Cardiac rejectionPlasmapheresis and cyclophosphamide in the treatment of humoral rejection after heart transplantation
Section snippets
Patients
Between April 1986 and April 1999, 1,108 orthotopic heart transplantations in 1,080 patients were performed. The mean age was 49.3 years (range, 1 week to 71 years), and 872 men and 208 women were transplantated. The indications were primary cardiomyopathy (61.8%), ischemic cardiomyopathy (30.7%), other secondary cardiomyopathies (3.5%), congenital heart disease (1.3%), and retransplantations (2.7%). All patients received triple-drug immunosuppression regimens with cyclosporine, azathioprine,
Results
We found no significant differences with regard to age, gender, indication for transplantation, or degree of sensitization (panel reactive antibodies) between Periods A and B, between neither the patients in general nor between the patients with rejection episodes with hemodynamic compromise (all p > 0.05).
Discussion
Comparing therapeutic blood purification during HRHC episodes (Group B) with a historical group of patients treated without plasmapheresis (Group A) limits the study. However, since the early 1990s we have obtained experimental evidence that blood purification is very effective in treating severe humoral rejection episodes.20, 21 Therefore, a prospective, randomized clinical trial seems unjustifiable. Furthermore, in both groups the patients received comparable induction and maintenance
Conclusion
Plasmapheresis, in addition to cytolytic antibodies, seems to improve outcomes in HRHC episodes after heart transplantation. Some patients showed “rejection disease” with myocardial impairment as well as rejection-related SIRS. In these episodes, plasmapheresis not only led to immediate myocardial recovery but also to restitution of peripheral resistance. However, in our patients, cyclophosphamide, as a maintenance immunosuppressive drug, failed to prevent further severe humoral rejection
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Cited by (67)
Perioperative Applications of Therapeutic Plasma Exchange in Cardiac Surgery: A Narrative Review
2020, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :In addition, regimens including bortezomib may be useful in treating AMR.146 While no randomized controlled trials exist, several observational studies have studied TPE in combination with other agents for treatment of AMR in adult heart transplant patients (Table 4).138-141 Recent data suggest that the use of eculizumab, a monoclonal antibody that binds to and inhibits the C5 complement protein, is effective for treating AMR along with TPE after renal transplantation.147
Promising utilization areas of therapeutic plasmapheresis in cardiovascular surgery practice
2018, Transfusion and Apheresis ScienceSafety and Efficacy of Immunoadsorption in Heart Transplantation Program
2016, Transplantation ProceedingsB cells in transplantation
2016, Journal of Heart and Lung TransplantationTherapeutic apheresis in transplantation medicine, experience with cardiac and lung transplantation in Jena
2013, Atherosclerosis SupplementsCitation Excerpt :To overcome a positive CM or rescue organs undergoing AMR two treatment protocols have been established for reducing HLA-ab: high dose IVIG and plasmapheresis (PP) combined with low dose cytomegalovirus (CMV) hyperimmune globulin or IVIG [13]. Grauhan et al. [14] altogether observed 29 humoral rejections in HTX patients with hemodynamic compromise (HRHC) episodes. 18 HRHC (7 patients) episodes were treated without PP, but only 2 patients survived, whereas in 11 HRHC episodes (6 patients) therapy included PP and all patients survived.