Rapid desensitization through immunoadsorption during cardiopulmonary bypass. A novel method to facilitate human leukocyte antigen incompatible heart transplantation

BACKGROUND

Anti-human leukocyte antigen (HLA)-antibody production represents a major barrier to heart transplantation, limiting recipient compatibility with potential donors and increasing the risk of complications with poor waiting-list outcomes. Currently there is no consensus to when desensitization should take place, and through what mechanism, meaning that sensitized patients must wait for a compatible donor for many months, if not years. We aimed to determine if intraoperative immunoadsorption could provide a potential desensitization methodology.

METHODS

Anti-HLA antibody-containing whole blood was added to a Cardiopulmonary bypass (CPB) circuit set up to mimic a 20 kg patient undergoing heart transplantation. Plasma was separated and diverted to a standalone, secondary immunoadsorption system, with antibody-depleted plasma returned to the CPB circuit. Samples for anti-HLA antibody definition were taken at baseline, when combined with the CPB prime (on bypass), and then every 20 min for the duration of treatment (total 180 min).

RESULTS

A reduction in individual allele median fluorescence intensity (MFI) to below clinically relevant levels (<1000 MFI), and in the majority of cases below the lower positive detection limit (<500 MFI), even in alleles with a baseline MFI >4000 was demonstrated. Reduction occurred in all cases within 120 min, demonstrating efficacy in a time period usual for heart transplantation. Flowcytometric crossmatching of suitable pseudo-donor lymphocytes demonstrated a change from T cell and B cell positive channel shifts to negative, demonstrating a reduction in binding capacity.

CONCLUSIONS

Intraoperative immunoadsorption in an ex vivo setting demonstrates clinically relevant reductions in anti-HLA antibodies within the normal timeframe for heart transplantation. This method represents a potential desensitization technique that could enable sensitized children to accept a donor organ earlier, even in the presence of donor-specific anti-HLA antibodies.

Lung transplantation in an 18-month-old with donor specific antibodies - The use of intraoperative, targeted plasma exchange

BACKGROUND

Sensitised patients undergoing Human Leukocyte Antigen-incompatible transplantation are at increased risk of hyperacute rejection and may be predisposed to antibody-mediated rejection, chronic lung allograft dysfunction and higher mortality.

CASE

We present a case of primary lung transplantation in the setting of late identification of donor specific antibodies treated with intraoperative target plasma exchange. The patient was treated with fresh human plasma to a final volume of 1.5 times the patient's systemic circulation. From a pre-transplant mean fluorescence intensity of 5002, donor-specific antibodies were undetectable following plasma exchange on single antigen bead assay.

CONCLUSIONS

This method represents a potential desensitisation technique for use in the intraoperative period.

Leadership and the everyday practice of Consultant Radiographers in the UK: Transformational ideals and the generation of self-efficacy

INTRODUCTION

This paper outlines findings from a broader, two-year project investigating the role of Consultant Radiographers (CRs) in the UK, focussing specifically on the leadership aspect of that role.

METHODS

Using a qualitative-thematic approach, the leadership-related experiences of a purposive sample of six participating CRs are explored, alongside the systems through which they evaluated how successful they had been as leaders.

RESULTS

It is evidenced that many of the ways in which participants describe their own leadership practice, particularly in the intra-team domain, is consistent with the precepts of the Transformational Leadership Model. For example, they highlight how they have asserted positive influence and encouraged collective action and decision-making. However, the experiential focus of the analysis reveals that in specific examples of practice, the transformational approach was not always seen as the most useful route to a productive outcome given constrictions on time and other resources within real professional environments. More 'direct' managerial approaches were sometimes deemed necessary, and at others leadership was reduced to simply 'solving other people's problems'. It was also found that the manner in which participants evaluated their own success as leaders was a practical concern, based in part upon having satisfied 'hard' institutional goals, but also on the more personal business of having affirmatively 'surprised' oneself, or a general sense of feeling trusted by colleagues.

CONCLUSION

These findings may help support CRs in the business of real leadership, not least through better understanding how even apparently mundane outcomes can have significant impacts on professional self-efficacy.

The role of competence and capacity in relation to consent for treatment in adult patients

Obtaining informed consent for dental and medical treatment is a fundamental ethical and legal responsibility for all clinicians. It is an opportunity for patients to have healthcare that is based on their informed choice. The assessment of a patient's competence is an essential part of the consent process and clinicians need to be aware that patients can be misunderstood and wrongly deemed incompetent. This paper aims to aid the clinician to better understand the concept of patient competency and capacity in relation to obtaining valid consent.

Developmental toxicity study in rats and rabbits administered an emulsion containing medium chain triglycerides as an alternative caloric source

Triglyceride-containing lipid emulsions have been designed as caloric sources that can be administered intravenously to patients that cannot meet their nutritional needs by conventional parenteral therapies. In their study, we evaluate the developmental toxicity of a 20% lipid emulsion that contains a 3:1 ratio of medium chain triglyceride (MCT) to one long chain containing lipid emulsion (LCT). This emulsion was administered by intravenous infusion to rats and rabbits at dosages of 1 and 4.28 g lipid/kg body weight (g lipid/kg) at dose volumes of 5 and 21.4 mL/kg, respectively, once daily during organogenesis to assess the potential developmental toxicity of the test article. The control group received 0.9% saline at a dose volume of 21.4 mL/kg. Animals were observed for clinical signs of toxicity and adverse effects on body weights and feed consumption. On Day 20 (rats) or Day 29 (rabbits), females were necropsied and examined for maternal and embryo/fetal toxicity. Fetuses were removed, weighed, and examined for external, soft tissue, and skeletal abnormalities. Dosages of 4.28 g lipid/kg resulted in lower feed consumption for rats and rabbits, an expected finding based on the high-caloric nature of the test article. Potentially test article-related gross necropsy findings, including enlarged lymph nodes and spleen, small thymus, and enlarged renal pelvis, for rats given 4.28 g lipid/kg were present at a low incidence. There were no adverse effects on fetal parameters for rats even in the presence of some maternal toxicity. However, embryo and fetal toxicity (i.e., resorptions) and skeletal abnormalities were present for rabbits given 4.28 g lipid/kg. Under the conditions of this study, the no-observable-effect level for developmental toxicity was greater than or equal to 4.28 g lipid/kg for rats and greater than or equal to 1 g lipid/kg but less than 4.28 g lipid/kg for rabbits.

Three-generation reproduction study with dioctyl sodium sulfosuccinate in rats

Groups of 30 male and 30 female rats (F0) were fed diets containing 0, 0.1, 0.5, or 1.0% dioctyl sodium sulfosuccinate (DSS) for 10 and 2 weeks, respectively. The F0 animals were then mated to produce an F1 litter. Groups of 30 male and 30 female F1 animals were fed the same dose levels for at least 10 weeks postweaning, and the breeding program was repeated to produce F2 animals. F3 animals were produced from F2 animals by the same procedure. The study was terminated with the F3 weanlings. Test diets were fed continuously throughout the study. All F0, F1, and F2 adults and F3 weanlings (one/sex/litter) were necropsied and given a macroscopic examination. There were no effects on reproductive function for parental animals of either sex during any of the three generations in this study. At the highest dose level (1.0% DSS), body weights were lower than those of controls during the premating phase for males in all three generations and for F1 and F2 females. Body weights for F1 and F2 males and females in the 0.5% dose group were also low during the premating phase. Pup weights on Lactation Day 0 were significantly lower than those of controls only for the high-dose group during the third generation. However, lower pup weight gains in the mid- and high-dose groups resulted in significantly lower pup weights on Day 21 for all three generations. Perinatal pup survival across three generations ranged from 96 to 100% for the control and treated groups. Pup survival ranged from 95 to 100% for controls, from 98 to 100% for low- and mid-dose groups, and from 91 to 99% for the high-dose group. There were no treatment-related mortality and antemortem or macroscopic observations. In summary, DSS administered in the diet to three successive generations of rats at levels of 0.5 and 1.0% caused a reduction in body weights for parental males in all generations and for F1 and F2 females. Pup weights at the 0.5 and 1.0% dose levels were also lower than those of the control in all three generations. However, the reduced body weights did not interfere with development of normal reproductive performance. DSS at levels up to 1.0% had no effects on the reproductive function of either sex in any generation and produced no treatment-related antemortem or macroscopic observations.