Intravenous immunoglobulin reduces anti-HLA alloreactivity and shortens waiting time to cardiac transplantation in highly sensitized left ventricularassist device recipients
R. John et al., Intravenous immunoglobulin reduces anti-HLA alloreactivity and shortens waiting time to cardiac transplantation in highly sensitized left ventricularassist device recipients, CIRCULATION, 100(19), 1999, pp. 229-235
Citations number
33
Categorie Soggetti
Cardiovascular & Respiratory Systems","Cardiovascular & Hematology Research
Background-Recipients of left ventricular assist devices (LVADs) develop pr
ominent B-cell hyperreactivity. We investigated the influence of anti-HLA a
ntibodies on waiting time to cardiac transplantation in LVAD recipients and
compared the effects of 2 immunomodulatory regimens on anti-HLA serum reac
tivity.
Methods and Results-Fifty-five previously nonsensitized LVAD recipients of
a TCI device implanted between 1990 and 1996 were studied. Patients with an
ti-HLA antibodies received monthly courses of either intravenous immunoglob
ulin (IVIg) or plasmapheresis, in conjunction with cyclophosphamide. The ef
fects of these regimens on anti-HLA alloreactivity and waiting time to tran
splantation were then determined by Kaplan-Meier log-rank statistics, nonpa
rametric Wilcoxon rank-sum test, and Student's t test. Prolongation in tran
splant waiting time was related to serum Ige anti-HLA class I alloreactivit
y. Infusion of IVIg (2 g/kg) caused a mean reduction of 33% in anti-HLA cla
ss I alloreactivity within 1 week. Waiting time to transplantation was sign
ificantly reduced by IVIg therapy and subsequently approximated that in non
sensitized patients. Side effects of IVIg (2 g/kg) were minimal and related
primarily to immune complex disease. Although plasmapheresis caused a simi
lar reduction in alloreactivity to IVIg, this effect was achieved after lon
ger treatment. Moreover, plasmapheresis was associated with an unacceptably
high frequency of infectious complications. In patients resistant to low-d
ose (2 g/kg) IVIg therapy, high-dose (3 g/kg) IVIg was effective in reducin
g alloreactivity but was associated with a high incidence of reversible ren
al insufficiency.
Conclusions-These results indicate that IVIg is an effective and safe modal
ity for sensitized recipients awaiting cardiac transplantation, reducing se
rum anti-HLA alloreactivity and shortening the duration to transplantation.
The therapeutic and safety profile of IVIg would appear to be superior to
plasmapheresis.