Treatment of severe cardiac allograft rejection with extracorporeal photochemotherapy

Abstract

Two patients were treated with photopheresis for marked cardiac allograft rejection with hemodynamic compromise that had become unresponsive to standard therapy. Multiple episodes of rejection had occurred, and initial response to standard therapy was favorable. However, progressive deterioration was documented by serial endomyocardial biopsies, fever, congestive heart failure, and abnormal cardiac catheterization findings. In the absence of retransplantation, death seemed imminent. Photopheresis was begun. Both patients received oral 8-methoxypsoralen and > or = 5 x 10(9) mononuclear cells were collected, treated with ultraviolet light A for 1.5 hours, and were reinfused. One procedure was performed weekly x4 and then monthly x5. Responses were striking with rapid loss of fever, improvement in exercise tolerance, normalization of cardiac hemodynamics, and improvement in endomyocardial biopsies. Although our experience with these two patients is anecdotal, photopheresis merits further study as treatment for severe cardiac allograft rejection.

Extracorporeal photopheresis: Past, present, and future

“…Early studies in small numbers of patients undergoing cardiac transplantation indicated that ECP plus conventional immunosuppressant treatment could reduce the incidence of rejection episodes among those at high risk of rejection, and reduce or reverse rejection in patients who have developed severe, recurrent, or refractory rejection. [49][50][51][52][53] In addition, ECP allowed patients to reduce their immunosuppressant therapies, thus sparing them from therapy-associated morbidity and mortality. 51,52 These promising preliminary results were followed by larger studies to investigate the prophylactic use of ECP plus conventional therapy compared with conventional therapy alone.…”

Extracorporeal photopheresis in chronic graft-versus-host disease

“…Although the mechanisms are less clear, ECP has also demonstrated similar efficacy in a number of autoimmune disorders, including scleroderma, pemphigus vulgaris, rheumatoid arthritis, systemic lupus erythematosis, and solid organ allograft rejection (Table 1). 22,[24][25][26][27][28] …”

Successful Reversal of Recalcitrant Hepatic Allograft Rejection by Photopheresis

“…21,22 This range of indications for photopheresis has now been expanded to include prophylactic treatment immediately after heart transplantation [23][24][25] and rescue therapy for severe racalcitrant cardiac allograft rejection. 26 In addition, we and others have recently shown the efficacy of photopheresis in the reversal of both renal 27,28 and pulmonary allograft rejection. 29,30 Because hepatic allograft rejection is a pathophysiologically similar process, we postulated that photopheresis might be equally effective in its reversal.…”