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Jaiswal A, Bell J, DeFilippis EM, Kransdorf EP, Patel J, Kobashigawa JA, Kittleson MM, Baran DA. Assessment and management of allosensitization following heart transplant in adults. J Heart Lung Transplant 2022; 42:423-432. [PMID: 36702686 DOI: 10.1016/j.healun.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/29/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Immunological injury to the allograft, specifically by antibodies to de novo donor specific human leukocyte antigen (dnDSA) and antibody mediated injury and rejection are the major limitations to graft survival after heart transplantation (HT). As such, our approach to allosensitization remains limited by the inability of contemporaneous immunoassays to unravel pathogenic potential of dnDSA. Additionally, the role of dnDSA is continuously evaluated with emerging methods to detect rejection. Moreover, the timing and frequency of dnDSA monitoring for early detection and risk mitigation as well as management of dnDSA remain challenging. A strategic approach to dnDSA employs diagnostic assays to determine relevant antibodies in conjunction with clinical presentation and injury/rejection of allograft to tailor therapeutics. In this review, we aim to outline contemporary knowledge involving detection, monitoring and management of dnDSA after HT. Subsequently, we propose a diagnostic and therapeutic approach that may mitigate morbidity and mortality while balancing adverse reactions from pharmacotherapy.
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Affiliation(s)
- Abhishek Jaiswal
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut.
| | - Jennifer Bell
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Evan P Kransdorf
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jignesh Patel
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michelle M Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David A Baran
- Cleveland Clinic, Heart, Vascular and Thoracic Institute, Advanced Heart Failure Program, Weston, Florida
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Immohr MB, Böttger C, Aubin H, Westenfeld R, Oehler D, Bruno RR, Dalyanoglu H, Tudorache I, Akhyari P, Lichtenberg A, Boeken U. IgM-enriched immunoglobulin as adjuvant therapy for heart transplant after infection of left ventricular assist devices. ESC Heart Fail 2022; 9:3630-3635. [PMID: 35854478 DOI: 10.1002/ehf2.14074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/07/2022] [Accepted: 06/27/2022] [Indexed: 11/07/2022] Open
Abstract
Patients undergoing heart transplantation (HTx) with active infection of left ventricular assist devices (LVAD) are at high risk for postoperative infections. Between 2021 and 2022, five (P1-P5) of a total of n = 44 patients underwent HTx in our department while suffering from LVAD infection. Postoperatively, patients received adjuvant IgM-enriched human intravenous immunoglobulin (IGM-IVIG), consisting of 76% IgG, 12% IgM, and 12% IgA as a novel approach to prevent infective complications. While in P1, P2, and P4, LVAD driveline infection was known before HTx; in P3 and P5, abscess of device pocket was found incidentally during HTx. After a single dose of IGM-IVIG, all patients showed adequate rise in serum immunoglobulins. In the postoperative course, no patient developed infective complications. All patients were successfully discharged and in good condition at the last follow-up. Therefore, IGM-IVIG seems to be an effective adjuvant treatment for patients undergoing HTx with LVAD infections.
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Affiliation(s)
- Moritz Benjamin Immohr
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Charlotte Böttger
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Daniel Oehler
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Raphael Romano Bruno
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Hannan Dalyanoglu
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Immohr MB, Akhyari P, Aubin H, Westenfeld R, Mehdiani A, Bruno RR, Sipahi NF, Erbel-Khurtsidze S, Reinecke P, Tudorache I, Lichtenberg A, Boeken U. Treatment of donor-specific antibody-mediated rejection after heart transplantation by IgM-enriched human immunoglobulin. ESC Heart Fail 2021; 8:3413-3417. [PMID: 33969938 PMCID: PMC8318410 DOI: 10.1002/ehf2.13409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/07/2021] [Accepted: 04/24/2021] [Indexed: 12/25/2022] Open
Abstract
Antibody‐mediated graft rejection caused by donor‐specific antibodies (DSA‐MR) remains a serious problem after heart transplantation (HTx). IgM‐enriched human intravenous immunoglobulin (IGM‐IVIG) consists of 76% IgG, 12% IgM, and 12% IgA and provides a new multifactorial approach for DSA‐MR. Between 2017 and 2020, four (P1–4) of 102 patients developed DSA‐MR after HTx in our department and were repetitively treated with IGM‐IVIG in combination with anti‐thymocyte globulin. While in P1 and P4, DSA‐MR occurred within the early post‐operative interval, P2 and P3 developed DSA‐MR approximately 1 year after transplantation. An impairment of ventricular function was observed in three of four patients. Furthermore, P1 and P4 suffered from malign ventricular arrhythmias. After the application of IGM‐IVIG, the ventricular function recovered, and all patients could be discharged from the hospital. As part of a multifactorial therapeutic approach, treatment with IGM‐IVIG seems to be a safe and effective strategy to address DSA‐MR.
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Affiliation(s)
- Moritz Benjamin Immohr
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Arash Mehdiani
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Raphael Romano Bruno
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Nihat Firat Sipahi
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Sophiko Erbel-Khurtsidze
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Petra Reinecke
- Institute of Pathology, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany
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