TISSUE BANKING :

1. TISSUE BANKING: Standards, Procedures, and Applications

2. Tissue Banking: History Prior to 1980’s, very few active tissue banks existed. • Apart from corneas, storage of human tissue was not common • Tissues for transplantation were scarce • No professional standards and government control meant that effectiveness were uncertain

3. Tissue Banking: History Introduction of Immunosuppressant drugs in the 1980’s led to: • Successful organ transplants • Public support and effective organ donation programs • Paved the way for use of cadaver tissue donations. • Increased availability of tissue allografts • Tissue banks combined with organ and tissue procurement agencies (COPA, UNOS)

4. Tissue Banking: History Early Tissue Banking • Originally managed by surgeons, had many quality control problems • Poor stored tissue quality • Very little disease testing • Poor tracking of tissue sources TMS Involvement Improved Quality of Work • ABO, Rh typing • Improvements in source tracking • Better quality storage equipment • Reputation of blood banking improved community relations and donor pool

5. Tissue Banking: History Government Regulations of Tissue Banks • In 1993, an Interim Rule was implemented by the FDA • Allowed FDA inspection of tissue banks, ability to recall and destroy unsuitable tissues • FDA requirements focused on assuring safety of tissue for transplant, accuracy of medical history and records, proper processing and storage of tissue.

6. Tissue Banking: History Increasing Surgical Demands For Allografts • Demand for bone in hip replacements, femoral head allografts, mending acetabular and femoral defects. • Demands for cadaver skin in burn patients exceeds supply in US, skin imported from Europe to meet demands.

7. Tissue Banking: Applications Apart From Blood, Banked Tissues Include: • Bone, frozen, freeze-dried, and de-mineralized • Corneas • Heart valves • Tendons • Skin • Haematopoetic Tissues, bone marrow and cord blood • Dura mater, ear ossicles, and cartilage, to a lesser degree

8. Tissue Banking: Applications Growth In Tissue Banking • 300,000 bone allografts made annually • 40,000 corneas transplanted annually • 20,000 cadaveric organs transplanted annually • 50,000-100,000 vials of powdered bone in dental practice annually

9. Tissue Banking: Applications Common Clinical Uses For Banked Tissue • Bone allografts used in spinal fusion surgery • Tendon allografts for knee ligament replacement • Heart valves for treatment of congenital heart defect in children • Viable and non-viable skin dressing for burn patients • Powdered bone used in dental repairs • Hematopoetic stem cells and marrow used to replace bone marrow

10. Tissue Banking: Standards Process required for Safe Tissue Transplantation • Donor’s medical and social history – next of kin, physicians, hospital records • Donor blood microbiological testing • Serologic • PCR • Physical examination of cadavers • tattoos • needle marks • other indications of risky lifestyle • Review of autopsy exam results. • Aseptic tissue retrieval.

11. Tissue Banking: Standards Requirements For Donor Selection • National Blood Service require: • HIV 1 & 2 • Hepatitis B & C • serologic testing for syphilis • Non-mandatory tests: CMV, Hepatitis G, and HTLV I & II Various Testing Methods Used to Detect Viruses • Hepatitis B testing for surface antigens • HIV and Hepatitis C detect presence of antibodies to virus • ELISA used for HIV, may not detect donors in seroconversion • PCR used to detect HIV viral nucleotide without depending on antibody response – more sensitive and specific

12. Procedures: ABO, Rh ABO & Rh Typing • Major ABO mismatching can cause rapid graft rejection due to damage by ABO antibodies, causing endothelial damage and thrombosis • ABO matching is important to the success of all vascular tissue grafts – liver, kidneys, heart, lungs, and pancreas ABO/Rh Typing Not Needed For Non-Vascular Tissue Grafts • Fascia • Bone • Heart Valves • Skin • Corneas

13. Procedures: HLA HLA A, B, and Dr Loci are Matched For: • Kidneys and other soft organs when time permits • Bone marrow • Peripheral blood stem cells • Second cornea grafts HLA Matching Not Needed For Non-Viable Tissue • Bone • Tendon • Fascia • Cartilage • Epidermal Dressing

14. Procedures: Bone Collection Collection Procedures • Fresh, autologous bone taken from illiac crest, reduces risk of disease transmission • Allograft bone also collected when conditions make autologous collection in impractical • Can be frozen or freeze-dried, and stored at room temperature for five years • Freeze dried bone is processed to remove marrow and blood, treated with alcohol, and irradiated, resulting in decreased risk of disease transmission • Demineralizing bone makes proteins and growth factors readily available, promoting healing

15. Procedures: Skin Collection Collection Procedures • Allograft skin used as dressing in deep burn patients • Layers of skin 0.015 inch thick are removed • Skin can be stored at 2-8 OC for up to 14 days, in a nutrient and antibiotic broth media • Skin frozen and stored in liquid nitrogen freezer, or at –70 OC. • Tissue stored using Dimethylsulfoxide, 15% Glycerol, or Phosphate Buffered Saline and another Cryoprotective Agent • Thawing depends on freezing media used, some have cytotoxic effects at higher temperatures

16. Procedures: Skin Collection Many Factors Affect Quality Of Skin • Delay in post-mortem collection reduces viability of tissue • Autolytic and enzymatic degradation of tissue allows for enhancement of bacterial load Secondary Concern Is Surface Contamination • Skin primarily collected in mortuary or funeral home. Proper Aseptic Retrieval • Use of sterile drapes • Decontamination of Skin • Operating room techniques • Use of sterile collection containers and instruments

17. Procedures: Skin Collection Normal Skin carries both residual and transient normal flora • Normal flora reduced by transport at low temperatures in a sealed container • Normally placed in an antibiotic transport solution • Transport solution similar to medium used to grow tissue cultures, helps maintain viability of graft

18. Procedures: Heart Valve Collection Collection Procedures • Allografts do not require anticoagulation therapy like mechanical grafts. • Whole Heart aseptically collected in Operating Room or at autopsy. • Aortic and pulmonary valves removed. • Placed in DMSO, frozen in liquid nitrogen for storage

19. Procedures: Infection Control Diseases Transmitted By Transplants: • HIV transmitted by bone and solid organ transplants • Hepatitis transmitted by bone, bone marrow, and other organs • Tuberculosis transmitted by bone and heart valves • Prion diseases transmitted by corneas and dura mater • Rabies has been transmitted by corneas Incidence of Fungal and Bacterial Diseases • Occasionally of donor origin • More commonly, acquired during tissue procurement, processing, or storage

20. Procedures: Infection Control Sterilization of Banked Tissues • Antimicrobial mixtures used must be effective against bacterial and fungal contamination • Ohio Valley Tissue and Skin Center – 0.4 mM L-glutamine, 100 units penicillin, 100 g streptomycin, 200 g kanamycin, 8 mg gentamycin, and 100 g nystatin. • “Reina Sofia” Cordoba Spain – 50 g/ml tobramycin, 50 g/ml co-trimoxazole, 50 g/ml vancomycin, 50 g/ml amphotericin B • In clinical trials, both mixtures were 100% effective against normal flora gram-positive bacteria and had varying degrees of effectiveness against gram-negative and drug resistant gram-positive bacteria. • Against Candida sp., the Reina Sofia mixture was 100% effective, while the OVTSC mixture was shown to be ineffective on all trials.

21. Procedures: UNC Hospitals Frozen Skin at UNC: • UNC Hospitals use tissue banked by OVTSC for skin allograft • Tissues ordered and distributed by the Transfusion Medicine Services • Tissue stored in -70 Degree Celsius Freezer • Collected in 2x8 and 3x8 strips, ordered by square foot ABO, Rh, HLA at UNC • UNC requires ABO/Rh type match on all tissues and organs • HLA match done pre-transplant on kidneys only • HLA match done post-transplant on heart, liver, lungs, and other organs, due to need for rapid transplant of these organs