Transplant Immunology: Innovation at its best

Kenyatta National Hospital is a world-class patient-centered specialized care hospital.

By Kilivwa Mukaya

Its primary mission is to optimize patient experience through innovative, evidencebased specialized healthcare, facilitate training and research, and participate in national health policy formulation.

In line with our mission of improving our services through innovation, the department of Laboratory Medicine, on the realization that molecular medicine was shaping up as an important technological advancement in diagnostic services, endeavored to keep pace with the emerging trend.

Among the training opportunities projected in the departmental annual training projection of FY 2010/2011, was Molecular Medicine.

One staff member Kilivwa J S Mukaya secured an opportunity to pursue a Master of Science degree in Molecular Medicine. This opened the avenue towards achieving the intended goal by the department.

Molecular medicine is a broad field, where physical, chemical, biological, bioinformatics, and medical techniques are used to describe molecular structures and mechanisms, identify fundamental molecular and genetic errors of disease, and develop molecular interventions to correct them.

The molecular medicine perspective emphasizes cellular and molecular phenomena and interventions rather than the previous conceptual and observational focus on patients and their organs.

In 2012, the Renal Team under the late Dr. Antony Were, who was then the Head of Renal Unit, was faced with the challenge of establishing HLA Tissue Typing services.

This was a big issue because all patients projected for Kidney Transplantation could not access these services locally. All the compatibility tests were referred either to South Africa or India. This process delayed interventional time. It also increased the cost of carrying out this transplantation procedure.

The cost of putting up and equipping a Transplant Immunology laboratory is prohibitive.

Furthermore, this concept was new in the country and Africa as a whole, save for South Africa and part of North Africa.

Proposals were done for funding through Private Public Partnership (PPP) without success. In 2015, the Africa Development Bank in partnership with the East African governments embarked on the establishment of Centres of excellence in East Africa.

Kenya was picked to host the East Africa Kidney Institute (EAKI). This came as a blessing to the aspiration and desire to have a Transplant Immunology Laboratory within our locality.

As per the plan, the current Renal Unit would be improved to offer specialized services as well as train on behalf of EAKI. Part of the funds released for batch one equipment was used to procure LUMINEX machine, a critical equipment in HLA Tissue Typing analysis.

Mr. Alphonce Kioko, validating HLA typing assay using the LUMINEX fluoroanalyzer machine

PHOTO | COURTESY

Installed LUMINEX Fluoroanalyzer for HLA Tissue Typing

A further request was made to the project to release more funds to procure the accompanying equipment and accessories required for comprehensive analysis of HLA Typing and Antibody Detection. This request was honored in 2019 when equipment and molecular-based reagents kits were procured for this facility.

Initially, there was a big challenge on space to accommodate the laboratory as well as the cost of putting up the facility.

The hospital identified several possible locations, but finally, the current space within Renal Unit was adopted for renovation.

Luckily, at this moment in time, the hospital was also undergoing reorganization. The coming into office of Dr. Evanson Kamuri, EBS as the new Chief Executive Officer, Kenyatta National Hospital, was a boost to the Renal Team’s effort to actualize the dream of establishing the HLA Tissue Typing service within the hospital.

He breathed in a new impetus to the project. He sourced funds, that were pumped into the renovation exercise. The renovation works were completed by end of 2019.

Requirements for a molecular laboratory are unique. The laboratory has the following features;

Controlled air circulation, controlled access features, smoke detectors, negative pressure, unidirectional workflow, epoxy floor covering, gypsum ceiling, granite benches, sufficient sinks, and working space among others.

The laboratory has been compartmentalized into seven unique work-stations, that is, the general working area, refrigeration (-80 deep freezer and fridges), consumables store (room temperature), DNA extraction room, Amplification room, Luminex machine room, and Complement Dependent Cytotoxicity (CDC).

A kidney transplant is a surgical procedure to place a healthy kidney from a living or deceased donor into a person whose kidneys no longer function properly.

The kidneys are two bean-shaped organs located on each side of the spine just below the rib cage. Each is about the size of a fist. Their main function is to filter and remove waste, minerals, and fluid from the blood by producing urine. When your kidneys lose this filtering ability, harmful levels of fluid and waste accumulate in the body, which can raise blood pressure and result in kidney failure (end-stage kidney disease). The end-stage renal disease occurs when the kidneys have lost about 90% of their ability to function normally.

The Renal Unit department, KNH, has a team of specialized kidney doctors who work hand in hand with their peers from the University of Nairobi in the management of patients. Their effort to achieve maximum success is hampered by delays in the preparation process before grafting is done.

According to Dr. John Ngigi, a nephrologist and Senior DirectorKenyatta Prime Care Clinic, KNH handles 130 patients that receive dialysis treatment. On average, approximately 260 patients require transplantation every year.

Ms. Nancy Wangombe, a Kidney Transplant co-ordinator attributes the low number of transplant operations to the unavailability of HLA Tissue Typing services locally. She is upbeat that the number is set to increase upon commencement of the transplant immunology tests within Kenyatta.

The Ultra-modern facility has competent staff who are up to the task. Dr. Anne Baraza (Immunologist) and Dr. Kassim Ali (clinical pathologist) are leading the team.

Other players include Kilivwa J S Mukaya, Patricia Nabende, Alphonce Kioko, Jeniffer Mutua, and Mishack Kirimi. Kilivwa J S Mukaya and Alphonce Kioko further attended Observership training in an HLA Tissue Typing Laboratory at Apollo Hospital, India. The two, later on, attended a two-week LUMINEX Machine-User Training at Immucor Company, Georgia-Atlanta.

With the know-how and thestate-of-art equipment available coupled with the goodwill from our collaborating partners, this important facility is set to be rolled out soon.

This will come as a relief to our customers because our Turn Around Time (TAT) has been projected to be 24 hours. Our charges have been greatly subsidized compared to what our clients have been paying out there.

As a hospital, we will endeavor to live up to our vision and mission in order to continuously improve on our services and meet the client expectations. This new facility will remain as a living testimony.

Temperature-controlled centrifuges important equipment in a molecular laboratory

PHOTO | COURTESY

For a start, the following services shown below will be available;

TEST PROPOSED CHARGE PER TEST

1 HLA-A 2 HLA-B 3 HLA-C 4 HLA-DR 7,900 7,900 8,900 7,900

5 HLA-DQ 7,900

6 HLA-DP

7,900 7 Class I&II Antibody 5,500

8 Class I ID Antibody Detection 12,700

9 Class II IDv2 Antibody Detection 12,100

10 Donor Specific Antibody Detection 5,500

11 Single Antigen Class I Detection 23,900

12 Single Antigen Class II Detection 20,300

13 Single Antigen MIC Antibody Detection 12,500

14 Complement dependent Cytotoxicity 11,500