Mortality and morbidity in pre-sensitized pediatric heart transplant recipients with a positive donor crossmatch utilizing peri-operative plasmapheresis and cytolytic therapy.
BACKGROUND
The difficulty in obtaining a prospective negative donor/recipient crossmatch limits the ability to successfully transplant pediatric heart transplant candidates who show evidence of antibodies to multiple human leukocyte antigens (pre-sensitized patients).


METHODS
We utilized a protocol that included peri-operative plasmapheresis, thymoglobulin and cyclophosphamide in 17 pre-sensitized (panel-reactive antibodies [PRA] >10%) pediatric patients to accept donors for these patients without a prospective crossmatch between 1995 and 2005. A retrospective review of survival, rejection and infection was performed, comparing the frequency of rejection and infection in our patients who were transplanted with a complement-dependent cytotoxic (CDC)-positive donor/recipient crossmatch to those patients transplanted with a negative crossmatch.


RESULTS
Thirteen of 17 patients were found to have a CDC-positive crossmatch. Actuarial survival after transplantation was 85% at 1 year and 73% at 3 years. Twelve of 13 (92%) of these patients experienced rejection, and 5 of 13 (38%) had recurrent rejection, generally in the first 2 months after transplantation. Rejection was associated with hemodynamic compromise in 58% of first rejection episodes and 67% of episodes of recurrent rejection. The frequency of rejection in these patients was significantly greater than the frequency in patients with a negative crossmatch in the first 6 months after transplantation, but not afterward. The frequency of infection episodes was not significantly different between the groups.


CONCLUSIONS
Heart transplantation in pre-sensitized pediatric recipients with a CDC-positive donor/recipient crossmatch may result in reasonable short-term survival, but with a high frequency of early rejection, often with hemodynamic compromise.
Holt
D Byron
DB
Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA.
Lublin
Douglas M
DM
Phelan
Donna L
DL
Boslaugh
Sarah E
SE
Gandhi
Sanjiv K
SK
Huddleston
Charles B
CB
Saffitz
Jeffrey E
JE
Canter
Charles E
CE
D000293:Adolescent; D000328:Adult; D000961:Antilymphocyte Serum / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D003520:Cyclophosphamide / Q000627:therapeutic use*; D003601:Cytotoxicity Tests, Immunologic; D006084:Graft Rejection / Q000628:therapy; D006680:HLA Antigens / Q000276:immunology; D016027:Heart Transplantation; D006648:Histocompatibility; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D007223:Infant; D007518:Isoantibodies / Q000097:blood; D019990:Perioperative Care; D010956:Plasmapheresis
D000961:Antilymphocyte Serum; D006680:HLA Antigens; D007166:Immunosuppressive Agents; D007518:Isoantibodies; D003520:Cyclophosphamide