Abstract
Preoperative sensitization of the cardiac transplant recipient, defined as the presence of anti-Human Leukocyte Antigen (HLA) antibodies before transplant, represents a significant management challenge for physicians. Sensitization prolongs the pre-transplant wait time and is associated with postoperative transplant complications and death. It is critical that sensitized heart transplant candidates be identified and optimized before surgery. In this review, we describe the risk for sensitization, discuss the means through which sensitization may be diagnosed, and highlight some of the new therapeutic options for managing the sensitized cardiac transplant patients.
Highlights
HLA antibodies can cause antibody-mediated allograft injury via the binding C1q, which activates the classical complement cascade
We describe the risk for sensitization, discuss the means through which sensitization may be diagnosed, and highlight some of the new therapeutic options for managing the sensitized cardiac transplant patients
Sensitization can exert problematic effects across all phases of organ transplantation; its presence preoperatively reduces the likelihood of identifying a compatible donor organ, leading to increased wait times and concomitant increase in wait-list morbidity and mortality, and in the postoperative setting, anti–HLA donorspecific antibody (DSA) can increase the likelihood of decreased survival as a result of development of antibody-mediated rejection (AMR) and cardiac allograft vasculopathy (CAV) [16]
Summary
A 27-year-old female heart transplant candidate with non-ischemic adriamycin-induced cardiomyopathy supported by HeartMate II left ventricular assist device (LVAD) before transplant received an organ offer. She was blood type O and her calculated panel reactive antibodies (CPRA) of 87% based on MFI cut-off of 3,000 due to pregnancy. Percent CPRA is calculated based on the frequency of unacceptable antigens (HLA antigens against which candidate has antibodies) in various ethnic donor populations [2]. Both percent PRA and CPRA provide an estimate of the percentage of likely incompatible donors. A recent study demonstrated that CPRA values greater than 50% are associated with significantly lower rates of heart transplantation and higher waitlist mortality [3]
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