1 VIRTUAL PRA AND CROSSMATCHING Dolly B. Tyan, PhD Cedars-Sinai Medical Center Los Angeles, CA.
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Transcript of 1 VIRTUAL PRA AND CROSSMATCHING Dolly B. Tyan, PhD Cedars-Sinai Medical Center Los Angeles, CA.
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VIRTUAL PRA AND CROSSMATCHING
Dolly B. Tyan, PhD
Cedars-Sinai Medical Center
Los Angeles, CA
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PURPOSE OF PRA
• TO INFORM THE CLINICIAN/SURGEON OF THE:
–LIKELIHOOD OF A TRANSPLANT
–ANTIBODY SPECIFICITY
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PRAPanel Reactive Antibody – (%)
•Relatively uninformative
•No specificity
•Population dependent
•Can vary widely by panel tested
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PRA VARIABILITY50 cell panel
A2+ CELLS
ON PANEL
PRA
(%)
5 10
10 20
25 50
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CDCCDC 102102 162 162CDCCDC 102102 162 162
PRA ANALYSIS BY DIFFERING PRA ANALYSIS BY DIFFERING METHODLOGIESMETHODLOGIES
PRA ANALYSIS BY DIFFERING PRA ANALYSIS BY DIFFERING METHODLOGIESMETHODLOGIES
POSITIVEPOSITIVE NEGATIVENEGATIVEPOSITIVEPOSITIVE NEGATIVENEGATIVE
AHG-CDCAHG-CDC 116 116 (+13%)(+13%) 148 148AHG-CDCAHG-CDC 116 116 (+13%)(+13%) 148 148
ELISAELISA 127 127 (+10%)(+10%) 137 137ELISAELISA 127 127 (+10%)(+10%) 137 137
FLOWFLOW 139 139 (+10%)(+10%) 125 125FLOWFLOW 139 139 (+10%)(+10%) 125 125
Gebel and Bray, Transplantation 69:1370-1374, 2000.Gebel and Bray, Transplantation 69:1370-1374, 2000.
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Calculated PRA value
Based on: ABSOLUTE antibody specificity andACTUAL HLA antigen frequencies in donor populationINDEPENDENT of the method
Calculated PRA value
Based on: ABSOLUTE antibody specificity andACTUAL HLA antigen frequencies in donor populationINDEPENDENT of the method
Virtual PRA
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NATIONAL PRA
Calculatethe antigen frequency
of all donors ever typedin UNET database
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CALCULATED PRA –STANDARDIZED
Antibody Specificity PRA (%)
A1 21
B8 17
A1 + B8 28
DR3 24
A1 + B8 + DR3 45
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ConclusionsConclusions
Virtual PRA antibody detection must:- Be Sensitive and HLA-Specific - Be able to Predict the final crossmatch- Be able to identify ALL unacceptable (avoid) antigens (A-, B-, Cw, DRB1, DQB1, DP??) Requires accurate typing of deceased donors - Incorporate Both Class I and Class II specificities
Current definition of PRA must change:- Need local/national donor pool antigen frequencies- Incorporate both Class I and II antigens
Results in National PRA Equivalence
Virtual PRA antibody detection must:- Be Sensitive and HLA-Specific - Be able to Predict the final crossmatch- Be able to identify ALL unacceptable (avoid) antigens (A-, B-, Cw, DRB1, DQB1, DP??) Requires accurate typing of deceased donors - Incorporate Both Class I and Class II specificities
Current definition of PRA must change:- Need local/national donor pool antigen frequencies- Incorporate both Class I and II antigens
Results in National PRA Equivalence
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PURPOSE OF CROSSMATCH
• TO INFORM THE CLINICIAN/SURGEON OF THE RISK* FOR:
–PRESENCE OF DSA (DONOR SPECIFIC ANTIBODIES)
–HYPERACUTE REJECTION–HUMORAL REJECTION
* (not contraindication)
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CAN WE DO A VIRTUAL CROSSMATCH???
WE ARE DOING IT NOW! (BUT NOT WELL…)
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WHAT IS A VIRTUAL CROSSMATCH?
• Recipient antibodies fully characterized, known, and computerized (i.e., UNOS “unacceptable/avoid” algorithm)
• Recipients with antibody to donor antigens are eliminated without crossmatch– parameters for which antibodies important
determined at local level
• Not a substitute for final crossmatch for remaining potential recipients
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FINAL XM WORKLOADCURRENT PRACTICE
• Regional trays by ABO blood group– (First phase XMs – 100s of samples)
• Final XMs– Negative patients from first phase with
highest number of points (may be up to 25)• Highly sensitized patients often positive in
final XM done by more sensitive technique (e.g., Flow) – i.e., wasted effort
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CALCULATED PRA –STANDARDIZED
Antibody Specificity PRA (%)
A1 21
B8 17
A1 + B8 28
DR3 24
A1 + B8 + DR3 45
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VIRTUAL XMPROPOSED PRACTICE
• No first phase testing• Final XMs
– Incompatible recipients excluded by computer
– Select top 5 – 10 patients on match run for final XM
– Highly sensitized patients likely to be transplanted
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Crossmatch Comparison
• First phase XMs– 3-4 hrs
• Final XMs – >25– Repeat CDC– Flow
• Highly sensitized patients eliminated at final – wasted effort
• First phase XMs– 3-4 hrs
• Final XMs - 5– Repeat CDC– Flow
• Highly sensitized patients transplanted
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VIRTUAL CROSSMATCH
• CHALLENGES– Requires complete and accurate knowledge
of historical and current antibody specificity/isotype by most sensitive methods
– Requires real time updating of “unacceptables” in UNET
– Requires regular screening (not less than quarterly) – More for desensitization protocols
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VIRTUAL CROSSMATCH
• CHALLENGES cont’d– Antibody profiles can change over time
(e.g., become weaker)– Desensitization protocols can cause real
time variation in antibody profile– May eliminate an eligible recipient
depending on local preference (e.g., patient with antibody to 50% of the A2+ cells on panel)
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VIRTUAL CROSSMATCH
• BENEFITS– Decreases number of patients needing actual
final crossmatch
(No regional screen trays)– Decreases time required for final crossmatching
– Minimizes wasted time crossmatching highly sensitized patients with known incompatibilities
– Decrease in CIT in some regions
Accelerates organ placement
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CONCLUSIONS
VIRTUAL PRA
–Results in National PRA Equivalence
VIRTUAL CROSSMATCH- Accelerates organ placement
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CAVEAT
A variant systemis requiredfor patients
undergoing desensitization