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Patients who undergo heart transplantation may be in need of a second heart transplant if they develop severe graft dysfunction. Due to the long periods of time that these patients have been on calcineurin inhibitors, chronic kidney disease may ensue. These patients who need a second heart transplant may also need a combined kidney transplant. It has not been established in these redo heart transplant patients as to what GFR places them at risk for chronic dialysis post redo heart transplant. Between 2010 and 2021, we assessed 41 heart transplant patients who underwent redo heart transplant alone. These patients were divided into GFR quintiles (<42, 42 to <52, 53 to <61, 61 to <80 and ≥80 cc/minutes) to assess subsequent need for chronic kidney dialysis post-redo heart transplant. A group of 22 combined heart-kidney transplant patients were also included for comparison. Other endpoints included post-transplant 1-year survival, freedom from cardiac allograft vasculopathy (CAV), freedom from acute cellular rejection (ACR) and freedom from antibody mediated rejection (AMR). Redo heart transplant patients undergoing a heart transplant alone in the lowest quintile had a trend toward increased need for chronic hemodialysis post-transplant. At 1-year post-transplant, GFR remained low for those redo heart patients with baseline GFR <52cc/minute. Among the GFR quintile groups, there was no significant difference in post-transplant 1-year survival, freedom from CAV, freedom from ACR and freedom from AMR. In comparison, the redo heart transplant with combined kidney transplant patients appeared to have good outcome. (see table) Redo heart transplant patients with GFR < 42 cc/min appear to be at high risk for chronic hemodialysis post redo heart transplant. These patients might be considered for a combined redo heart transplant with kidney transplantation. Larger number of patients are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

For patients awaiting heart transplantation (HTx), who have high levels of circulating antibodies (greater than 70% PRA) desensitization therapy may be indicated. This will allow expansion of the donor pool for a compatible donor. As women appear to be more highly sensitized (due to multiple pregnancies), it is not clear as to whether women compared to men can benefit from desensitization therapy. We sought to answer this question with review of our large, single center database. Between 2008 and 2020, we assessed 49 patients awaiting HTx who underwent desensitization therapy. These patients were divided into groups by sex to evaluate their response to desensitization therapy. Our desensitization protocols consist of regimens including intravenous immune globulin, anti-CD20 monoclonal antibody, plasmapheresis, proteosome inhibitors. A response to desensitization therapy was assessed by the decline of the dominant circulating antibody determined by mean fluorescence intensity (MFI). Post-HTx data was assessed for 1-year survival and freedom from rejections (acute cellular rejection [ACR], antibody-mediated rejection [AMR]). Rejection episodes were compared to a control group of non-sensitized patients transplanted during the same period (n=771). Desensitization therapy in women appeared to be comparable to men considering similar desensitization protocols. There were no significant differences in waitlist mortality, time on the waitlist, or 1-year post-transplant survival, 1-year freedom ACR or AMR, between the two groups. Compared to non-sensitized patients, freedom from AMR was significantly lower in both sensitized men and women (72.7% men and 78.9% women vs. 96.5% control group). Sensitized women awaiting HTx compared to men appear to have similar response to various desensitization regimens. Post-HTx, there was more AMR in both groups, suggesting sensitization may be responsible. [ABSTRACT FROM AUTHOR]

The use of eculizumab, which is a complement blockade inhibitor, has been demonstrated to be efficacious in highly sensitized patients undergoing heart transplantation (HTx). The hypothesis is that the complement blockade protects the heart from hyperacute rejection and from other potential adverse responses. It is postulated that the complement blockade may downregulate antibody production. We reviewed our single center study using eculizumab for highly sensitized patients to assess for post-transplant outcomes. Between 2013 and 2020, we assessed 29 HTx patients who are highly sensitized, defined as calculated panel reactive antibody (cPRA) greater than 70% who underwent HTx with eculizumab therapy perioperatively. In all cases, donor-specific antibody (DSA) was crossed at the time of transplant but with a negative CDC prospective crossmatch. Eculizumab was given intraoperatively, post-op day 1, post-op day 7, and then given weekly for the first month and monthly for the second and third months post-transplant. The development of hyperacute rejection, antibody-mediated rejection, hemodynamic compromise rejection, and development of de novo DSA in the first-year post-transplant were assessed. Eculizumab use in highly sensitized patients resulted in 93.1% 1-year survival and no patient developing hyperacute rejection. There were 11 first-year AMR episodes noted, with one episode associated with hemodynamic compromise. All antibody levels began to wane in the first-year post-transplant. The use of eculizumab in highly sensitized patients (crossing DSA at transplant) appears to be effective in allowing these patients to undergo safe heart transplantation. [ABSTRACT FROM AUTHOR]