Serum dilutions as a predictive biomarker for peri-operative desensitization: An exploratory approach to transplanting sensitized heart candidates.

Antibody-mediated rejection (AMR) of cardiac allografts mediated by anti-HLA Donor Specific Antibodies (DSA) is one of the major barriers to successful transplantation for the treatment of end-stage heart failure. Therapeutic plasma exchange (TPE) is a first-line treatment for pre-transplant desensitization. However, indications for treatment regimens and treatment end-points have not been well established. In this study, we investigated how sera dilutions could guide TPE regimens for effective peri-operative desensitization and early AMR treatment. Our data show that 1:16 dilutions of EDTA-treated sera and 1.5 volume TPE reduce anti-HLA class I and class II antibody levels in the same manner and, therefore, allows to predict which antibodies would respond to peri-operative TPE. We successfully applied this approach to transplanting three highly sensitized cardiac recipients (CPRA 85-93%) with peri-operative desensitization based on a virtual crossmatch performed on 1:16 diluted serum. Furthermore, we have used sera dilutions to guide DSA treatment post-transplant. Although these findings have to be confirmed in a larger prospective study, our data suggest that serum dilutions can serve as a predictive biomarker to guide peri-operative desensitization and post-transplant immunologic management.

Antiplatelet and anticoagulation medications and the surgical patient.

BACKGROUND: Acute coronary syndrome affects more than 750,000 Americans per year, and antiplatelet agents are the cornerstones of treatment. Atrial fibrillation affects 2.4 million patients in the United States, and venous thromboembolism occurs in 1 to 2 per 1,000 adults per year. Anticoagulants are commonly prescribed to affected patients. Surgeons are commonly called upon to care for patients taking medications that affect normal coagulation. It is important that the surgical community has a fundamental understanding of these agents' pharmacology, which may impact patients' clinical course. METHODS: A review of recent literature on pharmacologic agents that affect coagulation was performed. RESULTS: A number of medications that alter normal coagulation were reviewed in this article including their pharmacologic properties and reversal strategies. CONCLUSIONS: There are a variety of medications that affect a patient's coagulation ability, including many newer agents on the market. This review provides surgeons with the knowledge needed to assist in caring for individuals receiving these drugs.