Plasma Exchange and Immunoadsorption of Patients with Thoracic Organ Transplantation

Abstract

Primary organ failure after transplantation (TX) remains a serious complication and leads to a high percentage of lethality. It is known, however, that the speed of rejection and tissue destruction depends on 3 main factors: antibody titer, the ability of the tissue to repair itself, and immunosuppressive measures. Especially with evidence for antibodies against human leukocyte antigen (HLA-ab), the immunological risk of persistent and acute episodes of rejection increases. The role of non-HLA-ab in rejection episodes is often underestimated and should be studied further. Antibody-mediated rejection (AMR) is still an unsolved problem in thoracic organ TX. An essential pillar of antihumoral therapy are the extracorporeal procedures like plasmapheresis (PP), therapeutic plasma exchange (TPE), and immunoadsorption (IA), because only they have the ability to remove preformed or de novo developed antibodies quickly and effectively. The quick removal of antibodies and other plasma factors through TPE or IA remains an effective and supportive method for treating AMR and allows the TX despite preformed antibodies. The pertinent literature does not disclose, however, how often and for how long treatment should be administered. It is known, that repeated treatment cycles with adequately processed plasma volume must be used to overcome redistribution of pathological antibodies. Based on our experience in heart transplant recipients with compromised graft function due to non-HLA-ab and HLA-ab, IA seems to be more effective.

Protein A-Based Immunoadsorption Is More Efficient Than Conventional Plasma Exchange to Remove Circulating Anti-HLA Antibodies

“…Beyond its superiority in terms of efficacy, IA might also provide a better tolerance profile [20] . The higher risk of hemorrhagic complications, the need of human blood-derived replacement fluids and the need of repeated sessions to achieve similar desensitization with PE techniques are other important points to consider when comparing these techniques.…”

Immunoadsorption enables successful rAAV5-mediated repeated hepatic gene delivery in nonhuman primates

“…22 In contrast, IA results in the selective removal of immunoglobulins from separated plasma through high-affinity adsorbers and allows near complete clearance of circulating immunoglobulins of all types and subtypes. IA has high therapeutic efficacy even in diseases for which plasma exchange is not effective, [23][24][25][26][27][28] and is currently clinically used to treat multiple antibody-mediated or immunological medical conditions. [29][30][31] Different research groups have reported that extensive plasmapheresis may reduce NABs to undetectable levels only when initial anti-AAV NAB titers are low.…”

Approach to the Sensitized Patient Awaiting Heart Transplantation

“…Sensitized recipients receiving plasmapheresis and IVIg prior to heart transplantation have had similar rates of rejection and graft survival compared to non-sensitized control recipients [30]. Immunoadsorption allows targeted removal of alloantibodies and may be more effective than plasmapheresis [31].…”