Therapeutic plasma exchange rapidly improves cardiac allograft function in patients with presumed antibody‐mediated rejection

Abstract

The rapid improvement in allograft function in our patients is most likely due to TPE as other pharmacologic interventions have longer onset. TPE should be considered a first-line intervention in the setting of pAMR.

The apheresis management of patients undergoing transplantation: a concise review

“…Antibody‐mediated rejection (AMR) may be treated with TPE along with immunosuppressive medications; however, the evidence supporting it as a treatment option is observational . If the patient has severe allograft dysfunction, it is not unreasonable to initiate TPE emergently before a definite diagnosis is made . TPE can be performed daily for the first 2 to 3 days and then every other day for a total of five to seven procedures, with the goal to quickly remove implicated donor‐specific antibodies (DSAs) and/or inflammatory mediators .…”

“…5 If the patient has severe allograft dysfunction, it is not unreasonable to initiate TPE emergently before a definite diagnosis is made. 9 TPE can be performed daily for the first 2 to 3 days and then every other day for a total of five to seven procedures, with the goal to quickly remove implicated donorspecific antibodies (DSAs) and/or inflammatory mediators. 5 The replacement fluid usually is 5% albumin unless the patient is on an anticoagulant medication and/or there are abnormalities of the coagulation profile (e.g., hypofibrinogenemia, high PT/INR/aPTT), active bleeding, and/or immediately before or after an invasive procedure, when plasma may be indicated for at least part of the replacement fluid, usually toward the end of the procedure.…”

Indications for and outcomes of therapeutic plasma exchange after cardiac transplantation: A single center retrospective study

“…However, it also highlights the difficulty in determining the optimal treatment schedule and number of TPE procedures. In the literature, with regards to AMR treatment, as few as 2 and as many as 19 TPE procedures have been used . Additional studies are needed to determine the optimal number of TPE procedures for each TPE cardiac transplant indication and to determine whether a more individualized approach to TPE is warranted.…”

“…10 Across many studies of cardiac transplantation, AMR is a common use of TPE 2 ; however, as we found in our study, TPE is also frequently used for treatment of elevated PRA antibodies or positive HLA antibodies and positive crossmatch. 6,7,40 Given the high incidence of TPE use for these indications, TPE use for positive crossmatch status and positive HLA antibodies/PRA should be considered in the next iteration of the ASFA guidelines.…”

“…An important and commonly used treatment modality in cardiac transplantation is therapeutic plasma exchange (TPE) . Although primarily used to preserve allograft function, TPE in cardiac transplantation can be used in 1 or more of the following ways: to facilitate transplant across a positive crossmatch; treat antibody‐mediated rejection (AMR); treat primary graft dysfunction; reduce donor‐specific human leukocyte antigen (HLA) antibody titers (DSA); and, in highly‐sensitized patients, decrease panel reactive antibody (PRA) titers . Of these indications, the only ones categorized in the American Society for Apheresis (ASFA) national guidelines are desensitization (ASFA category II; Grade 1C) and AMR (ASFA category III; Grade 2C) .…”