Transforming Diagnostics for Tissue Transplantation

When Ahmed Mostafa, PhD, MD, F(ACHI), joined the Laboratory Medicine Provincial Program as the HIL clinical director in 2019, he made it his goal to validate and introduce Sequence-based high-resolution typing. The lab’s typical workflow used SSO and XR beads, followed by SSP for only HLA-A and B, then reporting based on CWD version 2.00—an onerous process since all the non-excluded alleles were included in the report.

The protocols for high-resolution and deceased donor testing were also challenging for the small team of Laboratory Technologists: turnaround time was four to five hours for deceased donor typing and up to eight weeks for in-house high-resolution typing.

Exploring Advanced Technologies in Response to Growing Patient Demand

In recent years, the Saskatchewan Health Authority HIL has experienced significant changes in demand. Since 2016, the number of adult hematopoietic stem cell patients they are testing has doubled, and the number of pediatric oncology/hematology patients has increased tenfold.

Dr. Mostafa knew that he had a unique and exciting opportunity to transform the lab’s operations to improve diagnostic results and his team’s workload. “My first aim when I joined,” he says, “was to bring Next Generation Sequencing (NGS) into the lab and to do true high-resolution typing.”

His secondary priority to advance diagnostics was to adopt Real-Time PCR for deceased donor typing, a change that would improve lab efficiency and satisfaction within the department.

But just as he began validation of lab’s chosen NGS assay, the unexpected happened: the arrival of the COVID-19 pandemic, which overwhelmed Saskatchewan and the rest of the world.

But Dr. Mostafa was determined to push forward and work with his team of Technologists despite the constraints being experienced with new public health restrictions of travel and a reduced workforce. The validation process would be challenging but necessary if the lab was ever to adopt sequence-based high-resolution typing.

A Rigorous Approach to Assay and Vendor Evaluation

To find the right assay, Dr. Mostafa and his team required criteria by which he and his team assessed different NGS assays.

One key component of his assessment was the analysis software. “Most of the time, the challenge with NGS is not the lab work, it’s the analysis. If you’re working with good, easy software, you can finish the analysis quickly,” says Dr. Mostafa.

Along with the software’s speed and ease of use, he made sure to explore the server requirements of all the assays under evaluation. When choosing an NGS assay, “the first people to talk to are your IT team,” Dr. Mostafa advises. “Some vendors do not have strong IT to support this process. We invited the vendor to speak to our IT group before we decided anything. We wanted to ensure the IT infrastructure of our vendor and SHA Digital Health were in full agreement.”

Clinical Validation in the Time of COVID-19

Dr. Mostafa and his team began testing in November 2020 with a proper validation plan template. Dr. Mostafa took a hands-on role, designing the validation process and even performing the runs when needed.

The Saskatchewan HIL completed validation in early March 2021 and has since gone live with the assay.

The Benefits of Better Testing Capabilities for the Lab, the Clinic, and the Patient

Dr. Mostafa and his team have invested many long hours into modernizing the HIL testing protocol, but the results are starting to pay off. “In the last year,” he says, “the lab has been transformed. It’s a 180-degree difference.”

Previously, with low-resolution typing, one technologist would take a day to complete typing for two or three loci.

The Real-Time PCR method for HLA typing is currently considered the gold standard for HLA typing for deceased donors. HLA typing by Real-Time PCR can be performed in 90 minutes, a much shorter turnaround time than their current testing protocol. This will significantly reduce the cold ischemia time for solid organ donation.

Meanwhile, the sequence-based high-resolution tests are getting rave reviews from his partners at transplant clinical centers, who are receiving faster results that allow for deeper insights into the patient’s level of risk.

The lab staff is also enjoying the benefits of a faster, easier, and more efficient workflow. This enables the diagnostic testing capacity to expand as transplant numbers increase which decreases stress of workload processing within the lab.

Now that Dr. Mostafa and his team have more time, they’re strategizing the next step towards becoming a full transplantation lab offering pre- and post-transplant risk assessment with tests like B-HOT panel, non-HLA antibody detection, engraftment monitoring, and KIR for both hematopoietic and solid organ recipients.

They’re also planning for a future where the Saskatchewan Health Authority HIL will be a reference and educational lab that welcomes fellows from all over Canada for rotations.