Asymptomatic Antibody-mediated Rejection After Heart Transplantation Predicts Poor Outcomes

• Published in: The Journal of heart and lung transplantation Vol. 28; no. 5; pp. 417 - 422
• Main Authors: Wu, Grace W., BS, Kobashigawa, Jon A., MD, Fishbein, Michael C., MD, Patel, Jignesh K., MD, PhD, Kittleson, Michelle M., MD, PhD, Reed, Elaine F., PhD, Kiyosaki, Krista K., BA, Ardehali, Abbas, MD
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01.05.2009; Elsevier
• Subjects: Actuarial Analysis; Adult; Aged; Antigens, CD - blood; Antigens, Differentiation, Myelomonocytic - blood; Biological and medical sciences; Biopsy; Capillaries - immunology; Capillaries - pathology; Cardiology. Vascular system; Complement C4b; Coronary Artery Disease - immunology; Coronary Artery Disease - mortality; Coronary Artery Disease - pathology; Coronary Vessels - immunology; Coronary Vessels - pathology; Endocardium - immunology; Endocardium - pathology; Female; Graft Rejection - immunology; Graft Rejection - mortality; Graft Rejection - pathology; Heart Failure - immunology; Heart Failure - pathology; Heart Transplantation - immunology; Heart Transplantation - mortality; Heart Transplantation - pathology; Humans; Immunoenzyme Techniques; Isoantibodies - blood; Macrophages - immunology; Macrophages - pathology; Male; Medical sciences; Middle Aged; Myocardium - immunology; Myocardium - pathology; Peptide Fragments - blood; Postoperative Complications - immunology; Postoperative Complications - mortality; Postoperative Complications - pathology; Prognosis; Retrospective Studies; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Survival Rate; Ventricular Dysfunction, Left - immunology; Ventricular Dysfunction, Left - pathology; Heart; Graft(material); Prognosis; Antibody; Prediction; Transplantation; Asymptomatic; Homotransplantation; Phlebology; Rejection; Treatment; Surgery; Graft; Evolution; Circulatory system; Cardiology
• ISSN: 1053-2498; 1557-3117
• DOI: 10.1016/j.healun.2009.01.015

Background Antibody-mediated rejection (AMR) has been associated with poor outcome after heart transplantation. The diagnosis of AMR usually includes endomyocardial biopsy findings of endothelial cell swelling, intravascular macrophages, C4d+ staining, and associated left ventricular dysfunction. The significance of AMR findings in biopsy specimens of asymptomatic heart transplant patients (normal cardiac function and no symptoms of heart failure) is unclear. Methods Between July 1997 and September 2001, AMR was found in the biopsy specimens of 43 patients. Patients were divided into 2 groups: asymptomatic AMR (AsAMR, n = 21) and treated AMR (TxAMR with associated left ventricular dysfunction, n = 22). For comparison, a control group of 86 contemporaneous patients, without AMR, was matched for age, gender, and time from transplant. Outcomes included 5-year actuarial survival and development of cardiac allograft vasculopathy (CAV). Patients were considered to have AMR if they had ≥ 1 endomyocardial biopsy specimen positive for AMR. Results The 5-year actuarial survival for the AsAMR (86%), TxAMR (68%), and control groups (79%) was not significantly different ( p = 0.41). Five-year freedom from CAV (≥ 30% stenosis in any vessel) was AsAMR, 52%; TxAMR, 68%; and control, 79%. Individually, freedom from CAV was significantly lower in the AsAMR group compared with the control group ( p = 0.02). There was no significant difference between AsAMR vs TxAMR and TxAMR vs control for CAV. Conclusions Despite comparable 5-year survival with controls after heart transplantation, AsAMR rejection is associated with a greater risk of CAV. Trials to treat AsAMR to alter outcome are warranted.