心脏移植受者高免疫风险患者仅在移植后进行预防性治疗的良好结局。

Favorable Outcome of an Exclusively Posttransplant Prophylactic Strategy After Heart Transplantation in Recipients With High Immunological Risk.

机构信息

Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP). Sorbonne University Medical School, Paris, France.

Department of Cardiology, University Hospital, Liège, Belgium.

出版信息

Transplantation. 2019 Jul;103(7):1439-1449. doi: 10.1097/TP.0000000000002503.

DOI:10.1097/TP.0000000000002503

PMID:30376551

Abstract

BACKGROUND

Management of the increasing number of sensitized heart transplant candidates has become a recurrent issue. Rather than using pretransplant desensitization therapies, we used a posttransplant prophylactic strategy. Our aim was to describe outcomes in transplant recipients with preformed donor-specific anti-HLA antibodies (pfDSA) managed with this strategy.

METHODS

A posttransplant protocol was applied to patients transplanted with pfDSA, consisting of perioperative management of DSA (polyvalent immunoglobulins +/- perioperative plasmapheresis sessions, according to DSA level, as well as induction therapy) and systematic treatment of subsequent antibody-mediated rejection (AMR), even when subclinical. We performed a retrospective analysis of this prospective protocol. The study included all consecutive first recipients of a noncombined heart transplant performed between 2009 and 2015 at our center. The primary endpoint was all-cause mortality. Secondary endpoints included primary graft dysfunction, early posttransplant bleeding, rejection, and cardiac allograft vasculopathy-free survival.

RESULTS

A total of 523 patients were studied, including 88 (17%) and 194 (37%) transplanted with DSA mean fluorescence intensity (MFI) of 500 to 1000 and greater than 1000, respectively. The median follow-up period was 4.06 years. Survival was not significantly different between groups. Rejection-free survival was worse in patients with pfDSA MFI >1000, evidenced by a fourfold increase in the risk of antibody-mediated rejection. The incidence of primary graft dysfunction and cardiac allograft vasculopathy-free survival did not significantly differ between groups. Perioperative plasmapheresis increased the risk for transfusion of packed red blood cells.

CONCLUSIONS

This exclusively posttransplant prophylactic strategy achieved favorable outcomes in heart transplant recipients with pfDSA.

摘要

背景

管理越来越多致敏心脏移植候选者已成为一个反复出现的问题。我们没有使用移植前脱敏治疗，而是使用了移植后的预防策略。我们的目的是描述使用这种策略管理的具有预先形成的供体特异性抗 HLA 抗体（pfDSA）的移植受者的结果。

方法

我们为具有 pfDSA 的移植受者应用了一种移植后方案，包括 DSA 的围手术期管理（根据 DSA 水平，使用多价免疫球蛋白 +/- 围手术期血浆置换疗程，以及诱导治疗）和随后的抗体介导的排斥反应（AMR）的系统治疗，即使是亚临床的 AMR。我们对这个前瞻性方案进行了回顾性分析。这项研究包括了我们中心在 2009 年至 2015 年间进行的所有连续首次非联合心脏移植的受者。主要终点是全因死亡率。次要终点包括原发性移植物功能障碍、移植后早期出血、排斥反应和心脏同种异体移植血管病无复发生存率。

结果

共研究了 523 例患者，其中 88 例（17%）和 194 例（37%）分别移植的 DSA 平均荧光强度（MFI）为 500 至 1000 和大于 1000。中位随访时间为 4.06 年。两组间的生存率无显著差异。pfDSA MFI > 1000 的患者的排斥反应无复发生存率更差，抗体介导的排斥反应的风险增加了四倍。原发性移植物功能障碍和心脏同种异体移植血管病无复发生存率在两组间无显著差异。围手术期血浆置换增加了输注浓缩红细胞的风险。