Extracorporeal Photopheresis With Low-Dose Immunosuppression in High-Risk Heart Transplant Patients—A Pilot Study

Abstract

In severely ill patients undergoing urgent heart transplant (HTX), immunosuppression carries high risks of infection, malignancy, and death. Low-dose immunosuppressive protocols have higher rejection rates. We combined extracorporeal photopheresis (ECP), an established therapy for acute rejection, with reduced-intensity immunosuppression. Twenty-eight high-risk patients (13 with high risk of infection due to infection at the time of transplant, 7 bridging to transplant via extracorporeal membrane oxygenation, 8 with high risk of malignancy) were treated, without induction therapy. Prophylactic ECP for 6 months (24 procedures) was initiated immediately postoperatively. Immunosuppression consisted of low-dose tacrolimus (8–10 ng/ml, months 1–6; 5–8 ng/ml, >6 months) with delayed start; mycophenolate mofetil (MMF); and low maintenance steroid with delayed start (POD 7) and tapering in the first year. One-year survival was 88.5%. Three patients died from infection (POD 12, 51, 351), and one from recurrence of cancer (POD 400). Incidence of severe infection was 17.9% (n = 5, respiratory tract). Within the first year, antibody-mediated rejection was detected in one patient (3.6%) and acute cellular rejection in four (14.3%). ECP with reduced-intensity immunosuppression is safe and effective in avoiding allograft rejection in HTX recipients with risk of severe infection or cancer recurrence.

Mode of action, indications and recommendations on extracorporeal photopheresis (ECP)

“…Recent published data also demonstrated the possibility of combining ECP with reduced intensity immunosuppression, which has been shown to be safe and effective in preventing allograft rejection in heart transplant recipients 85 …”

The value of extracorporeal photopheresis as an immunosuppression-modifying approach in solid organ transplantation: a potential solution to an unmet medical need

“…(2022) established a prophylactic ECP protocol for heart transplant recipients at high risk of cancer recurrence or post-operative infection. A total of 28 patients were treated with ECP immediately following heart transplantation in this single arm pilot cohort study ( 37 ). The main outcome of the study was one-year survival of patients, which was 88.5% (25/28) patients.…”

Wirkweise, Indikationen und Therapieempfehlungen der extrakorporalen Photopherese (ECP)

“…84 Kürzlich veröffentlichte Daten zeigen auch die Möglichkeit der Kombination der ECP mit einer reduzierten Intensität der Immunsuppression, die sich als sicher und wirksam bei der Verhinderung der Abstoßung von Allotransplantaten bei herztransplantierten Empfängern erwiesen hat. 85 Der Einsatz der ECP zur Behandlung der chronischen Abstoßungsreaktion nach Herztransplantation wird…”