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Abstracts / Human Immunology 73 (2012) 49–167
ACUTE HEART TRANSPLANT REJECTION IN THE PRESENCE OF APPARENTLY WEAK, NON-COMPLEMENTFIXING DONOR-SPECIFIC ANTIBODIES DETECTED AT THE TIME OF TRANSPLANT. Anthony Nizio 1, Paul Mather 2, Beth Colombe 1. 1 Clinical Laboratory-Tissue Typing, Thomas Jefferson University Hospital, Philadelphia, PA, USA; 2 Department of Medicine-Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Aim: A 66 year old female with an end-stage NYHA class IV inotrope-dependent, ischemic cardiomyopathy received a heart transplant on 9-12 from a donor having antigens B13 and DR7. Pre-transplant antibody testing indicated only weakly positive, non-complement-fixing donor-specific antibodies. The patient suffered a cardiac arrest on POD#6 and was resuscitated. She was in cardiogenic shock from allograft failure and subsequently expired on POD#9 of multiorgan failure due to ‘‘acute humoral rejection’’. These antibodies were investigated further. Methods: Antibodies were evaluated using both Labscreen PRA (One Lambda) and Labscreen Single Antigen (One Lambda) beads, and crossmatching was performed using standard T and B cell CDC and flow cytometry methods. Results: Pre-transplant antibody studies (Labscreen PRA) had shown the presence of clearly defined antibodies to B27, DR4 and a possible weak anti-DR7. Retrospective Labscreen Single Antigen(SA) (One Lambda) testing revealed antibodies to B13 and DR7, both donor-specific antibodies. MFI values were 2000 for B13 and 5000 for DR7. The pre-transplant crossmatches (CDC and flow cytometry) were negative except for a positive B cell CDC. The patient received blood products on POD#3. Crossmatching on POD# 3 showed only a weakly positive T flow crossmatch and negative DSA. However, SA antibody studies on POD#6 showed high MFI values of 19,000 (B13) and 23,000 (DR7), and strongly positive T and B CDC and flow crossmatches. C1q studies of sera from POD#0 and #3 showed the DSA were non-complement fixing. However, by POD#6, the DS antibodies were now clearly complement-fixing. The patient expired on POD#9. Myocardium tissue from the left ventricle taken at autopsy showed positive staining for C4d. Conclusions: DSA with relatively weak MFI values can be a significant risk to both organ and patient survival. Non-complement fixing DSAs also pose a risk and can become expressed as complement-fixing antibodies in an acute immune response to mismatched donor antigens.
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CASE STUDY OF A MULTIPLE STEM CELL’S RECIPIENT WITH ACUTE LYMPHOBLASTIC LEUKEMIA. Lucie Richard, Diane Roy. Stem Cell and Reference Laboratory, Hema-Quebec, Saint-Laurent, QC, Canada. Aim: All stem cell recipients have their own story, each one being more complicated than others. We report here the case of an 18 year old female who developed an acute lymphoblastic leukemia 10 years ago and went through many stem cell grafts. Complications in HLA typing due to chimerisms had to be addressed in an unconventional way. Methods: The HLA-A, -B, -C and -DRB1 were analysed in 2002 using serological methods and SSO low resolution and DRB1 and DQB1 were also analysed in high resolution by SSP. More than nine years after, the HLAA, -B, -C, -DRB1 and -DQB1 were performed by sequencing, using PCR reactions of exons 2, 3 for loci A, B and DQB1, exon 2 for DRB1, exons 2, 3 and 4 for C and SSP. Blood sample, mouth swabs and hair follicles were used for DNA extraction and HLA typing. Results: The patient was diagnosed with acute leukemia and Ph(+) in 2002. HLA typing was performed at low resolution for the related donor search. No sibling was compatible and the transplant team had to rapidly graft a 4/6 compatible cord blood unit. In 2008, the patient relapsed and received a second 4/6 compatible cord blood graft, using once again the HLA low resolution typing. Again, by the end of 2011, the patient relapsed and blood samples were sent to Hema-Quebec HLA lab to perform high resolution typing and start an unrelated donor search. The level of chimerism was interfering with the HLA typing of loci B, C, DRB1 and DQB1. The DNA extracted from mouth swabs was also chimeric. The unrelated donor search had to be initiated with high resolution HLA typing deduced from the parent’s inherited haplotypes. The patient’s typing still had to be confirmed and the only material left to do it was the hair follicles. Because this material is not routinely used in our lab, DNA extraction was performed by the Quebec forensic laboratory, allowing us to perform the high resolution confirmatory typing. Conclusions: An unrelated donor could be identified and the patient is now being prepared for her third stem cell graft.
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Abstracts / Human Immunology 73 (2012) 49–167
ACUTE HEART TRANSPLANT REJECTION IN THE PRESENCE OF APPARENTLY WEAK, NON-COMPLEMENTFIXING DONOR-SPECIFIC ANTIBODIES DETECTED AT THE TIME OF TRANSPLANT. Anthony Nizio 1, Paul Mather 2, Beth Colombe 1. 1 Clinical Laboratory-Tissue Typing, Thomas Jefferson University Hospital, Philadelphia, PA, USA; 2 Department of Medicine-Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Aim: A 66 year old female with an end-stage NYHA class IV inotrope-dependent, ischemic cardiomyopathy received a heart transplant on 9-12 from a donor having antigens B13 and DR7. Pre-transplant antibody testing indicated only weakly positive, non-complement-fixing donor-specific antibodies. The patient suffered a cardiac arrest on POD#6 and was resuscitated. She was in cardiogenic shock from allograft failure and subsequently expired on POD#9 of multiorgan failure due to ‘‘acute humoral rejection’’. These antibodies were investigated further. Methods: Antibodies were evaluated using both Labscreen PRA (One Lambda) and Labscreen Single Antigen (One Lambda) beads, and crossmatching was performed using standard T and B cell CDC and flow cytometry methods. Results: Pre-transplant antibody studies (Labscreen PRA) had shown the presence of clearly defined antibodies to B27, DR4 and a possible weak anti-DR7. Retrospective Labscreen Single Antigen(SA) (One Lambda) testing revealed antibodies to B13 and DR7, both donor-specific antibodies. MFI values were 2000 for B13 and 5000 for DR7. The pre-transplant crossmatches (CDC and flow cytometry) were negative except for a positive B cell CDC. The patient received blood products on POD#3. Crossmatching on POD# 3 showed only a weakly positive T flow crossmatch and negative DSA. However, SA antibody studies on POD#6 showed high MFI values of 19,000 (B13) and 23,000 (DR7), and strongly positive T and B CDC and flow crossmatches. C1q studies of sera from POD#0 and #3 showed the DSA were non-complement fixing. However, by POD#6, the DS antibodies were now clearly complement-fixing. The patient expired on POD#9. Myocardium tissue from the left ventricle taken at autopsy showed positive staining for C4d. Conclusions: DSA with relatively weak MFI values can be a significant risk to both organ and patient survival. Non-complement fixing DSAs also pose a risk and can become expressed as complement-fixing antibodies in an acute immune response to mismatched donor antigens.
176-P
CASE STUDY OF A MULTIPLE STEM CELL’S RECIPIENT WITH ACUTE LYMPHOBLASTIC LEUKEMIA. Lucie Richard, Diane Roy. Stem Cell and Reference Laboratory, Hema-Quebec, Saint-Laurent, QC, Canada. Aim: All stem cell recipients have their own story, each one being more complicated than others. We report here the case of an 18 year old female who developed an acute lymphoblastic leukemia 10 years ago and went through many stem cell grafts. Complications in HLA typing due to chimerisms had to be addressed in an unconventional way. Methods: The HLA-A, -B, -C and -DRB1 were analysed in 2002 using serological methods and SSO low resolution and DRB1 and DQB1 were also analysed in high resolution by SSP. More than nine years after, the HLAA, -B, -C, -DRB1 and -DQB1 were performed by sequencing, using PCR reactions of exons 2, 3 for loci A, B and DQB1, exon 2 for DRB1, exons 2, 3 and 4 for C and SSP. Blood sample, mouth swabs and hair follicles were used for DNA extraction and HLA typing. Results: The patient was diagnosed with acute leukemia and Ph(+) in 2002. HLA typing was performed at low resolution for the related donor search. No sibling was compatible and the transplant team had to rapidly graft a 4/6 compatible cord blood unit. In 2008, the patient relapsed and received a second 4/6 compatible cord blood graft, using once again the HLA low resolution typing. Again, by the end of 2011, the patient relapsed and blood samples were sent to Hema-Quebec HLA lab to perform high resolution typing and start an unrelated donor search. The level of chimerism was interfering with the HLA typing of loci B, C, DRB1 and DQB1. The DNA extracted from mouth swabs was also chimeric. The unrelated donor search had to be initiated with high resolution HLA typing deduced from the parent’s inherited haplotypes. The patient’s typing still had to be confirmed and the only material left to do it was the hair follicles. Because this material is not routinely used in our lab, DNA extraction was performed by the Quebec forensic laboratory, allowing us to perform the high resolution confirmatory typing. Conclusions: An unrelated donor could be identified and the patient is now being prepared for her third stem cell graft.