Organ recipient, Janine Cassata, right, with HLA lab supervisor, Angela Busacco.
On December 16, Janine Cassata will celebrate the one-year anniversary of her organ transplant.
The 50-year-old realtor from Chili was diagnosed with Type 1 diabetes when she was just 2 years old. It wasn’t until after she suffered an e-coli infection as an adult and her kidneys began to fail that her doctor told her she would need a kidney transplant. He suggested a pancreas transplant as well.
Just six months after being added to a waiting list, Cassata was woken up by an early morning phone call. It was the organ transplant coordinator at Strong Memorial Hospital.
“He said, ‘We have a kidney and a pancreas for you and you need to come in right away if you’re interested,” recalls Cassata. “I had to collect my thoughts,” she said. “I was in shock.”
An hour later, she went in for the procedure, which was a success. Months later, she got the rare chance to meet someone who played a part in her transplant behind the scenes.
Cassata was at a graduation at her neighbor’s house when the host introduced her to a fellow party guest, Angela Busacco.
Unbeknownst to her, Busacco is the chief supervisor in the HLA Typing Laboratory at URMC. This lab performs that complex testing that makes it possible to match organ donors and recipients.
Lab employees almost never get the chance to meet the people they help. So when Busacco was introduced to Cassata, tears came to her eyes. What’s more, she remembered her by name. The women talked and embraced.
“These names that we see on a regular basis; they become people,” said Busacco.
The organ donation process is highly collaborative – with a team of people and organizations working around the clock to ensure the best match possible. Here we describe how the lab plays a key role in this journey from Day 1.
How it Works:
The HLA/Tissue Typing Lab team at Strong Memorial Hospital.
When a patient needs an organ transplant, they go through an initial medical evaluation that includes blood and serum tests.
The DNA in their blood cells is tested to identify which human leukocyte antigen (HLA) genes and antigens the patient is born with. Importantly, the recipient’s serum must also be screened for HLA antibodies that could cause a transplant to be unsuccessful.
HLAs are microscopic proteins that exist on the surface of white blood cells. They help the body’s immune system respond to foreign cells by presenting information to T and B cells that may target and attack foreign cells.
In order to be matched with a suitable donor, the recipient must not have antibodies that would actively target transplanted tissue. You can acquire HLA antibodies in different ways, such as having a prior transplant (successful or unsuccessful) or through a blood transfusion. They can also be present in women who have had multiple pregnancies.
All of this information is reported back to the clinicians before the patient gets listed in a national database (managed by the United Network for Organ Sharing, or UNOS) to be eligible to receive a deceased donor organ as it becomes available.
Each patient has their own unique profile when it comes to antigens and antibodies, so every case must be examined closely.
“Some people know you by face, but we get to know somebody by their antibody profile,” said Myra Coppage, Ph.D., Lab Director.
Kidneys are the most transplanted organ at Strong Memorial Hospital. Half of these transplants are from living donors, often relatives who closely match the recipient’s blood and HLA typing. The other half, currently about 350 patients, are waiting for kidneys from deceased organ donors.
Each month, the HLA Lab obtains a serum sample from every patient on the waiting list. The serum is tested on an ongoing basis to monitor any changes and to check for any new HLA antibodies.
A large portion of the daily work flowing through the lab is HLA typing for potential donors who must undergo the same thorough screening. Lab techs perform flow cytometry cross matching to check for compatibility. In this case, cells from the donor are mixed in the same tube with serum from the recipient to see if a rejection reaction takes place.
William Femec (MT) and Helene McMurray; Ph.D. in the HLA Laboratory.
There is always a lab tech on call 24/7 to respond to a call for a deceased donor. This is when an organ donor dies and their HLA typing from DNA must be performed as soon as possible to identify a matching recipient who is willing and able to receive the organ while it’s still viable.
When a call about a deceased donor comes in, time is crucial, explains Helene McMurray, Ph.D., the HLA Lab’s director-in-training.
“It’s a little bit like being Batman,” said McMurray. “When the bat signal goes off, somebody has to show up to work.”
Oftentimes, calls for deceased donors come in late at night or in the early morning when the on-call tech must perform the HLA typing as soon as possible. The process includes manual and automated steps that follow a tight protocol. It can take up to five hours for the tech to finish each step.
“They are juggling HLA typing on the patient, doing the cross match procedure, and potentially antibody screening at the same time by themselves,” said Busacco. “The stuff that we batch and rotate among everybody in the lab (during the day) – that person is doing it all alone.”
The tech must multitask like a chef juggling different side dishes on a tight deadline. Meanwhile, they are taking calls from doctors, nurses, and organ procurement staff checking on the status of the results.
After the HLA typing is complete, the donor’s information is entered into the UNOS database so the organ can be matched with a list of potential recipients.
Once the ordered list of matching recipients is generated, the transplant center coordinators can contact recipients like Janine Cassata and offer them a lifesaving opportunity to receive a transplant.
It is not unusual for the lab tech to get most of the way through the lengthy HLA typing process only to learn that the donation will not happen. This could either because the family of the deceased has chosen not to move forward, or the organ procurement organization determines the organs are not of acceptable quality. This is a difficult but familiar part of the job.
At the end of the day, however, the HLA team knows that each piece of their highly technical role directly impacts positive patient outcomes.
“A transplant is not happening without our piece of it,” said Busacco. “There wouldn’t be an error where we were skipped over or weren’t needed. It just wouldn’t happen.”
Helping ‘Complicated’ Patients
As Laboratory Director, Dr. Myra Coppage has advocated for patients on a national level with the American Society for Histocompatibility and Immunogenetics (ASHI), where she has held a variety of roles, most recently, Program Director for Laboratory Accreditation.
Coppage has served on committees that changed the national rules specifically addressing transplants for immunologically complicated patients who can sit on waiting lists for years.
Patients who have multiple antibodies, either from having many children or failed transplants, were previously stuck waiting for a match while others skipped ahead of them.
“The techs have people they’re always pulling for because they come to the top a lot and have been waiting for a long time,” said Coppage. “Those are the people who need us.”
A new video produced by the Transfusion Medicine's Patient Blood Management Program highlights the importance of conservative transfusion and the initiatives aimed at providing the highest quality care and optimal patient outcomes.
It includes testimonials from esteemed URMC providers, including Peter Knight, M.D., Michael Eaton, M.D., and Anthony Pietropaoli, M.D.
In non-life-threatening situations, the potential risks versus the expected benefits of blood transfusions must be considered. UR Medicine has strategies for:
- Avoiding transfusions when it may not be necessary for patients
- Approaches for those who choose to refuse blood transfusions for religious (i.e. Jehovah’s Witnesses) or personal reasons
- Provisions for those who opt to only accept transfusions or blood component therapy in life-threatening situations
This video can help staff educate our patients and families on the benefits of blood management by highlighting strategies used to avoid transfusion, explaining why this is important. Blood transfusion should be considered a “liquid organ transplant,” and the decision to transfuse blood should always include careful assessment of the potential risks versus the expected benefits.
More info is available at www.TransfusionSafety.urmc.edu.
UR Medicine Labs is a large operation with many moving parts. From phlebotomists who draw blood at patient clinics across Monroe, Genesee, and Livingston counties to couriers who transport the specimens to locations where testing is performed.
More than half of these outpatient specimens are sent to the outpatient (OP) laboratory on Ridgeland Road in Henrietta.
Much of the building is leased by the Department of Pathology and Laboratory Medicine, and also houses the Microarray Lab, Clinical Trials, Lab Outreach, Client Services, and Courier Services.
The OP lab has a staff of 12 who run tests six days a week. While a large portion of outpatient tests for UR Medicine Labs are performed there, the lab can sometimes go unnoticed due to its location, says lab manager, Liz Peterdy.
“I think people are surprised to know how much we do and that we have the large equipment that they have at the main lab (at Strong Memorial Hospital),” she said.
Besides the chemistry and hematology areas, the lab at Ridgeland has a fully staffed specimen management and reference lab.
Pathology first began leasing space in the building in 2008. The following year, a lab was set up to allow for testing of clinical trials specimens. More equipment was added to accommodate outpatient testing, and volume has continued to grow ever since.
Today, the lab at Ridgeland tackles a wide scope of work. There are a combined 4 million clinical trials and outpatient tests performed there every year.
Helping Build Something
Clinical trials specimens come from patients participating in a variety of trials for new or experimental treatments.
These specimens are received from across the U.S. and beyond, and their results will be used for the development of treatments for anything from Parkinson’s disease to infertility, or certain types of cancer.
“The CT samples are definitely unique to this lab,” said assistant lab supervisor, Jason Thomas. “The majority of our work is outpatient, but the CTs are interwoven with those clinical samples, which make very unique challenges,” he said. “We have interactions not just with the samples, but with the CT team.”
This means assisting with outside audits that ensure the lab is compliant with regulations for clinical trials testing. Each step of the process, from the time the specimens arrive to when their results are reported, is calculated with great care.
“With all of that, we look at the structure of everything we do and scrutinize our processes – more, I think, than other labs do,” said Thomas.
From a lab perspective, it’s often gratifying to know that you’re playing an important role in helping patients.
“We get a lot of feedback from our clinical trials team and a lot of satisfaction from seeing the results used in the studies when they go on for FDA submission,” said Peterdy. “It’s really rewarding to see that you are helping them build something.”
The lab’s days at Ridgeland Road are numbered as the department prepares to move all of its operations to Bailey Road. The first phase of the relocation project is breaking ground in October 2017 and the Ridgeland team is slated to move into the space by early 2019.
Being the “first” lab at Bailey will be an adjustment as it moves into a larger space adjacent to other testing areas, but is expected to improve communication and workflow as labs come under one roof.
Kelly Brewer is a technical specialist who works at Ridgeland’s chemistry lab. She said she likes the current location because it allows her to do a variety of things.
“I get to work Chemistry, Hematology, and it’s a small enough group that we all get along,” she said. “We’re like our own little family.”
Brewer said she looks forward to relocating, though it will mean changing the way things are now.
“It’s going to be different, but I think it’ll be good,” she said.
Top: Liz Jackson, MT, tracks samples at the Chemistry Laboratory.
Above: Erika De Almeida, MT, reads blood specimen tubes in the Hematology Lab at Ridgeland Road.
An employee from the Department of Pathology & Laboratory Medicine has started a charity drive to collect items to help the victims of Hurricane Maria.
Julia Polidore (pictured at right) is a native of Dominica, a small, independent country in the northeastern Caribbean. Her parents were among those affected by the destructive hurricane early last week.
Polidore has worked in Histopathology for 13 years and is currently a student at the Warner School of Education pursuing her doctorate degree in Education and Human Development.
She explained that Dominica already has a shaky economic infrastructure and widespread poverty.
Her parents pastor two churches that will distribute any donated goods they receive to the local villages.
“Because there is limited access to goods and resources, it’s more than likely that the villages are going to depend on the churches for help,” said Polidore.
She thanked those participating in the collection effort and said it will make a real impact on those in need.
“For me, this is very faith-driven,” she said. “It exemplifies what it means to be the hands and feet to help those who can’t help themselves.
There are five collection barrels where you may drop off any donated items from the list below. Donations will be accepted until Friday, October 13.
Where to Donate
Collection barrels are placed at the following UR Medicine Labs locations:
- Microbiology, Rm. 2-6431 (autoclave room)
- Lab Administration, Suite 2-2100 (break room)
- G-1500 Suite (break room)
- Surgical Pathology, Suite G-5204 (main lobby)
- 77 Ridgeland Road (main lobby)
- Non-perishable food items
- Canned goods & can opener
- Dry beans, rice, flour, sugar
- Garden/agriculture seeds
- Paper products and plastic eating utensils
- Toiletries (especially sanitary napkins, soap)
- Baby items (diapers, formula)
- Flashlight & batteries
- First aid kits
- Clothing (undergarments, all sizes)
For questions or to find out how to make a monetary donation, email Julia_Polidore@urmc.rochester.edu.