The Role of Therapeutic Plasma Exchange for the Treatment of Allograft Rejection in Solid Organ Transplant: A Single Center Experience
Alhamar M, Uzuni A, and Lopez-Plaza I. The Role of Therapeutic Plasma Exchange for the Treatment of Allograft Rejection in Solid Organ Transplant: A Single Center Experience. Vox Sanguinis 2019; 114:208-209.
Background: Transplanted organ failure due to antibody mediated rejection in ABO-compatible organs is a serious complication with a bad prognosis. The goal treatment in these cases encompasses the following strategies: adjustment of the immunosuppressive medications, IVIG infusion, antibody removal by therapeutic plasma exchange, and/or the use of target-specific monoclonal antibody medications to lymphocytes, plasma cells, and/or complement. The 2016 American Society for Apheresis has assigned a category I to the use of therapeutic plasma exchange for the treatment of ABO-compatible antibody mediated rejection in kidney, but a category III to all other ABO compatible organs: Liver, Lung, and Heart. At our institution, a standardized approach for the use of therapeutic plasma exchange as a supportive intervention for ABO-compatible immune mediated rejection, regardless of the organ type, has been in place since 2011. Aims: A retrospective review was performed to evaluate our patient outcomes using therapeutic plasma exchange for the treatment of antibody mediated allograft rejection in ABO-compatible solid organ transplantation. Methods: Patients used for the retrospective review were selected from an existing therapeutic apheresis list. The therapeutic plasma exchange protocol consists of: adjustment of the immunosuppressive medications, IVIG infusion, antibody removal by therapeutic plasma exchange, and/or the use of target-specific monoclonal antibody medications to lymphocytes, plasma cells, and/or complement. It is performed as follows: One plasma volume exchange is performed on days 1,2,3, 5, 7, 9 along with one or more of the above strategies followed by an IVIG infusion. Cases with allograft rejection in which plasmapheresis was not used were excluded. Results: We evaluated the effectiveness of therapeutic plasma exchange in 37 patients who experienced allograft rejection in solid organ transplant between 2013-2016. Eight transplanted patients (heart, lung) had more than one set for separate rejection episodes and all liver transplant recipients received photo-pheresis after the therapeutic plasma exchange. • Total number of patients: 36 o Heart: 11 o Lung: 22 o Liver: 3 • Rejection Types: o Antibody-Mediated: 6 o Cellular/Antibody-Mediated: 28 o Uncertain: 2 All patients had IVIG as an adjunct, and only six patients received Rituximab, Eculi-zumab or Bortezomib. All procedures were tolerated well. There were two adverse events reported in association with the therapeutic plasma exchange: 1 transient febrile episode and 1 citrate toxicity, without sequelae. Patient Survival: • Heart: 63.6% o Alive: 7 o Deceased due to organ rejection: 2-18% o Deceased due to disease not related to rejection: 2-18% • Lung: 50% o Alive: 11 o Deceased due to organ rejection: 5-23% o Deceased due to disease not related to rejection: 6-27% • Liver: 100% o Alive: 3 21/36 patients (59%) are alive, 7/36 patients (19%) are deceased due to organ rejection, and 8/36 patients (22%) are deceased due to disease not related to rejection. Summary/Conclusions: The use of therapeutic plasma exchange for the treatment of antibody mediated rejection in solid organ transplant is safe and effective when used along with other treatment modalities. Further studies will help determine whether it can be reproduced in larger cohorts and whether it is more effective in certain organs.