What kind of policies or agreements do you have in place in your lab regarding the order of patients crossmatched for a deceased donor offer? 

Do you strictly go by the UNOS matchrun, or do you allow your programs to pick and choose the patients they would want to crossmatch? if yes, how much flexibility do you give them? do you expect them to put in decline codes before they move down the list to another patient? 

Thank you,

Eszter Lazar-Molnar

One of the goals of the order is the improvement in the transplant pipeline. Since histocompatibility is so critical for transplants to occur, we are in the frontline of that process. Maybe we should use the momentum to become more visible and proudly expose our important contribution to the organ allocation in the transplant process and to patients affected by ESRD pre- and post-transplant.

Furthermore, maybe this is the right time to resume our old battle for PhD directors/clinical consultants to be able to bill for the professional component related to test interpretations and virtual crossmatches/immunological assessments. If our expertise is required, why we cannot be appropriately compensated?

Well, do not think I do not know the old and silly excuse “because we are PhDs, not MDs”. What about the clinical psychologists, they are PhDs and still can bill Medicare for the professional component according to the CMS regulatory exception in terms of who can provide the supervision for psychological tests. This regulation allows both, a clinical psychologist (CP) or a physician, to perform the general supervision assigned to diagnostic psychological and neuropsychological tests, which is, basically, the interpretation of the test to reach a diagnosis.

The truth is that our services are needed and will be needed even more after this executive order takes effect. We all love what we do and I am sure many of us will still do it even in the absence of compensation; such is the passion that we feel for our field and for helping people in need. However, in view of justice and fairness, we should continue pursuing and fighting this battle. The most fundamental principle of justice defined by Aristotle more than two thousand years ago is the principle that “equals should be treated equally”. In its contemporary form, this principle could be expressed as “Individuals should be treated the same, unless they differ in ways that are relevant to the situation in which they are involved”. Hence, the obvious question is: How our role as PhD HLA lab directors/clinical consultants differ from the role of MD HLA lab directors/clinical consultants? The obvious answer is “there is no difference” and yet, PhDs cannot be compensated while MDs, in the very same role, can.

Siva Kanangat, Ph.D., D (ABHI)

Director & Associate Professor

Histocompatibility and Immunogenetics

Dept. of Pathology

Rush University Medical Center

1653 West Congress Parkway

Jelke Building, Room 1109

Chicago, IL 60612

Phone  312-942-2054 [Direct Line]

What type of tray or tube do others use for Adsorbout treatments?

Does anyone treat in PCR-sized tubes or 0.7mL tubes? I'm concerned about getting a good rock/rotation with small volume.

Our first test will be treating 60uL serum in 0.7mL tubes, laying tubes on the sides, incubate on rocker. This would minimize the number of times we move sample to a new tube, but will the sample get adequately Adsorbed? We shall see...

How much FTE is dedicated to the directorship of other HLA labs?

My lab adds EDTA to all samples before Luminex single antigen testing (we use LABScreen). Currently the techs measure out the sample into a new tube and use a pipette to add the appropriate amount of EDTA to each one. However, it takes a lot of time to label the new tube and do the pipetting. We are trying to figure out how to make the entire process less time consuming.

We were thinking about doing something like estimating the volume of serum in each tube and adding EDTA directly to the original tube. But I am wondering if anyone can share how their lab does it or provide any hints for how to simplify it further. 

And if anyone has any suggestions for how to make adsorbing sera any simpler I would greatly appreciate that as well.

Thanks!

Susan

I am interested in polling forum members to see how many labs use either EDTA treatment of serum or use a dilution (not endpoint titer) to address interferences such as prozoning for SAB testing.  Please respond with any of the following:

No pretreatment

EDTA

Dilution

Other

I will share my findings when complete.

Thanks

John Schmitz

I think it is important that Directors view these regulatory changes not from the perspective of practices at their own center but from a patient safety perspective – I would like to start a Discussion/Debate in this secure space with ASHI Directors.

Given the known limitations of our Luminex assays (serum interference, allele assumptions using low res HLA typing, shared epitopes leading to weaker reactivity on beads (ie Bw4) —I propose maintaining a physical crossmatch for HLA sensitized waitlist candidates to provide the broadest safety net.

Relying on Virtual Crossmatch only for candidates showing no HLA sensitization (majority of candidates) on sensitive immunoassays using at least 2 separate sera (safeguard for sample switch) and for whom the date of the most recent serum tested is in compliance with the transplant center's testing agreement (safeguard against re-activation of a candidate who has not had testing done in a long while).

Alternatively, maintain physical crossmatch for broadly sensitized candidates and all DSA+ cases would provide a more amenable regulation but would NOT provide the greatest patient safety given the limitations in our immunoassays.

We have a patient with reactivity to all DRB1 and DRB3/4/5 antigens (including self-alleles) when tested by Luminex single antigen (One Lambda). We have seen it before, as have many others, but I would like to do a survey about how other labs would handle such a case.

1. Are there any publications showing the cause of this reactivity or demonstrating its clinical relevance (or lack thereof)?

2. How would you report these results to clinicians? For example, do you just include all the specificities on a report but don’t call them unacceptable in UNET, or do you include the specificities on the report and add a comment about non-clinically relevant reactivity, or do you not report any specificities?

3. Is there any kind of serum treatment or assay modification that can get rid of this reactivity, while maintaining any “real” antibody that might be present underneath it?

Thanks very much for your help with this.

Susan

I was wondering if anyone else has had a chance to demo Waitlist and DonorNet in Beta Portal, that now reflects the upcoming changes to the HLA equivalency tables? They've added many more alleles to the dropdown menus for both candidate and donor typing, and also to the unacceptable antigen boxes.

https://optn.transplant.hrsa.gov/governance/public-comment/update-hla-equivalency-tables/

betaportal.unos.org/

Basically, I'm encountering a potential problem with the programming logic linking antigens and alleles in a match run. I created dummy recipient and donors and entered different combinations of allele or antigen level typing. Then I ran match runs as the OPO with different scenarios. For me, it seems that if the candidate and donor typing are both entered at the allele level and the alleles are mismatched, they do not appear as 0MM on the match run even though they are actually matched at the serological/antigen level.

I attached a screenshot of one example scenario.

Other issues I encountered are:

1. In Waitlist, if you list a patient with typing at the allele level (A*02:01), you can block the antigen level (A2) with no warning. You do get a warning ("Are you sure?") if you go the other direction.

2. The cPRA calculator does not factor in alleles of A, B and most DR, DQ; but alleles of DRB345 reflect the same cPRA as the whole antigen.

I was wondering if anyone has encountered the same issues?

Nicole

Nicole Valenzuela, PhD, D(ABHI)

UCLA Immunogenetics Center

Is anyone out there successfully recouping funds for VXM, Hold & Freeze, or Postage Paid sample mailers? What billing/CPT codes are you using?

Appreciate your help!

Caroline Raasch Alquist, MD, PhD

 Section of Transfusion Medicine & Histocompatibility

Department of Pathology and Laboratory Medicine

Ochsner Health System

504.842.5035 (Blood Bank & HLA Offices)

It is my understanding there are two (2) types of business/financial models for HLA Laboratories:

1.  Subsidiary of Hospital or University (Independent)  OR

2.  Hospital or University based

Would you be able to outline the guidelines of both types of labs and their business plan and financial map?

If anyone has experience in either type, can you please share any information and your experience.

If you need further explanation and details of my question, please contact me @ 216-213-2387.

Kind regards,

Dr. Aiwen Zhang

Director Allogen Lab, Cleveland Clinic Foundation

The use of single antigen testing for complement-fixing antibodies has been controversial in the past. Does your experience indicate that this testing is clinically useful? One of our transplant nephrologists is advocating that instead of a complement-fixing single antigen bead assay, we simply test the serum at a 1:16 dilution. Can anyone recommend that? Is there credible support in the literature? Thank you so much!

Best wishes,

Charlie Lutz

I have a patient on our heart waiting list that was on ECMO and has an RVAD and LAVD implanted.  He is very highly sensitized with a Bw4 antibody, additional B unacceptables, DR, DQ and DP antibodies.  Our big concern is with his DP antibodies.  He is DPB1*04:01 homozygous with antibodies >10,000 to almost all other DP antigens.  We have done several surrogate crossmatches and they have all been B cell positivewith anyone that is not 04:01 homozygous.  

Does anyone have experience performing heart transplants across DP positive crossmatches? Did the patients have any issues post transplant?  I know some have done kidney transplants with some success, but I have not seen any data about hearts.

Thanks!