Impact on Outcome of Preoperative Plasmapheresis in Sensitized Lung Transplant Recipients

Abstract

Presence of donor specific HLA antibodies (DSA) before lung transplantation may jeopardize the prognosis. Preoperative plasmapheresis (PP) for desensitization may improve graft outcomes but may have complications, mainly bleeding and infections. The primary objective of this study was to evaluate the efficacy of PP in term of level of DSA (micro fluorescent intensity (MFI)) and occurrence of antibody mediated rejection (AMR). Secondary outcomes included perioperative surgical revision, occurrence of pneumonia, and ICU mortality. We reviewed the charts of patients with preoperative DSA from 2015 to 2018. Patient's DSA were identified and followed by Luminex Single Antigen assay at three time points: before transplantation, in early (< 15 days) and late (up to 6 weeks) postoperative periods. PP was performed when MFI was >1,000 and was associated with an induction treatment. 3 sessions of postoperative plasmapheresis were performed when preoperative MFI was >3,000. Patients without PP represented control group. 205 patients were included, in whom 29 had PP (14%). During the predefined time frame, the kinetic of sum of DSA MFI did not differ between the two groups (ANOVA p=0.47) (Figure). Course of the highest MFI value seemed to stabilize in the PP group and differed from the control group (ANOVA p<0.005). They were no difference between the 2 groups in the occurrence of acute cellular rejection (38% vs 61%) or AMR (20% vs 17%). The PP group had more surgical revision in the first postoperative 48h (28% vs 10%; p=0.005). The incidence density rate of pneumonia was similar between the 2 groups (2.4±2.7 vs 3.1±4.7; p=0.11). ICU mortality rate was significantly higher in patients with PP (21% vs 8%; p=0.04). Our results suggested that PP stabilized the course of highest DSA and probably had an impact on the rate of episodes of AMR. However, the increase rate of surgical revision and ICU mortality rate suggested that such treatment should be used in selected patients.