Heart transplantation across the antibodies against HLA and ABO

Abstract

Summary We have intentionally performed heart transplantation in a 5‐year‐old child, despite the most unfavourable risk factors for patient survival; the presence of high level of antibodies against donor's human leucocyte antigen (HLA) class I/II and blood group antigens. Pretransplant treatment by mycophenolate mofetil, prednisolone, tacrolimus, intravenous immunoglobulin, rituximab, protein‐A immunoadsorption (IA) and plasma exchange reduced antibody titres against the donor's lymphocytes from 128 to 16 and against the donor's blood group antigen from 256 to 0. The patient was urgently transplanted with a heart from an ABO incompatible donor (A1 to O). A standard triple‐drug immunosuppressive protocol was used. No hyperacute rejection was seen. Antibodies against the donor's HLA antigens remained at a low level despite three acute rejections. Rising anti‐A1 blood group antibodies preceded the second rejection and were reduced by two blood group‐specific IAs and remained at a low level. The patient is doing well despite the persistence of donor‐reactive antibodies.

Pushing the boundaries: The current status of ABO-incompatible cardiac transplantation

“…64 This was more often seen in patients who were older at the time of transplant or had pre-existing HLA sensitization, and was not associated with an increased risk of AMR or death. This supports other reports from the UK 37 and Sweden, 65 which showed re-accumulation of donor blood group-specific isohemagglutinins, but without graft damage. Thus, in these patients, B-lymphocyte elimination does not occur and alternative mechanisms of graft tolerance need to be invoked.…”

“…This patient was also highly HLA sensitized and underwent a desensitization protocol that decreased anti-A titers to zero by the time of transplant. 65 There was only one AMR episode, on Day 14, with an increase in anti-A titers to 1:64. This episode was managed with methylprednisolone, anti-thymocyte globulin (ATG) and immunoadsorption using Glycosorb columns, which reduced anti-A titers to 1:2.…”

Intentional ABO-incompatible heart transplantation: A case report of 2 adult patients

“…9 Plasmapheresis was performed preoperatively and post-operatively, and the patient was treated according to a protocol very much based on the protocol used in our patients.…”

Intravenous immunoglobulins in liver transplant patients: Perspectives of clinical immune modulation

“…Increased immunologic sensitization may result from pregnancy, transfusion or previous transplants [127] . The implementation of immune modulation protocols including high doses of IVIg, plasmapheresis and potent immunosuppressive drugs resulted in attenuation of the humoral alloimmune response and in acceptable outcome in highly sensitized kidney and heart transplants [127][128][129][130][131][132][133] . The prognostic relevance of a positive T-lymphocytotoxic crossmatch in LT is, however, still discussed controversially [127,[134][135][136][137][138][139][140][141][142][143][144] .…”

“…Immunologic incompatibility was, therefore, originally considered as a contraindication in all organ transplants, except LT [127][128][129][130][131][132][133][134] .…”