 DR1,14 (52) DQB5,6 Previous Donor A1, B8 DR7,17 (53,52) DQB2 Unacceptable antigens: A1, A36, B8
34 HLA Class II antibody analysis Patient A3,31 B7,60 DR1,14 (52) DQB5,6 Previous Donor A1, B8 DR7,17 (53,52) DQB2 Unacceptable antigens: DR7, DR53, DQ2
35 Canadian PRA calculator
36 Canadian PRA calculator Tinckam, Liwski, Pochinco, Mousseau, Grattan, Nickerson and Campbell, AJT 2015
37 Virtual Crossmatching Correlation between donor HLA typing and recipient HLA antibody testing. Presence/Absence of Donor Specific Antibodies (DSA)
38 Class I HLA antibody analysis Donor specific antibodies: A1, B8 Recipient HLA typing (mother) A3,3 B7,7 Cw7,7 DR4,15 DQ6,7 Donor HLA typing (son) A1,3 B7,8 Cw7,7 DR4,17 DQ2,7
39 Class II HLA antibody analysis Donor specific antibodies: DR17, DQ2? Recipient HLA typing (mother) A3,3 B7,7 Cw7,7 DR4,15 DQ6,7 Donor HLA typing (son) A1,3 B7,8 Cw7,7 DR4,17 DQ2,7
40 Renal Transplant Patient Workup Cardiac and Liver Tx Patients HLA typing, SSO: HLA-A, B, C, DRB1/3/4/5, DQB1/A1 +/- DPB1/A1. Sera collected monthly and after sensitizing event. Antibody identification by Luminex every 3 months. Unacceptable antigens and HLA typing are entered into MOTP database. Donor HLA typing, HDSSO, entered into MOTP database. Virtual crossmatch excludes potential recipients with unacceptable mismatches. Top 5 potential recipients are selected for FCXM. Top 2 recipients with negative FCXM proceed to transplantation. Post Transplant Antibody Monitoring (Day of Tx, 3 wk, 3/6/12 mo)
41 Renal Transplant Patient Workup Cardiac and Liver Tx Patients HLA typing, SSO: HLA-A, B, C, DRB1/3/4/5, DQB1/A1 +/- DPB1/A1. Sera collected monthly and after sensitizing event. Antibody identification by Luminex every 3 months. Unacceptable antigens and HLA typing are entered into MOTP database. Donor HLA typing, HDSSO, entered into MOTP database. Virtual crossmatch excludes potential recipients with unacceptable mismatches. Top 5 potential recipients are selected for FCXM. Top 2 recipients with negative FCXM proceed to transplantation. Post Transplant Antibody Monitoring (Day of Tx, 3 wk, 3/6/12 mo)
42 Virtual Crossmatch > 200 patients HLA typing VXM HLA antibodies identified Patient 1 A1,3 B8,50 DR4,17 A11,A24,A25,B18,B44,DR17 Patient 2 A2,3 B44,62 DR7,8 A1,A26,A33,B52,DR15 Patient 3 A3,11 B8,18 DR4,15 A2,A31,A66,B7,B52 Patient 4 A1,24 B7,45 DR9,12 A3,A30,B60,B61,DR15,DR16 Patient 5 A23,24 B27,35 DR10,16 A1,B8,B44,DR7 Patient 6 A2,23 B51,55 DR9,17 A3,B60,B61,B62,B63,DR12,DR13 Patient 7 A1,30 B7,60 DR11,13 A2,DR1,DR7,DR8 Patient 8 A3,31 B27,61 DR4,7 A1,A23,A24,B18,B45,DR11,DR12 Patient 9 A2,24 B7,45 DR1,8 B27,B51,DR15,DR16 Patient 10 A2,2 B37,44 DR9,12 B8,B60,B61,DR10
43 Virtual Crossmatch Donor A1,2 B7,8 DR4,17 HLA typing VXM HLA antibodies identified Patient 1 A1,3 B8,50 DR4,17 A11,A24,A25,B18,B44,DR17 Patient 2 A2,3 B44,62 DR7,8 A1,A26,A33,B52,DR15 Patient 3 A3,11 B8,18 DR4,15 A2,A31,A66,B7,B52 Patient 4 A1,24 B7,45 DR9,12 A3,A30,B60,B61,DR15,DR16 Patient 5 A23,24 B27,35 DR10,16 A1,B8,B44,DR7 Patient 6 A2,23 B51,55 DR9,17 A3,B60,B61,B62,B63,DR12,DR13 Patient 7 A1,30 B7,60 DR11,13 A2,DR1,DR7,DR8 Patient 8 A3,31 B27,61 DR4,7 A1,A23,A24,B18,B45,DR11,DR12 Patient 9 A2,24 B7,45 DR1,8 B27,B51,DR15,DR16 Patient 10 A2,2 B37,44 DR9,12 B8,B60,B61,DR10
44 Virtual Crossmatch Donor A1,2 B7,8 DR4,17 HLA typing VXM HLA antibodies identified Patient 1 A1,3 B8,50 DR4,17 A11,A24,A25,B18,B44,DR1 Patient 2 A2,3 B44,62 DR7,8 A1,A26,A33,B52,DR15 Patient 3 A3,11 B8,18 DR4,15 A2,A31,A66,B7,B52,DR17,DR18 Patient 4 A1,24 B7,45 DR9,12 A3,A30,B60,B61,DR15,DR16 Patient 5 A23,24 B27,35 DR10,16 A1,B8,B44,DR4,DR7 Patient 6 A2,23 B51,55 DR9,17 A3,B60,B61,B62,B63,DR12,DR13 Patient 7 A1,30 B7,60 DR11,13 A2,DR1,DR7,DR8 Patient 8 A3,31 B27,61 DR4,7 A1,A23,A24,B18,B45,DR11,DR12 Patient 9 A2,24 B7,45 DR1,8 B27,B51,DR15,DR16 Patient 10 A2,2 B37,44 DR9,12 B8,B60,B61,DR10
45 Virtual Crossmatch Donor A1,2 B7,8 DR4,17 HLA typing VXM HLA antibodies identified Patient 1 A1,3 B8,50 DR4,17 -ve A11,A24,A25,B18,B44,DR1 Patient 2 A2,3 B44,62 DR7,8 +ve A1,A26,A33,B52,DR15 Patient 3 A3,11 B8,18 DR4,15 +ve A2,A31,A66,B7,B52,DR17,DR18 Patient 4 A1,24 B8,45 DR9,17 -ve A3,A30,B60,B61,DR15,DR16 Patient 5 A23,24 B27,35 DR10,16 +ve A1,B8,B44,DR4,DR7 Patient 6 A2,23 B51,55 DR9,17 -ve A3,B60,B61,B62,B63,DR12,DR13 Patient 7 A1,30 B7,60 DR11,13 +ve A2,DR1,DR7,DR8 Patient 8 A3,31 B27,61 DR4,7 +ve A1,A23,A24,B18,B45,DR11,DR12 Patient 9 A2,24 B7,45 DR4,8 -ve B27,B51,DR15,DR16 Patient 10 A2,2 B37,44 DR9,12 +ve B8,B60,B61,DR10
46 Virtual Crossmatch Donor A1,2 B7,8 DR4,17 HLA typing VXM HLA antibodies identified Patient 1 A1,3 B8,50 DR4,17 -ve A11,A24,A25,B18,B44,DR1 Patient 4 A1,24 B8,45 DR9,17 -ve A3,A30,B60,B61,DR15,DR16 Patient 6 A2,23 B51,55 DR9,17 -ve A3,B60,B61,B62,B63,DR12,DR13 Patient 9 A2,24 B7,45 DR4,8 -ve B27,B51,DR15,DR16
47 Start Buffy coat Impact on crossmatch and recipient DNA ready Gel ready selection time typing ready h PCR/gel 30 cells ready CXM ready to read CXM ready to enter CXM reported 4h 3h h 1h Lympho/T quik CXM CXM reading CXM entry SMM Review 12-15h Top 2 recipients called in based on virtual crossmatch results (7-8h) 1h 45 2h SMM Plate setup FCXM 25 FCXM 9-11h < 1% False Positive FCXM
48 Highly sensitized patient lass I specificity 1 A23 A24 A25 A32 B13 B27 B37 B38 B41 B44 B45 B47 B48 B49 B50 B51 B52 B53 B57 B58 B59 60 B61 B63 B7 B76 B77 B8 B81 B82 PRA = 96% Patient typing A*11,33 B*35,35 Cw*04,04 DRB1*04,13 DR52, 53 DQ*03(7),03(8) Donor typing A*11,03 B*35,62 Cw*04,10 DRB1*04,11 DR52, 53 DQ*03(7),03(8)
49 # of transplants Access to transplants for highly sensitized patients Deceased donor transplants (April 2011-October 2011) % % PRA 14%
50 Virtual Crossmatching National Impact Canadian Transplant Registry Kidney Paired Exchange (KPD) Highly Sensitized Patient Registry (HSP), cpra 95%
51 KPD Data Review KPD Match Cycles Of the 425 Transplants completed to date: Courtesy: Mr. Sean Delaney
52 Canadian Transplant Registry & Programs: KPD Activity by Transplant Centre VGH SPH UAH FMC SPH HSC LHSC SJH TGH SMH HSC TOH HMR HND HRV CHS HDQ QE2 BC AB SK MB ON QC Atl. 140 Registered Candidate Transplant Transplant Waitlist Transplant Candidates Registered Total Transplants in Province % of National Total 33% 10% 4% 5% 36% 8% 5% 20 Tx Courtesy: Mr. Sean Delaney
53 Canadian Transplant Registry & Programs: KPD Transplant Recipients by cpra Waitlist Registered % 1%-79% 80-94% 95-96% 97% % of Candidate Population 19% 36% 12% 3% 30% % of Recipients (n=409*) 27% 43% 14% 4% 10% % of Candidates in cpra Group Transplanted 49% 57% 65% 58% 16% *Includes both Registered and Waitlist Recipients. cpra information for 6 Waitlist Recipients (1%) not available. Courtesy: Mr. Sean Delaney
54 HSP Data Review Tracking by Home Province BC AB SK MB ON QC NB NS PEI NL Total HSP transplanted Interprovincial transplants Intraprovincial transplants Based on Recipient PHN Province 19 Tx + 2 Courtesy: Mr. Sean Delaney
55 Proportion Transplanted (with count) HSP Data Review HSP Transplants by cpra and Proportion Transplanted 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % 62% 57% 56% 29% 33 5% cpra (%) Courtesy: Mr. Sean Delaney
56 Proportion Transplanted (with count) HSP Data Review HSP Transplants by cpra and Proportion Transplanted 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % 62% 57% 56% 29% 33 5% cpra (%) Courtesy: Mr. Sean Delaney
57 Canadian Experience with virtual crossmatching (as of March 2015) Live Donor Paired Exchange 5 years 249 transplants negative virtual XM 24 positive FCXM 10 False pos (TX) 14 True pos 10, DQ/DP missing 2, DSA not listed in error 2, new DSA Highly Sensitized Patient Registry, cpra 95% 6 months Transplanted 74/511 pt 44 pt, cpra > 97% 3 FCXM pos Halifax Lab (0 positive FCXM)
58 Flow Crossmatch Protocol Halifax Protocol Incubate 5x10 5 cells (30 ml) and serum 30 ml (4 o C) 30 min 1.5x10 5 cells (15 ml) 30 ml (RT) 20 min Wash x3 (5 min/spin) 15 min (1 min/spin) 3 min Incubate with 100 ml anti-igg-fitc/cd3/cd19 (4 o C) 30 min (RT) 5 min Wash x2 (5min/spin) 10 min (1 min/spin) 2 min Total assay time 2 HOURS 1h 25 min 30 min
59 Rapid Optimized Flow Crossmatch Protocol Halifax/Halifaster Protocol Incubate 5x10 5 cells (30 ml) and serum 30 ml (4 o C) 30 min 1.5x10 5 cells (15 ml) 30 ml (RT) 20 min Wash x3 (5 min/spin) 15 min (1 min/spin) 3 min Incubate with 100 ml anti-igg-fitc/cd3/cd19 (4 o C) 30 min (RT) 5 min Wash x2 (5min/spin) 10 min (1 min/spin) 2 min Total assay time 2 HOURS >70% Time Reduction 1h 25 min 30 min
60 Going with the Flow, Canadian Crossmatch Standardization Robert Liwski, Denise Pochinco, Kathryn Tinckam, Howard Gebel, Patricia Campbell and Peter Nickerson On behalf of the Nationwide Laboratory Oversight Committee & Canadian Blood Services Liwski et al ASHI 2012
61 Delta MCF FXM Result Variability (Cell 1 vs Serum 1) T cell X-match 250 B cell X-match Neg Neg Neg Neg 50 0 Neg Neat 1/2 1/4 Neg 50 0 Neg Neg Neat 1/2 1/4 Neg Neg Neg Class I DSA: Class II DSA: A33 (2.5K), B13 (7K) DP17 (5K) Liwski et al ASHI 2012
62 Delta MCF T cell FXM comparison Lab Method 350 Halifax Protocol Neat 1/2 1/4 1/8 1/16 0 Neat 1/2 1/4 1/8 1/16 Moderate class I HLA DSA Liwski et al ASHI 2012
63 Delta MCF FXM signal/noise ratio Lab vs Halifax Protocol T cell XM *** *** *** * Lab Halifax B cell XM ** ** ns ** Lab Halifax Lab HFX protocol ns ns Lab HFX protocol ns ns vs A 2 vs A 3 vs A 1 vs B 2 vs B 3 vs B 0 1 vs A 2 vs A 3 vs A 1 vs B 2 vs B 3 vs B Paired Student s t-test, 2 tail analysis *p < **p < 0.01, ***p < Liwski et al ASHI 2012
64 Relative Standard Error (%) FXM Precision Lab vs Halifax Protocol T cell XM Lab Halifax B cell XM Lab Halifax 6 4 Lab HFX protocol vs A 2 vs A 3 vs A 1 vs B 2 vs B 3 vs B 7.0+/-1.3 vs 4.0+/-1.5 p< /-2.2 vs 5.9+/-2.2 p=0.058 Liwski et al ASHI 2012
65 Time (minutes) FXM time Lab vs Halifax Protocol FXM time per lab Average FXM time Lab Halifax *** Lab Halifax Paired Student s t-test, 2 tail analysis ***p < Liwski et al ASHI 2012
66 Brazilian FCXM PT Result correlation Rob Liwski on behalf of ABH
67 # reactions Significantly reduction in false pos/neg reactions vs false rxns false rxns 4 false rxns 5 false rxns FN T cell FP T cell FN B cell FP B cell Q Q Q Q4
68 % Positive FCXM Santa Casa Lab, VXM vs FCXM Correlation Standard vs Halifax Protocol T cell (A and/or B) K 2-5K 5-10K >10K Standard (n=405) FP rate = 3.3% B cell (A and/or B and/or DR) Cumulative SAB MFI range 0 1-2K 2-5K 5-10K >10K Halifax (n=2483) FP rate = 3.0% Neumann and Liwski, manuscript in prep.
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72 Wait List 2016 Impact of: virtual XM Local priority for cpra >80% KPD HSP
73 Wait list patients by cpra 60 55% % 30 24% 21% N=279
74 Wait list patients by cpra, female vs male /64.6 % / / n=115 female male n=164
75 Wait list patients by cpra First Time Transplant Candidates % /0 26.3/ /83.6 n=46 female male n=
76 Wait list patients by cpra, Previous Transplant Patients % /62 10/28.6 5/ n=20 female male n=42
77 Wait list patients by cpra First Time Transplant Candidates % n=279 Wait List Transplanted n=172 11/ /
78 Wait list patients by cpra First Time Transplant Candidates 60 % Advantaged National Priority Advantaged Local Priority n=279 Wait List Transplanted n=172 11/ /
79 Wait list patients by cpra First Time Transplant Candidates % Disadvantaged Despite Priority Advantaged National Priority Advantaged Local Priority n=279 Wait List Transplanted n=172 11/ /
80 Wait list patients by cpra First Time Transplant Candidates % Disadvantaged Despite Priority Advantaged National Priority Advantaged Local Priority Disadvantaged? n=279 Wait List Transplanted n=172 11/ /
81 # Years Average wait time by cpra, wait list patients Disadvantaged Despite Priority Advantaged National Priority Advantaged Local Priority Disadvantaged? all
82 Wait list patients by cpra Previous Tx vs First Time Tx Candidates 160 % / / / / n=217 No Tx Previous Tx n=62
83 Disadvantaged patients cpra %: females, hx of pregnancy 72.5%: re-transplants Prevention better HLA matching at time of first Tx withdrawal of immunosuppression? Willing to cross DSA Stratify % using decimal point cpra
84 Better HLA matching at time of first transplant
85 # patients Patients with previous transplants cpra vs degree of mismatch
86 Class II DSA Mainly DQ specific Wiebe et al. AJT 12:1157, 2012
87 Class II DSA Mainly DQ specific Wiebe et al. AJT 12:1157, 2012
88 Wiebe et al. AJT 13:3114, 2013
89 Wiebe et al. AJT 13:3114, 2013
90 Wiebe et al. AJT 13:3114, 2013
91 Wiebe et al. AJT 13:3114, 2013
92 Disadvantaged patients cpra %: females, hx of pregnancy 72.5%: re-transplants Prevention better HLA matching at time of first Tx withdrawal of immunosuppression? Willing to cross DSA Stratify % using decimal point cpra
93 Willing to Cross DSA
94 Retrospective single center study, 660 kidney Tx patients with negative pre-tx FCXM. 162 patients with DSA by SAB. Treated with standard immunosuppression: Tac/Myc/Ster (Basiliximab or ATG) Impact on survival, AR and GFR
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97 Background Groups have published acceptable outcomes with crossing low level/selected antibody To increase access for the difficult to match group Suggest we consider identifying antibodies that we would be willing to cross Bead positive current Flow XM negative. Courtesy: Dr. Trish Campbell
98 Crossing Antibodies Clinicians will identify suitable candidates for 'Willing to Cross' HLA Labs will determine what antibodies to cross and reason why HLA Committee will review WTC outcome data over time to inform future strategies HLA Committee recommend piloting 'Willing to Cross' for patients with cpra > 98% in the KPD program Crossing antibodies for a patient would be a clinical and HLA Lab decision Courtesy: Dr. Trish Campbell
99 Crossing Antibodies Questions Which group of patients should be used for willing to cross? KPD first then HSP cpra > 98% Blood Group Wait Times If a patient s cpra drops below 95%, is the patient still eligible for KPD cpra points and does ranking apply to Willing To Cross cpra or original cpra? Are programs open to proceeding with a Flow XM negative DSA positive result? Does the current and the historical crossmatch with the most sensitized sera need to be negative or just the current? Should we adopt uniform immunosuppressive protocols? Courtesy: Dr. Trish Campbell
100 Willing to Cross DSA patient cases
101 Patient Case 1 47 yo female 100% cpra (CI/II: 98/98) 3 pregnancies, 11 transfusions Wait listed since June 2011 On HSP registry
102 Patient Case 1 Patient Donor A B C DRB DRB3/4/5 03(52) 04(53) 03(52) DQB DQA DPB1* /10MM Weak DSA against HLA-DP2, Husband was DP2 positive
103 Class II pre-tx
104 Negative FCXM Class II pre-tx
105 Class II 7 days post
106 Class II 12 days post
107 Class II 6 weeks post
108 Class II 5 months post
109 Patient Case 2 39 yo female Dilated Cardiomyopathy 100% cpra (CI/II: 100/29) pregnancies, transfusions Wait listed since August 2014
110 Patient Case 2 Patient Donor A B C DRB (17) 09 DRB3/4/5 03(52) 4(53) DQB (9) DQA DPB1* Weak DSA against HLA-A1, 1500 MFI Strong A1 DSA in historical sera, 20,000 MFI
111 Class I, 1 year pre-tx
112 Class I, Pre Tx
113 Class I, Pre Tx Negative FCXM, current sera Strong Positive FCXM, historical sera
114 Class I, 1 week post
115 Class I, 2 weeks post
116 Class I, 2 months post
117 Class I, 13 months post
118 Conclusions Continued improvement in HLA testing over the last few years Implemented state of the art methodology Allows more complete assessment of immunologic risk Decreased TAT Decreased cost Allowed for our participation in LDPE and HSP program Increased transplantation of Highly Sensitized patients Future Directions Refinement of allocation strategy Improve matching epitope Consider Willing to Cross DSA approach to improve transplantation of highly sensitized (99-100) patients.
119 Acknowledgements Halifax Lab Technologists Geoff Adams Geoff Peladeau Kelly Heinstein National Collaborators Kathryn Tinckam Patricia Campbell Peter Nickerson National PT Testing Committee Canadian Blood Services Labs (west to east) Vancouver Edmonton Calgary Saskatoon Winnipeg Toronto Ottawa Hamilton London Montreal Laval Quebec City Halifax
120 Acknowledgements Halifax Lab Technologists Labs (west to east) Geoff Adams Vancouver Geoff Peladeau Edmonton Kelly Heinstein Calgary Saskatoon Welcome to Dr. Anna Greenshields Winnipeg Kathryn Tinckam Toronto ASHI Director-in-Training Patricia Campbell Ottawa Peter Nickerson Hamilton London National Collaborators National PT Testing Committee Canadian Blood Services Montreal Laval Quebec City Halifax
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