Setting up ABO-incompatible renal transplants is a major undertaking and requires close coordination between Transfusion Medicine and the clinical team. This post addresses my experience in setting up this program in 2019 at HMC in Qatar.
Like any process involving titration, it is best to automate it to minimize inter-technologist variability. Unfortunately, doing both IgG and IgM titers takes up to 1 hour per machine and totally monopolizes the machine during that interval. I did not have sufficient staff to even consider doing the titrations manually. Performing automated titers disrupted my workflow so I encouraged the clinicians to send the specimens for off-peak processing.
- Obtain the full clinical protocol and especially note the thresholds for transplantation.
- Determine the methodologies used at the reference site. Can you do this at your local site or do you have to use an alternative method?
- Do you have equipment to automatically titer? Doing both IgG and IgM may monopolize an immunohematology analyzer for one hour? How will this affect your other testing?
- Regardless if it is the same method, you must still correlate your titers with the protocol site, both IgG and IgM.
- If you are using multiple analyzers for titration, you must do a comparison study between them. How much does the titer vary?
- Determine column inventory and order the A, B, and AB columns. You must order enough to finish the course of treatment. It may take weeks to get additional columns, depending on your supply chain. Each column costs thousands of euros.
- Where are you going to store the columns? Ours needed 2-8C storage. Can you keep them away from quarantined products and patient specimens?
- Are your columns single-use?
- If multi-use, who is going to restore them after use? How do you ensure that it is dedicated for the right patient?
- How are you going to attach the column to the apheresis equipment?
- Will you use your therapeutic apheresis equipment like Terumo Optia directly or will you use a second machine (e.g. Medicap)?
- Do you have all the clamps, tubing, and holder for the column?
- Do you have sufficient apheresis nurses to perform the procedures? You may be running the apheresis for up to 8 hours. How does this impact your other procedures or donor center operations? Our pool of apheresis nurses was very limited. They also covered routine blood donation. How will doing this process impact your regular donation and other apheresis operations—donor and therapeutic?
- Do you have sufficient supplies of ACD-A anticoagulant and calcium gluconate?
- Perform titrations expeditiously: Can you finish titration testing before the next scheduled procedure? In our institution, we collected specimens at 0400 and had them directly brought to the blood bank for testing. Results were ready at 0600 so the clinicians could decide early if another procedure was needed.
Table of Permissible ABO Types:
- Define acceptable blood products by blood type—take into consideration pathogen inactivation and platelet additive solution if used. At our institution, all RBCs were in additive solution and all platelets were pathogen-inactivated in platelet additive solution PAS so residual ABO antibodies were minimal in the final components. Since the platelets contain only minimal plasma, we did not concern ourselves with matching their ABO type with the donor kidney. Otherwise, platelet types with plasma compatible to the donor kidney must be selected.
- Prepare a truth table for acceptable ABO component types based on #16 above.
- Include the titer cutoff for IgG and IgM antibodies in the organ transplant module.
Selection of blood component for ABO-incompatible renal transplantation is discussed in a separate post that will follow.