Mortality and Morbidity in Pre-sensitized Pediatric Heart Transplant Recipients With a Positive Donor Crossmatch Utilizing Peri-operative Plasmapheresis and Cytolytic Therapy

• Published in: The Journal of heart and lung transplantation Vol. 26; no. 9; pp. 876 - 882
• Main Authors: Holt, D. Byron, MD, Lublin, Douglas M., MD, Phelan, Donna L., CHS, Boslaugh, Sarah E., PhD, MPH, Gandhi, Sanjiv K., MD, Huddleston, Charles B., MD, Saffitz, Jeffrey E., MD, Canter, Charles E., MD
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01.09.2007; Elsevier Science
• Subjects: Adolescent; Adult; Antilymphocyte Serum - therapeutic use; Biological and medical sciences; Child; Child, Preschool; Cyclophosphamide - therapeutic use; Cytotoxicity Tests, Immunologic; Graft Rejection - therapy; Heart Transplantation; Histocompatibility; HLA Antigens - immunology; Humans; Immunosuppressive Agents - therapeutic use; Infant; Isoantibodies - blood; Medical sciences; Perioperative Care; Plasmapheresis; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Human; Heart; Suboptimal donor; Pediatrics; Therapy; Respiratory disease; Mortality; Cardiovascular disease; Transplantation; Homotransplantation; Epidemiology; Morbidity; Plasmapheresis; Treatment; Surgery; Graft; Child
• ISSN: 1053-2498; 1557-3117
• DOI: 10.1016/j.healun.2007.07.011

Background The difficulty in obtaining a prospective negative donor/recipient crossmatch limits the ability to successfully transplant pediatric heart transplant candidates who show evidence of antibodies to multiple human leukocyte antigens (pre-sensitized patients). Methods We utilized a protocol that included peri-operative plasmapheresis, thymoglobulin and cyclophosphamide in 17 pre-sensitized (panel-reactive antibodies [PRA] >10%) pediatric patients to accept donors for these patients without a prospective crossmatch between 1995 and 2005. A retrospective review of survival, rejection and infection was performed, comparing the frequency of rejection and infection in our patients who were transplanted with a complement-dependent cytotoxic (CDC)-positive donor/recipient crossmatch to those patients transplanted with a negative crossmatch. Results Thirteen of 17 patients were found to have a CDC-positive crossmatch. Actuarial survival after transplantation was 85% at 1 year and 73% at 3 years. Twelve of 13 (92%) of these patients experienced rejection, and 5 of 13 (38%) had recurrent rejection, generally in the first 2 months after transplantation. Rejection was associated with hemodynamic compromise in 58% of first rejection episodes and 67% of episodes of recurrent rejection. The frequency of rejection in these patients was significantly greater than the frequency in patients with a negative crossmatch in the first 6 months after transplantation, but not afterward. The frequency of infection episodes was not significantly different between the groups. Conclusions Heart transplantation in pre-sensitized pediatric recipients with a CDC-positive donor/recipient crossmatch may result in reasonable short-term survival, but with a high frequency of early rejection, often with hemodynamic compromise.