Kalp Nakli Sonrası Dekompanze Kalp Yetmezliğine Neden Olan Akut Rejeksiyonda Plazmaferezin Rolü

Yıl 2022, Cilt: 32 Sayı: 6, 719 - 723, 31.12.2022

Mehmet Karahan , Doğan Emre Sert , Abdulkadir Yılmaz , Fatih Yamac , Servet Turgut , Burcu Demırkan , Tekin Güney , Simten Dagdas , Sinan Sabit Kocabeyoğlu , Seref Alp Kucuker , Mehmet Özatik , Zeki Çatav , Erol Sener

https://doi.org/10.54005/geneltip.1203306

Öz

Özet
Amaç: Bu çalışmada ortotopik kalp nakli (OHT) yapılan, takip sırasında dekompanze kalp yetmezliğine neden olan akut rejeksiyon ile kliniğimize başvuran ve endomiyokardiyal biyopsi (EMB) yapılamayan hastaların sonuçları değerlendirildi.
Yöntemler: Çalışmaya Aralık 1998-Kasım 2021 tarihleri arasında kliniğimizde OHT yapılıp, takip sırasında dekompanze kalp yetmezliğine neden olan akut rejeksiyon ile başvuran ve EMB uygulanamayan, IV pulse steroid + plazmaferez uygulanan 27 hasta dahil edildi. Hastaların demografik özellikleri, tedavi öncesi sol ventrikül fonksiyonları, sağkalım oranları ve mortalite nedenleri analiz edildi.
Bulgular: Hastaların 19'u (%70.4) erkekti ve yaş ortalaması 28.7 ± 14.7 (3-54) idi. OHT sonrası genel sağkalım oranları 1., 3. ve 5. yılda sırasıyla %92.6, %77.6 ve %69.4 idi. İzlemde dekompanze kalp yetmezliği ile başvuran ve pulse steroid + plazmaferez uygulanan hastaların plazmaferez sonrası 1., 3. ve 5. yılda sağkalım oranları sırasıyla %70.4, %58.8 ve %53.4 idi. Nakil sonrası median rejeksiyon süresi 19 aydı (0-113 ay). Tedavi öncesi ve sonrası sol ventrikül ejeksiyon fraksiyonları sırasıyla %25.11±%11.1 ve %52.14±%13.4 idi (p<0.05). Mortalitenin önde gelen nedeni ise sepsise neden olan pnömoni (5/13 hasta) idi.
Sonuç: EMB'nin yapılmasının mümkün olmadığı dekompanze kalp yetmezliği olan akut rejeksiyon hastalarında, IV pulse steroid tedavisine ek olarak plazmaferez uygulanması sağkalımı olumlu etkileyebilir.

Anahtar Kelimeler

greft rejeksiyonu, kalp nakli, plazmaferez

The Role of Plasmapheresis in Acute Rejection with Decompensated Heart Failure after Heart Transplantation

Öz

Abstract
Background/Aims: In this study, the results of patients who had orthotopic heart transplantation (OHT) in acute rejection who admitted to our clinic with decompensated heart failure and who could not undergo endomyocardial biopsy (EMB) were evaluated.

Methods: The study included 27 patients who underwent OHT in our clinic between December 1998 and November 2021, who admitted with acute rejection causing decompensated heart failure during follow-up, and who could not undergo EMB and administered IV pulse steroid plus plasmapheresis. Demographics of patients, peri-treatment left ventricular functions, survival rates and causes of mortality were analyzed.

Results: 19 (70.4%) were male and mean age was 28.7 ± 14.7 (range: 3-54). After OHT, overall survival rates were 92.6%, 77.6%, and 69.4% at 1st, 3rd and 5th year respectively. During the follow-up, the survival rates of patients who presented with decompensated heart failure and given pulse steroid plus plasmapheresis were 70.4%, 58.8%, and 53.4% at 1st, 3rd and 5th year respectively after plasmapheresis. Median rejection time after transplant was 19 months (range 0-113 months). Pre-, and post-treatment left ventricle ejection fractions were 25.11% ± 11.1%, and 52.14% ± 13.4% respectively (p<0.05). The leading causes of mortality were pneumonia causing sepsis (5/13 patients).

Conclusions: In acute rejection patients with decompensated heart failure in whom EMB is not possible, administration of plasmapheresis in addition to IV pulse steroid therapy may have a positive effect on survival in this patient group.

Anahtar Kelimeler

graft rejection, heart transplantation, plasmapheresis

Kaynakça

• Khush KK, Hsich E, Potena L, Cherikh WS, Chambers DC, Harhay MO, et al. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Thirty-eighth adult heart transplantation report - 2021; Focus on recipient characteristics. J Heart Lung Transplant 2021;40(10):1035-49.
• Rodriguez ER, Tan CD. The Pathology of Heart Transplantation. In: Ruiz P, editor. Transplantation Pathology 2 ed Cambridge: Cambridge University Press 2018. p. 133-55.
• Colvin MM, Cook JL, Chang P, Francis G, Hsu DT, Kiernan MS, et al. Antibody-mediated rejection in cardiac transplantation: emerging knowledge in diagnosis and management: a scientific statement from the American Heart Association. Circulation 2015;131(18):1608-39.
• Chou HW, Chi NH, Lin MH, Chou NK, Tsao CI, Yu HY, et al. Steroid pulse therapy combined with plasmapheresis for clinically compromised patients after heart transplantation. Transplant Proc 2012;44(4):900-2.
• Pajaro OE, Jaroszewski DE, Scott RL, Kalya AV, Tazelaar HD, Arabia FA. Antibody-mediated rejection in heart transplantation: case presentation with a review of current international guidelines. J Transplant 2011;2011:351950.
• Kervan U, Sert DE, Turan N. Humoral Rejection in Cardiac Transplantation: Management of Antibody-Mediated Rejection: IntechOpen 2018.
• Herskowitz A, Soule LM, Ueda K, Tamura F, Baumgartner WA, Borkon AM, et al. Arteriolar vasculitis on endomyocardial biopsy: a histologic predictor of poor outcome in cyclosporine-treated heart transplant recipients. J Heart Transplant 1987;6(3):127-36.
• Hammond EH, Yowell RL, Nunoda S, Menlove RL, Renlund DG, Bristow MR, et al. Vascular (humoral) rejection in heart transplantation: pathologic observations and clinical implications. J Heart Transplant 1989;8(6):430-43.
• Michaels PJ, Espejo ML, Kobashigawa J, Alejos JC, Burch C, Takemoto S, et al. Humoral rejection in cardiac transplantation: risk factors, hemodynamic consequences and relationship to transplant coronary artery disease. J Heart Lung Transplant 2003;22(1):58-69.
• Uber WE, Self SE, Van Bakel AB, Pereira NL. Acute antibody-mediated rejection following heart transplantation. Am J Transplant 2007;7(9):2064-74.
• McNamara D, Di Salvo T, Mathier M, Keck S, Semigran M, Dec GW. Left ventricular dysfunction after heart transplantation: incidence and role of enhanced immunosuppression. J Heart Lung Transplant 1996;15(5):506-15.
• Mills RM, Naftel DC, Kirklin JK, Van Bakel AB, Jaski BE, Massin EK, et al. Heart transplant rejection with hemodynamic compromise: a multiinstitutional study of the role of endomyocardial cellular infiltrate. Cardiac Transplant Research Database. J Heart Lung Transplant 1997;16(8):813-21.
• Wu GW, Kobashigawa JA, Fishbein MC, Patel JK, Kittleson MM, Reed EF, et al. Asymptomatic antibody-mediated rejection after heart transplantation predicts poor outcomes. J Heart Lung Transplant 2009;28(5):417-22.
• Lones MA, Czer LS, Trento A, Harasty D, Miller JM, Fishbein MC. Clinical-pathologic features of humoral rejection in cardiac allografts: a study in 81 consecutive patients. J Heart Lung Transplant 1995;14(1 Pt 1):151-62.
• Crespo-Leiro MG, Veiga-Barreiro A, Domenech N, Paniagua MJ, Pinon P, Gonzalez-Cuesta M, et al. Humoral heart rejection (severe allograft dysfunction with no signs of cellular rejection or ischemia): incidence, management, and the value of C4d for diagnosis. Am J Transplant 2005;5(10):2560-4.
• Miller LW, Wesp A, Jennison SH, Graham MA, Martin TW, McBride LR, et al. Vascular rejection in heart transplant recipients. J Heart Lung Transplant 1993;12(2):S147-52.
• Almuti K, Haythe J, Dwyer E, Itescu S, Burke E, Green P, et al. The changing pattern of humoral rejection in cardiac transplant recipients. Transplantation 2007;84(4):498-503.
• Sert DE, Kervan U, Kocabeyoglu SS, Karahan M, Kucuker SA, Ozatik MA, et al. Early and long-term results of heart transplantation with reoperative sternotomy. Turk Gogus Kalp Damar Cerrahisi Derg 2020;28(1):120-6.
• Coutance G, Zouhry I, Racapé M, Drieux F, Viailly PJ, Rouvier P, François A, Chenard MP, Toquet C, Rabant M, Berry GJ, Angelini A, Bruneval P, Duong Van Huyen JP. Correlation Between Microvascular Inflammation in Endomyocardial Biopsies and Rejection Transcripts, Donor-specific Antibodies, and Graft Dysfunction in Antibody-mediated Rejection. Transplantation 2022 Jul 1;106(7):1455-1464.
• Kobashigawa J, Crespo-Leiro MG, Ensminger SM, Reichenspurner H, Angelini A, Berry G, et al. Report from a consensus conference on antibody-mediated rejection in heart transplantation. J Heart Lung Transplant 2011;30(3):252-69.
• Hammond MEH, Kfoury AG. Antibody-mediated rejection in the cardiac allograft: diagnosis, treatment and future considerations. Current Opinion in Cardiology 2017;32(3):326-35.
• Olsen SL, Wagoner LE, Hammond EH, Taylor DO, Yowell RL, Ensley RD, et al. Vascular rejection in heart transplantation: clinical correlation, treatment options, and future considerations. J Heart Lung Transplant 1993;12(2):S135-42.
• Zand MS. B-cell activity of polyclonal antithymocyte globulins. Transplantation 2006;82(11):1387-95.
• Zand MS, Vo T, Huggins J, Felgar R, Liesveld J, Pellegrin T, et al. Polyclonal rabbit antithymocyte globulin triggers B-cell and plasma cell apoptosis by multiple pathways. Transplantation 2005;79(11):1507-15.
• Taylor DO, Bristow MR, O'Connell JB, Ensley RD, Olsen SL, Hammond EH, et al. A prospective, randomized comparison of cyclophosphamide and azathioprine for early rejection prophylaxis after cardiac transplantation. Decreased sensitization to OKT3. Transplantation 1994;58(6):645-9.
• Lefaucheur C, Nochy D, Andrade J, Verine J, Gautreau C, Charron D, et al. Comparison of combination Plasmapheresis/IVIg/anti-CD20 versus high-dose IVIg in the treatment of antibody-mediated rejection. Am J Transplant 2009;9(5):1099-107.
• Kobashigawa JA, Miller LW, Russell SD, Ewald GA, Zucker MJ, Goldberg LR, et al. Tacrolimus with mycophenolate mofetil (MMF) or sirolimus vs. cyclosporine with MMF in cardiac transplant patients: 1-year report. Am J Transplant 2006;6(6):1377-86.
• Ravichandran AK, Schilling JD, Novak E, Pfeifer J, Ewald GA, Joseph SM. Rituximab is associated with improved survival in cardiac allograft patients with antibody-mediated rejection: a single center review. Clin Transplant 2013;27(6):961-7.
• Garrett HE, Jr., Duvall-Seaman D, Helsley B, Groshart K. Treatment of vascular rejection with rituximab in cardiac transplantation. J Heart Lung Transplant 2005;24(9):1337-42.
• Kaczmarek I, Deutsch MA, Sadoni S, Brenner P, Schmauss D, Daebritz SH, et al. Successful management of antibody-mediated cardiac allograft rejection with combined immunoadsorption and anti-CD20 monoclonal antibody treatment: case report and literature review. J Heart Lung Transplant 2007;26(5):511-5.