Plasmapheresis with intravenous immunoglobulin G is effective in patients with elevated panel reactive antibody prior to cardiac transplantation

Background: Patients with a PRA > 10% are considered to be at greater risk for the development of not only acute cellular and humoral rejection but al so increased mortality when compared to nonsensitized patients following tr ansplantation. All patients with a PRA > 10% at our institution are treated with plasmapheresis and intravenous immunoglobulin G immediately prior to cardiac transplantation. Methods: Sixteen (Group 1) of 118 patients awaiting cardiac transplantation were found to be sensitized. These patients underwent plasmapheresis follo wed by 20 gm of intravenous immunoglobulin G (IVIG) immediately prior to ca rdiac transplantation. Group 1 was compared to the remaining 102 patients w ith a PRA < 10% (Group 2). Results: Despite more patients in Group 1 having a positive crossmatch, pul monary hypertension, and requiring mechanical circulatory Support, there wa s no statistically significant difference in length of stay or mortality at a mean; follow-up of 21.6 +/- 15.0 months. There was no difference in the occurrence of mild, moderate or severe cellular rejection or humoral reject ion in these sensitized patients when compared to Group 2. Conclusions: Pretransplant plasmapheresis followed by intravenous immunoglo bulin G may be an effective therapy that obviates the need for a prospectiv e crossmatch and allows sensitized patients to undergo cardiac transplantat ion. There is no increase in the post transplant length of stay, occurrence of rejection or short term mortality. Long term follow up is necessary to evaluate whether there is a difference in the development of late rejection , transplant vasculopathy and survival.