Asante-Korang Alfred, Amankwah Ernest K, Lopez-Cepero Mayra, Ringewald Jeremy, Carapellucci Jennifer, Krasnopero Diane, Berg Alex, Quintessenza James, Jacobs Jeffrey P
Divisions of Pediatric Cardiology.
Clinical and Translational Research Organization, All Children's Hospital/Johns Hopkins Medicine, St Petersburg, Florida.
J Heart Lung Transplant. 2015 Feb;34(2):175-81. doi: 10.1016/j.healun.2014.09.027. Epub 2014 Sep 28.
Previous studies have suggested that children with pre-formed anti-HLA antibodies (PRA) undergoing orthotopic heart transplantation (OHT) have increased risk for rejection, coronary artery vasculopathy (CAV) and death. In 2005, our program started utilizing aggressive desensitization (including plasmapheresis, IVIg, pulse cytoxan and rituximab) with the goal of improving outcomes for these patients. The purpose of this study was to compare outcomes with this new strategy in recipients with pre-OHT high PRA (>10%) vs low PRA ≤10%).
A retrospective study of 70 consecutive pediatric OHT patients was undertaken between January 2005 and July 2013 to identify patients with pre-OHT PRA >10% (high PRA), or PRA ≤10% (low PRA). Demographic/data information and detailed post-OHT outcomes, including rejection, 30-day and overall mortality, freedom from significant rejection, and CAV, were analyzed.
Fourteen (20%) patients had high PRA and 56 (80%) did not. There was a significant decrease in PRA values before and after desensitization. Thirty-day and overall mortality and the proportion of patients with rejections or CAV were lower in the high PRA group, although the difference was not statistically significant. Kaplan-Meier survival analysis revealed no significant difference in survival between the two groups. There was a significant difference in survival in our sensitized patients before 2005 vs after 2005.
We identified no significant differences in outcomes between high or low PRA patients. These preliminary findings may suggest improvement in OHT outcomes for high PRA patients as a result of aggressive desensitization. A larger study is warranted to confirm these findings.
既往研究表明，接受原位心脏移植（OHT）的预先存在抗人类白细胞抗原（HLA）抗体（PRA）的儿童发生排斥反应、冠状动脉血管病变（CAV）和死亡的风险增加。2005年，我们的项目开始采用强化脱敏疗法（包括血浆置换、静脉注射免疫球蛋白、环磷酰胺冲击治疗和利妥昔单抗），目的是改善这些患者的预后。本研究的目的是比较这种新策略在移植前PRA高（>10%）与低（≤10%）的受体中的预后情况。
对2005年1月至2013年7月期间连续70例小儿OHT患者进行回顾性研究，以确定移植前PRA>10%（高PRA）或PRA≤10%（低PRA）的患者。分析人口统计学/数据信息以及详细的移植后预后情况，包括排斥反应、30天和总体死亡率、无严重排斥反应、以及CAV。
14例（20%）患者PRA高，56例（80%）患者PRA不高。脱敏前后PRA值显著降低。高PRA组的30天和总体死亡率以及发生排斥反应或CAV的患者比例较低，尽管差异无统计学意义。Kaplan-Meier生存分析显示两组之间生存率无显著差异。2005年前与2005年后我们的致敏患者生存率存在显著差异。
我们发现高PRA和低PRA患者的预后无显著差异。这些初步发现可能表明强化脱敏疗法改善了高PRA患者的OHT预后。需要进行更大规模的研究来证实这些发现。
