Pediatric Cardiac Transplantation in Children With High Panel Reactive Antibody

Jacobs, Jeffrey P.; Quintessenza, James A.; Boucek, Robert J.; Morell, Victor O.; Botero, Luis M.; Badhwar, Vinay; Gelder, Hugh M. van; Asante‐Korang, Alfred; McCormack, Jorge; Daicoff, George R.

doi:10.1016/j.athoracsur.2004.03.031

Cited by 124 publications

(101 citation statements)

References 16 publications

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“…7 This observation is found elsewhere in the literature, both in adult and pediatric patients. 1,22 In our experience, sensitized patients (4/13) experienced an actuarial survival of 89% and 71% at 30 days and at 1 year which is lower than our overall institutional actuarial survival (30 day and 1 year survival of 95% and 84%, respectively) but very encouraging in this "high risk" population.…”

Section: Overall Survivalmentioning

confidence: 71%

“…1,23 Given our positive experience with rituximab initially on detection of AMR and, most recently in a preemptive manner perioperatively in sensitized patients, the move to pretreatment is the next logical step programmatically.…”

Section: Pretreatmentmentioning

confidence: 99%

“…14,17 Donor-directed HLA antibodies increase the risk for post-transplant complications in the cardiac allograft. 1,6 Both antibodies to Class I and Class II antigens appear to be related to an elevated risk of rejection. 18 ACR, AMR, and CAV are all associated with a donor specific positive cross-match.…”

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confidence: 99%

“…[1][2][3][4][5][6][7][8] There has been an increase in heart transplant candidates allosensitized to HLA antigens over the years 9 which may result from exposure to blood products, 5,10 homograft material used in surgical palliation of congenital heart disease, 11,12 use of ventricular assist and mechanical support devices, 4 and in a growing number of patients requiring retransplantation. 7 Determinations of Panel Reactive Antibody (PRA) are done to delineate a patient's potential for sensitization to donor HLA antigens.…”

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confidence: 99%

“…35 Some transplant programs require a prospective negative donor-specific cross-match for patients with PRA screens Ͼ10% to 15%, 14,21 some exclude highly sensitized recipients, and a few centers use strategies to attempt to reduce the formation of circulating cytotoxic alloantibodies before transplantation (desensitization) using treatments (alone or in combination) such as intravenous immune globulin (IVIG), cyclophosphamide, mycophenolate mofetil (MMF), and rituximab. 1,5,14,[22][23][24] Although prospective crossmatching has not routinely been done for consideration of donor acceptance at our institution, we have adopted an evolving aggressive pre-and perioperative management protocol that includes as possible options: pretreatment of sensitized patients, intraoperative plasma exchange, posttransplant plasmapheresis, and T-and B-cell suppression rather than excluding such patients from HTx. We evaluated our experience with HLA-sensitized pediatric HTx recipients in order to report our management strategies and assess intermediate-term outcomes.…”

mentioning

confidence: 99%

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Pediatric Heart Transplantation in Human Leukocyte Antigen–Sensitized Patients

Pollock-BarZiv

Hollander²,

Ngan³

et al. 2007

Circulation

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Background— There is an elevated risk for poor outcomes after heart transplant (HTx) in patients sensitized to human leukocyte antigens including graft dysfunction, acute cellular and antibody-mediated (AMR) rejection, and cardiac allograft vasculopathy. We report our experience with human leukocyte antigens–sensitized pediatric HTx recipients. Methods and Results— We identified pediatric HTx patients with elevated pre-HTx Panel Reactive Antibody (Class I/II; >10%), or a positive T- or B-cell crossmatch. Thirteen patients met criteria (5 female, 39%). The median age at HTx was 7 months (3.5 months to 15.5 years). Nine were infants who had prior palliation for congenital heart disease. Four were older patients (median 7.3 years; 4.8 to 15.5 years): 2 had congenital heart disease (Fontan), 2 were re-HTx. B-cell therapies were used in all patients, guided by assessment of CD19+ and CD20+ cells. Immunosuppression included thymoglobulin induction, and tacrolimus, mycophenolate mofetil, and steroids. Daily plasmapheresis ± intravenous immunoglobulin G was used if there was a positive crossmatch on day 1, with a gradual, biopsy-guided weaning schedule. Rituximab was used when AMR was detected on biopsy: more recently (n=3), used empirically perioperatively. AMR was confirmed in 9 patients within median 0.9 months post-HTx. Seven had early acute cellular rejection (≥ ISHLT Grade 2 R) with no hemodynamic compromise or graft dysfunction. There were 4 deaths post-HTx (range, 11 days to 9 months). The median follow-up of 9 survivors was 1.7 years (0.3 to 3.7 years). Of 7 patients >6 months post-HTx, no AMR or cardiac allograft vasculopathy was observed at a mean of 1.9+1.1 years post-HTx and no cardiac allograft vasculopathy. Conclusions— Despite aggressive management, acute cellular rejection and AMR occurred frequently early post-HTx. An algorithm of B cell–directed strategies can be effective in managing these patients with reasonable intermediate-term outcomes.

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Section: Overall Survivalmentioning

confidence: 71%

Section: Pretreatmentmentioning

confidence: 99%

mentioning

confidence: 99%