PLASMAPHERESIS AND IVIG IN THE MANAGEMENT OF THE SENSITIZED CARDIAC RECIPIENT.

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PLASMAPHERESIS AND IVIG IN THE MANAGEMENT OF THE SENSITIZED CARDIAC RECIPIENT.
Stephen H. Leech, M.D., Ph.D. , Mayra Lopez-Cepero Ph.D.,dip. ABHI and William M. LeFor, Ph.D., HCLD (ABB) . Philadelphia PA, Temple University School of Medicine, 19140, Pathology and Laboratory Medicine and Tampa FL, LifeLink, 33606, Transplant Immunology Laboratory .

The combination of plasmapheresis (PP) and IVIG has been reported by an increasing number of transplant centers to be beneficial in the successful renal transplantation of the immunologically sensitized patient. We therefore studied recipients of cardiac allografts in order to determine whether or not such a combination can provide similar benefit for the heart patient with circulating alloantibodies.
The current study included 21 recipients of orthotopic heart transplants (OHT), 2 having also received renal allografts at the time of OHT. Two patients were African Americans, 1 Hispanic and the remainder were Caucasian. The male:female ratio was 8/13. Average age 50 years at transplantation (range 27-66). The causes of sensitization were multiparity (8), transfusion (7), VAD (5) and previous transplant (1). All patients underwent PP and received IVIG and other immunosuppressives.
Endomyocardial biopsy specimens were graded for rejection according to the ISHLT schema. Methods used for lymphocytoxic antibody identification included CDC or FlowBeads™. Crossmatch was by CDC and/or flow cytometry, and was positive in 17 cases.
PP and IVIG were associated with falls in the average PRA for T cells from 51% and 21%, and for B cells from 31% to15%. Ten patients experienced rejection; findings strongly suggestive of a vascular (humoral) being identified in 4 of those cases. Follow-up post-OHT ranged from a few days for cases just transplanted to 6.3 years; average being 1 year. Three deaths occurred: 2 of them in the immediate post-operative period -- the third almost 6 months post-OHT.
We conclude that the combination of PP and IVIG may be useful in the management of the sensitized cardiac patient undergoing OHT, often allowing a successful outcome to transplantation performed across a positive crossmatch.