The roles of therapeutic plasmapheresis (TPE) and extracorporeal photopheresis (ECP) for the treatment of liver allograft rejection
Umar B, Eisenbrey A, Tashakori M, Raoufi M, Moonka D, and Lopez-Plaza I. The roles of therapeutic plasmapheresis (TPE) and extracorporeal photopheresis (ECP) for the treatment of liver allograft rejection. J Clin Apheresis 2018; 33(2):145-146.
J Clin Apheresis
Purpose The current ASFA guidelines recommendations for liver transplantation include TPE for ABO desensitization in living donor transplantation (category I); ABO desensitization in cadaveric donor transplant (category III); and Antibody mediated rejection (AMR)(ABO and/or HLA) (category III). Current literature has shown that persistent elevation of donor specific antibodies (DSAs) is associated with intractable allograft liver transplant rejection and continued liver injury. Retrospective studies suggest that TPE in combination with enhanced immunosuppression may be effective in reversing humoral rejection of the liver allograft. For two years our institution has added therapeutic plasma exchange and intravenous immunoglobulin (TPE1IVIG) and extracorporeal photopheresis (ECP) to the immunosuppression of early and delayed liver allograft rejection. We retrospectively reviewed our experience using these two therapeutic apheresismodalities. Methods An institutional protocol for liver transplant allograft rejection, either AMR or acute cellular rejection (ACR), is followed which may consist of a combination of TPE 1IVIG, or TPE1IVIG1ECP or ECP alone. Each TPE treatment cycle consists of 6 TPE procedures followed by IVIG infusion after each procedure; the first 3 procedures are performed daily; the second 3 procedures are performed every other day. Each TPE procedure consists of the processing of one plasma volume using a combination of 5% albumin and thawed plasma or 5% albumin alone as replacement fluid. After completion of the 6 TPE procedures the patient is started on ECP using a schedule of weekly × 4, biweekly × 4 andmonthly × 4. Each ECP procedure consists of the processing of 1500 mL of whole blood followed by treatment of the harvested buffy coat with psoralen and UV light which then is returned to the patient, performed on two consecutive days. Immunosuppressive medications are continued per liver transplant protocol. Antirejection treatment response was monitored by serial liver enzymes (AST, ALT, Total Bilirubin & Alkaline phosphate), measurement of DSAs and liver biopsy. Results A total of 6 patients have been treated with the above described protocol. One patient with no evidence of AMR was treated with ECP only. Results are summarized in table 1. Conclusion In our cohort of patients with refractory liver allograft rejection, we observed that TPE/ECP could be used as an effective additional treatment modality, which alleviates rejection as evidenced by clinic-pathologic parameters. No adverse events related to therapeutic apheresis were observed. (Table Presented).