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Issitt R, Booth J, Crook R, Robertson A, Molyneux V, Richardson R, Cross N, Shaw M, Tsang V, Muthurangu V, Sebire NJ, Burch M, Fenton M. Intraoperative anti-A/B immunoadsorption is associated with significantly reduced blood product utilization with similar outcomes in pediatric ABO-incompatible heart transplantation. J Heart Lung Transplant 2021; 40:1433-1442. [PMID: 34187714 PMCID: PMC8579753 DOI: 10.1016/j.healun.2021.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 11/16/2022] Open
Abstract
Background Intraoperative anti-A/B immunoadsorption (ABO-IA) was recently introduced for ABO-incompatible heart transplantation. Here we report the first case series of patients transplanted with ABO-IA, and compare outcomes with those undergoing plasma exchange facilitated ABO-incompatible heart transplantation (ABO-PE). Methods Data were retrospectively analysed on all ABO-incompatible heart transplants undertaken at a single centre between January 1, 2000 and June 1, 2020. Data included all routine laboratory tests, demographics and pre-operative characteristics, intraoperative details and post-operative outcomes. Primary outcome measures were volume of blood product transfusions, maximum post-transplant isohaemagglutinin titres, occurrence of rejection and graft survival. Secondary outcome measures were length of intensive care and hospital stay. Demographic and survival data were also obtained for ABO-compatible transplants during the same time period for comparison. Results Thirty-seven patients underwent ABO-incompatible heart transplantation, with 27 (73%) using ABO-PE and 10 (27%) using ABO-IA. ABO-IA patients were significantly older than ABO-PE patients (p < 0.001) and the total volume of blood products transfused during the hospital admission was significantly lower (164 [126-212] ml/kg vs 323 [268-379] ml/kg, p < 0.001). No significant differences were noted between methods in either pre or post-transplant maximum isohaemagglutinin titres, incidence of rejection, length of intensive care or total hospital stay. Survival comparison showed no significant difference between antibody reduction methods, or indeed ABO-compatible transplants (p = 0.6). Conclusions This novel technique appears to allow a significantly older population than typical to undergo ABO-incompatible heart transplantation, as well as significantly reducing blood product utilization. Furthermore, intraoperative anti-A/B immunoadsorption does not demonstrate increased early post-transplant isohaemagglutinin accumulation or rates of rejection compared to ABO-PE. Early survival is equivalent between ABO-IA, ABO-PE and ABO-compatible heart transplantation.
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Affiliation(s)
- Richard Issitt
- Perfusion Department, Great Ormond Street Hospital, London, UK; Institute of Cardiovascular Science, University College London, London, UK; Digital Research Informatics and Virtual Environment Unit, NIHR Great Ormond Street Hospital BRC, London, UK.
| | - John Booth
- Digital Research Informatics and Virtual Environment Unit, NIHR Great Ormond Street Hospital BRC, London, UK
| | - Richard Crook
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Alex Robertson
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | | | | | - Nigel Cross
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Michael Shaw
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Victor Tsang
- Institute of Cardiovascular Science, University College London, London, UK; Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - Vivek Muthurangu
- Institute of Cardiovascular Science, University College London, London, UK
| | - Neil J Sebire
- Digital Research Informatics and Virtual Environment Unit, NIHR Great Ormond Street Hospital BRC, London, UK
| | - Michael Burch
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK; Department of Paediatric Cardiology, Institute of Child Health, University College London, London, UK
| | - Matthew Fenton
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK; Department of Paediatric Cardiology, Institute of Child Health, University College London, London, UK
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Bikhet M, Morsi M, Hara H, Rhodes LA, Carlo WF, Cleveland D, Cooper DK, Iwase H. The immune system in infants: Relevance to xenotransplantation. Pediatr Transplant 2020; 24:e13795. [PMID: 32845539 PMCID: PMC7606572 DOI: 10.1111/petr.13795] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/10/2020] [Accepted: 06/22/2020] [Indexed: 12/17/2022]
Abstract
Despite the improvement in surgical interventions in the treatment of congenital heart disease, many life-threatening lesions (eg, hypoplastic left heart syndrome) ultimately require transplantation. However, there is a great limitation in the availability of deceased human cardiac donors of a suitable size. Hearts from genetically engineered pigs may provide an alternative source. The relatively immature immune system in infants (eg, absence of anti-carbohydrate antibodies, reduced complement activation, reduced innate immune cell activity) should minimize the risk of early antibody-mediated rejection of a pig graft. Additionally, recipient thymectomy, performed almost routinely as a preliminary to orthotopic heart transplantation in this age-group, impairs the T-cell response. Because of the increasing availability of genetically engineered pigs (eg, triple-knockout pigs that do not express any of the three known carbohydrate antigens against which humans have natural antibodies) and the ability to diagnose congenital heart disease during fetal life, cardiac xenotransplantation could be preplanned to be carried out soon after birth. Because of these several advantages, prolonged graft survival and even the induction of tolerance, for example, following donor-specific pig thymus transplantation, are more likely to be achieved in infants than in adults. In this review, we summarize the factors in the infant immune system that would be advantageous in the success of cardiac xenotransplantation in this age-group.
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Affiliation(s)
- Mohamed Bikhet
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Mahmoud Morsi
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Leslie A. Rhodes
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar F. Carlo
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David Cleveland
- Department of Pediatric Cardiovascular Surgery, Children’s Hospital of Alabama, Birmingham, AL, USA
| | - David K.C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Hayato Iwase
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, AL, USA
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Issitt R, Crook R, Shaw M, Robertson A. The Great Ormond Street Hospital immunoadsorption method for ABO-incompatible heart transplantation: a practical technique. Perfusion 2020; 36:34-37. [PMID: 32493108 PMCID: PMC7770210 DOI: 10.1177/0267659120926895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Traditionally, ABO-incompatible heart transplantation was accomplished using a plasma exchange technique to remove recipient plasma containing donor-incompatible anti-A/B isohaemagglutinins. However, this technique exposed patients to large volumes of allogeneic blood and blood products (up to three times the patient’s circulating volume). In 2018, we published the first reported case of an ABO-incompatible heart transplant using an intraoperative immunoadsorption technique which minimises the exposure to blood products by specifically targeting anti-A/B isohaemagglutinins. We have subsequently used this technique in all children undergoing ABO-incompatible heart transplantation and become convinced of its efficacy in this population while observing no adverse effects. This article outlines the practical details required to perform the technique in order to avoid hyperacute rejection.
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Affiliation(s)
- Richard Issitt
- Perfusion Department, Great Ormond Street Hospital, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | - Richard Crook
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Michael Shaw
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Alex Robertson
- Perfusion Department, Great Ormond Street Hospital, London, UK
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Abstract
Neonatal heart transplantation was developed and established in the 1980's as a durable modality of therapy for complex-uncorrectable heart disease. Patients transplanted in the neonatal period have experienced unparalleled long-term survival, better than for any other form of solid-organ transplantation. However, the limited availability of neonatal and young infant donors has restricted the indications and applicability of heart transplantation among newborns in the current era. Indications for heart transplantation include congenital heart disease not amenable to other forms of surgical palliation, and cardiomyopathy, including some primary tumors. Use of ABO-incompatible transplants, and organs with prolonged cold ischemic time or marginal function have all been associated with good outcomes in infants. These extended strategies to increase the donor pool may also someday include donation after determination of circulatory death and the use of anencephalic donors. The operative techniques for donors and recipients of neonatal heart transplantation are unique and have been well-described. Immunosuppression protocols for neonates need not include induction and are largely steroid-free. Newborn and young infant transplant recipients have fewer episodes of rejection, less coronary allograft vasculopathy, less post-transplant lymphoproliferative disease and less renal dysfunction than their older counterparts. Long-term outcomes have been very encouraging in terms of graft survival, patient survival, and quality of life. Our review highlights the history, current indications, techniques and outcomes of heart transplantation in this immunologically-privileged subset of patients.
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Affiliation(s)
- Mohan John
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, California, USA
| | - Leonard L Bailey
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, California, USA
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Abstract
Kidney transplantation across the ABO blood group barrier was long considered a contraindication for transplantation, but in an effort to increase donor pools, specific regimens for ABO-incompatible (ABOi) transplantation have been developed. These regimens are now widely used as an integral part of the available treatment options. Various desensitization protocols, commonly based on transient depletion of preformed anti-A and/or anti-B antibodies and modulation of B-cell immunity, enable excellent transplant outcomes, even in the long-term. Nevertheless, the molecular mechanisms behind transplant acceptance facilitated by a short course of anti-humoral treatment are still incompletely understood. With the evolution of efficient clinical programmes, tailoring of recipient preconditioning based on individual donor-recipient blood type combinations and the levels of pretransplant anti-A/B antibodies has become possible. In the context of low antibody titres and/or donor A2 phenotype, immunomodulation and/or apheresis might be dispensable. A concern still exists, however, that ABOi kidney transplantation is associated with an increased risk of surgical and infectious complications, partly owing to the effects of extracorporeal treatment and intensified immunosuppression. Nevertheless, a continuous improvement in desensitization strategies, with the aim of minimizing the immunosuppressive burden, might pave the way to clinical outcomes that are comparable to those achieved in ABO-compatible transplantation.
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Lee AL, Kim HO, Huh KH, Kim MS. Successful Pediatric ABO-Incompatible Kidney Transplantation without Pretransplant Plasmapheresis: Report of a Case. KOREAN JOURNAL OF TRANSPLANTATION 2014. [DOI: 10.4285/jkstn.2014.28.1.39] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- A-Lan Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Ok Kim
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu Ha Huh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
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Dendritic cell-based approaches for therapeutic immune regulation in solid-organ transplantation. J Transplant 2013; 2013:761429. [PMID: 24307940 PMCID: PMC3824554 DOI: 10.1155/2013/761429] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 09/16/2013] [Indexed: 12/18/2022] Open
Abstract
To avoid immune rejection, allograft recipients require drug-based immunosuppression, which has significant toxicity. An emerging approach is adoptive transfer of immunoregulatory cells. While mature dendritic cells (DCs) present donor antigen to the immune system, triggering rejection, regulatory DCs interact with regulatory T cells to promote immune tolerance. Intravenous injection of immature DCs of either donor or host origin at the time of transplantation have prolonged allograft survival in solid-organ transplant models. DCs can be treated with pharmacological agents before injection, which may attenuate their maturation in vivo. Recent data suggest that injected immunosuppressive DCs may inhibit allograft rejection, not by themselves, but through conventional DCs of the host. Genetically engineered DCs have also been tested. Two clinical trials in type-1 diabetes and rheumatoid arthritis have been carried out, and other trials, including one trial in kidney transplantation, are in progress or are imminent.
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Akiyoshi T, Hirohashi T, Alessandrini A, Chase CM, Farkash EA, Neal Smith R, Madsen JC, Russell PS, Colvin RB. Role of complement and NK cells in antibody mediated rejection. Hum Immunol 2012; 73:1226-32. [PMID: 22850181 DOI: 10.1016/j.humimm.2012.07.330] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 07/07/2012] [Accepted: 07/19/2012] [Indexed: 01/26/2023]
Abstract
Despite extensive research on T cells and potent immunosuppressive regimens that target cellular mediated rejection, few regimens have been proved to be effective on antibody-mediated rejection (AMR), particularly in the chronic setting. C4d deposition in the graft has been proved to be a useful marker for AMR; however, there is an imperfect association between C4d and AMR. While complement has been considered as the main player in acute AMR, the effector mechanisms in chronic AMR are still debated. Recent studies support the role of NK cells and direct effects of antibody on endothelium cells in a mechanism suggesting the presence of a complement-independent pathway. Here, we review the history, currently available systems and progress in experimental animal research. Although there are consistent findings from human and animal research, transposing the experimental results from rodent to human has been hampered by the differences in endothelial functions between species. We briefly describe the findings from patients and compare them with results from animals, to propose a combined perspective.
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Affiliation(s)
- Takurin Akiyoshi
- Department of Pathology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
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Subramanian V, Ramachandran S, Klein C, Wellen JR, Shenoy S, Chapman WC, Mohanakumar T. ABO-incompatible organ transplantation. Int J Immunogenet 2012; 39:282-90. [DOI: 10.1111/j.1744-313x.2012.01101.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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