Massad M G, Cook D J, Schmitt S K, Smedira N G, McCarthy J F, Vargo R L, McCarthy P M
Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Ohio 44195-5066, USA.
Ann Thorac Surg. 1997 Oct;64(4):1120-5. doi: 10.1016/s0003-4975(97)00807-2.
Patients bridged to transplantation (TX) with the implantable left ventricular assist device (LVAD) may be at increased risk for the development of panel-reactive antibodies (PRA) during support.
To investigate that, we evaluated 60 patients who received the HeartMate LVAD at our institution, of whom 53 had PRA results available for analysis. T lymphocyte PRA levels were examined before LVAD, at the peak PRA level during LVAD support (PEAK), and just before TX. A PRA level more than 10% was considered indicative of sensitization against HLA antigens.
The only factor that had a significant effect on PRA levels before LVAD was patient's sex (1.3% for men versus 7.4% for women; p = 0.005). During LVAD support, peak PRA levels increased significantly and the sex-associated differences were no longer evident (33.3% men, 34.3% women; not significant). At the time of TX, PRAs decreased to 10.9% (men) and 7.0% (women) (not significant). We examined the influence of blood products received before TX on PRA levels. Patients who received less than the median number of total units (<median) had lower peak PRA values (22.3% versus 49.2%; p = 0.01) and TX PRA values (3.5% versus 22.1%; p = 0.02) than those receiving more than the median (>median). When examined by the type of blood product, only the number of platelet transfusions significantly increased the peak PRA (<median: 24% versus >median: 46.9%; p = 0.03). Patients who received blood that was leukocyte-depleted tended to have lower TX PRA levels (2.9%) compared with those who did not (13.9%, p = 0.18). Forty-two patients were successfully bridged to TX, with three early and two late deaths after TX. Whereas 39 patients received transplants without intervention, 3 were treated by plasmapheresis with a 77% reduction in their HLA antibody levels at TX as measured by flow cytometry.
Patients with the implantable LVAD are at significant risk for the development of anti-HLA antibodies during support. Although this sensitization is often transient, intervention using plasmapheresis may be useful for some patients.
使用植入式左心室辅助装置（LVAD）过渡到移植（TX）的患者在辅助治疗期间发生群体反应性抗体（PRA）的风险可能会增加。
为了对此进行研究，我们评估了在我院接受HeartMate LVAD的60例患者，其中53例有PRA结果可供分析。在植入LVAD前、LVAD辅助治疗期间PRA水平峰值时（PEAK）以及TX前检测T淋巴细胞PRA水平。PRA水平超过10%被认为提示对HLA抗原致敏。
LVAD植入前对PRA水平有显著影响的唯一因素是患者性别（男性为1.3%，女性为7.4%；p = 0.005）。在LVAD辅助治疗期间，PRA峰值水平显著升高，性别相关差异不再明显（男性为33.3%，女性为34.3%；无显著性差异）。在TX时，PRA降至10.9%（男性）和7.0%（女性）（无显著性差异）。我们研究了TX前接受的血液制品对PRA水平的影响。接受的总单位数少于中位数（<中位数）的患者，其PRA峰值水平（22.3%对49.2%；p = 0.01）和TX时PRA水平（3.5%对22.1%；p = 0.02）低于接受的总单位数多于中位数（>中位数）的患者。按血液制品类型分析时，仅血小板输注次数显著增加PRA峰值（<中位数：24%对>中位数：46.9%；p = 0.03）。接受白细胞去除血液的患者TX时PRA水平往往较低（2.9%），而未接受白细胞去除血液的患者为13.9%（p = 0.18）。42例患者成功过渡到TX，TX后有3例早期死亡和2例晚期死亡。39例患者未经干预接受了移植，3例接受了血浆置换治疗，TX时通过流式细胞术检测其HLA抗体水平降低了77%。
植入LVAD的患者在辅助治疗期间有发生抗HLA抗体的显著风险。尽管这种致敏通常是短暂的，但血浆置换干预可能对一些患者有用。
