Stephen H. Leech

Management of the sensitized cardiac recipient : the use of plasmapheresis and intravenous immunoglobulin

Abstract:  Previously, we reported that the combination of plasmapheresis (PP) and intravenous immunoglobulin (IVIg) allow sensitized patients to undergo orthotopic heart transplantation (OHT), even across a positive crossmatch. In the current study, the effect of that combination, PP +IVIg, on survival of a larger group of such recipients is investigated. The latter group (I) consisted of 35 sensitized patients who received PP + IVIG together with standard immunosuppressive drugs. Rejection was seen in 11 patients, findings strongly suggestive of a vascular (humoral) being identified in five of those cases. Four deaths occurred, two of them in the immediate post‐operative period, one after almost six months, and one after almost two yr post‐OHT. Follow‐up range 4.5 months to 7.8 yr post‐OHT (average = 1.1 yr). Patient survival was analyzed after generation of a Kaplan–Meier plot. Comparison with a control OHT group (II) given standard immunosuppressive drugs only (N = 276) showed enhanced survival of group I (p = 0.0414 by log‐rank test). We conclude that the combination of PP and IVIG (i) is associated with declines in T‐ and B‐percent‐reactive antibody and in crossmatch positivity, and (ii) is very useful in the management of the sensitized cardiac patient undergoing OHT, often allowing a successful outcome to transplantation in the face of a positive crossmatch.

Cardiac transplantation across a positive prospective lymphocyte cross-match in sensitized recipients.

Abstract: Background: Although there is an increasing body of evidence for a deleterious effect of mismatched donor HLA antigens on the outcome of human cardiac transplantation, the role of anti‐HLA lymphocytotoxic antibodies remains controversial. Thus, their appearance after cardiac transplantation has been associated with poor outcome by some groups; whereas others have reported them to be of no clinical significance. Furthermore, their presence prior to cardiac transplantation has also been the subject of similarly conflicting reports. The deleterious effect of such pre‐existing antibodies has been predicted by a positive lymphocyte cross‐match (LCM), which, for most patients awaiting renal transplantation and in many requiring a cardiac allograft, leads to cancellation of the operation. The reason for undertaking the current study was to test the hypothesis that the constraints which a positive LCM result impose in preventing renal transplantation may not apply to orthotopic heart transplantation (OHT).