9監(jiān)測(cè)ABO不相容性腎移植的ABO血型抗體滴度

1、wei cai, m.t. (ascp)johns hopkins medical institutionbackground informationnjohns hopkins hospitalndepartment of pathology transfusion medicine divisionnspecialist in blood bank technology aabb (american association of blood banks)nabo incompatible kidney transplant program 背背 景景 知知 識(shí)識(shí)約

2、翰 霍伯金斯大學(xué)醫(yī)院病理系 輸血醫(yī)學(xué)部美國(guó)血庫協(xié)會(huì) 血庫技術(shù)專家abo 血型不相容性腎移植計(jì)劃crossing the abo barrier for kidney transplantsas of may 25, 2007: 75,711 patients awaiting kidney transplantation in 2006, 17,092 kidney transplants were performed (6,433 or 37.6% living donors): group o 7,662 a 6,354 b 2,255 ab 821至至20072007年年5 5月月252

3、5日止，日止， 有有75,71175,711名病人在等待進(jìn)行腎移植名病人在等待進(jìn)行腎移植20062006年年 進(jìn)行了進(jìn)行了17,90217,902個(gè)腎移植，其中個(gè)腎移植，其中6,4336,433約約37.6%37.6%是活是活體腎移植體腎移植 腎移植腎移植 deaths on waiting list in 2006, 4,056 patients died waiting for a kidney transplant, or 11.1 patients died per day n2,049 group on1,250 group an629 group bn128 group ab在等待

4、中死去的病人在等待中死去的病人 as of 5/25/07registered5 or more yearsall abo75,7118,079o39,7134,459a21,4571,844b12,3791,592ab2,162184等待尸腎移植的病人數(shù)及等待時(shí)間等待尸腎移植的病人數(shù)及等待時(shí)間至07年5月25日 登記 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 2,162 184cadaveric kidney transplant waitnif registered in 200

5、1-2002, median wait times as of may 25, 2007 blood groupdays o1836a1135b2032ab732血型天數(shù)o1836a1135b2032ab732objectivesnexpand donor pool and availability of organs for transplantation ndecrease time on organ waiting list ncircumvent hyperacute rejection and/or amr (due to abo and/or hla antibodies) by

6、developing immunomodulatory protocols 目目 的的n擴(kuò)大器官捐獻(xiàn)群體及移植器官的來源n減少器官移植的等待時(shí)間n通過免疫調(diào)節(jié)方案，防止超急性排斥反應(yīng)及/或因abo血型或hla抗體介導(dǎo)的排斥反應(yīng)abo不相容性供-受者交配反應(yīng)陽性（hla）病人移植后出現(xiàn)抗體介導(dǎo)的排斥反應(yīng)(hla) abo incompatible transplantationnbased on japanese experiencenbased on our experience/protocol for crossmatch positive donor/recipient pairs an

7、d antibody-mediated rejection nfacilitated by laparoscopic donor nephrectomynpreparative regimen with intensive follow up pre/postoperative plasmapheresis ivigg and immunosuppressionaboabo不相容的移植不相容的移植基于日本的經(jīng)驗(yàn)基于我們對(duì)交配陽性的供-受者和抗體介導(dǎo)的 排斥反應(yīng)的經(jīng)驗(yàn)/方案腹腔鏡捐獻(xiàn)者取腎促進(jìn)了該類移植強(qiáng)化隨訪的予處理方案 術(shù)前/后血漿置換 靜脈注射igg和免疫抑制referencerefere

8、nceabo不相容性腎移植的長(zhǎng)期結(jié)果不相容性腎移植的長(zhǎng)期結(jié)果abo不相容性病人在親屬活體腎移植后抗不相容性病人在親屬活體腎移植后抗-a、b的滴度變化的滴度變化our program- inktpnspecialized incompatible kidney transplant service and clinicnweekly interdisciplinary rounds, composed of blood bank, apheresis service, hla lab, nephrology, transplant surgery, pharmacist, psychologis

9、t, and social worker 我們的我們的不相容腎移植不相容腎移植項(xiàng)目項(xiàng)目專業(yè)化的服務(wù)和臨床每周跨科的綜合查房，包括血庫、單采、hla實(shí)驗(yàn)室、腎科、移植外科、藥劑師、心理學(xué)家和社會(huì)工作者our protocolnmodified from the japanese protocolninitial evaluationndonor and recipient medical, psychological and social work evaluationsnhla and abo typing and titers nreview at weekly meeting ndeter

10、mination of optimal donor (hla vs abo)ntreatment plan established我們的方案我們的方案n根據(jù)日本方案改進(jìn)n初步評(píng)價(jià) 捐獻(xiàn)者和受者進(jìn)行醫(yī)學(xué)、心理和社會(huì)服務(wù)的 評(píng)估 hla和abo分型及抗體滴度分析 每周會(huì)議的評(píng)述 根據(jù)hla與 abo相配情況決定最佳捐獻(xiàn)者 建立治療方案treatment plannimmunosuppression, may include splenectomy nall patients vaccinated (pneumococcus, meningococcus, haemophilus influenza

11、e), regardless of splenectomy status npheresis plan established (number of procedures pre and postop)治治 療療 方方 案案n 免疫抑制，可能包括脾切除n 不管是否脾切除，所有病人接種疫苗（肺炎球菌、腦膜炎球菌、流感嗜血桿菌 ）plasmapheresisnremoves natural anti-a and/or anti-b antibodisnboth preop and postop proceduresnremove 1 plasma volumenreplace at 100% of

12、 volume removednreplace with 5% albumin血血 漿漿 置置 換換n去除天然的抗-a/抗-b抗體n術(shù)前/后都進(jìn)行置換n去除一個(gè)血漿容量n等量替換n用5% 的白蛋白置換除術(shù)前/后立即的置換外，只用血漿置換abo antibody titer goalsnpretransplant goal: titer 16 or lessaboabo抗體滴度目標(biāo)抗體滴度目標(biāo)n移植前目標(biāo)：滴度16n移植后繼續(xù)監(jiān)測(cè)abo抗體滴度對(duì)于預(yù)測(cè)抗體介導(dǎo)的排斥反應(yīng)的意義仍不確定plasmapheresis procedures血漿置換過程血漿置換過程abo antibody titersc

13、onventional test tube methodnaabb technical manual 15th ed. bethesda: american association of blood banks, 2005. nserial dilutions of each sample were prepared in 0.9% salinenpooled indicator cells (immucor, norcross, ga) of the appropriate abo type were addedn30 minutes 22c incubation test phasen30

14、 minutes 37c incubation test phasenahg test phase using monospecific anti-igg (immucor, norcross, ga) nagglutination was scored using the marsh 0 to 12 scoring systemnahg titer endpoint was the reciprocal of the highest dilution demonstrating macropscopic (score 3) agglutination aboabo抗體滴定抗體滴定常規(guī)的試管法

15、naabb技術(shù)手冊(cè)n樣品用0.9%的鹽水進(jìn)行連續(xù)稀釋 n加入適量的混合abo血型指示細(xì)胞（ immucor ，norcross, ga ）n22度孵育30分鐘n37度孵育30分鐘n單特異性抗-igg (immucor, norcross, ga) 的抗人球蛋白（ahg）實(shí)驗(yàn)階段n用marsh 0到12打分系統(tǒng)給凝集打分nahg最終滴度是樣品出現(xiàn)肉眼可見的（3分）凝集的最高稀釋倍數(shù)abo antibody titersnit is time consumingnturn around time is criticalnour experience indicates that only the

16、ahg titer values are criticalntiter endpoint is demonstrated with a macroscopic agglutination aboabo抗體滴度抗體滴度n這是一個(gè)花費(fèi)時(shí)間的實(shí)驗(yàn)n關(guān)鍵是出現(xiàn)結(jié)果的時(shí)間n我們的經(jīng)驗(yàn)表明只有ahg滴度是關(guān)鍵值n最終滴度是由肉眼可見的凝集決定objectivesnthe goal of the present study was to streamline abo antibody titer determinations by assessing ahg titers using 1) a revise

17、d test tube method where the room temperature incubation phase was eliminated 2) an anti-igg gel microcolumn method目目 的的n本研究的目的是通過評(píng)估ahg 滴度，系列測(cè)定abo抗體 1) 應(yīng)用不需要室溫孵育過程的改良試管法 2) 應(yīng)用抗-igg凝膠微柱法material and methods revised test tube titration methodnserial dilutions of each sample were prepared in 0.9% salin

18、enpooled indicator cells (immucor, norcross, ga) of the appropriate abo type were addedn30 minutes room temperature was omittedntiters were incubated for 30 minutes 37c and then converted to the ahg test phase using monospecific anti-igg (immucor, norcross, ga) nagglutination was scored using the ma

19、rsh 0 to 12 scoring systemnahg titer endpoint was the reciprocal of the highest dilution demonstrating macropscopic (score 3) agglutination實(shí)驗(yàn)材料和方法實(shí)驗(yàn)材料和方法 material and methods anti-igg microcolumn gel methodnserial dilutions of each sample were preparedntwenty-five microliters of each plasma dilution

20、 and 50 microliters of 0.8% indicator red cells prepared in mts diluent 2 were added to the gel card microcolumnsnafter incubation at 37c for 15 minutes, the gel cards were centrifuged for 10 minutesnthe titer endpoint was the reciprocal of the highest dilution demonstrating 1+實(shí)驗(yàn)材料和方法抗-igg微柱凝膠法n每個(gè)樣品

21、系列稀釋n在微柱凝膠卡中加入25微升每一稀釋度的血漿和50微升應(yīng)用mts稀釋液2制備的0.8%的指示紅細(xì)胞。n37孵育15分鐘后將凝膠卡離心10分鐘n最終滴度是顯示1+凝集的最高稀釋度的倒數(shù)anti-igg microcolumn gel cards micro typing systems, mts, ortho clinical diagnostics, raritan, nj, usa抗抗-igg-igg微柱凝膠卡片微柱凝膠卡片micro typing systems, mts, ortho clinical diagnostics, raritan, nj, usa 微型血型儀pati

22、ent samplesnserial edta plasma samples from patients in our abo inkt programnfifty samples with anti-a and/or anti-b antibodiesnahg titers ranging from 2 to 512n18 of the 50 (36%) samples were selected with titers of 16病人樣品n我們 abo不相容的腎移植項(xiàng)目的病人edta血漿標(biāo)本n50個(gè)有抗-a/抗-b抗體的標(biāo)本nahg 滴度在2-512之間n50個(gè)中有18個(gè)樣本滴度為16pa

23、tient samples number of samplestitersanti-aanti-banti-a/anti-btotal2-8622101612511832-649312128-25672951211total3413350病病 人人 樣樣 本本樣 本 數(shù)滴度抗-a抗-b抗-a/抗-b總計(jì)2-8622101612511832-649312128-25672951211總計(jì)3413350results結(jié)結(jié) 果果results (table 1)ncomparison of antiglobulin (ahg) titer results by test tube methods w

24、ith and without a room temperature (rt) incubation phase conventional test tube methodrevised test tube method (rtt)n=identical to ctt ahg titer ctt ahg titer傳統(tǒng)ahg滴度 ctt ahg titer傳統(tǒng)ahg滴度 rtt ahg titer改良試管法滴度 改良試管法滴度 2114321866161816232761645512864225632151211總計(jì)5043 (86%)5 (10%)2 (4%)resultsnall the ahg titer results (100%) varied no more than one standard dilution which is within the acceptab