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EFI MeetingUlm 2009
Teaching session: Blood Sweat and Tears
Derek O’Neill and Ilias Doxiadis
Program BSTCrossmatching and Screening
• M. Howell / D. O’Neill: Examples from the thoracic transplantation
• I. Doxiadis: Stem cell transplantation: to do or not?• C. Navarrete: Transfusion related graft injury
(TRALI)• NN: Other than HLA targets for antibodies in
transplantation • I. Doxiadis: The conundrum of single antigen bead
testing • M. Arnold: IgG1 and complement activation• CDC is an old dated method: let’s stop it
– Pro: Derek O’Neill– Con: Ilias Doxiadis
Stem cell transplantationsome publications
• Mickelson EM: HLA matching in hematopoietic cell transplantation. Hum Immunol. 2000 61:92-100
• Ottinger et al: Positive serum crossmatch as predictor for graft failure in HLA-mismatched allogeneic blood stem cell transplantation. Transplantation. 2002 73(8):1280-5
• Narimatsu H: Successful engraftment in crossmatch-positive HLA-mismatched peripheral blood stem cell transplantation after depletion of antidonor cytotoxic HLA antibodies with rituximab and donor platelet infusion. Bone Marrow Transplant. 2005 36:555-6.
Conclusion: Higher incidence of graft failure, but not a contraindication
Evolution of HLA antibody screening commercialhome made
SPA = solid phase assay
Evolution of the crossmatch
CDC FCM SPA gen SPA sin
CDC FCM SPA gen ( ) SPA sin
Immunoglobulin isotype switch
IgM IgG3 IgA2IgG1IgEIgD
IgA1 IgG2
IgG4
One way street
sIgM+IgD+
Spriewald, Arnold
C’activation
CDC • Complement Dependent Cytotoxicity
• Terasaki PI and McClealand JD: Microdroplet assay of human serum cytotoxins. Nature, 1964: 204:998-1000.
NEG POS
Conundrum?
• co nun drum ⋅ ⋅• Spelled Pronunciation [kuh-nuhn-druhm] • 1. a riddle, the answer to which involves a pun
or play on words, as What is black and white and read all over? A newspaper.
• 2. anything that puzzles. • Origin: • 1590–1600; pseudo-L word of obscure orig.
Method (s)%-chance to miss a
specificity (75% consensus rule)
%-chance for more specifcities (95% consensus rule)
CDC 16.9 10.8CDC/ELI 17.8 8.7
CDC/LUM 6.7 17.2CDC/ELI/LUM 7.6 13.6
LUM 17.4 85.5
CDC: complement dependent cytotoxicity; ELI: ELISA; LUM: Luminex 75% consensus rule: If 75% of the participants report a specificity than this isregarded as correct; 95% consensus rule: if ≥5% of the participants report a specificity than this is regarded as incorrectConclusion: the use of two methods lead to better results
Example of an External Proficiency Testing exercise
?
Cardiothoracic OrgansAntibody screening & Crossmatching
• Questions– To crossmatch or not ?
• CDC/Flow crossmatch ? – timelines involved and organisation
• Virtual crossmatch?
– Antibody screening to support these • What methods – what sensitivity?
• Some examples from two centres
Renal/Pancreatic Antibody screening & Crossmatching
• EFI - requirements
• Methods – practicalities and cost
• Minimum or maximum approach?
• How sensitive is too sensitive ?
Crossmatching - cdc or flow or cdc/flow?