Resident Manual

Clinical Pathology Resident Rotation in Histocompatibility

General Objectives

The rotation in Histocompatibility (HLA) and Clinical Immunology should equip the Pathology Resident or BB/TM fellow with a complete overview of the role of this laboratory and the testing it performs, in the workup of the various types of patients and donors it serves.  The resident/fellow will learn the essential administrative, laboratory, and clinical aspects of  solid organ and bone marrow transplantation.  The resident/fellow will become familiar with quality control, quality assurance, quality improvement, and ethical issues as they relate to Histocompatibility.  The resident or fellow will become familiar with the various regulatory agencies and requirements that impact on this unit of the laboratory.

The resident/fellow will observe serological and molecular testing done in this laboratory, and will have the opportunity to perform test procedures.  Daily meetings with the Medical Director or the Technical Supervisor are encouraged in order to assist in correlating laboratory procedures with clinical considerations.

The length of this rotation is one month.  Advanced elective rotations are encouraged and can be arranged with the Medical Director and the Program Director.

 ACGME Core Competencies

The ACGME Core Competencies will be incorporated into these goals and objectives and will also be the basis for resident and fellow evaluation during this rotation.  The following summarizes the core competencies.

Patient Care (PC):

• Resident demonstrates a satisfactory level of diagnostic competence and the ability to provide appropriate and effective consultation in the context of pathology services (specifically, Histocompatibility services).

• Resident provides patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

• Resident works with health care professionals, including those from other disciplines, to provide patient-focused care.

Medical Knowledge (MK):

• Resident demonstrates knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care and to pathology (specifically, Histocompatibility).

• Resident demonstrates an investigatory and analytic thinking approach to clinical and pathological situations (specifically, Histocompatibility).

• Resident knows and applies the basic and clinically supportive sciences appropriate to pathology (specifically, Histocompatibility).

Practice-Based Learning and Improvement (PBLI):

• Resident demonstrates the ability to investigate and evaluate their diagnostic and consultative practices, appraise and assimilate scientific evidence and improve their patient care practices.

• Resident locates, appraises, uses, and assimilates evidence and information from scientific studies related to their patients’ health problems.

• Resident applies knowledge of study designs and statistical methods to the appraisal of clinical studies.

• Resident uses information technology to manage information and support their own education.

• Resident facilitates the learning of students and other health care professionals.

Interpersonal and Communication Skills (ICS):

• Resident demonstrates interpersonal and communication skills that result in effective information exchange and teaming with other health care professionals, patients, and their families.

• Resident creates and sustains a therapeutic and ethically sound relationship with patients, colleagues, and other health care professionals.

• Resident uses effective listening skills.

• Resident works effectively with others (including faculty, other residents, nurses, and laboratory staff).

Professionalism (P):

• Resident demonstrates a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

• Resident demonstrates respect, compassion, and integrity; responsiveness to the needs of patients that supersedes self-interest; accountability to patients, colleagues, and the profession; and, a commitment to excellence and on-going professional development.

• Resident demonstrates a commitment to ethical principles pertaining to confidentiality of patient information, informed consent, and business practices.

• Resident demonstrates sensitivity and responsiveness to patients’ culture, age, gender, and disabilities.

Systems-Based Practice (SBP):

• Resident demonstrates an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care and pathology services (specifically, Histocompatibility services) that are of optimal value.

• Resident understands how their pathology services (specifically, Histocompatibility services) and professional practices affect other health care professionals and organizations.

• Resident understands principles underlying the practice of cost-effective health care and resource allocation that does not compromise quality of service or patient care.

Goals for Cognitive Improvement

The following is a specific list of goals and objectives for this rotation.  The resident or fellow should have achieved competency in these areas by the end of the first month of rotation.  Rotations beyond the basic one month will address these goals and objectives in more depth.  The abbreviation of each ACGME Core Competency specific to each goal is noted in parenthesis at the end of each statement.

1. Know the nomenclature and be able to describe the organization and polymorphism of the human major histocompatibility complex (MHC), including HLA class I, II, and III genes. (MK)

2. Understand the basic function, protein structure, and cell expression of HLA class  I and class II gene products. (MK)

3. Understand the role of HLA typing in organ and bone marrow/stem cell transplantation and how HLA antigen mismatching results in allogeneic reactions in recipients. (MK, PC)

4. Understand clinical presentations and laboratory assessment of acute and chronic graft-versus-host disease. (MK, PC)

5. Understand clinical presentations and basic mechanisms of rejection, including hyperacute rejection, acute rejection, and chronic rejection of various organs. (MK, PC)

6. Know HLA typing techniques including serologic methods, microcytotoxicity assays, nucleic acid assays (e.g., sequence-specific primer amplification, direct sequencing, and sequence-specific oligonucleotide hybridization), and lymphocyte culture techniques. (MK, PC)

7. Understand approaches to evaluate the humoral response to transplantation antigens, including crossmatching and panel reactive antibody screens using cell-based methods (cytotoxicity and flow cytometry) and antigen-based methods (ELISA and bead counters). (MK, PC)

8. Understand the association of particular HLA alleles with disease and understand the test procedures used for nontransplant clinical purposes (e.g., to test for HLA-B27 in assessment of disease association or risk). (MK, PC)

9. Demonstrate familiarity with standards for histocompatibility and reporting set forth by United Network for Organ Sharing (UNOS), American Society of Histocompatibility and Immunogenetics (ASHI), National Marrow Donor Program (NMDP), and the College of American Pathologists (CAP). (PC, SBP)

10. Understand the HLA test procedures and protocols used for solid organ transplantation (living and deceased donor workups). (PC, SBP)

11. Understand the procedures, including testing for panel reactive antibodies (PRA), used for the periodic update of patient eligibility. (PC)

12. Understand classification of donor and recipient matching and mismatching, including criteria for unacceptable HLA antigen matches. (PC)

13. Be aware of laboratory tests required to prevent infections spread by transplantation. (PC, SBP)

14. Understand the HLA test procedures and protocols used for hematopoietic stem cell/bone marrow transplantation, including initial evaluation and final donor selection for both related and unrelated donors, and role of identity testing to assess engraftment. (MK, PC, SBP)

15. Understand the HLA test procedures and protocols used for transfusion support, particularly regarding initial evaluation and selection of HLA-matched platelets. (PC)

16. Demonstrate an ability to select appropriate HLA test methodologies. (PC)

17. Demonstrate competence in trouble shooting and resolving technical problems. (PC)

18. Demonstrate an ability to prepare comprehensive HLA test reports that include pertinent information and test interpretation. (PC, SBP, PBLI, ICS)

19. Show an ability to assist requesting physicians in the appropriate use and interpretation of HLA tests. (PC, SBP, PBLI, ICS, P)

20. Understand methods to assess chimerism after stem cell or bone marrow transplant. (MK, PC)

21. Understand methods to test parentage. (MK, PC)

22. Understand how organ transplant patients are tested to assess their immune function. (MK, PC)

23. Understand the basics of platelet antibody testing and its use in conjunction with HLA-matching in evaluating patients who are refractory to platelet transfusion. (MK, PC)

24. Understand management of the histocompatibility laboratory operations, such as the need for emergency typing and crossmatching and laboratory receiving and processing functions. (PC, SBP, PBLI, ICS, P)

25. Be familiar with programs of quality control, quality assurance, and quality improvement for histocompatibility laboratory services. (PC, SBP, PBLI, ICS)

26. Develop an appreciation of the operation of a regional organ procurement organization (OPO) and its relationship with the histocompatibility laboratory. (SBP, PBLI)

27. Be cognizant of the potential paternity implications of tissue typing. (PC, SBP, P)

28. Be familiar with some of the major ethical issues in tissue and organ transplantation (e.g., confidentiality, informed consent, living-related and –unrelated organ donation, demonstration of nonpaternity in typing workups, etc.). (P)

Formal Conferences and Rounds

1. Transplant Grand Rounds
   Generally held monthly by the surgical transplant services.  Check the current schedule.

2. Hematology/Oncology Grand Rounds
   Held weekly by the Division of Hematology/Oncology.  Check the current schedule.

3. Clinical Pathology Conferences
   Held Tuesday and Thursday of each week.  Mandatory attendance is required for the Thursday conference.  Topics vary.  Check weekly schedule.

4. ACGME Core Competency Lecture Series
   This is a monthly conference, generally held on the first Thursday of the month, and attendance is required.  Topics vary and generally cover systems-based practice, professionalism, communication, etc.  This conference is mandatory and any missed lectures can be observed on-line.

5. Other
   A number of other conferences are held throughout the year, such as teleconferences in histocompatibility and transplantation, and will be communicated to the resident when rotating through the laboratory.

Recommended Reading

1. Manual of Molecular and Clinical Laboratory Immunology. 2006

2. HLA: Beyond Tears. 2^nd Edition. Rodey, Glen. 2000.

3. Wang E, Marincola FM, Stroncek D. Human Leukocyte Antigen and Human Neutrophil Antigen Systems. Chapter 138. In, Hoffman, Hematology: Basic Principles and Practice, 4^th edition, 2005.

4. Histocompatibility Laboratory Standard Operating Procedures Manual.

5. ASHI Laboratory Manual, Fourth Edition, 2000.

Resident and Fellow Evaluation

The HLA Laboratory Director will meet with the Pathology resident at the beginning of the rotation to discuss objectives and provide a general orientation to the section.  Periodically the Laboratory Director will meet with the resident/fellow to discuss his/her progress toward meeting objectives, and will make suggestions for improvement if problems are noted.  Any such matters are better discussed as they happen so that they can be corrected, rather than waiting until the end of the rotation.  If at any time the resident/fellow feels that there is a problem or deficiency with the rotation, the resident/fellow should immediately consult the Laboratory Director or the Pathology Program Director or the institution’s resident ombudspersons.  During the last week of the rotation the Laboratory Director will:  1) prepare a written subjective evaluation, noting strong points and/or areas for improvement; 2) review this written evaluation with the resident or fellow; 3) forward a copy of this evaluation to the appropriate Program Director.

Technical Instruction

Resident technical instruction consists of training sessions with the HLA Laboratory staff at the bench.  The resident is expected to observe all of the following tests.  The resident should schedule these sessions with the HLA Laboratory Chief Technologist.  The resident is not expected to become expert in all of these procedures, but is expected to learn principles, uses and applications.  Resident exercises are intended solely for the education of the resident, and any bench work performed by the resident or fellow will not be used for patient care under any circumstances.

Topics To Be Covered

1.  Orientation

• Serological Testing
          HLA A, B, C, DR typing
          Serum Screening
                 - Cytotoxicity
                 - ELISA

• Molecular Testing
          Low resolution HLA A, B, C, DR/DQ typing
          High resolution/allele specific HLA DR/DQ typing

2.  Renal Transplant Recipient Workup

• Living Related Donor
          Serological Testing: HLA A, B, C typing
          Molecular Testing: HLA DR/DQ typing
          Preliminary T and B cell WBC Crossmatch
          Auto-Crossmatch

• Cadaver Donor Recipient Workup
          Serological Testing: HLA A, B, C typing
          Molecular Testing: HLA DR/DQ typing
          Auto-Crossmatch
          Leucocyte Antibody Screen
          Antibody Identification
          Preliminary WBC Crossmatch
          Final WBC Crossmatch
          DTT-Screen & Crossmatch

3.  Cardiac and Liver Transplant Recipient Workups

• Leucocyte Antibody Screen

• Auto-Crossmatch

• Rapid Screen

• Serological Testing: HLA A, B, C typing

• Molecular Testing: HLA DR/DQ typing

• Final WBC Crossmatch

4.  Pancreas Transplant Recipient Workup

• Serological Testing: HLA A, B, C typing

• Molecular Testing: HLA DR/DQ typing

• Leucocyte Antibody Screen

• Auto-Crossmatch

• Preliminary WBC Crossmatch

• Final WBC Crossmatch

5.  Cadaver Donor Workup

• Stat HLA A, B, C, DR typing

• Stat Preliminary & Final Crossmatches

6.  Bone Marrow Transplant Recipient Workup

• Serological Testing: HLA A, B, C typing

• Molecular Testing: HLA DR/DQ typing

• WBC Crossmatch

7.  HLA - Matched Platelet Recipient

• Serological Testing: HLA A, B, C typing

• Leucocyte Antibody Screen: Rapid Screen

8.  Disease Association Studies

• Single Class I Antigen Typing
          HLA B27, B5, A29, A51

  Single Class II Antigen Typing
          HLA DR4
          HLA DQ2/DQ8

SEROLOGICAL TESTS

     Identification of HLA A, B, C & DR antigens on donor & recipient cells
           Patient Lymphocytes (unknown antigens)
        + Anti-HLA Sera (known HLA antibodies)
        + C' & vital dye ®  Cell lysis

2.  Serum Screening

     Identification of antibodies in patient sera directed against HLA antigens
           Panel of normal donor lymphocytes (known HLA antigens)
        + Patient serum (unknown antibodies)
        + C’ & vital dye ®  Cell lysis

• performed periodically (monthly, bimonthly)

• patients' sera tested against lymphocytes from panel of normal donors representing majority of HLA A, B, C, DR antigens

• results = Percent Reactive Antibody (PRA)

     B.  Preliminary Crossmatch (PWXM) (Single serum, single concentration)

Living donor: Lymphocytes from all family members considered as donors, tested against patient sera.

Cadaver donor: Cadaver donor’s lymphocytes tested against sera from all potential recipients (crossmatch tray).

     C.  Final Crossmatch (FWXM) (multiple sera, multiple dilutions)

Living donor: Lymphocytes from selected family member tested against sera from patient.

Cadaver donor: Cadaver donor’s lymphocytes tested against serum samples of potential recipient chosen for transplant.

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