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.”