Therapeutic apheresis in transplantation medicine, experience with cardiac and lung transplantation in Jena.

Immunological problems like preformed donor specific antibodies (DSA) or high degree of immunization complicate the transplantation (TX) and can limit the therapeutic success. Essential pillars of antihumoral therapy are the extracorporeal procedures like therapeutic plasma exchange (TPE) and high plasma volume immunoadsorption (IA). Both extracorporeal treatments have the ability to remove pre-existing or newly formed antibodies quickly and effectively. In the last 5 years a total of 27 patients, 12 heart transplant (HTX) patients, 3 patients after combined lung and heart transplantation (Lu/HTX) and 12 lung transplant (LuTX) patients were treated for prevention (6 patients) or in case of rejection (20 patients) with TPE, cascade filtration (CF) or IA. 6 HTX recipients and 5 LuTX recipients were tested positive for HLA-ab either donor specific or de novo HLA-ab. Altogether 7 patients were tested positive for non-HLA-ab. 6 patients were treated prior to TX with 1-3 TPEs. After TX we treated 24 patients initially with TPE and performed on average 4 TPEs (1-11) for antibody elimination. 22 of 27 treated patients survived with stable graft function. The extracorporeal procedures we performed are qualified for rescue therapy of antibody mediated rejection (AMR).

Positive virtual crossmatch with negative flow crossmatch results in two cases.

Pre-transplant (Tx) presence of HLA antibodies (HLA-Ab) especially donor specific antibodies (DSA) has been correlated with post-Tx rejection. While crossmatch (XM) is the specific method to identify DSA, logistical reasons prevent performing a prospective XM in all transplants. In such cases DSA as identified by solid-phase assay (SPA) are being used to perform a virtual crossmatch (VXM). We present two cases, a heart-lung transplant and a kidney transplant, for which testing detected a presumptive DSA with discordant results: a negative flow cytometric crossmatch (FXM) and a positive VXM using SPA. The subsequent investigation determined the antibody, in both cases, was presumably directed against an epitope of a HLA-B*44 antigen found on the single antigen beads (SAB) used in the SPA but not against the native form on the donor lymphocytes used in the FXM. Manufacturing of SAB beads results in denaturation of epitopes, majority of which are removed from the final product, but residual amount is present on the final product. Denaturation of majority of antigen epitopes on single antigen beads did not remove the activity of the recipient's antibodies but it did diminish the activity of positive control serum. This indicates denaturation of some of the HLA-B*44 antigen during manufacturing of the SAB may have lead to the reactivity. Antibody mediated rejection does not appear to be associated with the titer of this antibody to denatured antigen in the first case and so clinical relevance of such antibodies is unclear. Subsequently a second case of discordant FXM and VXM was identified in a potential kidney transplant patient who went on to an uneventful transplant. In this case, lymphocytes from the donor were positively shown to express HLA-B*44:02 using known anti- HLA-B*44:02 control serum. Platelets identified as HLA-B*44:02 could adsorb the anti-HLA-B*44:02 from the control serum activity but not from that of the recipient's anti- HLA-B 44 antibody adding evidence that this antibody should best be classified as a false positive finding. The presence of such an antibody if misidentified may result in unnecessary therapy being instituted or the inappropriate denial of an organ for transplantation.

Colchicine-induced rhabdomyolysis in a heart/lung transplant patient with concurrent use of cyclosporin, pravastatin, and azithromycin.

We report a case of colchicine-induced rhabdomyolysis in a heart/lung-transplanted man treated with cyclosporin. A treatment was to resolve an acute gouty arthritis and was started with 3 mg of colchicine the first day, then 2 mg the second and the third day, and finally 1 mg/d during 6 days. Eight days later, the patient developed multiple organ failure and rhabdomyolysis. The concentration of colchicine analyzed was greater than the standard 153 hours after his last intake. Pharmacokinetic interactions are responsible of this toxicity. Cyclosporin, pravastatin, and azithromycin are known to inhibit P-glycoprotein, which will enhance the intracellular colchicine level by acting in its bioavailability and moderating hepatic and renal excretion. Moreover, long-term treatment by cyclosporin generates chronic renal failure that will, in the same time, decrease colchicine elimination. Even short-term administration of therapeutic colchicine dose may cause colchicine-related toxicity, especially in the setting of a renal failure and/or polymedicinal treatment.

Two-year outcomes in thoracic transplant recipients after conversion to everolimus with reduced calcineurin inhibitor within a multicenter, open-label, randomized trial.

BACKGROUND: Use of the mammalian target of rapamycin inhibitor everolimus with an accompanying reduction in calcineurin inhibitor (CNI) exposure has shown promise in preserving renal function in maintenance thoracic transplant patients, but robust, long-term data are required. METHODS: In a prospective, open-label, multicenter study, thoracic transplant recipients more than or equal to 1 year posttransplant with mild-to-moderate renal insufficiency were randomized to continue their current CNI-based immunosuppression or convert to everolimus with predefined CNI exposure reduction. After a 12-month core trial, patients were followed up to month 24 after randomization. RESULTS: Of 245 patients who completed the month 12 visit, 235 patients (108 everolimus and 127 controls) entered the 12-month extension phase. At month 24, mean measured glomerular filtration rate had increased by 3.2±12.3 mL/min from the point of randomization in everolimus-treated patients and decreased by 2.4±9.0 mL/min in controls (P<0.001), a difference that was significant within both the heart and lung transplant subpopulations. During months 12 to 24, 5.6% of everolimus patients and 3.1% of controls experienced biopsy-proven acute rejection (P=0.76). There were no significant differences in the rate of adverse events or serious adverse events (including pneumonia) between groups during months 12 to 24. CONCLUSIONS: Converting maintenance thoracic transplant recipients to everolimus with low-exposure CNI results in a renal benefit that is sustained to 2 years postconversion, with significantly improved measured glomerular filtration rate in both heart and lung transplant patients. Despite reductions of more than 50% in CNI exposure, there was no marked loss of efficacy. The safety profile of the everolimus-based regimen was acceptable.

Systemic and exhaled cytokine and chemokine profiles are associated with the development of bronchiolitis obliterans syndrome.

BACKGROUND: The mechanisms that lead to the fibrotic obliteration in bronchiolitis obliterans syndrome (BOS) may involve the interactions between T-helper (Th)1 and Th2 cytokines. The aim of this study is to determine the Th1 and Th2 cytokine and chemokine profiles in serum and exhaled breath condensate (EBC) in lung transplant recipients and to assess their usefulness as biomarkers to predict the development of BOS. METHODS: Serum and EBC from 10 patients with BOS (BOS(pos)) and 10 patients without BOS (BOS(neg)), matched for clinical and demographic variables, were analyzed with a multiplex immunoassay to measure a panel of 27 cytokines and chemokines. RESULTS: The pro-inflammatory cytokines in serum were elevated in lung transplant recipients compared with controls. BOS(pos) patients had significantly lower concentrations of interleukin (IL)-4, IL-13, and vascular endothelial growth factor (VEGF) compared with BOS(neg) patients. The concentration of IL-5, however, was significantly higher in BOS(pos) patients. Levels of IL-4 and IL-5 were hardly detectable in EBC. IL-13 and VEGF, both decreased in serum in BOS(pos) patients, were also decreased in EBC in BOS(pos) patients compared with BOS(neg) patients. Longitudinal analysis of cytokines and chemokines in serum and EBC from the time of lung transplantation onwards did not reveal significant trends in cytokines and chemokines that preceded the diagnosis of BOS. CONCLUSIONS: Levels of pro-inflammatory cytokines were increased in lung transplant recipients compared with controls. From the moment of transplantation onwards, there is a different pattern of Th2 cytokines in serum in BOS(pos) patients than in BOS(neg) patients.

My approach to cardiothoracic transplantation and the role of the histocompatibility and immunogenetics laboratory in a rapidly developing field.

Cardiothoracic transplantation presents specific challenges. The lack of long-term replacement therapy (such as dialysis for kidney patients) creates a more urgent situation than for other forms of transplantation, necessitating a different approach. This review looks at ways in which the challenges are being met and the integral role of the histocompatibility and immunogenetics laboratory.

Lung and heart lung transplantation at the University of Alberta 1986-2010.

The lung transplantation program at the University of Alberta has been in existence for 25 years. The current volume is 35-40 new lung transplants per year. We offer single-lung, bilateral lung, heart/lung and bilateral living lobar transplantation as options. Experience has allowed for widening of the indications and acceptance of patients with more risk. Donor evaluation and management has allowed for extended donors to be included in the donor pool. Results will likely continue to improve with increased understanding of the mechanisms and management of bronchiolitis obliterans syndrome. Our research interests have been in the areas of risk analysis, outcome assessment, and quality of life changes from transplantation.

Lack of serologic immunity against vaccine-preventable diseases in children after thoracic transplantation.

We investigated whether children after heart- (HTx) or heart-lung transplantation (HLTx) show protective antibody levels against recommended vaccinations, whether vaccination schedules are completed and which factors influence serologic immunity. We performed a cross sectional ELISA - quantification of specific antibodies in 46 patients after pediatric thoracic Tx. Findings were correlated to vaccination history, age at Tx, clinical course and immunosuppressive regimen. We found protective antibody levels against diphtheria in 74% of patients, against tetanus in 22%, against Haemophilus influenzae type b in 30% and against Streptococcus pneumoniae in 59%. Antibody concentrations against live attenuated vaccines were significantly lower in children transplanted in the first 2 years of life. Antibodies were absent for measles in 55% of late - and 81% of early transplanted children, for mumps in 66%/94%, for rubella in 30%/56% and for Varicella in 34%/63%. We found significant correlation of low antibody concentrations and age at Tx. Patients without protective antibody concentrations had significantly longer use of steroids. Vaccination schedules were incomplete or delayed in the majority of patients associated with more days in hospital pre-Tx. Our study shows that closer adherence to pretransplantation vaccination schedules and also post-transplantation monitoring of antibody levels are required in transplant patients.

Renal after cardiothoracic transplant: the effect of repeat mismatches on outcome.

BACKGROUND: Histocompatibility matching is not considered important in nonrenal solid organ transplants (NRSOT). There is no evidence to base guidance on whether mismatched human leukocyte antigen (HLA) antigens should be avoided in subsequent renal transplantation. METHODS: This study examines the effect of repeat HLA mismatches on renal allograft survival and function in all renal after cardiothoracic transplants undertaken in the United Kingdom between 1997 and 2003 using the UK Transplant data. RESULTS: A repeat HLA-A, -B, or -DR mismatch occurred in 16 of 53 (30%) cases. Recipients without a repeat mismatch were more likely to be male, but recipient age, donor age, recipient-donor age difference, donor gender, donor type, or cold ischemia time were comparable. Immunosuppressive therapy was similar in both groups. No differences were observed in renal allograft function at 1 or 5 years between the repeat mismatch group (estimated glomerular filtration rate [mean+/-standard deviation] 41.6+/-16.6 and 37.5+/-12.8 mL/min/1.73 m2) and the no repeat mismatch group (47.2+/-15.7 and 48.0+/-15.9 mL/min/1.73 m2). Renal allograft survival was also similar in the two groups at 1 and 5 years. CONCLUSIONS: In this limited, heterogeneous, observational cohort of cardiothoracic transplant patients who went on to receive a sequential kidney transplant, a repeated HLA antigen mismatch was not associated with a detrimental effect on kidney transplant outcome.

Lung and heart-lung transplantation at University of Pittsburgh: 1982-2009.

The Lung Transplantation program at the University of Pittsburgh began in 1982. From the beginning to December 31, 2009, 1347, lung and heart lung transplantations have been done. (674 double-lung, 310 left single-lung, 227 right single-lung and 130 heart-lung transplantations. University of Pittsburgh maintains a data base, from the time of the inception of the program, of all recipients and donors. There is an increasing trend to do double-lung transplantation, as 5- and 10-year survival is better with double than single lungs. Our experience with heart-lung transplantation is considerable. The 4 most common indications for lung transplantation are: chronic obstructive disease (COPD), idiopathic pulmonary fibrosis (IPF), cystic fibrosis (CF) and pulmonary arterial hypertension. (PAH). Potential recipients are evaluated over 2 weeks. There is also a pathway for accelerated evaluation of sicker patients. Our recipient criteria are expanded and flexible; as many patients, who have been denied lung transplantation, at other major centers have been successfully transplanted by us with good outcomes. The median waiting time on the list in 2009 was 37 days. Our altruistic flexibility in recipient selection, balanced with respect to the altruistic gift of donor families, has been described in considerable detail. To solve the problem of shortage of donor lungs, we have expanded our donor selection criteria beyond the historic ideal donor, without comprising on outcomes. These selection criteria and our donor-lungs management protocol are also described in reasonable detail. We started using lungs from donors after cardiac death (DCD) in January 2007. Recently we reviewed our experience and literature, and devised a protocol; which is given in a robust table. We also participate as faculty in the educational program initiated by the Organ Procurement Organizations (OPO) of Pennsylvania. During procurement we use 500 microg of prostaglandin E-1 into the pulmonary artery just before X clamp, Perfedex infusion after X-clamp, at 70 ml/kg, with 500 microg of prostaglandin and 50 mg of nitroglycerine in the first bag, and retrograde flush of 500 ccs in each pulmonary vein. We have refined our recipient operation, from clam shell incision to bilateral antero-axillary incisions, preserving the sternum and internal mammary arteries, for both double and single-lung transplantation, with good outcomes. This technique and results have been described in generous detail. We use pneumoplegia, similar to cardioplegia, to protect the allograft from ischemic and reperfusion injury (Appendix III). Our technique of bronchial anastomosis and intraoperative management of septic lung disease has remained unchanged. Post-operatively we continue to use the ventilatory management of low FiO2 and high PEEP. Our immunosuppression and infection prophylaxis protocol is the same since 2003, when we started using Alemtuzumab (Campath) for induction, with minimization of the use of steroids. For maintenance, we use Tacrolimus and Mycophenolate Mofetil. Now, we also monitor the functional activity of the T cell by Cylex ImmuKnow. Lowered activity (< 100 ng/ml) suggests an increased risk of infection; and higher activity (> 200 ng/ml) suggests greater risks for rejection. Although we have expanded our recipient and donor pools, our outcomes have continued to improve. The overall survival of double-lung transplantation from 2003-2009 was 82.8% at one year and 56.8% at 5 years. This compares well with the international data which shows an overall survival rate of 80% at one year and 56% at 5 years. Results of lung transplantation will continue to improve, with our increasing understanding of mechanisms and management of ischemic-reperfusion injury, acute rejection and bronchiolitis obliterans syndrome.

Retransplantation after single lung transplantation.

OBJECTIVE: Our lung transplant program started in June 1989 with primary grafts including 21 heart-lung, 11 single lung, and 5 bilateral sequential single lung transplantation. Three patients required retransplantation for single lung and 2 patients for heart-lung grafts. The primary cause of death after lung transplantation is chronic graft dysfunction--bronchiolitis obliteran--though other causes, namely acute graft failure, have been mentioned. Retransplantation is considered to be the only treatment option. In experienced centers, the 1- and 5-year survivals are not as good as for other organ transplantations and for retransplantations the outcome is even worse. Our objective herein was to describe factors to be taken into account for retransplantation in our program, including the timing and indication for retransplantation and the presence of comorbidities. PATIENTS AND METHODS: In our experience of 11 single lung transplantations, 3 (27.3%) were retransplantations. The 3 patients were 3, 5, and 2 years after primary transplantation. The indications were overexpansion of the remaining lung compressing the new lung in one and bronchiolitis obliterans in the others. RESULTS: One patient with emphysema died in hospital after retransplantation because of acute myocardial infarction. One patient with lymphangioleiomyomatosis (LAM) disease died of lung complication after sudden cardiac arrest at 1.5 years after retransplantation. One patient with idiopathic pulmonary fibrosis is still alive at 5 years after retransplantation. CONCLUSIONS: Bronchiolitis obliterans was a common reason for retransplantation among our patients as well as in other reports. Bronchiolitis exists with superimposed infection for years if it is the mild form. However, the clinical setting is progressively worse if it could not be controlled leading to retransplantation. At this stage, progressive deterioration of lung function must be considered because of inadequate therapy for infection. Finally, when there is infection usually both lungs are involved. The decision whether to replace the transplanted lung or the remaining lung is a concern, especially when the donor availability is scarce. In conclusion, lung retransplantation is the only treatment option for severe graft dysfunction, if there is no other therapy that can prolong life. Though bronchiolitis obliterans often is the indication for retransplantation, bronchiolitis itself is the signal of retransplantation.

Donor brain death mechanisms and outcomes after heart transplantation.

We sought to explore whether the cause of donor brain death influenced recipient outcomes after cardiac transplantation. In retrospect, 358 consecutive donors provided cardiac allografts to adult patients undergoing orthotopic heart transplantation at a single urban US medical center from January 2000 through December 2005. Alternate recipients were excluded. Mechanism and cause of donor brain injury and death were divided into five categories: anoxia (nontraumatic) (n=36), blunt head trauma (n=220), penetrating head trauma (n=83), brain tumor/infection (n=7), and cerebrovascular event (n=12). The five subgroups were categorized as traumatic or nontraumatic. The end points of the study were causes of early and late mortality, survival, and rejection rate. There were 59 deaths in the 6-year period. Total and short-term recipient mortality were found to be statistically higher among heart transplant recipients when the donors suffered from traumatic brain death compared to those whose brain death etiology was nontraumatic (P=.045, P=.033, respectively). Rejection rate was similar in all groups (P=.497). In conclusion, donor traumatic brain death was found to be a valid risk factor for recipient mortality after heart transplantation. Caution should be used when evaluating such donors, particularly in the presence of other risk factors.

Sirolimus-associated infertility: case report and literature review of possible mechanisms.

The mammalian-target-of-rapamycin/mTOR-inhibitor sirolimus as a component of the immunosuppressive strategy after solid organ transplantation is effective at preventing allograft rejection. However, recent reports indicate that sirolimus is associated with altered sex hormone levels and impaired sperm quality parameters. Herein, we report on a case of sirolimus-associated infertility in a young male heart-lung transplant recipient and provide a detailed synopsis of potential mechanisms by which sirolimus may negatively influence spermatogenesis. Testicular immunohistochemistry, the course of sex hormone and sperm quality parameters of our patient support the hypothesis that mTOR might act as an important key regulator in the reproductive system. Fortunately, due to withdrawal of sirolimus as part of the maintenance, immunosuppression improved sperm quality and sex hormone parameters could be observed. Recently, these improvements even resulted in a spontaneous pregnancy of the patient's wife more than 1 year after the drug was withdrawn. In our view, oligospermia as a possible and at least partly reversible side-effect of mTOR inhibitors has to be taken into consideration, particularly, when administrated to young male patients.

Tacrolimus with mycophenolate mofetil (MMF) or sirolimus vs. cyclosporine with MMF in cardiac transplant patients: 1-year report.

The most advantageous combination of immunosuppressive agents for cardiac transplant recipients has not yet been established. Between November 2001 and June 2003, 343 de novo cardiac transplant recipients were randomized to receive steroids and either tacrolimus (TAC) + sirolimus (SRL), TAC + mycophenolate mofetil (MMF) or cyclosporine (CYA) + MMF. Antilymphocyte induction therapy was allowed for up to 5 days. The primary endpoint of >/=3A rejection or hemodynamic compromise rejection requiring treatment showed no significant difference at 6 months (TAC/MMF 22.4%, TAC/SRL 24.3%, CYA/MMF 31.6%, p = 0.271) and 1 year (p = 0.056), but it was significantly lower in the TAC/MMF group when compared only to the CYA/MMF group at 1 year (23.4% vs. 36.8%; p = 0.029). Differences in the incidence of any treated rejection were significant (TAC/SRL = 35%, TAC/MMF = 42%, CYA/MMF = 59%; p < 0.001), as were median levels of serum creatinine (TAC/SRL = 1.5 mg/dL, TAC/MMF = 1.3 mg/dL, CYA/MMF = 1.5 mg/dL; p = 0.032) and triglycerides (TAC/SRL = 162 mg/dL, TAC/MMF = 126 mg/dL, CYA/MMF = 154 mg/dL; p = 0.028). The TAC/SRL group encountered fewer viral infections but more fungal infections and impaired wound healing. These secondary endpoints suggest that the TAC/MMF combination appears to offer more advantages than TAC/SRL or CYA/MMF in cardiac transplant patients, including fewer >/=3A rejections or hemodynamic compromise rejections and an improved side-effect profile.

The pH of exhaled breath condensate of patients with allograft rejection after lung transplantation.

Endogenous airway acidification, as assessed by the condensate pH, has been implicated in the pathophysiology of inflammatory airway diseases such as cystic fibrosis and asthma. The aim of this study was to investigate the pH of condensate in patients after lung transplantation (LTX). From the cohort of transplanted patients at our center, 83 patients (9 heart-lung transplantation, 48 double-lung transplantation, 26 single-lung transplantation) were recruited and analyzed in a cross-sectional manner: 26 patients were diagnosed with chronic rejection or bronchiolitis obliterans syndrome (BOS), 7 patients were diagnosed with acute rejection (AR) while 50 patients had no evidence of rejection according to the International Society for Heart and Lung Transplantation criteria. The condensate pH was significantly reduced in patients with BOS and AR when compared to patients without rejection and control subjects (5.8 +/- 0.5 and 6.2 +/- 0.4 versus 6.6 +/- 0.4 and 6.5 +/- 0 .4, respectively; p < 0.05). Moreover, there was a significant correlation between condensate pH levels and the BOS grade (r =-0.62; p < 0.01), the FEV(1) (r = 0.39; p < 0.01) and the total cell and neutrophil count in bronchoalveolar lavage fluid (r =-0.39 and r =-0.56, respectively; p < 0.01). Airway acidification occurs in BOS and may directly or indirectly reflect airway inflammation in patients with allograft rejection after LTX. Measuring condensate pH might thus be a new tool for the evaluation of rejection in lung transplant patients.