title: ABO-incompatible cardiac transplantation in pediatric patients with high isohemagglutinin titers.
abstract: BACKGROUND
  ABO-incompatible (ABOi) cardiac transplantation is now used widely in infants with isohemagglutinin titers <1:4, but there is increasing evidence that ABOi transplantation can also be used in children with significantly higher titers. We reviewed our high-titer ABOi transplants and report our results here.
  
  
  METHODS
  Patients who underwent ABOi cardiac transplantation from 2000 to 2013 with pre-existing isohemagglutinin titers of ≥1:16 were identified from departmental databases. Outcomes were reviewed using medical and laboratory records.
  
  
  RESULTS
  Thirty patients underwent ABOi cardiac transplantation between 2000 and 2013. Twelve (40%) had pre-transplant isohemagglutinin titers of ≥1:16 and were included for further study. Median age was 14.9 (range 9.8 to 107.3) months and median weight was 9.6 (range 7.6 to 25) kg. Five (42%) were male. Pre-transplant diagnosis was cardiomyopathy in 8 of 12 (67%) and congenital heart disease in 4 of 12 (33%). Highest pre-transplant isohemagglutinin titer was 1:256 in 2 patients. Four patients (33%) had early antibody-mediated rejection (AMR), all within 15 days post-transplant. Management included use of rituximab, bortezomib, immunoadsorption and eculizumab. Three patients died but no deaths were associated with high isohemagglutinin titers.
  
  
  CONCLUSIONS
  ABOi cardiac transplantation in patients with isohemagglutinin titers ≥1:16 is possible. AMR may occur early and immunoadsorption has proven effective at decreasing antibody titers.
authors.affiliation: Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK. Electronic address: caw9@doctors.org.uk.
authors.forename: Claire A
authors.initials: CA
authors.lastname: Irving
authors.affiliation: Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
authors.forename: Andrew R
authors.initials: AR
authors.lastname: Gennery
authors.affiliation: NHS Blood and Transplant, Newcastle upon Tyne, UK.
authors.forename: Vaughan
authors.initials: V
authors.lastname: Carter
authors.affiliation: Department of Haematology, Freeman Hospital, Newcastle upon Tyne, UK.
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Wallis
authors.affiliation: Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.
authors.forename: Asif
authors.initials: A
authors.lastname: Hasan
authors.affiliation: Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.
authors.forename: Massimo
authors.initials: M
authors.lastname: Griselli
authors.affiliation: Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.
authors.forename: Richard
authors.initials: R
authors.lastname: Kirk
mesh_terms: D000017:ABO Blood-Group System; D001787:Blood Group Incompatibility; D002648:Child; D002675:Child, Preschool; D005260:Female; D006333:Heart Failure / Q000097:blood* / Q000209:etiology / Q000601:surgery*; D016027:Heart Transplantation; D006388:Hemagglutinins / Q000097:blood*; D006801:Humans; D007223:Infant; D008297:Male; D012189:Retrospective Studies; D016896:Treatment Outcome; D006113:United Kingdom
chemical_list: D000017:ABO Blood-Group System; D006388:Hemagglutinins
keywords: ABO-incompatible; cardiac transplantation; high isohemagglutinin titers; pediatric