監(jiān)測abo不相容性腎移植的【-】

StreamliningABOAntibodyTitersForMonitoringABOIncompatibleKidneyTransplantsWeiCai,M.T.(ASCP)JohnsHopkinsMedicalInstitution

監(jiān)測ABO不相容性腎移植的

ABO血型抗體滴度

約翰霍伯金斯醫(yī)學(xué)院

蔡偉BackgroundInformationJohnsHopkinsHospitalDepartmentofPathologyTransfusionMedicineDivisionSpecialistinBloodBankTechnologyAABB(AmericanAssociationofBloodBanks)ABOIncompatibleKidneyTransplantProgram

背景知識約翰霍伯金斯大學(xué)醫(yī)院病理系輸血醫(yī)學(xué)部美國血庫協(xié)會血庫技術(shù)專家ABO血型不相容性腎移植計劃CrossingtheABOBarrierforKidneyTransplantsAsofMay25,2007:75,711patientsawaitingkidneytransplantationIn2006,17,092kidneytransplantswereperformed(6,433or37.6%livingdonors): GroupO 7,662 A 6,354 B 2,255 AB 821 至2007年5月25日止，

有75,711名病人在等待進(jìn)行腎移植

2006年

進(jìn)行了17,902個腎移植，其中6,433約37.6%是活體腎移植

血型腎移植

O7,662

A6,354

B2,255

AB821

克服ABO血型障礙進(jìn)行的腎移植DeathsonWaitingList

In2006,4,056patientsdiedwaitingforakidneytransplant,or11.1patientsdiedperday

2,049GroupO1,250GroupA629GroupB128GroupAB在等待中死去的病人

2006年，共有4,056名等待腎移植的病人死亡，即每天有11.1名病人在等待中死去。CadavericKidneyTransplantWaitAsof5/25/07Registered5orMoreYearsAllABO75,7118,079O39,7134,459A21,4571,844B12,3791,592AB2,162184等待尸腎移植的病人數(shù)及等待時間至07年5月25日登記等待5年或5年以上所有血型 75,711 8,079O

39,7134,459A 21,4571,844B 12,3791,592AB2,162184CadavericKidneyTransplantWaitIfregisteredin2001-2002,medianwaittimesasofMay25,2007

BloodGroupDaysO1836A1135B2032AB7322001-2002年間登記的病人，到2007年5月25日平均等待時間是血型天數(shù)O1836A1135B2032AB732ObjectivesExpanddonorpoolandavailabilityoforgansfortransplantationDecreasetimeonorganwaitinglistCircumventhyperacuterejectionand/orAMR(duetoABOand/orHLAantibodies)bydevelopingimmunomodulatoryprotocolsABOincompatibleDonor-recipientwithpositivecrossmatches(HLA)PosttransplantpatientswhodevelopAMR(HLA)目的擴(kuò)大器官捐獻(xiàn)群體及移植器官的來源減少器官移植的等待時間通過免疫調(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)ABOIncompatibleTransplantationBasedonJapaneseexperienceBasedonourexperience/protocolforcrossmatchpositivedonor/recipientpairsandantibody-mediatedrejectionFacilitatedbylaparoscopicdonornephrectomyPreparativeregimenwithintensivefollowuppre/postoperativeplasmapheresisIVIgGandimmunosuppressionABO不相容的移植基于日本的經(jīng)驗基于我們對交配陽性的供-受者和抗體介導(dǎo)的排斥反應(yīng)的經(jīng)驗/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ReferenceReferenceABO不相容性腎移植的長期結(jié)果ABO不相容性病人在親屬活體腎移植后抗-A、B的滴度變化OurProgram-InkTpSpecializedIncompatibleKidneyTransplantserviceandclinicWeeklyinterdisciplinaryrounds,composedofbloodbank,apheresisservice,HLAlab,nephrology,transplantsurgery,pharmacist,psychologist,andsocialworker

我們的不相容腎移植項目專業(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實驗室、腎科、移植外科、藥劑師、心理學(xué)家和社會工作者OurProtocolModifiedfromtheJapaneseprotocolInitialevaluationdonorandrecipientmedical,psychologicalandsocialworkevaluationsHLAandABOtypingandtitersReviewatweeklymeetingdeterminationofoptimaldonor(HLAvsABO)treatmentplanestablished我們的方案根據(jù)日本方案改進(jìn)初步評價捐獻(xiàn)者和受者進(jìn)行醫(yī)學(xué)、心理和社會服務(wù)的評估HLA和ABO分型及抗體滴度分析

每周會議的評述根據(jù)HLA與ABO相配情況決定最佳捐獻(xiàn)者建立治療方案TreatmentPlanImmunosuppression,mayincludesplenectomyAllpatientsvaccinated(pneumococcus,meningococcus,haemophilusinfluenzae),regardlessofsplenectomystatusPheresisplanestablished(numberofprocedurespreandpostop)治療方案

免疫抑制，可能包括脾切除不管是否脾切除，所有病人接種疫苗（肺炎球菌、腦膜炎球菌、流感嗜血桿菌）建立置換計劃（術(shù)前/術(shù)后的置換程序和次數(shù)）PlasmapheresisRemovesnaturalanti-Aand/oranti-BantibodisBothpreopandpostopproceduresRemove1plasmavolumeReplaceat100%ofvolumeremovedReplacewith5%albuminexceptproceduresimmediatelypre-andpost-surgery,replacewithplasma血漿置換去除天然的抗-A/抗-B抗體術(shù)前/后都進(jìn)行置換去除一個血漿容量等量替換用5%的白蛋白置換除術(shù)前/后立即的置換外，只用血漿置換ABOAntibodyTiterGoalsPretransplantgoal:

titer16orlessPosttransplantContinuetomonitorABOantibodytitersSignificanceinpredictionofantibodymediatedrejectionisuncertainABO抗體滴度目標(biāo)移植前目標(biāo)：滴度≤16移植后繼續(xù)監(jiān)測ABO抗體滴度對于預(yù)測抗體介導(dǎo)的排斥反應(yīng)的意義仍不確定PlasmapheresisProceduresABOAntibodyTiter(AHG)PretransplantTreatments(#)PosttransplantTreatments(#)<16221622323364431285-632567-845129-104102410-124>1024>155血漿置換過程ABO抗體滴度移植前治療次數(shù)移植后治療次數(shù)<16221622323364431285-632567-845129-104102410-124>1024>155ABOAntibodyTitersConventionaltesttubemethodAABBtechnicalmanual

15thed.Bethesda:AmericanAssociationofBloodBanks,2005.Serialdilutionsofeachsamplewerepreparedin0.9%salinePooledindicatorcells(Immucor,Norcross,GA)oftheappropriateABOtypewereadded30minutes22Cincubationtestphase30minutes37CincubationtestphaseAHGtestphaseusingmonospecificanti-IgG(Immucor,Norcross,GA)AgglutinationwasscoredusingtheMarsh0to12scoringsystemAHGtiterendpointwasthereciprocalofthehighestdilutiondemonstratingmacropscopic(score3)agglutination

ABO抗體滴定常規(guī)的試管法AABB技術(shù)手冊樣品用0.9%的鹽水進(jìn)行連續(xù)稀釋加入適量的混合ABO血型指示細(xì)胞（Immucor，Norcross,GA）22度孵育30分鐘37度孵育30分鐘單特異性抗-IgG(Immucor,Norcross,GA)的抗人球蛋白（AHG）實驗階段用Marsh0到12打分系統(tǒng)給凝集打分AHG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)ABOAntibodyTitersItistimeconsumingTurnaroundtimeiscriticalOurexperienceindicatesthatonlytheAHGtitervaluesarecriticalTiterendpointisdemonstratedwithamacroscopicagglutinationABO抗體滴度這是一個花費時間的實驗關(guān)鍵是出現(xiàn)結(jié)果的時間我們的經(jīng)驗表明只有AHG滴度是關(guān)鍵值最終滴度是由肉眼可見的凝集決定ObjectivesThegoalofthepresentstudywastostreamlineABOantibodytiterdeterminationsbyassessingAHGtitersusing

1)Arevisedtesttubemethodwheretheroomtemperatureincubationphasewaseliminated2)Ananti-IgGgelmicrocolumnmethod目的本研究的目的是通過評估AHG滴度，系列測定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Materialandmethods

RevisedtesttubetitrationmethodSerialdilutionsofeachsamplewerepreparedin0.9%salinePooledindicatorcells(Immucor,Norcross,GA)oftheappropriateABOtypewereadded30minutesroomtemperaturewasomittedTiterswereincubatedfor30minutes37CandthenconvertedtotheAHGtestphaseusingmonospecificanti-IgG(Immucor,Norcross,GA)AgglutinationwasscoredusingtheMarsh0to12scoringsystemAHGtiterendpointwasthereciprocalofthehighestdilutiondemonstratingmacropscopic(score3)agglutination實驗材料和方法

改良的試管法每個樣品用0.9%的鹽水進(jìn)行系列稀釋加入適當(dāng)?shù)腁BO血型的混合指示細(xì)胞（Immucor，Norcross,GA）省略室溫30分鐘孵育37度孵育30分鐘后用單特異性抗-IgG進(jìn)行AHG實驗用Marsh打分系統(tǒng)對凝集進(jìn)行打分AHG最終滴度是樣品出現(xiàn)肉眼可見的（3分）凝集的最高稀釋度的倒數(shù)MaterialandmethodsAnti-IgGmicrocolumngelmethodSerialdilutionsofeachsamplewerepreparedTwenty-fivemicrolitersofeachplasmadilutionand50microlitersof0.8%indicatorredcellspreparedinMTS?Diluent2wereaddedtothegelcardmicrocolumnsAfterincubationat37Cfor15minutes,thegelcardswerecentrifugedfor10minutesThetiterendpointwasthereciprocalofthehighestdilutiondemonstrating1+實驗材料和方法

抗-IgG微柱凝膠法每個樣品系列稀釋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。37℃孵育15分鐘后將凝膠卡離心10分鐘最終滴度是顯示1+凝集的最高稀釋度的倒數(shù)Anti-IgGMicrocolumnGelCards

MicroTypingSystems,MTS?,OrthoClinicalDiagnostics,Raritan,NJ,USA抗-IgG微柱凝膠卡片MicroTypingSystems,MTS?,OrthoClinicalDiagnostics,Raritan,NJ,USA微型血型儀PatientsamplesSerialEDTAplasmasamplesfrompatientsinourABOINKTprogramFiftysampleswithanti-Aand/orAnti-BantibodiesAHGtitersrangingfrom2to51218ofthe50(36%)sampleswereselectedwithtitersof16病人樣品我們ABO不相容的腎移植項目的病人EDTA血漿標(biāo)本50個有抗-A/抗-B抗體的標(biāo)本AHG滴度在2-512之間50個中有18個樣本滴度為16Patientsamples

NumberofSamplesTitersAnti-AAnti-BAnti-A/Anti-BTotal2-8622101612511832-649312128-25672951211Total3413350病人樣本樣本數(shù)滴度抗-A抗-B抗-A/抗-B總計2-8622101612511832-649312128-25672951211總計3413350Results結(jié)果Results(table1)Comparisonofantiglobulin(AHG)titerresultsbytesttubemethodswithandwithoutaroomtemperature(RT)incubationphaseConventionaltesttubemethodRevisedTesttubemethod(RTT)N=IdenticaltoCTTAHGtiter>CTTAHGtiter<CTTAHGtiter211433864216181323327412645321286321256311151211Total5032(64%)7(14%)11(22%)結(jié)果（表1）有、無室溫孵育的試管法抗人球（AHG）滴度實驗結(jié)果的比較(CTT)傳統(tǒng)試管法改良的試管法N=與傳統(tǒng)試管法滴度相等>傳統(tǒng)AHG滴度<傳統(tǒng)AHG滴度的211433864216181323327412645321286321256311151211總計5032(64%)7(14%)11(22%)Results(table2)ComparisonofconventionaltesttubeAHGtitersthatincludedaroomtemperaturetestphasetothetitersperformedwithanti-IgGgelcards(IgGGEL)ConventionaltesttubemethodIgGGelTesttubemethodN=IdenticaltoCTTAHGtiter>CTTAHGtiter<CTTAHGtiter211432186421618133232723264532128612325632151211Total5026(52%)12(24%)12(24%)結(jié)果（表2）有室溫孵育的傳統(tǒng)試管法與抗-IgG凝膠卡法AHG滴度的比較(CTT)傳統(tǒng)試管法IgG凝膠卡法N=與傳統(tǒng)試管法滴度相等>傳統(tǒng)AHG滴度<傳統(tǒng)AHG滴度211432186421618133232723264532128612325632151211總計5026(52%)12(24%)12(24%)Results(table3)ComparisonofrevisedtesttubeAHGtiterresultswiththeIgGGELtitersRevisedtesttubemethod(RTT)IgGGelTesttubemethodN=IdenticaltoRTTAHGtiter>RTTAHGtiter<RTTAHGtiter2114321866161816232761645512864225632151211Total5043(86%)5(10%)2(4%)結(jié)果（表3）改良試管法和IgG凝膠法AHG滴度的比較改良的試管法IgG凝膠試管法N=與改良的試管法滴度相等>改良試管法滴度<改良試管法滴度2114321866161816232761645512864225632151211總計5043(86%)5(10%)2(4%)ResultsAlltheAHGtiterresults(100%)variednomorethanonestandarddilutionwhichiswithintheacceptablelimitsfortitrationmethodsTechnicalManual.15thed.Bethesda:AmericanAssociationofBloodBanks,2005.

Yes!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!結(jié)果

所有AHG滴度測定的結(jié)（100%）的變化上下不超過一個稀釋度，均在可接受范圍內(nèi)（2005年第15版美國AABB技術(shù)手冊標(biāo)準(zhǔn)）

DiscussionThisstudyshowsthatboththerevisedtesttubeandIgGGELareacceptablealternativemethodsformonitoringABOantibodytiters.TheIgGGELmethodoffersthebestturnaroundtimeandrequireslesshands-ontime.Becausethereactionsarestable,batchtiterscanbebetteraccommodatedbyIgGGEL.Asaresultofthisstudy,ourlaboratoryisintheprocessofimplementingABOantibodytitersbytheIgGGELmethodwhichwillenableustoprovidetitervaluesinamoretimely-mannerforpatientsintheABOINKTprogram.

討論本研究表明改良的試管法和IgG凝膠法均可用于監(jiān)測ABO抗體滴度IgG凝膠法提供了出現(xiàn)最佳結(jié)果的時間，所需手工操作的時間更少由于反應(yīng)穩(wěn)定，IgG凝膠法的批間滴度更好。因此，我們實驗室在用IgG凝膠法監(jiān)測ABO抗體滴度，這使我們能為ABO不相容的腎移植病人提供更及時的ABO抗體滴度。!%*)-02468aceghjlnprtvxzACEGIKMOQSTVXZ!%*)+12468acegikmnprtvxzBDFGIKMOQSUWYZ!%*)+13578acegikmoqrtvxzBDFHJLMOQSUWY#$&*)+13579bdegikmoqsuwxzBDFHJLNPQSUWY#$&(-013579bdfhjkmoqsuwyACDFHJLNPRTVWY#$&(-024579bdfhjlnpqsuwyACEGIJLNPRTVXZ!$&(-02468abdfhjlnprtuwyACEGIKMOPRTVXZ!%*)-02468aceghjlnprtvxzACEGIKMOQSTVXZ!%*)+13468acegikmnprtvxzBDFGIKMOQSUWYZ!%*)+13578acegikmoqstvxzBDFHJLMOQSUWY#$&*)+13579bdegikmoqsuwxzBDFHJLNPRSUWY#$&(-013579bdfhjkmoqsuwyACDFHJLNPRTVWY#$&(-024679bdfhjlnpqsuwyACEGIJLNPRTVXZ!$&(-02468abdfhjlnprtvwyACEGIKMOPRTVXZ!%*)-02468aceghjlnprtvxzACEGIKMOQSUVXZ!%*)+13468acegikmnprtvxzBDFGIKMOQSUWYZ!%*)+13578acegikmoqstvxzBDFHJLMOQSUWY#$&*)+13579bdegikmoqsuwxzBDFHJLNPRSUWY#$&(-013579bdfhjkmoqsuwyACDFHJLNPRTVWY#$&(-024679bdfhjlnpqsuwyACEGIJLNPRTVXZ!$&(-02468abdfhjlnprtvwyACEGIKMOPRTVXZ!%*)-02468aceghjlnprtvxzACEGIKMOQSUVXZ!%*)+13468acegikmnprtvxzBDFGIKMOQSUWYZ!%*)+13579acegikmoqstvxzBDFHJLMOQSUWY#$&*)+13579bdegikmoqsuwyzBDFHJLNPRSUWY#$&(-013579bdfhjkmoqsuwyACDFHJLNPRTVXY#$&(-024679bdfhjlnpqsuwyACEGIJLNPRTVXZ!$&(-02468acdfhjlnprtvwyACEGIKMOPRTVXZ!%*)-02468aceghjlnprtvxzBCEGIKMOQSUVXZ!%*)+13468acegikmnprtvxzBDFGIKMOQSUWY#!%*)+13579acegikmoqstvxzBDFHJLMOQSUWY#$&*)+13579bdfgikmoqsuwyzBDFHJLNPRSUWY#$&(-013579bdfhjkmoqsuwyACEFHJLNPRTVXY#$&(-024679bdfhjlnpqsuwyACEGIJLNPRWY#$&(-013579bdfhjkmoqsuwyACDFHJLNPRTVWY#$&(-024679bdfhjlnpqsuwyACEGIJLNPRTVXZ!$&(-02468abdfhjlnprtuwyACEGIKMOPRTVXZ!%*)-02468aceghjlnprtvxzACEGIKMOQSTVXZ!%*)+13468acegikmnprtvxzBDFGIKMOQSUWYZ!%*)+13578acegikmoqstvxzBDFHJLMOQSUWY#$&*)+13579bdegikmoqsuwxzBDFHJLNPRSUWY#$&(-013579bdfhjkmoqsuwyACDFHJLNPRTVWY#$&(-024679bdfhjlnpqsuwyACEGIJLNPRTVXZ!$&(-02468abdfhjlnprtvwyACEGIKMOPRTVXZ!%*)-02468aceghjlnprtvxzACEGIKMOQSUVXZ!%*)+13468acegikmnprtvxzBDFGIKMOQSUWYZ!%*)+13579acegikmoqstvxzBDFHJLMOQSUWY#$&*)+13579bdegikmoqsuwyzBDFHJLNPRSUWY#$&(-013579bdfhjkmoqsuwyACDFHJLNPRTVXY#$&(-024679bdfhjlnpqsuwyACEGIJLNPRTVXZ!$&(-02468acdfhjlnprtvwyACEGIKMOPRTVXZ!%*)-02468aceghjlnprtvxzBCEGIKMOQSUVXZ!%*)+13468acegikmnprtvxzBDFGIKMOQSUWY#!%*)+13579acegikmoqstvxzBDFHJLMOQSUWY#$&*)+13579bdfgikmoqsuwyzBDFHJLNPRSUWY#$&(-013579bdfhjkmoqsuwyACEFHJLNPRTVXY#$&(-024679bdfhjlnpqsuwyACEGIJLNPRTVXZ!%&(-02468acdfhjlnprtvwyACEGIKMOPRTVXZ!%*)-02468aceghjlnprtvxzBCEGIKMOQSUVXZ!%*)+13468acegikmnprtvxzBDFGIKMOQSUWY#!%*)+13579acegikmoqstvxzBDFHJLMOQSUWY#$&*)+13579bdfgikmoqsuwyzBDFHJLNPRSYZ!%*)+13578acegikmoqstvxzBDFHJLMOQSUWY#$&*)+13579bdegikmoqsuwxzBDFHJLNPRSUWY#$&(-013579bdfhjkmoqsuwyACDFHJLNPRTVWY#$&(-024679bdfhjlnpqsuwyACEGIJLNPRTVXZ!$&(-02468abdfhjlnprtvwyACEGIKMOPRTVXZ!%*)-02468aceghjlnprtvxzACEGIKMOQSUVXZ!%*)+13468acegikmnprtvxzBDFGIKMOQSUWYZ!%*)+13579acegikmoqstvxzBDFHJLMOQSUWY#$&*)+13579bdegikmoqsuwyzBDFHJLNPRSUWY#$&(-013579bdfhjkmoqsuwyACDFHJLNPRTVXY#$&(-024679bdfhjlnpqsuwyACEGIJLNPRTVXZ!$&(-02468acdfhjlnprtvwyACEGIKMOPRTVXZ!%*)-02468aceghjlnprtvxzBCEGIKMOQSUVXZ!%*)+13468acegikmnprtvxzBDFGIKMOQSUWY#!%*)+13579acegikmoqstvxzBDFHJLMOQSUWY#$&*)+13579bdfgikmoqsuwyzBDFHJLNPRSUWY#$&(-013579bdfhjkmoqsuwyACDFHJLNPRTVXY#$&(-024679bdfhjlnpqsuwyACEGIJLNPRTVXZ!$&(-02468acdfhjlnprtvwyACEGIKMOPRTVXZ!%*)-4579bdfhjlnpqsuwyACEGIJLNPRTVXZ!$&(-02468abdfhjlnprtuwyACEGIKMOPRTVXZ!%*)-02468aceghjlnprtvxzACEGIKMOQSTVXZ!%*)+13468acegikmnprtvxzBDFGIKMOQSUWYZ!%*)+13578acegikmoqstvxzBDFHJLMOQSUWY#$&*)+13579bdegikmoqsuwxzBDFHJLNPRSUWY#$&(-013579bdfhjkmoqsuwyACDFHJLNPRTVWY#$&(-024679bdfhjlnpqsuwyACEGIJLNPRTVXZ!$&(-02468