Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
Curr Opin Organ Transplant. 2019 Jun;24(3):233-238. doi: 10.1097/MOT.0000000000000639.
This review summarizes contemporary desensitization strategies for patients awaiting cardiac transplantation in an era when specific management is still somewhat controversial.
The number of sensitized patients awaiting heart transplantation is rising. Clinical assessment of antibody levels is mostly focused on human leukocyte antigen (HLA) antibodies. Sensitization to HLA antigens increases the risk of antibody medicated rejection and cardiac allograft vasculopathy after transplant, thus translates to reduced access to compatible donors and increased wait time to transplant. Desensitization therapy is commonly considered in listed patients with cPRA more than 50%, to either decrease the amount of circulating anti-HLA antibodies, reduce the antibody production, or a combination of both. Despite promising results on specific therapies (e.g., plasmapheresis, intravenous immunoglobulin, rituximab, bortezomib), there is a significant gap in knowledge on desensitization therapies in heart transplantation. Most data are from small observational studies and extrapolated from nonheart solid organ transplants.
Management of the sensitized patient awaiting heart transplant is individualized. Desensitization can facilitate negative cross-match and successful transplantation, but is associated with significant cost and potential adverse effects. The long-term outcomes of desensitization therapy remain to be determined, further emphasizing the importance of personalizing the treatment approach to each patient.
在特定治疗方案仍存在一定争议的时代，本综述总结了当前等待心脏移植患者的脱敏策略。
等待心脏移植的致敏患者数量正在增加。对抗体水平的临床评估主要集中在人类白细胞抗原（HLA）抗体上。致敏 HLA 抗原增加了移植后抗体介导排斥反应和心脏同种异体血管病的风险，从而降低了与相容供体的接触机会，并延长了移植等待时间。在 cPRA 超过 50%的已列入名单的患者中，通常会考虑脱敏治疗，以减少循环抗 HLA 抗体的数量、减少抗体产生，或两者兼而有之。尽管在特定治疗方法（如血浆置换、静脉注射免疫球蛋白、利妥昔单抗、硼替佐米）上取得了有希望的结果，但心脏移植中脱敏治疗的知识仍存在很大差距。大多数数据来自小型观察性研究，并从非心脏实体器官移植中推断得出。
等待心脏移植的致敏患者的管理是个体化的。脱敏治疗可以促进负交叉匹配和成功移植，但与高昂的成本和潜在的不良反应有关。脱敏治疗的长期结果仍有待确定，这进一步强调了根据每位患者的情况制定治疗方案的重要性。
