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Eckman PM, Hanna M, Taylor DO, Starling RC, Gonzalez-Stawinski GV. Management of the sensitized adult heart transplant candidate. Clin Transplant 2011; 24:726-34. [PMID: 20482565 DOI: 10.1111/j.1399-0012.2010.01259.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Heart transplant recipients sensitized to human leukocyte antigens comprise a challenging subgroup of patients. Sensitization has been associated with a variety of effects that determine short-term and long-term outcomes. These include a higher rate of acute rejection and graft loss, and a heightened risk for developing cardiac allograft vasculopathy. Because of improvements in both tissue typing and immunomodulatory therapies coupled with the growing population receiving mechanical circulatory support/LVAD, the percent of sensitized patients listed for heart transplantation has increased, inflicting a greater burden to the already scarce donor pool. Despite these potentially adverse developments, pre-transplant immunologic management has resulted in decreased waiting times and outcomes that were not possible over 10 yr ago. The following review will focus on the contemporary management of the sensitized heart transplant candidate and highlight therapies that have allowed the successful transplantation of this growing and challenging patient population, including several approaches in development.
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Affiliation(s)
- Peter M Eckman
- Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, OH, USA.
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102
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Abstract
PURPOSE OF REVIEW This paper briefly and subjectively reviews a number of the modest or tentative, but noteworthy, advances in heart transplantation that have been made during the past 18 months or so. RECENT FINDINGS The advances reviewed concern the selection of recipients, the management of the heart transplantation waiting list, the management of donors, post-heart transplant monitoring of immunological status, the early diagnosis of rejection, the role of mammalian target of rapamycine inhibitors and induction agents, and the definition and grading of cardiac allograft vasculopathy. SUMMARY The findings reviewed indicate progress in the clarification of issues that were in most cases already being investigated. Further studies will in general be needed before corresponding measures are adopted in clinical practice.
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Abstract
PURPOSE OF REVIEW The proportion of heart transplant candidates who are allosensitized has increased over time. Advances in tissue typing and immunosuppression have improved the rate of successful transplant in this challenging population. Recently published data regarding contemporary approaches to desensitization prior to and immunosuppression following transplant are summarized. RECENT FINDINGS Continued progress in measurement and characterization of antibodies and strategies to abrogate antibody production both prior to and following heart transplant have been encouraging. Updates on the role of non-human leukocyte antigen antibodies and the impact of mechanical circulatory support on allosensitization are provided. Data on current desensitization strategies, including the increasing use of monoclonal antibodies, are provided and the potential role of complement inhibitors will be reviewed. Increasing experience with potent novel agents is likely to provide the opportunity to improve transplant outcomes for highly sensitized patients. SUMMARY Although allosensitized heart transplant candidates remain a management challenge, excellent outcomes can be achieved with contemporary approaches. Advances in the understanding of B-cell biology are anticipated to further broaden options and improve outcomes.
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Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S, Fedson S, Fisher P, Gonzales-Stawinski G, Martinelli L, McGiffin D, Smith J, Taylor D, Meiser B, Webber S, Baran D, Carboni M, Dengler T, Feldman D, Frigerio M, Kfoury A, Kim D, Kobashigawa J, Shullo M, Stehlik J, Teuteberg J, Uber P, Zuckermann A, Hunt S, Burch M, Bhat G, Canter C, Chinnock R, Crespo-Leiro M, Delgado R, Dobbels F, Grady K, Kao W, Lamour J, Parry G, Patel J, Pini D, Towbin J, Wolfel G, Delgado D, Eisen H, Goldberg L, Hosenpud J, Johnson M, Keogh A, Lewis C, O'Connell J, Rogers J, Ross H, Russell S, Vanhaecke J, Russell S, Vanhaecke J. The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. J Heart Lung Transplant 2010; 29:914-56. [PMID: 20643330 DOI: 10.1016/j.healun.2010.05.034] [Citation(s) in RCA: 1157] [Impact Index Per Article: 82.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Accepted: 05/31/2010] [Indexed: 12/26/2022] Open
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105
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Diagnosis of antibody-mediated rejection in cardiac transplantation: a call for standardization. Curr Opin Organ Transplant 2010; 15:769-73. [DOI: 10.1097/mot.0b013e32834016e4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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106
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Deutsch MA, Kauke T, Sadoni S, Kofler S, Schmauss D, Bigdeli AK, Weiss M, Reichart B, Kaczmarek I. Luminex-based virtual crossmatching facilitates combined third-time cardiac and de novo renal transplantation in a sensitized patient with sustained antibody-mediated cardiac allograft rejection. Pediatr Transplant 2010; 14:E96-E100. [PMID: 19775252 DOI: 10.1111/j.1399-3046.2009.01208.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Allosensitization represents a major obstacle to successful re-transplantation since circulating antibodies can elicit antibody-mediated rejection episodes with subsequent graft failure. Since sensitization is primarily considered a contraindication to transplantation the duration for patients waiting for a suitable donor organ to become available is considerably prolonged. Herein, we report on the successful application of a Luminex-based virtual crossmatch approach to facilitate combined third-time cardiac and de novo renal transplantation in a sensitized patient with sustained antibody-mediated cardiac allograft rejection.
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Affiliation(s)
- Marcus-André Deutsch
- Department of Cardiac Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Marchioninistrasse, Munich, Germany
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Batal I, Zeevi A, Lunz JG, Aggarwal N, Shapiro R, Randhawa P, Girnita A. Antihuman leukocyte antigen–specific antibody strength determined by complement-dependent or solid-phase assays can predict positive donor-specific crossmatches. Arch Pathol Lab Med 2010; 134:1534-40. [PMID: 20923311 DOI: 10.5858/2009-0581-oa.1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT The association of circulating donor-specific antibody (DSA) strength with crossmatch results is of potential interest to predict allograft outcome. OBJECTIVES To systematically investigate the aforementioned association and to attempt to define a cutoff value for DSA strength that can predict a positive crossmatch result. DESIGN We analyzed DSA strength and crossmatch results from the 2006 to 2008 proficiency testing samples of the American Society of Histocompatibility and Immunogenetics (n = 50). We further validated our findings in candidates for potential kidney transplant (n = 19). RESULTS Proficiency test samples with positive antihuman globulin T-cell crossmatch results had significantly higher DSA strength, as assessed by Luminex (Austin, Texas) mean fluorescent intensity (MFI; MFI [SD], 7860 [4770]), compared with samples with negative crossmatch results (MFI [SD], 2900 [1820]; P = .001). Similarly, higher Luminex values were observed in samples from candidates for transplant with positive antihuman globulin T-cell crossmatch results (MFI [SD], 7910 [2370] versus 2840 [1960]; P < .001). The MFI value of 6540 had 61% and 75% sensitivity and 92% and 94% specificity for predicting positive antihuman globulin T-cell crossmatches in proficiency test samples and in candidates for transplant, respectively. CONCLUSIONS The DSA strength correlates well with crossmatch results. An MFI of 6540 predicted a positive antihuman globulin T-cell crossmatch.
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Affiliation(s)
- Ibrahim Batal
- Departments of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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108
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Pre- and posttransplantation allosensitization in heart allograft recipients: major impact of de novo alloantibody production on allograft survival. Hum Immunol 2010; 72:5-10. [PMID: 20971146 DOI: 10.1016/j.humimm.2010.10.013] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 09/01/2010] [Accepted: 10/15/2010] [Indexed: 01/25/2023]
Abstract
The involvement of humoral response in allograft rejection has been suggested by both immunologic and histochemistry studies. In the present study, we explored the role of alloantibodies in a large cohort of heart allograft recipients followed for 15 years. Sequential samples of sera were obtained from 950 recipients of heart allografts before and after transplantation at the time when protocol endomyocardial biopsies were performed. The presence of anti-human leukocyte antigen (HLA) antibodies was investigated using complement mediated cytotoxicity and solid phase assay (SPA). Our data reveal an inverse correlation between the development of alloantibodies after transplantation and heart allograft survival. The 15-year graft survival was highest in patients who never developed alloantibodies (70%) or who displayed them only before transplantation (71%); graft survival in recipients who showed antibodies both before and after transplantation (56%), or only after transplantation (47%), was lower. The deleterious effect of antibodies on graft survival started 8 years after transplantation, suggesting that the production of de novo antibodies may have been triggered by some later event. We found that patients with de novo antibodies appearing more than 1 year after transplantation had the poorest survival. Furthermore, the development of de novo antibodies was preceded in 76% of these patients by cellular rejection grade 3 or higher, according to the International Society for Heart Transplantation (ISHT) grading criteria. Development of antibody-mediated rejection (AMR) had a significant negative impact on graft survival (16% in AMR(+) vs 63% in AMR(-) patients, p = 0.0008). Of the 23 patients with AMR, 21 displayed cytotoxic donor-specific antibodies (DSA) at the time of diagnosis, and in 18 of these cases SPA showed that they were directed against the donors' HLA. The data demonstrate that the detection of alloantibodies permits a better definition of AMR in heart allograft recipients. Identification of patients at risk for developing AMR is of great importance for early treatment of rejection episodes.
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109
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On solid-phase antibody assays. J Heart Lung Transplant 2010; 29:1207-9. [DOI: 10.1016/j.healun.2010.06.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 06/14/2010] [Accepted: 06/30/2010] [Indexed: 11/15/2022] Open
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110
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Antibody-mediated rejection after heart transplantation - an overview of current concepts. COR ET VASA 2010. [DOI: 10.33678/cor.2010.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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111
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Ross H, Tinckam K, Rao V, West LJ. In praise of ventricular assist devices—mechanical bridge to virtual crossmatch for the sensitized patient. J Heart Lung Transplant 2010; 29:728-30. [DOI: 10.1016/j.healun.2010.02.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2010] [Revised: 01/29/2010] [Accepted: 02/04/2010] [Indexed: 11/26/2022] Open
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112
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Lund LH, Matthews J, Aaronson K. Patient selection for left ventricular assist devices. Eur J Heart Fail 2010; 12:434-43. [DOI: 10.1093/eurjhf/hfq006] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lars H. Lund
- Department of Cardiology, Section for Heart Failure; Karolinska University Hospital; N305 171 76 Stockholm Sweden
| | - Jennifer Matthews
- Division of Cardiovascular Medicine, Department of Internal Medicine; University of Michigan; Ann Arbor MI USA
| | - Keith Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine; University of Michigan; Ann Arbor MI USA
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113
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Controversies in defining cardiac antibody-mediated rejection: Need for updated criteria. J Heart Lung Transplant 2010; 29:389-94. [DOI: 10.1016/j.healun.2009.10.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Revised: 10/27/2009] [Accepted: 10/27/2009] [Indexed: 11/19/2022] Open
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114
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Antihuman leukocyte antigen antibody-induced autoimmunity: role in chronic rejection. Curr Opin Organ Transplant 2010; 15:16-20. [PMID: 19898237 DOI: 10.1097/mot.0b013e3283342780] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW We provide evidence for the role of de-novo development of immune responses to self-antigens in the posttransplant period and its possible induction by alloimmunity in the pathogenesis of chronic rejection following lung, heart and kidney transplantation. The present review details recent findings for the two distinct yet interdependent immune processes in the immunopathogenesis of chronic rejection. RECENT FINDINGS The contribution of both humoral and cell-mediated alloimmune responses against mismatched donor histocompatibility antigens (HLA) in the pathogenesis of chronic rejection is well established. Recent studies have focused on development of immune responses to self-antigens during the posttransplant period and its correlation with chronic rejection. These self-antigens include myosin and vimentin in cardiac, K-alpha-1-tubulin and collagen-V in lung and angiotensin II type 1 receptor, collagen-IV and VI in kidney transplants. During the posttransplant period, the development of immune responses to self-antigens is facilitated by induction of a distinct subset of autoreactive T-helper cells referred to as Th17 cells. SUMMARY Following organ transplantation, tissue injury and remodeling inflicted by antibodies (Abs) to HLA antigens is conducive to develop autoimmunity. Abs to HLA and self-antigens are detectable in the serum of transplant recipients who develop chronic rejection. Anti-HLA Abs are often present transiently but precede the development of Abs to self-antigens.
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115
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Characteristics of patients on the waiting list for heart transplantation. COR ET VASA 2010. [DOI: 10.33678/cor.2010.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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116
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Kristen AV, Sack FU, Schonland SO, Hegenbart U, Helmke BM, Koch A, Schnabel PA, Röcken C, Hardt S, Remppis A, Goldschmidt H, Karck M, Ho AD, Katus HA, Dengler TJ. Staged heart transplantation and chemotherapy as a treatment option in patients with severe cardiac light-chain amyloidosis. Eur J Heart Fail 2010; 11:1014-20. [PMID: 19789405 DOI: 10.1093/eurjhf/hfp121] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
AIMS The prognosis of advanced cardiac light-chain amyloidosis is poor. Heart transplantation might enable causative therapy and ultimately improve prognosis. METHODS AND RESULTS Nineteen patients with cardiac amyloidosis but no obvious involvement of other organs were scheduled for heart transplantation. Four to 6 months later, high-dose melphalan chemotherapy and autologous stem cell transplantation (HDM-ASCT) was planned in patients not in complete remission. Seven of nineteen patients died while waiting for heart transplantation. The remaining 12 patients (complete remission, n = 4) underwent surgery. Chemotherapy in patients not in complete remission consisted of HDM-ASCT (n = 5/12; subsequent complete remission, n = 2; partial remission, n = 3) or melphalan-prednisolone (partial remission, n = 1). Two of twelve patients were ineligible for any chemotherapy. Three of twelve patients died [423.5 (105-2131) days] from progressive disease, relapse, or sepsis. The 1- and 3-year survival rates were 83 and 83%, respectively, similar to those of patients undergoing heart transplantation for standard indications. Corresponding survival rates stratified by haematological response were 100 and 100% for complete remission (partial remission, 100 and 100%; progressive disease, 0 and 0%). CONCLUSION Heart transplantation in advanced cardiac amyloidosis is a promising approach to interrupting the vicious circle of ineligibility for potential curative chemotherapeutic treatment and extremely poor prognosis of cardiac amyloidosis without chemotherapy. Highly urgent heart transplantation combined with subsequent HDM-ASCT appears to offer a successful treatment option to improve the poor outcome of cardiac amyloidosis. However, it should be restricted to highly selected patients in specialized centres.
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Affiliation(s)
- Arnt V Kristen
- Department of Cardiology, Angiology, and Respiratory Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 410, Heidelberg D-69120, Germany.
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117
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Mandras SA, Crespo J, Patel HM. Innovative application of immunologic principles in heart transplantation. Ochsner J 2010; 10:231-235. [PMID: 21603389 PMCID: PMC3096230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND Each year, approximately 2,200 heart transplants are performed in the United States. As our understanding of the immune system grows, new tools are being developed to find compatible organ donors and to help with immune surveillance after transplantation. The purpose of this article is to review 3 of these techniques: the virtual crossmatch, the Cylex ImmuKnow assay, and the AlloMap test. METHODS Two authors (S.A.M. and J.C.) independently performed a literature search with the PubMed database using the key words ImmuKnow, Allomap, and virtual crossmatch in conjunction with heart transplantation. Articles were selected for inclusion if they had a primary focus on the use of virtual crossmatch in heart transplantation, the Cylex ImmuKnow assay, and the AlloMap test. Articles were not excluded on the basis of sample size but were excluded if they did not include heart transplant patients. RESULTS The virtual crossmatch is a technique that is being used successfully in heart transplant candidates to predict compatibility of donor organs by comparing the potential recipient's HLA-specific antibodies with the HLA type of the prospective donor. The ImmuKnow assay is a noninvasive blood test that measures the strength of immune activity, allowing clinicians to predict risk of infection and possible rejection in heart transplant patients. The AlloMap test is a noninvasive test that quantifies intracellular mRNA levels in mononuclear cells in peripheral blood samples using real-time polymerase chain reaction; this test has been shown to distinguish the dynamic changes in gene expression that occur in the presence or absence of acute cellular rejection. CONCLUSION As the science of transplant immunology advances, transplant cardiologists are taking advantage of the growing fund of knowledge to help their sensitized transplant candidates increase their chances of finding a compatible donor heart and are using commercially available tests to monitor the immune system and rule out rejection after transplantation.
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Affiliation(s)
- Stacy A. Mandras
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
| | - Joaquin Crespo
- Department of Internal Medicine, Ochsner Clinic Foundation, New Orleans, LA
| | - Hamang M. Patel
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
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O'Connor MJ, Menteer J, Chrisant MR, Monos D, Lind C, Levine S, Gaynor JW, Hanna BD, Paridon SM, Ravishankar C, Kaufman BD. Ventricular assist device-associated anti-human leukocyte antigen antibody sensitization in pediatric patients bridged to heart transplantation. J Heart Lung Transplant 2010; 29:109-16. [DOI: 10.1016/j.healun.2009.08.028] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2009] [Revised: 08/27/2009] [Accepted: 08/30/2009] [Indexed: 12/15/2022] Open
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119
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Ho EK, Vlad G, Colovai AI, Vasilescu ER, Schwartz J, Sondermeijer H, Burke E, Marboe CC, Itescu S, Suciu-Foca N, Mancini D. Alloantibodies in heart transplantation. Hum Immunol 2009; 70:825-9. [DOI: 10.1016/j.humimm.2009.06.015] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Revised: 06/17/2009] [Accepted: 06/18/2009] [Indexed: 12/01/2022]
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120
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Stehlik J, Islam N, Hurst D, Kfoury AG, Movsesian MA, Fuller A, Delgado JC, Hammond MEH, Gilbert EM, Renlund DG, Bader F, Fisher PW, Bull DA, Singhal AK, Eckels DD. Utility of virtual crossmatch in sensitized patients awaiting heart transplantation. J Heart Lung Transplant 2009; 28:1129-34. [PMID: 19782589 DOI: 10.1016/j.healun.2009.05.031] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2008] [Revised: 05/23/2009] [Accepted: 05/24/2009] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Organ transplant candidates with serum antibodies directed against human leukocyte antigens (HLA) face longer waiting times and higher mortality while awaiting transplantation. This study examined the accuracy of virtual crossmatch, in which recipient HLA-specific antibodies, identified by solid-phase assays, are compared to the prospective donor HLA-type in heart transplantation. METHODS We examined the accuracy of virtual crossmatch in predicting immune compatibility of donors and recipients in heart transplantation and clinical outcomes in immunologically sensitized heart transplant recipients in whom virtual crossmatch was used in allograft allocation. RESULTS Based on analysis of 257 T-cell antihuman immunoglobulin complement-dependent cytotoxic (AHG-CDC) crossmatch tests, the positive predictive value of virtual crossmatch (the likelihood of an incompatible virtual crossmatch resulting in an incompatible T-cell CDC-AHG crossmatch) was 79%, and the negative predictive value of virtual crossmatch (the likelihood of a compatible virtual crossmatch resulting in a compatible T-cell CDC-AHG crossmatch) was 92%. When used in a cohort of 28 sensitized patients awaiting heart transplantation, 14 received allografts based on a compatible virtual crossmatch alone from donors in geographically distant locations. Compared with the other 14 sensitized patients who underwent transplant after a compatible prospective serologic crossmatch, the rejection rates and survival were similar. CONCLUSION Our findings are evidence of the accuracy of virtual crossmatch and its utility in augmenting the opportunities for transplantation of sensitized patients.
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Affiliation(s)
- Josef Stehlik
- U.T.A.H. Cardiac Transplant Program, University of Utah Hospital, and VA Salt Lake City Health Care System-Cardiology Section, 500 Foothill Blvd., Salt Lake City, UT 84148, USA.
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121
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Affiliation(s)
- Takeshi Nakatani
- Department of Organ Transplantation, National Cardiovascular Center
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