Department of Perfusion, Great Ormond Street Hospital, London.
Department of Perfusion, Great Ormond Street Hospital, London.
J Heart Lung Transplant. 2018 Apr;37(4):451-457. doi: 10.1016/j.healun.2017.05.006. Epub 2017 May 5.
Since 1996, ABO-incompatible heart transplantation has been undertaken by performing whole-body plasma exchange to remove isohemagglutinins using the cardiopulmonary bypass (CPB) circuit at the time of transplantation. This requires large volumes of donated blood and blood products, causes hemodynamic instability during the exchange transfusion, and limits practical use to small children. We sought to determine the efficacy of anti-A/B immunoadsorption within the CPB circuit on removal of isohemagglutinins in an ex vivo setting before its use clinically.
An anti-A/B immunoadsorption column was placed into a CPB circuit mimicking a typical ABO-incompatible transplant patient, which had been primed with type O whole human blood. Samples were taken for determination of isohemagglutinin titers following each plasma volume pass through the anti-A/B immunoadsorption column.
There was a linear decrease of at least 1 dilution seen in both anti-A and anti-B IgG and IgM antibodies with each plasma volume pass through the column. This predictable removal allowed the formulation of selection criteria for ABO-incompatible heart transplantation given the reciprocal of titer and patient weight. This degree of predictability allowed us to use it successfully in the clinical setting, reducing antibodies to an undetectable level during ABO-incompatible heart transplantation.
The incorporation of an anti-A/B immunoadsorption column into the extracorporeal circuit reduces allogeneic blood product requirement for ABO-incompatible heart transplantation, while providing efficacious removal of anti-A and anti-B isohemagglutinins. This can be undertaken within the time period of CPB before graft reperfusion and expands the potential recipient pool to larger patients with higher isohemagglutinin titers.
自 1996 年以来，通过在移植时使用体外循环（CPB）回路进行全身血浆置换来去除同种异型凝集素，进行 ABO 不相容心脏移植。这需要大量捐献的血液和血液制品，在交换输血过程中会导致血液动力学不稳定，并限制其在小儿童中的实际应用。我们试图在临床应用之前，通过 CPB 回路中的抗-A/B 免疫吸附确定其在体外去除同种异型凝集素的功效。
将抗-A/B 免疫吸附柱置于 CPB 回路中，模拟典型的 ABO 不相容移植患者，该回路已用 O 型全人血预充。在通过抗-A/B 免疫吸附柱的每个血浆体积后取样，以确定同种异型凝集素滴度。
在通过柱子的每个血浆体积后，抗-A 和抗-B IgG 和 IgM 抗体的至少 1 稀释度呈线性下降。这种可预测的清除作用允许根据效价和患者体重为 ABO 不相容心脏移植制定选择标准。这种可预测性允许我们在临床环境中成功使用它，在 ABO 不相容心脏移植期间将抗体减少到无法检测的水平。
将抗-A/B 免疫吸附柱纳入体外回路可减少 ABO 不相容心脏移植所需的同种异体血液制品，同时有效去除抗-A 和抗-B 同种异型凝集素。这可以在 CPB 期间在供体再灌注之前进行，并将潜在的受者群体扩大到具有更高同种异型凝集素滴度的更大患者。
