Division of Cardiology, Department of Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
Curr Opin Organ Transplant. 2019 Jun;24(3):239-244. doi: 10.1097/MOT.0000000000000635.
The number of sensitized heart transplant candidates is rising. Highly sensitized patients are disadvantaged because they encounter longer waiting times to heart transplant. Strategies to reduce their waiting times include waitlist prioritization and desensitization therapies. The purpose of this review is to describe the listing category for highly sensitized patients in the Canadian allocation system, examine the advantages and limitations of this strategy and provide an approach to the management of the highly sensitized patient awaiting heart transplant.
Analysis of data from the United Network of Organ Sharing shows that the incidence of death or removal from the waitlist in patients listed for heart transplant increases as the calculated panel reactive antibody (cPRA) increases and is independent of medical urgency. In the Canadian allocation system, patients with cPRA more than 80% have a similar incidence of death on the waitlist as less sensitized patients, suggesting they survive to be transplanted. Furthermore, prioritizing and transplanting highly sensitized patients has been associated with acceptable post-transplant outcomes.
The Canadian allocation system prioritizes highly sensitized patients to increase equity and access to transplantation while maintaining good post-transplant outcomes. Not all highly sensitized patients can wait for an organ, even if prioritized. A pragmatic individualized approach would consider the medical stability of the patient, the likelihood of transplant with a negative crossmatch and then determine whether waitlist prioritization or desensitization is the more appropriate strategy.
致敏心脏移植候选者的数量正在增加。高度致敏患者处于不利地位，因为他们等待心脏移植的时间更长。缩短他们等待时间的策略包括在候补名单上的优先排序和脱敏治疗。本文的目的是描述加拿大分配系统中高度致敏患者的列表类别，检查该策略的优缺点，并提供等待心脏移植的高度致敏患者的管理方法。
来自器官共享联合网络的数据分析表明，随着计算的群体反应性抗体（cPRA）的增加，心脏移植候补名单上患者的死亡或被移除的发生率增加，并且与医疗紧迫性无关。在加拿大的分配系统中，cPRA 超过 80%的患者与致敏程度较低的患者在候补名单上的死亡发生率相似，这表明他们可以存活并进行移植。此外，优先考虑和移植高度致敏患者与可接受的移植后结果相关。
加拿大的分配系统优先考虑高度致敏患者，以增加公平性和移植机会，同时保持良好的移植后结果。即使优先排序，并非所有高度致敏患者都可以等待器官。一种务实的个体化方法将考虑患者的医疗稳定性、与阴性交叉匹配进行移植的可能性，然后确定候补名单上的优先排序还是脱敏治疗更合适。
