title: Rejection with hemodynamic compromise: objective evidence for efficacy of photopheresis.
abstract: BACKGROUND
  Photopheresis therapy (photo) has been advocated as a therapy to improve outcome after recalcitrant or severe rejection, but objective evidence of a beneficial effect has been elusive. This study examined the hypothesis that photo provides protection against rejection, rejection with hemodynamic compromise (HC), and death from rejection after cardiac transplantation.
  
  
  METHODS
  Between 1990 and 2003, 36 adult patients (from 343 adult transplant recipients) received at least 3 months of photo (2-day treatment every 3 to 6 weeks for a target of 18 months) after HC rejection (n = 12), recurrent/recalcitrant rejection (n = 20), or as prophylaxis in the presence of anti-donor antibodies (n = 4). Survival and risk factors were examined by analysis using multivariate hazard function modulated renewal function.
  
  
  RESULTS
  Patients selected for photo were at greater risk for rejection (p < 0.0001) and HC rejection (p < 0.0001) than non-photo patients. After 3 months of photo therapy, rejection risk was decreased (p = 0.04). More importantly, the hazard for subsequent HC rejection or rejection death was significantly reduced toward the risk-adjusted level of lower-risk non-photo patients (p = 0.006).
  
  
  CONCLUSIONS
  This study provides objective evidence that photo reduces the risk of subsequent HC rejection and/or death from rejection when initiated for patients with high rejection risk. Photopheresis is recommended as an important therapeutic modality after rejection with hemodynamic compromise, although further studies are needed to define the precise mechanism of the effect and the potential for benefit in other patient sub-sets.
authors.affiliation: Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA. jkirklin@uab.edu
authors.forename: J K
authors.initials: JK
authors.lastname: Kirklin
authors.forename: R N
authors.initials: RN
authors.lastname: Brown
authors.forename: S T
authors.initials: ST
authors.lastname: Huang
authors.forename: D C
authors.initials: DC
authors.lastname: Naftel
authors.forename: S M
authors.initials: SM
authors.lastname: Hubbard
authors.forename: B K
authors.initials: BK
authors.lastname: Rayburn
authors.forename: D C
authors.initials: DC
authors.lastname: McGiffin
authors.forename: R B
authors.initials: RB
authors.lastname: Bourge
authors.forename: R L
authors.initials: RL
authors.lastname: Benza
authors.forename: J A
authors.initials: JA
authors.lastname: Tallaj
authors.forename: L J
authors.initials: LJ
authors.lastname: Pinderski
authors.forename: S V
authors.initials: SV
authors.lastname: Pamboukian
authors.forename: J F
authors.initials: JF
authors.lastname: George
authors.forename: M
authors.initials: M
authors.lastname: Marques
mesh_terms: D000328:Adult; D003131:Combined Modality Therapy; D003324:Coronary Artery Disease / Q000401:mortality; D005260:Female; D006084:Graft Rejection / Q000401:mortality / Q000517:prevention & control*; D016027:Heart Transplantation; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017893:Photopheresis; D016016:Proportional Hazards Models; D012189:Retrospective Studies