Challenges of Treating Late Onset Severe Antibody Mediated Rejection Post Orthotopic Heart Transplant

Abstract

<h3>Introduction</h3> Outcomes of severe antibody mediated rejection (AMR) post orthotopic heart transplant (OHT) are often poor & management a challenge. <h3>Case Report</h3> A 50-year-old multiparous female with stable donor specific antibodies (DSAs) presented with cardiogenic shock (CS) & severe left ventricular (LV) dysfunction 4 years post OHT. Maintenance immunosuppressants (IS) included tacrolimus, mycophenolate & prednisolone with good adherence. Urgent endomyocardial biopsy (EMB), coronary angiogram & right heart catheterisation were performed. Progression to SCAI Stage D shock necessitated venoarterial extracorporeal membrane oxygenation (VA ECMO) within 24 hrs. Based on clinical presentation, the patient was treated with methylprednisolone, intravenous immunoglobulin (IVIG) & IV thymoglobulin alongside hemodynamic & other organ support (dialysis, ventilation). EMB confirmed pAMR3 fulfilling criteria for severe AMR together with CS & raised DSAs. Within days the patient's cardiac output improved allowing removal of VA ECMO. Following MDT consensus given persistent graft dysfunction & DSAs an AMR specific regimen of plasmapheresis, IVIG & rituximab were administered resulting in significant improvement in LV function & DSAs. A serious consequence of high dose IS was severe CMV reactivation (CMV peak 18,000 copies/ml). Successful treatment with IV ganciclovir caused leukopenia requiring mycophenolate cessation. Fortunately our patient survived to discharge day 152 post admission with graft recovery & excellent functional capacity. Ongoing management remains a challenge due to severe CAV & balancing risks associated with high dose IS with AMR recurrence. <h3>Summary</h3> This case highlights the importance of urgent evaluation including EMB, hemodynamic support & targeted anti-rejection therapy in patients post OHT with severe allograft dysfunction. It exemplifies challenges when treating severe AMR illustrating the importance of a collaborative team approach for successful outcomes.