Long-term ex situ normothermic machine perfusion allows regeneration of human livers with severe bile duct injury.

Bile duct regeneration is hypothesized to prevent biliary strictures, a leading cause of morbidity after liver transplantation. Assessing the capacity for biliary regeneration may identify grafts as suitable for transplantation that are currently declined, but this has been unfeasible until now. This study used long-term ex situ normothermic machine perfusion (LT-NMP) to assess biliary regeneration. Human livers that were declined for transplantation were perfused at 36 °C for up to 13.5 days. Bile duct biopsies, bile, and perfusate were collected throughout perfusion, which were examined for features of injury and regeneration. Biliary regeneration was defined as new Ki-67-positive biliary epithelium following severe injury. Ten livers were perfused for a median duration of 7.5 days. Severe bile duct injury occurred in all grafts, and biliary regeneration occurred in 70% of grafts. Traditional biomarkers of biliary viability such as bile glucose improved during perfusion but this was not associated with biliary regeneration (P > .05). In contrast, the maintenance of interleukin-6 and vascular endothelial growth factor-A levels in bile was associated with biliary regeneration (P = .017 for both cytokines). This is the first study to demonstrate biliary regeneration during LT-NMP and identify a cytokine signature in bile as a novel biomarker for biliary regeneration during LT-NMP.

A novel magnetic bead-based immunoprecipitation method for anti-dense fine speckled 70 antibodies.

The indirect immunofluorescence assay (IIFA) on HEp-2 cells has been widely used for screening anti-nuclear antibodies (ANA) that are associated with systemic autoimmune rheumatic diseases (SARD). Sera containing ANA display multiple distinct fluorescence patterns on HEp-2 cells. Among them, a dense fine speckled (DFS) pattern caused by anti-DFS70 antibodies has been reported to have higher prevalence in healthy individuals than in patients with SARD. This DFS pattern is often difficult to distinguish amongst other SARD-associated ANA patterns, in particular a mixed homogeneous and speckled pattern. Furthermore, a strong DFS pattern can mask other SARD-associated patterns. Hence, we developed a novel immunoprecipitation method using magnetic beads to remove anti-DFS70 antibodies in serum prior to running IIFA. We also aimed to confirm the presence of anti-DFS70 and to uncover any SARD-associated ANA patterns masked by a strong DFS pattern. The sera used in our study were from 70 individuals who had routine ANA screen, of which 35 sera had an isolated DFS pattern with monospecific anti-DFS70 antibodies confirmed by a complementary assay, and 35 were control sera without a DFS pattern. An immunoprecipitation method using magnetic beads coated with recombinant human full length DFS70 protein was developed. The performance of this new method was evaluated in comparison to an immunoadsorption method using the same DFS70 protein. Our newly developed immunoprecipitation method demonstrated excellent sensitivity (91.4%) and specificity (100%) in confirming the DFS pattern associated with anti-DFS70 in sera. Additionally, our method was able to remove anti-DFS70 and uncover SARD-associated ANA patterns masked by a strong DFS pattern. It also showed a clearer background on IIFA than that of the immunoadsorption method. The novel magnetic bead-based immunoprecipitation method demonstrated satisfactory performance in removing anti-DFS70 without interfering with the detection of other antibodies. It can be easily integrated with IIFA to confirm anti-DFS70 associated DFS pattern. Additionally, it can simultaneously unmask other ANA patterns, which cannot be achieved by a conventional protocol that requires a complementary anti-DFS70 specific assay to be performed. Therefore, the novel method provides a more effective and accurate solution for ANA screening.

Serum protein electrophoresis and rheumatoid factor analysis is an effective screening strategy for cryoglobulinaemia.

Accurate serum cryoglobulin detection is important to allow prompt treatment but laboratory testing requires stringent pre-analytical conditions and has long turnaround times. Serum protein electrophoresis (EPG) for paraproteinaemia and rheumatoid factor (RF) analysis may offer an effective initial screening strategy for the presence of cryoglobulinaemia. We retrospectively assessed the sensitivity of ancillary EPG and RF testing for the presence of serum cryoglobulinaemia in 586 eligible cryoglobulin positive samples received at the Royal Prince Alfred and Liverpool Hospital immunopathology laboratories over an 11-year period. Ninety-one percent of all cryoglobulin positive samples had either a detectable paraprotein or RF activity, with greatest sensitivity for type I and type II cryoglobulins (97% and 98%, respectively). The sensitivity remained high irrespective of whether EPG and RF analysis was performed with the same, or different, pre-analytical collection conditions to the cryoglobulin collection (92% vs 90%, p=0.46). Only two patients with detected cryoglobulins and no associated paraprotein or RF activity had clinical features of cryoglobulinaemia and neither required treatment. This study demonstrates that serum EPG and RF analysis has high sensitivity for the detection of clinically relevant cryoglobulinaemia, even when not collected under ideal pre-analytical conditions, and potentially offers a prompt and effective screening strategy.

Intravenous immunoglobulin infusion contributes to a high incidence of false reactive screen results for human T-lymphotropic virus.

Intravenous immunoglobulin (IVIg) has been increasingly used to treat immunodeficiencies and inflammatory disorders. However, IVIg has also been shown to affect a wide range of laboratory testing, including human T-lymphotropic virus (HTLV) screening. Our laboratory frequently observes false reactive HTLV screens from patients receiving IVIg infusions, however the extent of IVIg contribution to the false reactivity has not been extensively investigated. The objective of this study was to explore the prevalence of HTLV-1/2 infection in patients from the Sydney metropolitan area and evaluate the positive predictive value for HTLV screening test in sera from patients with or without IVIg infusions. HTLV screening test results from sera of 3843 patients referred to Central Sydney Immunology Laboratory between June 2006 and May 2021 were retrospectively analysed. Among 72 (1.9%) sera reactive on screening enzyme-linked immunosorbent assay (ELISA), 62 (86.1%) were from patients receiving IVIg infusions, including 60 collected post-IVIg and two collected pre-IVIg infusions. Only two (3.3%) of the 60 post-IVIg sera were positive on confirmatory western blot. In contrast, in non-IVIg sera, five (50.0%) from the 10 screen-reactive sera were positive on western blot. If positive western blot is used as the reference for determining 'true' HTLV infection, we found the positive predictive value of HTLV screening ELISA in sera collected post-IVIg (3.3%) is considerably lower than that in non-IVIg and pre-IVIg sera (41.7%). The vast majority of false reactive screen results (89.2%) in our study cohort were from sera collected post-IVIg infusion. Our study suggests that the high incidence of falsely reactive results in HTLV screening ELISA could be attributed to IVIg infusion. Hence, collection of sera from patients on IVIg should be avoided and screen-reactive results should be interpreted with greater caution, particularly for patients from non-endemic areas.

A cost-effective sample pooling strategy for line blot assay in detecting onconeural antibodies.

BACKGROUND: Onconeural antibodies are a group of autoantibodies present in patients with paraneoplastic syndromes (PNS), and are indicative for underlying malignancies. The use of indirect immunofluorescence assay (IFA) as the sole screening method for onconeural antibodies without line blot assay (LBA) could potentially miss a significant population of patients with PNS. However, testing each serum individually on LBA will pose significant economical and labour burdens to clinical laboratories. Based on the screening result from IFA, we developed a cost-effective pooling strategy for the detection of onconeural antibodies on LBA. METHODS: Results of onconeural antibodies tested by IFA and LBA from 1887 serum samples received in the Central Sydney Immunology Laboratory were retrospectively analysed. Sera were pre-screened by IFA before proceeding to LBA. Sera with positive staining on IFA were tested individually on LBA while sera with negative IFA were examined by pooling. Agreements of antibody reactivity against onconeural antigens were evaluated for sera run by pooling and by individually. The estimate of the cost saving was also conducted for the pooling strategy. RESULTS: Antibody reactivity to each specific onconeural antigen from pooling run had over 95% qualitative result agreement with sera run individually on LBA. An excellent correlation (r = 0.88) of positive reactions quantitated by band signal intensity was also observed. Using our well-established sera pooling strategy for LBA, a cost saving of 50.1% was achieved for reagent alone. CONCLUSIONS: The sera pooling strategy for LBA is a reliable and cost-effective approach for testing low prevalence diseases such as PNS.

Improved performance of confirmatory assays for detecting dense fine speckled (DFS) 70 antibodies.

The presence of monospecific dense fine speckled 70 (DFS70) pattern in indirect immunofluorescence assay (IFA) without concomitant systemic autoimmune related diseases (SARD)-associated antibodies could be an exclusion biomarker for SARD. Since interpretation of DFS pattern on IFA is subjective, an assay for confirming the presence of anti-DFS70 is required. We evaluated the performance of two commercial assays [fluorescence enzyme immunoassay (FEIA) and line immunoassay (LIA)] for detecting anti-DFS70. Sera with monospecific DFS (n=176) and without DFS (n=179) pattern from referred patients for ANA testing, in two independent laboratories and healthy donors, were investigated for anti-DFS70 by FEIA (Phadia EliA) and LIA (Euroimmun). The assay performance including sensitivity and specificity at different cut-offs was evaluated, and optimal cut-offs were determined. The newly established optimal cut-offs (2.7 U/mL on EliA, band intensity of 28 on LIA) showed significantly better assay performance in detecting anti-DFS70 and confirming monospecific DFS pattern. A relative sensitivity of 93.7% with relative specificity of 100% on EliA and a relative sensitivity of 96.6% with relative specificity of 95.3% on LIA were achieved. Superior Cohen's Kappa agreements with IFA were also achieved for both assays (0.936 for EliA and 0.906 for LIA). Application of an optimal cut-off can significantly increase the assay performance for anti-DFS70 and enhance the accuracy in reporting DFS pattern by IFA.