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Review
. 2020 Sep 29;3(1):15-30.
doi: 10.36628/ijhf.2020.0034. eCollection 2021 Jan.

Heart Transplant Immunosuppression Strategies at Cedars-Sinai Medical Center

David H Chang  1 , Jong-Chan Youn  1   2 , Deanna Dilibero  1 , Jignesh K Patel  1 , Jon A Kobashigawa  1
Affiliations
Review

Heart Transplant Immunosuppression Strategies at Cedars-Sinai Medical Center

David H Chang et al. Int J Heart Fail. .

Abstract

Heart transplant is the optimal treatment for selected patients with end-stage heart failure. Immunosuppression after heart transplantation has significantly reduced the incidence of rejection and improved patient outcomes with the routine use of calcineurin inhibitors. Antimetabolites and proliferation signal inhibitors add to the improvement in patient outcomes as well. The goal of induction therapy is to provide intense immunosuppression when the risk of allograft rejection is highest. Most maintenance immunosuppressive protocols employ a 3-drug regimen consisting of a calcineurin inhibitor, an antimetabolite agent and glucocorticoids. The management of rejection proceeds in a stepwise fashion based on the severity of rejection detected on biopsy and the patient's clinical presentation. This review will cover induction, maintenance, rejection therapy and some special considerations including sensitization, renal sparing protocol, and corticosteroid weaning. It will end in consideration of potential future directions in immunosuppressive strategies to promote patient and graft survival.

Keywords: Desensitization, immunologic; Graft rejection; Heart transplantation; Immunosuppression; Maintenance.

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Conflict of interest statement

Conflict of Interest: D.H.C. received research grants from Amgen, Biocardia, and Mesoblast and has moderate stock interest in Abbot Laboratories, Abbvie Inc, Repligen Corporation, Amarin Corporation and Portola Pharmaceuticals. J.K.P. received research grants from Alexion Pharmaceuticals, Pfizer, Alnylam Pharmaceuticals and Astra Zeneca. J.A.K. received research grants from CareDx Inc., Sanofi-Genzyme and CSL-Behringer. All other authors have no conflicts of interest to disclose.

Figures

Figure 1
Figure 1. Summary flow diagram of immunosuppression strategies at Cedars-Sinai.
2R = moderate rejection; ACR = acute cellular rejection; AMR = antibody mediated rejection; ATG = anti-thymocyte globulin; CAV = cardiac allograft vasculopathy; CMV = cytomegalovirus; CNI = calcineurin inhibitor; cPRA = calculated panel reactive antibody; Cr = creatinine; EF = ejection fraction; HTx = heart transplant; PRA = panel reactive antibody; PSI = proliferation signal inhibitor; MMF = mycophenolate mofetil; IS = immunosuppressive; PSI = proliferation signal inhibitor.
Figure 2
Figure 2. Induction therapy with eculizumab.
ATG = anti-thymocyte globulin; IVIG = intravenous pooled immunoglobulin; MMF = mycophenolate mofetil.
Figure 3
Figure 3. Management of sensitized patients.
cPRA = calculated panel reactive antibody; HLA = human leukocyte antigen; IVIG = intravenous pooled immunoglobulin; MFI = mean fluorescence intensity; PRA = panel reactive antibody.
Figure 4
Figure 4. Outpatient desensitization protocol.
PRA = panel reactive antibody.
Figure 5
Figure 5. Inpatient desensitization protocol.
PRA = panel reactive antibody.
See this image and copyright information in PMC

References

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