Recent evidence suggests that belatacept reduces the durability of preexisting antibodies to class I and class II human leukocyte antigens (HLAs). In this case series of 163 highly sensitized kidney transplant candidates whose calculated panel‐reactive antibody (cPRA) activity was ≥98% to 100%, the impact of belatacept on preexisting HLA antibodies was assessed. Of the 163 candidates, 72 underwent transplantation between December 4, 2014 and April 15, 2017; 60 of these transplanted patients remained on belatacept consecutively for at least 6 months. We observed a decrease in the breadth and/or strength of HLA class I antibodies as assessed by FlowPRA in belatacept‐treated patients compared to controls who did not receive belatacept. Specifically, significant HLA antibody reduction was evident for class I (P < .0009). Posttransplant belatacept‐treated patients also had a clinically significant reduction in their cPRA compared to controls (P < .01). Collectively, these findings suggest belatacept can reduce HLA class I antibodies in a significant proportion of highly sensitized recipients and could be an option to improve pretransplant compatibility with organ donors.
BackgroundInitial studies of stereotactic body radiation therapy (SBRT) for refractory ventricular tachycardia (VT) have demonstrated impressive efficacy. Follow-up analyses have found mixed results and the role of SBRT for refractory VT remains unclear. We performed palliative, cardiac radio ablation in patients with ventricular tachycardia refractory to ablation and medical management.MethodsArrhythmogenic regions were targeted by combining computed tomography imaging with electrophysiologic mapping with collaboration from a radiation oncologist, electrophysiologist and cardiac imaging specialist. Patients were treated with a single fraction 25 Gy. Total durations of VT, the quantity of antitachycardia pacing (ATP) and shocks before and after treatment as recorded by implantable cardioverter-defibrillators (ICDs) were analyzed. Follow-up extended until most recent device interrogation unless transplant, death or repeat ablation occurred sooner.ResultsFourteen patients (age 50–78, four females) were treated and had an average of two prior ablations. Nine had ACC/AHA Stage D heart failure and three had left ventricular assist devices (LVAD). Two patients died shortly after SBRT, one received a prompt heart transplant and another had significant VT durations in the following months that were inaccurately recorded by their device. Ten of the 14 patients remained with adequate data post SBRT for analysis with an average follow-up duration of 216 days. Seven of those 10 patients had a decrease in VT post SBRT. Comparing the 90 days before treatment to cumulative follow-up, patients had a 59% reduction in VT, 39% reduction in ATP and a 60% reduction in shocks. Four patients received repeat ablation following SBRT. Pneumonitis was the only complication, occurring in four of the fourteen patients.ConclusionSBRT may have value in advanced heart failure patients with refractory VT acutely but the utility over long-term follow-up appears modest. Prospective randomized data is needed to better clarify the role of SBRT in managing refractory VT.
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