title: Therapeutic plasma exchange rapidly improves cardiac allograft function in patients with presumed antibody-mediated rejection.
abstract: BACKGROUND
  Allograft dysfunction due to presumed antibody-mediated rejection (pAMR) is one of the most serious complications of heart transplantation. Combination therapies of high-dose steroids, intravenous immune globulin, and/or therapeutic plasma exchange (TPE) are often used in this setting.
  
  
  METHODS
  We performed a 9-year retrospective review of all episodes of pAMR treated with TPE at our institution. pAMR diagnosis was based on clinical and pathologic findings. Left ventricular ejection fraction (LVEF) was measured at baseline, prior to initiation of TPE, and during the course of treatment.
  
  
  RESULTS
  There were 42 patients with 47 episodes of pAMR treated with TPE. The majority of episodes were treated with three TPE; however, eight required only two TPE and five episodes required >3 TPE. All episodes of pAMR had LVEF measured before and after the series of TPEs. The mean pre-TPE LVEF was 38% compared with a post-therapy mean LVEF of 50% (P < 0.0001). In 16 episodes of pAMR, for which LVEF was measured following each apheresis, there was significant improvement of allograft function after the first TPE (pre-TPE mean LVEF of 31% and post-first TPE mean LVEF of 37%; P = 0.02). Incremental and significant improvement in allograft function continued following each TPE. Changes in human leukocyte antigen-donor specific antibodies and fibrinogen did not correlate with ejection fraction response.
  
  
  CONCLUSIONS
  The rapid improvement in allograft function in our patients is most likely due to TPE as other pharmacologic interventions have longer onset. TPE should be considered a first-line intervention in the setting of pAMR.
authors.affiliation: Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Nirupama
authors.initials: N
authors.lastname: Singh
authors.forename: Sean
authors.initials: S
authors.lastname: Vanlandingham
authors.forename: Catlin
authors.initials: C
authors.lastname: Halverson
authors.forename: Marisa B
authors.initials: MB
authors.lastname: Marques
authors.forename: Jose
authors.initials: J
authors.lastname: Tallaj
authors.forename: James
authors.initials: J
authors.lastname: Kirklin
authors.forename: Jill
authors.initials: J
authors.lastname: Adamski
mesh_terms: D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D064591:Allografts; D002648:Child; D005260:Female; D005340:Fibrinogen / Q000032:analysis; D006082:Graft Enhancement, Immunologic / Q000379:methods*; D006084:Graft Rejection / Q000209:etiology / Q000276:immunology / Q000503:physiopathology / Q000517:prevention & control*; D006321:Heart / Q000503:physiopathology*; D016027:Heart Transplantation; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007518:Isoantibodies / Q000097:blood / Q000276:immunology*; D008297:Male; D008875:Middle Aged; D010951:Plasma Exchange; D012189:Retrospective Studies; D013318:Stroke Volume; D055815:Young Adult
chemical_list: D000305:Adrenal Cortex Hormones; D007166:Immunosuppressive Agents; D007518:Isoantibodies; D005340:Fibrinogen
keywords: antibody-mediated rejection; cardiac allograft rejection; therapeutic plasma exchange