Singh Nirupama, Vanlandingham Sean, Halverson Catlin, Marques Marisa B, Tallaj Jose, Kirklin James, Adamski Jill
Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama.
J Clin Apher. 2014 Dec;29(6):316-21. doi: 10.1002/jca.21338. Epub 2014 May 30.
Allograft dysfunction due to presumed antibody-mediated rejection (pAMR) is one of the most serious complications of heart transplantation. Combination therapies of high-dose steroids, intravenous immune globulin, and/or therapeutic plasma exchange (TPE) are often used in this setting.
We performed a 9-year retrospective review of all episodes of pAMR treated with TPE at our institution. pAMR diagnosis was based on clinical and pathologic findings. Left ventricular ejection fraction (LVEF) was measured at baseline, prior to initiation of TPE, and during the course of treatment.
There were 42 patients with 47 episodes of pAMR treated with TPE. The majority of episodes were treated with three TPE; however, eight required only two TPE and five episodes required >3 TPE. All episodes of pAMR had LVEF measured before and after the series of TPEs. The mean pre-TPE LVEF was 38% compared with a post-therapy mean LVEF of 50% (P < 0.0001). In 16 episodes of pAMR, for which LVEF was measured following each apheresis, there was significant improvement of allograft function after the first TPE (pre-TPE mean LVEF of 31% and post-first TPE mean LVEF of 37%; P = 0.02). Incremental and significant improvement in allograft function continued following each TPE. Changes in human leukocyte antigen-donor specific antibodies and fibrinogen did not correlate with ejection fraction response.
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.
推测由抗体介导的排斥反应（pAMR）导致的同种异体移植功能障碍是心脏移植最严重的并发症之一。在这种情况下，常使用大剂量类固醇、静脉注射免疫球蛋白和/或治疗性血浆置换（TPE）的联合疗法。
我们对本机构接受TPE治疗的所有pAMR发作进行了为期9年的回顾性研究。pAMR诊断基于临床和病理结果。在基线、开始TPE之前以及治疗过程中测量左心室射血分数（LVEF）。
有42例患者发生47次pAMR发作并接受了TPE治疗。大多数发作接受了三次TPE治疗；然而，8例仅需要两次TPE治疗，5例发作需要超过3次TPE治疗。所有pAMR发作在一系列TPE前后均测量了LVEF。TPE前平均LVEF为38%，治疗后平均LVEF为50%（P < 0.0001）。在16次pAMR发作中，每次单采后测量LVEF，首次TPE后同种异体移植功能有显著改善（TPE前平均LVEF为31%，首次TPE后平均LVEF为37%；P = 0.02）。每次TPE后同种异体移植功能持续有渐进性显著改善。人类白细胞抗原供体特异性抗体和纤维蛋白原的变化与射血分数反应无关。
我们患者同种异体移植功能的快速改善最可能归因于TPE，因为其他药物干预起效时间更长。在pAMR情况下，TPE应被视为一线干预措施。
