Favorable outcome of an exclusively posttransplant prophylactic strategy after heart transplantation in recipients with high immunological risk

Background Management of the increasing number of sensitised heart transplant candidates has become a recurrent issue. Rather than using pretransplant desensitisation therapies, we used a posttransplant prophylactic strategy. Our aim was to describe outcomes in transplant recipients with preformed donor-specific anti-HLA antibodies (pfDSA) managed with this strategy. Methods A posttransplant protocol was applied to patients transplanted with pfDSA, consisting of perioperative management of DSA (polyvalent immunoglobulins +/- perioperative plasmapheresis sessions, according to DSA level, as well as induction therapy) and systematic treatment of subsequent antibody-mediated rejection (ABMR), even when subclinical. We performed a retrospective analysis of this prospective protocol. The study included all consecutive first recipients of a noncombined heart transplant performed between 2009 and 2015 at our centre. The primary endpoint was all-cause mortality. Secondary endpoints included primary graft dysfunction, early posttransplant bleeding, rejection and cardiac allograft vasculopathy-free survival. Results A total of 523 patients were studied, including 88 (17%) and 194 (37%) transplanted with DSA mean fluorescence intensity (MFI) of 500–1000 and >1000, respectively. The median follow-up period was 4.06 years. Survival was not significantly different between groups. Rejection-free survival was worse in patients with pfDSA MFI >1000, evidenced by a fourfold increase in the risk of ABMR. The incidence of primary graft dysfunction and cardiac allograft vasculopathy-free survival did not significantly differ between groups. Perioperative plasmapheresis increased the risk for transfusion of packed red blood cells. Conclusions This exclusively posttransplant prophylactic strategy achieved favourable outcomes in heart transplant recipients with pfDSA. Institute of cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP). Paris, France. Corresponding author: Dr Guillaume Coutance, Service de Chirurgie Thoracique et Cardio-Vasculaire, Institut de Cardiologie - Groupe hospitalier Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital - 75651 Paris Cedex 13. Tel: +33 1/42-16-56-08, Fax: +33 1/42-16-55-76. Mail: guillaume.coutance@gmail.com Authorship page Guillaume Coutance participated in the performance of the research, in data analysis and in the writing of the paper. Virginie d'Orio participated in the performance of the research and in data analysis. Lisa Belin participated in data analysis and in the writing of the paper. Nicolas Bréchot participated in research design and in the performance of the research. Samir Saheb participated in research design and in the performance of the research. Guillaume Lebreton participated in research design and in the writing of the paper. Adrien Bouglé participated in the performance of the research and in the writing of the paper. Philippe Rouvier participated in the performance of the research and in the writing of the paper. Chantal Gautreau participated in the performance of the research and in the writing of the paper. Salima Ouldammar participated in the performance of the research. Xavier Chamillard participated in the performance of the research. Mélanie Huot participated in the performance of the research. Julien Amour participated in research design and in the writing of the paper. Alain Combes participated in research design and in the writing of the paper. Pascal Leprince participated in research design and in the writing of the paper. Shaida Varnous participated in research design and in the writing of the paper. Disclosure: The authors declare no conflicts of interest. Funding Source: Guillaume Coutance received research grants from the ADICARE association (2017). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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