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?