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1、Streamlining ABO Antibody Titers For Monitoring ABO Incompatible Kidney Transplants,Wei Cai, M.T. (ASCP) wcai2jhmi.edu Johns Hopkins Medical Institution,监测ABO不相容性肾移植的 ABO血型抗体滴度 约翰 霍伯金斯医学院 蔡伟,Background Information,Johns Hopkins Hospital Department of Pathology Transfusion Medicine Division Specialis
2、t in Blood Bank Technology AABB (American Association of Blood Banks) ABO Incompatible Kidney Transplant Program,背 景 知 识,约翰 霍伯金斯大学医院 病理系 输血医学部 美国血库协会 血库技术专家 ABO 血型不相容性肾移植计划,Crossing the ABO Barrier for Kidney Transplants,As of May 25, 2007: 75,711 patients awaiting kidney transplantation In 2006, 17
3、,092 kidney transplants were performed (6,433 or 37.6% living donors): Group O 7,662 A 6,354 B 2,255 AB 821,至2007年5月25日止， 有75,711名病人在等待进行肾移植 2006年 进行了17,902个肾移植，其中6,433约37.6%是活体肾移植 血型 肾移植 O 7,662 A 6,354 B 2,255 AB 821,克服ABO血型障碍进行的肾移植,Deaths on Waiting List,In 2006, 4,056 patients died waiting for a
4、 kidney transplant, or 11.1 patients died per day,2,049 Group O 1,250 Group A 629 Group B 128 Group AB,在等待中死去的病人,2006年，共有4,056名等待肾移植的病人死亡，即每天有11.1名病人在等待中死去。,Cadaveric Kidney Transplant Wait,等待尸肾移植的病人数及等待时间,至07年5月25日 登记 等待 5年或5年以上 所有血型 75,711 8,079 O 39,713 4,459 A 21,457 1,844 B 12,379 1,592 AB 2,16
5、2 184,Cadaveric Kidney Transplant Wait,If registered in 2001-2002, median wait times as of May 25, 2007,2001-2002年间登记的病人， 到2007年5月25日平均等待时间是,Objectives,Expand donor pool and availability of organs for transplantation Decrease time on organ waiting list Circumvent hyperacute rejection and/or AMR (due
6、 to ABO and/or HLA antibodies) by developing immunomodulatory protocols ABO incompatible Donor-recipient with positive crossmatches (HLA) Posttransplant patients who develop AMR (HLA),目 的,扩大器官捐献群体及移植器官的来源 减少器官移植的等待时间 通过免疫调节方案，防止超急性排斥反应及/或因ABO血型或HLA抗体介导的排斥反应 ABO不相容性 供-受者交配反应阳性（HLA） 病人移植后出现抗体介导的排斥反应(H
7、LA),ABO Incompatible Transplantation,Based on Japanese experience Based on our experience/protocol for crossmatch positive donor/recipient pairs and antibody-mediated rejection Facilitated by laparoscopic donor nephrectomy Preparative regimen with intensive follow up pre/postoperative plasmapheresis
8、 IVIgG and immunosuppression,ABO不相容的移植,基于日本的经验 基于我们对交配阳性的供-受者和抗体介导的 排斥反应的经验/方案 腹腔镜捐献者取肾促进了该类移植 强化随访的予处理方案 术前/后血浆置换 静脉注射IgG和免疫抑制,Reference,Reference,ABO不相容性肾移植的长期结果,ABO不相容性病人在亲属活体肾移植后抗-A、B的滴度变化,Our Program- InkTp,Specialized Incompatible Kidney Transplant service and clinic Weekly interdisciplinary r
9、ounds, composed of blood bank, apheresis service, HLA lab, nephrology, transplant surgery, pharmacist, psychologist, and social worker,我们的不相容肾移植项目,专业化的服务和临床 每周跨科的综合查房，包括血库、单采、HLA实验室、肾科、移植外科、药剂师、心理学家和社会工作者,Our Protocol,Modified from the Japanese protocol Initial evaluation donor and recipient medical
10、, psychological and social work evaluations HLA and ABO typing and titers Review at weekly meeting determination of optimal donor (HLA vs ABO) treatment plan established,我们的方案,根据日本方案改进 初步评价 捐献者和受者进行医学、心理和社会服务的 评估 HLA和ABO分型及抗体滴度分析 每周会议的评述 根据HLA与 ABO相配情况决定最佳捐献者 建立治疗方案,Treatment Plan,Immunosuppression,
11、 may include splenectomy All patients vaccinated (pneumococcus, meningococcus, haemophilus influenzae), regardless of splenectomy status Pheresis plan established (number of procedures pre and postop),治 疗 方 案,免疫抑制，可能包括脾切除 不管是否脾切除，所有病人接种疫苗（肺炎球菌、脑膜炎球菌、流感嗜血杆菌 ） 建立置换计划（术前/术后的置换程序和次数）,Plasmapheresis,Remo
12、ves natural anti-A and/or anti-B antibodis Both preop and postop procedures Remove 1 plasma volume Replace at 100% of volume removed Replace with 5% albumin except procedures immediately pre- and post- surgery, replace with plasma,血 浆 置 换,去除天然的抗-A/抗-B抗体 术前/后都进行置换 去除一个血浆容量 等量替换 用5% 的白蛋白置换 除术前/后立即的置换外
13、，只用血浆置换,ABO Antibody Titer Goals,Pretransplant goal: titer 16 or less Posttransplant Continue to monitor ABO antibody titers Significance in prediction of antibody mediated rejection is uncertain,ABO抗体滴度目标,移植前目标： 滴度16 移植后 继续监测ABO抗体滴度 对于预测抗体介导的排斥反应的意义仍不确定,Plasmapheresis Procedures,血浆置换过程,ABO Antibody
14、 Titers,Conventional test tube method AABB technical manual 15th ed. Bethesda: American Association of Blood Banks, 2005. Serial dilutions of each sample were prepared in 0.9% saline Pooled indicator cells (Immucor, Norcross, GA) of the appropriate ABO type were added 30 minutes 22C incubation test
15、phase 30 minutes 37C incubation test phase AHG test phase using monospecific anti-IgG (Immucor, Norcross, GA) Agglutination was scored using the Marsh 0 to 12 scoring system AHG titer endpoint was the reciprocal of the highest dilution demonstrating macropscopic (score 3) agglutination,ABO抗体滴定,常规的试管
16、法 AABB技术手册 样品用0.9%的盐水进行连续稀释 加入适量的混合ABO血型指示细胞（ Immucor ，Norcross, GA ） 22度孵育30分钟 37度孵育30分钟 单特异性抗-IgG (Immucor, Norcross, GA) 的抗人球蛋白（AHG）实验阶段 用Marsh 0到12打分系统给凝集打分 AHG最终滴度是样品出现肉眼可见的（3分）凝集的最高稀释倍数,ABO Antibody Titers,It is time consuming Turn around time is critical Our experience indicates that only the AHG titer values are critical Titer endpoint is de
