​​​​​ MLT`s Michael Naglich and David Kramer
MLT`s Michael Naglich and David Kramer are two examples of medical laboratory technologists who are making a difference in patients` lives. (Photo: UHN)

This is the final installment of a three-part series highlighting the Laboratory Medicine Program's
critical role in providing quality patient care. 

When it comes to organ donation, many factors are involved in ensuring a successful outcome. One of those key factors resides in the lab.

At University Health Network, it all begins with the Laboratory Medicine Program (LMP). It  plays a key role in ensuring that the clinician and patient have the testing information they need to move forward in their care.

But, with a test menu that includes thousands of tests, LMP has a responsibility to evaluate which tests are being ordered and when, and to examine whether changes might need to be made to certain orders.

In LMP's Histocompatibility and Immunogenetics Laboratory (HLA Lab for short), the laboratory staff is essential in determining compatibility of potential organ donors and recipients.

In humans there is a specific group of proteins called human leukocyte antigens (HLA); the more HLA antigens shared between a recipient and donor, the better the potential outcome of the transplantation.

Monitoring risk of rejection

Additionally, some recipients have pre-formed antibodies to certain HLA antigens conferring a high risk of rejection. The HLA lab is responsible for identifying the unique HLA types of donors and recipients, and monitoring these recipient antibodies in order to help the transplantation group find the best possible donor and improve the chance of successful transplant.

As with all other areas within laboratory medicine, the HLA Lab employs a "right test, right time, test strategy" said Brad Davis, Executive Director, Laboratory Medicine Program.

This means that each laboratory test is evaluated to ensure that it will deliver clear, actionable results to the physician in a way that will be most meaningful to the patient's care.

Improvements shared

What makes the HLA lab unique is that every improvement and change isn't just focused in our own HLA lab, but is also shared with HLA laboratories across the country.

"The HLA community is all about collaboration," said Dr. Kathryn Tinckam, co-director, HLA laboratory, LMP. "We have a loyalty to our discipline, so when we work on finding efficiencies, getting a better result for a patient or saving some money, we share it across the community – Canada wide."

In addition to serving as co-director of UHN's HLA laboratory, Tinckam is also co-Chair of the National HLA Collaboration Committee with representation from all 14 Canadian HLA Labs.

They review challenges in testing, collaborate on new test methodologies, share efficiency tools, and provide testing support to each other for evaluation of difficult cases.

Pushing beyond the status quo

In addition, the group is charged with setting and adhering to national HLA testing standards for testing and interpretation (which is unique in the HLA community specifically for the purpose of facilitating a national organ sharing network.)

"In HLA, we never settle for the status quo. We're a lab where many of our procedures are 'homegrown' rather than using commercial reagents, and centred on our unique patient population," added Tinckam.

"When we find something that works, I love being able to share our success with the HLA labs around the country and in turn hearing the ways that they have discovered that can help our patients, and our laboratory," he continued.

To illustrate…

A recent example that our HLA lab has shared with the broader community involved modification of a standard procedure to reduce reagent use when assessing a specific immune response for potential donors.

This modification, developed by lab technologist David Kramer, uses a type of plastic bead that bears similar antigens to the donor organs and provides a way of predicting the potential antibody response of a recipient.

In the assay, Kramer looks to see how the sample reacts to these foreign antigens and makes a diagnosis of which donor antigens identify a higher risk recipient.

Using a systematic validation plan, Kramer created a series of dilutions and measured them against the historical data in order to see just how much of the bead was needed. (Spoiler alert: Significantly less than the manufacturer suggested!).

He also took into account that while a dilution may use less product, it may take more time for the equipment and technologist to read, so he knew it was important to find a balance between the cost of the product and the cost of staff time.

Kramer has also developed an algorithm for analysis of these very complex antibodies which he has shared regionally in Ontario.

"We use reagents everyday – it's part of our standard workflow – but I think part of my job is trying to find ways to 'disrupt' the standard workflow and find new and better ways to do something," said Kramer.

"With these modifications, I wanted to ensure we were getting the most accurate data back to the physician and patient regarding transplant, in a way that was also as efficient as possible. I am empowered by our medical and management team to find the best system and I found it," he added.

"I am empowered by our medical and management team to find the best system and I found it." –David Kramer, UHN lab technologist

Michael Naglich, another technologist, modified a high-throughput HLA typing method (RSSO) to be used on a single donor, thereby allowing it to be used in the deceased donor transplant setting.

In doing so, there was a reduction in up to 2 hour​s for determining the deceased donor HLA type (thereby speeding up the time-sensitive allocation of precious organs), an increase in the resolution of the typing result and significant cost savings over the course of a year.

After repeated validations and testing, the new procedure that Naglich developed was put into practice in the HLA lab and through the National HLA Advisory Committee it's being shared by other labs across the country.

"It was really great to be able to bring this 'home grown' procedure to the Canadian group for their review," said Tinckam. "Knowing we have saved UHN money is great, but being able to tell the leaders of labs all across the country about it and save their institutions money, while delivering a superior test result, is truly what makes us a collaborative group." 

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