A Survey of Current Practice for Antibody-Mediated Rejection in Heart Transplantation
A Survey of Current Practice for Antibody-Mediated Rejection in Heart Transplantation
复制标题
DOI：
10.1111/ajt.12162
复制
发表时间：
2013-04-01
影响因子：
8.8
通讯作者：
Ross, H. J.
中科院分区：
文献类型：
--
作者：
Chih, S.;Tinckam, K. J.;Ross, H. J.
心脏移植中抗体介导的排斥反应（AMR）尚无循证管理指南。国际心肺移植学会（ISHLT）最近引入了AMR的标准化病理诊断标准（pAMR 03）。我们评估了AMR管理的国际惯例，重点关注pAMR等级、供体特异性抗体（DSA）和同种异体移植物功能。在线调查数据分析来自184名ISHLT成员（医生占78%，外科医生占20%）。大多数来自北美（60%）和欧洲（26%）的成人移植（84%）、大中型移植中心（移植/年：1025例，61%；2550例，19%）。无论pAMR分级和DSA如何，8390%的患者的射血分数下降（EF下降45%或>下降25%）。在稳定EF的情况下，越来越多的人选择治疗逐渐加重的pAMR等级（p < 0.001）和伴随的DSA （p < 0.05, pAMR 13）。静脉注射类固醇是最常用的治疗方法，其次是静脉注射免疫球蛋白（IVIG）或血浆置换、利妥昔单抗和胸腺球蛋白。血浆置换和利妥昔单抗有利于DSA阳性和阴性（p < 0.05）。在应答者中使用70%的共识阈值，可以考虑在EF下降、无症状pAMR 3或无症状pAMR 2伴DSA的情况下治疗AMR。建议联合类固醇、IVIG和血浆置换作为初始治疗。
No evidence based management guidelines exist for antibody mediated rejection (AMR) in heart transplantation. The International Society for Heart and Lung Transplantation (ISHLT) recently introduced standardized pathologic based diagnostic criteria for AMR (pAMR 03). We evaluated international practice for the management of AMR focusing on pAMR grade, donor specific antibody (DSA) and allograft function. On-line survey data were analyzed from 184 ISHLT members (physicians-78%, surgeons-20%). The majority were from adult-transplant (84%), medium-large volume centres (transplants/year: 1025, 61%; 2550, 19%) across North America (60%) and Europe (26%). Irrespective of pAMR grade and DSA, 8390% treated a drop in ejection fraction (EF 45% or >25% decrease). In the presence of stable EF, an increasing number elected treatment for progressively severe pAMR grade (p < 0.001) and for accompanying DSA (p < 0.05, pAMR 13). Intravenous steroid was the most commonly used therapy followed by intravenous immunoglobulin (IVIG) or plasmapheresis, rituximab and thymoglobulin. Plasmapheresis and rituximab were favored for positive versus negative DSA (p < 0.05). Using a threshold of 70% consensus among respondents, treatment for AMR may be considered for a drop in EF, asymptomatic pAMR 3 or asymptomatic pAMR 2 with DSA. Combination steroid, IVIG and plasmapheresis are suggested as initial therapies.