1. INTENDED USE BD Simultest™ Leucogate™ (CD45/ CD14) is a two-color direct immunofluorescence reagent for establishing an optimal lymphocyte gate for immunophenotyping of erythrocytelysed whole blood (LWB). BD Simultest Leucogate is for in vitro diagnostic use with BD in vitro diagnostic reagents. See the appropriate BD in vitro diagnostic package insert for additional information. BD Simultest™ Leucogate™ (CD45/CD14) For lymphocyte gating and quality control in immunophenotyping 50 Tests—Catalog No. 342408 2. SUMMARY AND EXPLANATION 3/2014 Immunophenotyping of human lymphocytes by flow cytometry can employ Leucogate, a negative control, and one or more monoclonal antibody reagents reactive with lymphocyte cellsurface antigens. BD Simultest Leucogate reagent is used to create a light-scatter analysis gate around the lymphocytes. Gating is necessary because monoclonal antibody immunophenotyping reagents can react not only with lymphocytes but also with nonlymphocytes in LWB preparations. BD Simultest Leucogate permits the gated cells to be characterized and enumerated, thereby permitting quality control evaluation of the data. Nonlymphocyte components of LWB that can contaminate the lymphocyte analysis gate include monocytes, granulocytes (neutrophils, eosinophils, basophils), and debris (residual erythrocytes, erythrocyte ghosts, and platelets).1 23-5297-02 IVD BD, BD Logo and all other trademarks are property of Becton, Dickinson and Company. © 2014 BD Becton, Dickinson and Company BD Biosciences 2350 Qume Drive San Jose, CA 95131 USA Benex Limited Pottery Road, Dun Laoghaire, Co. Dublin, Ireland Tel +353.1.202.5222 Fax +353.1.202.5388 BD Biosciences European Customer Support Tel +32.2.400.98.95 Fax +32.2.401.70.94 [email protected] Becton Dickinson Pty Ltd, 4 Research Park Drive, Macquarie University Research Park, North Ryde NSW 2113, Australia NOTE For additional information and an overview of human lymphocyte immunophenotyping, see the appropriate BD in vitro diagnostic immunophenotyping reagent instructions for use (IFU). Becton Dickinson Limited, 8 Pacific Rise, Mt. Wellington, Auckland, New Zealand bdbiosciences.com [email protected] 1 gating efficiency by determining the number of lymphocytes within the gate compared to total lymphocytes in the sample. 3. PRINCIPLES OF THE PROCEDURE When monoclonal antibody reagents are added to human whole blood, the fluorochrome-labeled antibodies bind specifically to antigens on the surface of leucocytes. Monoclonal antibodies can be used to identify lymphocyte subpopulations. The percentage of each identifiable nonlymphocyte contaminant included in the lymphocyte gate can also be determined for quality control purposes. The maximum allowable percentages of nonlymphocytes that can be included in the gate are 3% monocytes, 6% granulocytes, and 10% debris events. Values greater than these limits will be flagged by the software. An aliquot of the stained patient sample is introduced into the flow cytometer and passed in a narrow stream through the path of a laser beam. The stained cells fluoresce when excited by the laser beam and the emitted light is collected and processed by the flow cytometer. We also recommend using BD Simultest™ Control γ1/γ2a (IgG1 FITC/IgG2a PE) and BD Simulset software to set fluorescence 1 (FL1) and fluorescence 2 (FL2) markers around the negative lymphocyte population and to assess the amount of nonantigen-specific binding (nonspecific staining) present, particularly that caused by Fc receptors. We recommend using BD Simultest Leucogate with BD Simulset™ software to establish a lymphocyte analysis gate that includes greater than or equal to 98% of the normal mature (nonblast) lymphocytes in the sample. However, if the gate contains greater than 3% monocytes, the software automatically reduces or tightens the light-scatter gate to collect greater than or equal to 95% of the lymphocytes contained in the sample. 4. REAGENTS Reagents Provided, Sufficient for 50 Tests The BD Simultest Leucogate reagent, sufficient for 50 tests, is provided in 1 mL of buffered saline with gelatin and 0.1% sodium azide. It contains FITC-labeled CD45 (Anti–HLe-1), clone 2D1,2-4 for identification of leucocytes, and PElabeled CD14, clone MϕP9,5-7 for identification of monocytes. The fluorescein-to-protein ratio (F:P) for BD IgG monoclonal antibody reagents is 2 to 5. The F:P ratio for CD45 (Anti– HLe-1) FITC has been optimized for its intended use. The process by which the BD Simultest Leucogate tube data is analyzed is a multistep procedure (see Figure 1). The procedure is performed automatically with BD Simulset software, but can also be performed manually with BD CONSORT™ 30 or BD LYSYS™ II software (see the captions of Figure 1 to set gates manually). Quality control criteria for the lymphocyte analysis gate require that greater than or equal to 95% of all the lymphocytes in the sample be included in the analysis gate. The software evaluates The CD45 (Anti–HLe-1)4 antibody is composed of mouse IgG1 heavy chains and kappa light chains. 2 The CD45 antigen is present on all human leucocytes, including lymphocytes, monocytes, granulocytes, eosinophils, and basophils in peripheral blood and has a role in signal transduction, modifying signals from other surface molecules.8 The CD45 antibody recognizes human leucocyte antigens, 180 to 220 kilodaltons (kDa), that are members of the T200 family.8 Figure 1 Steps used to establish the optimal lymphocyte light-scatter gate The CD14 antibody is composed of mouse IgG2b heavy chains and kappa light chains. CD14 recognizes a human monocyte antigen of 53 kDa.9 The CD14 antigen is present on the majority of normal peripheral blood monocytes.10 Precautions No. Description 1 Set a gate around the lymphocyte population that expresses low side scatter (SSC) and is negative for CD14 PE. Record the x- and y-coordinates for SSC. 2 Set a gate around the leucocytes to exclude most of the debris events. Record the x- and y-coordinates for forward scatter (FSC). 3 Use the coordinates for FSC and SSC from steps 1 and 2 to establish the optimal lymphocyte gate. 3 • For in vitro diagnostic use. • When stored at 2°C–8°C, antibody reagents are stable until the expiration date shown on the label. Do not use after the expiration date. • The antibody reagent should not be frozen or exposed to direct light during storage or during incubation with cells. Keep the reagent vial dry. • Alteration in the appearance of the reagent, such as precipitation or discoloration, indicates instability or deterioration. In such cases, the reagent should not be used. • The antibody reagents contain sodium azide as a preservative. However, care should be taken to avoid microbial contamination, which can cause erroneous results. A white blood cell (WBC) count and a differential white cell count should be obtained from the same sample of whole blood before staining. BD Simultest Leucogate can be used on samples with WBCs in the usable range of any BD in vitro diagnostic reagent. Check the appropriate BD in vitro diagnostic IFU for the usable range of the immunophenotyping reagent. For samples with counts lower than the lower limit, more blood might be needed and a separation procedure might be required to concentrate the cells. Samples with counts higher than the upper limit of the range might need to be diluted with 1X phosphate-buffered saline (PBS) containing 0.1% sodium azide. WARNING All biological specimens and materials coming into contact with them are considered biohazards. Handle as if capable of transmitting infection11,12 and dispose of with proper precautions in accordance with federal, state, and local regulations. Never pipette by mouth. Wear suitable protective clothing, eyewear, and gloves. 5. INSTRUMENT BD Simultest Leucogate reagent is designed for use on a BD FACS™ brand flow cytometer equipped with appropriate computer hardware, software, and gating electronics. The flow cytometer must be equipped to detect two-color fluorescence, FSC, and SSC. We recommend using BD Simulset software, version 2.5 or later, for data acquisition and analysis. Interfering Conditions Previously fixed and stored patient specimens should not be used. Whole blood samples refrigerated prior to staining can give aberrant results. For optimal results, blood samples should be stained within 6 hours of venipuncture. Samples obtained from patients taking immunosuppressive drugs can yield poor resolution.15 The presence of blast cells or unlysed or nucleated red blood cells (RBCs) can interfere with test results. Hemolyzed samples should be rejected. Follow the collection tube manufacturer’s guidelines for the minimum volume of blood to be collected. All performance characteristics were obtained using a BD FACScan™ flow cytometer. Other systems can have different characteristics and should be verified by the user. 6. SPECIMEN AND COLLECTION PREPARATION Collect blood aseptically by venipuncture13,14 into a sterile (lavender top) BD Vacutainer® EDTA blood collection tube or equivalent. A minimum of 1 mL of whole blood is required for this procedure. Blood should be stained within 6 hours of drawing for optimal results. Anticoagulated blood can be stored at room temperature (20°C–25°C) for up to 6 hours until ready for staining. Blood samples refrigerated prior to staining can give aberrant results. CAUTION Use standard precautions when obtaining, handling, and disposing of all human blood samples and potentially carcinogenic reagents. 7. PROCEDURE Reagents Provided See Reagents Provided and Precautions in Section 4, Reagents. 4 Reagents and Materials Required But Not Provided • Reagent-grade (both distilled and deionized) water. • BD Simultest Control. • Appropriate immunophenotyping reagent. • BD FACS™ lysing solution (10X) (Catalog No. 349202). For dilution instructions and warnings, see the IFU. • BD Vacutainer EDTA blood collection tubes or equivalent. • BD Calibrite™ beads (Catalog No. 349502). For detailed information on use, see the IFU. Staining and Fixing the Cells Whole blood samples are first stained with BD Simultest Leucogate (tube A), BD Simultest Control (tube B), and the appropriate BD lymphocyte immunophenotyping reagent (tube C). Diluted (1X) BD FACS lysing solution is then used to lyse RBCs following staining. Use care to protect the tubes from direct light. Perform the procedure at room temperature (20°C–25°C) using room temperature reagents. See Precautions in Section 4, Reagents. • Falcon®* disposable 12 x 75-mm polystyrene test tubes or equivalent. • Vortex mixer. • Low-speed centrifuge (200g) with swinging bucket rotor and 12 x 75-mm tube carriers. • Vacuum aspirator with trap. • Micropipettor with tips • BD CellWASH™ (Catalog No. 349524) or a wash buffer of PBS with 0.1% sodium azide. • BD CellFIX™ (Catalog No. 340181) or 1% paraformaldehyde solution in PBS with 0.1% sodium azide. Store at 2°C–8°C in amber glass for up to 1 week. • BD FACSFlow™ sheath fluid (Catalog No. 342003) or equivalent. 1. For each patient sample, label three 12 x 75-mm tubes A, B, and C. If there are other reagents in the panel, label additional tubes as required. Also label each tube with the sample identification number. 2. Place 20 µL of BD Simultest Leucogate reagent into tube A, 20 µL of BD Simultest Control into tube B, 20 µL of the appropriate immunophenotyping reagent into tube C, and 20 µL of each additional immunophenotyping reagent in the panel into separate tubes as required. 3. For each patient sample tube, use a fresh micropipettor tip and carefully add 100 µL of the correct concentration of well-mixed, anticoagulated, whole blood patient sample into the bottom of each of the labeled tubes. Use care to prevent blood from running down the side of CAUTION Use only BD FACSFlow sheath fluid diluent to dilute BD Calibrite beads. * Falcon is a registered trademark of Corning Incorporated. 5 9. Vortex thoroughly at low speed to resuspend the cell pellet in the residual fluid, and then add 0.5 mL of BD CellFIX solution or 1% paraformaldehyde to each tube. Vortex thoroughly at low speed for 3 seconds. Make sure that the cells are well mixed with the fixing solution. the tube. Vortex thoroughly at low speed for 3 seconds and incubate for 15 to 30 minutes at room temperature. NOTE Protect samples from direct light during this incubation procedure and use care to prevent blood from running down the side of the tube. If whole blood remains on the side of the tube, it may not be stained with the reagent. 10. The cells are now ready to be analyzed on the flow cytometer. Cap or cover the prepared tubes and store at 2°C– 8°C in the dark until flow cytometric analysis can be performed. Analyze the fixed cells within 24 hours after staining. Vortex the cells thoroughly (at low speed) before putting them through the flow cytometer to help reduce cell aggregation.16 4. Add 2 mL of room temperature 1X BD FACS lysing solution to each tube. Immediately vortex thoroughly at low speed for 3 seconds and incubate for 10 to 12 minutes at room temperature in the dark. Do not exceed 12 minutes. Flow Cytometry Follow the BD instructions for two-color flow cytometric analysis. NOTE Avoid prolonged exposure of the cells to lytic reagents, which can cause white cell destruction. For information on tubes B and C, see the appropriate reagent IFU. 5. Immediately after incubation, centrifuge tubes at 300g for 5 minutes at room temperature. Quality Control For optimal results, we recommend using BD Calibrite beads and BD FACSComp™ software for setting the photomultiplier tube (PMT) voltages, setting the fluorescence compensation, and checking instrument sensitivity prior to use of BD Simultest reagents on a BD FACScan flow cytometer. 6. Aspirate the supernatant, leaving approximately 50 µL of residual fluid in the tube to avoid disturbing the cell pellet. 7. Vortex thoroughly at low speed to resuspend the cell pellet in the residual fluid, and then add 2 mL of BD CellWASH solution or PBS with 0.1% sodium azide to each tube. Vortex thoroughly at low speed for 3 seconds. Centrifuge at 200g for 5 minutes at room temperature. We recommend that a control sample from a normal adult subject be run daily to optimize instrument settings and as a quality control check of the system. Correct results for a hematologically normal patient are illustrated in Figure 1. 8. Aspirate the supernatant, leaving approximately 50 µL of residual fluid in the tube to avoid disturbing the pellet. 6 BD Simulset software will automatically inspect the data and alert the operator with a number of possible error messages. See the BD Simulset Software User’s Guide for a list of possible messages. The software uses the following criteria for inspection of the dot plots obtained for each sample to evaluate the quality of the data obtained. • • • 8. RESULTS Percent Lymphocyte Conversion When the Percent Lymphocyte Conversion computation is performed, the lymphocyte subset for the in vitro diagnostic immunophenotyping reagent is reported as a percentage of lymphocytes in the lymphocyte analysis gate. If the computation is not performed, results will be reported as a percentage of the gated events. The operator should reject the results if any one of the following error messages is received for the normal control: no separation between cellular populations; too few lymphocytes (less than 500); excessive RBC or nucleated RBC contamination and debris (greater than 10%); or excessive monocyte (greater than 3%) or granulocyte (greater than 6%) contamination of the lymphocyte gate. 9. LIMITATIONS Three-Part Differential For lysed whole blood, it is possible to estimate monocytes, lymphocytes, and granulocytes as a percentage of leucocytes using BD Simultest Leucogate reagent (tube A). BD Simulset software automatically calculates a three-part differential. See the BD Simulset Software User’s Guide for representative data printouts. If there is no obvious reason for the normal control to fail, a sample from another normal control should be restained and rerun and the entire staining procedure repeated on all subsequent samples. NOTE Do not use the differential from the BD Simulset software report to compute absolute counts. The differential provided by BD Simulset software is printed only for comparison with results from an independent laboratory differential white cell count for quality control purposes and should not be used in place of an independent laboratory differential white cell count in patient charts or entered into BD Simulset software to obtain absolute counts. Samples with nucleated RBCs can contain too much debris because of incomplete lysis of the nucleated erythrocytes with BD FACS lysing solution. Too much debris can also occur when assaying blood samples from patients with certain hematological disorders where red cells are difficult to lyse (for example, myelofibrosis and spherocytosis). Nucleated erythrocytes will be counted as debris and, if debris exceeds 10%, the software will flag the sample as “too many nonlymphs in the gate” and the sample results should be rejected. • 7 Variation in either automatic or manual lymphocyte acquisition gate settings will change the relative amounts of subsets assayed. BD Simulset software uses the BD Leucogate tube to include at least 95% of the total lymphocytes in the sample to set the lymphocyte analysis gate and requires a visual inspection of the gate setting for validation. • • Linearity-Recovery Linearity of response over a wide range of WBCs is determined for each BD in vitro diagnostic immunophenotyping reagent using Leucogate in the assay procedure. See the appropriate BD reagent IFU for the usable WBC range. BD Simultest Leucogate reagent is not intended for screening samples for the presence of leukemic cells or for use in phenotyping samples from leukemia patients. The presence of blast cells might not allow the Leucogate reagent to set an adequate lymphocyte analysis gate. The software will flag the sample and results will not be printed. WARRANTY Unless otherwise indicated in any applicable BD general conditions of sale for non-US customers, the following warranty applies to the purchase of these products. THE PRODUCTS SOLD HEREUNDER ARE WARRANTED ONLY TO CONFORM TO THE QUANTITY AND CONTENTS STATED ON THE LABEL The ability of the flow cytometer to select lymphocytes and to eliminate platelets, red blood cells, debris, granulocytes, and monocytes from the lymphocyte gate depends on the existence of a clear demarcation between these formed elements and lymphocytes on a display of FSC versus SSC. For some patients, this demarcation is not clear and lymphocyte gating will be less effective. OR IN THE PRODUCT LABELING AT THE TIME OF DELIVERY TO THE CUSTOMER. BD DISCLAIMS HEREBY ALL OTHER WARRANTIES, EXPRESSED OR IMPLIED, INCLUDING WARRANTIES OF MERCHANTABILITY AND FITNESS FOR ANY PARTICULAR PURPOSE AND NONINFRINGEMENT. BD’S SOLE LIABILITY IS LIMITED TO EITHER REPLACEMENT OF THE PRODUCTS OR REFUND OF THE PURCHASE PRICE. BD IS NOT LIABLE FOR PROPERTY DAMAGE OR ANY INCIDENTAL OR CONSEQUENTIAL DAMAGES, INCLUDING PERSONAL INJURY, OR ECONOMIC LOSS, CAUSED BY THE PRODUCT. REFERENCES 1. Loken M, Brosnan J, Bach B, Ault K. Establishing optimal lymphocyte gates for immunophenotyping by flow cytometry. Cytometry. 1990;11:453-459. 2. Beverley P. Production and use of monoclonal antibodies in transplantation immunology. In: Touraine J, Trager J, Betuel H, eds. Transplantation and Clinical Immunology XI. Amsterdam: Excerpta Medica; 1980:87-94. 3. Cobbold S, Hale G, Waldmann H. Non-lineage, LFA-1 family, and leucocyte common antigens: new and previously defined clusters. In: McMichael A, ed. Leucocyte Typing III: White Cell Differentiation Antigens. New York, NY: Oxford University Press; 1986:788-803. 4. Rowe D, Beverley P. Characterisation of breast cancer infiltrates using monoclonal antibodies to human leucocyte antigens. Br J Cancer. 1984;49:149-159. 5. Bernard A, Boumsell L, Hill C. Joint report of the First International Workshop on Human Leucocyte Differentiation Antigens by the investigators of the participating laboratories: M2 protocol. In: Bernard A, Boumsell L, Dausset J, Milstein C, Schlossman S, eds. Leucocyte Typing. Berlin: Springer-Verlag; 1984:82-108. 10. PERFORMANCE CHARACTERISTICS For lymphocyte immunophenotyping performance data using BD Simultest Leucogate and other BD immunophenotyping reagents, see the appropriate reagent IFU. Cross-Reactivity CD14 reacts weakly with granulocytes as well as monocytes/macrophages.17 The CD45 antibody has been reported to weakly react with mature circulating erythrocytes and platelets.8,18 8 6. Dimitriu-Bona A, Burmester G, Waters S, Winchester R. Human mononuclear phagocyte differentiation antigens. I. Patterns of antigenic expression on the surface of human monocytes and macrophages defined by monoclonal antibodies. J Immunol. 1983;130:145-152. 7. Herrmann F, Komischke B, Odenwald E, Ludwig W. Use of monoclonal antibodies as a diagnostic tool in human leukemia. I. Acute myeloid leukemia and acute phase of chronic myeloid leukemia. Blut. 1983;47:157-163. 8. Schwinzer R. Cluster report: CD45/CD45R. In: Knapp W, Dörken B, Gilks WR, eds. Leucocyte Typing IV: White Cell Differentiation Antigens. New York, NY: Oxford University Press; 1989:628-634. 9. Goyert S, Tesio L, Ashman L, et al. Report on the CD14 Cluster Workshop. In: Knapp W, Dörken B, Gilks WR, eds. Leucocyte Typing IV: White Cell Differentiation Antigens. New York, NY: Oxford University Press; 1989:789-794. 10. Bernstein I, Self S. Joint report of the myeloid section of the Second International Workshop on Human Leukocyte Differentiation Antigens. In: Reinherz E, Haynes B, Nadler L, Bernstein I, eds. Leukocyte Typing II: Human Myeloid and Hematopoietic Cells. New York, NY: Springer-Verlag; 1984:1-25. 16. Jackson A, Warner N. Preparation, staining, and analysis by flow cytometry of peripheral blood leukocytes. In: Rose N, Friedman H, Fahey J, eds. Manual of Clinical Laboratory Immunology. 3rd ed. Washington, DC: American Society for Microbiology; 1986:226-235. 17. Jayaram Y, Hogg N. Surface expression of CD14 molecules on human neutrophils. In: Knapp W, Dörken B, Gilks W, et al, eds. Leucocyte Typing IV: White Cell Differentiation Antigens. New York, NY: Oxford University Press; 1989:796-797. 18. Jackson A. Basic phenotyping of lymphocytes: selection and testing of reagents and interpretation of data. Clin Immunol Newslett. 1990;10:49-55. 11. Protection of Laboratory Workers from Occupationally Acquired Infections; Approved Guideline—Third Edition. Wayne, PA: Clinical and Laboratory Standards Institute; 2005. CLSI document M29-A3. 12. Centers for Disease Control. Perspectives in disease prevention and health promotion update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR. 1988;37:377-388. 13. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard— Six Edition. Wayne, PA: Clinical and Laboratory Standards Institute; 2007. CLSI document H3-A6. 14. Enumeration of Immunologically Defined Cell Populations by Flow Cytometry; Approved Guideline—Second Edition. Wayne, PA: Clinical and Laboratory Standards Institute; 2007. CLSI document H42-A2. 15. Giorgi JV. Lymphocyte subset measurements: significance in clinical medicine. In: Rose NR, Friedman H, Fahey JL, eds. Manual of Clinical Laboratory Immunology. 3rd ed. Washington, DC: American Society for Microbiology; 1986:236-246. 9
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