Abstract
Purpose Biopsy negative rejection (BNR) after heart transplantation is not uncommon. BNR is diagnosed when there is an acute reduction in cardiac function along with symptoms of heart failure. As the endomyocardial biopsy shows no rejection, a search for other causes is pursued. Non-HLA antibodies may not demonstrate C4d deposition in the heart biopsy therefore remains a possible cause of this form of rejection. It is not clear if non-HLA antigens are detected during these cases. Therefore, we reviewed our experience with BNR and detection of non-HLA antibodies. Methods Between 2000 and 2017 we performed 1391 heart transplants and identified 96 cases of BNR (6.9%). Non-HLA antibodies were obtained at the time of BNR and included angiotensin type 1 receptor (AT1R), major-histocompatibility-complex (MHC) class I-related chain A (MICA) and anti-endothelial cell antibodies. All patients with BNR were treated with various anti-rejection regimens including high dose corticosteroids, immune globulin (IVIG), anti-lymphocyte globulin (ATG) and/or plasmapheresis. Results BNR was detected in 96 patients. The following non-HLA antibodies were detected: AT1R (15 patients), MICA (7 patients), and anti-endothelial cell antibodies (3 patients). This constituted 26% of BNR patients. 24% percent of patients recovered with initial anti-humoral therapy. The percent of BNR with anti-HLA antibodies was 12.0% percent. Conclusion BNR is not uncommon after heart transplantation. Non-HLA antibodies are observed in approximately 26.0% percent of patients with BNR, thus, non-HLA testing is worthwhile to initiate appropriate anti-rejection therapy.
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