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Am J Transplant. 2018 Sep;18(9):2148-2162. doi: 10.1111/ajt.14876. Epub 2018 May 28.

Pediatric heart transplantation across a positive crossmatch: First year results from the CTOTC-04 multi-institutional study.

Author information

1
Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA.
2
Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
3
Rho Federal Systems Division, Chapel Hill, NC, USA.
4
Division of Pediatric Cardiology, Columbia University Medical Center, New York, NY, USA.
5
Department of Pediatric Cardiology, Boston Children's Hospital, Boston, MA, USA.
6
Department of Paediatrics, Hospital for Sick Children, Labatt Family Heart Center, Toronto, Ontario, Canada.
7
Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
8
Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
9
Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis, MO, USA.
10
Division of Pediatric Cardiology, Albert Einstein College of Medicine/Children's Hospital at Montefiore, Bronx, NY, USA.
11
Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, GA, USA.
12
Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.

Abstract

Sensitization is common in pediatric heart transplant candidates and waitlist mortality is high. Transplantation across a positive crossmatch may reduce wait time, but is considered high risk. We prospectively recruited consecutive candidates at eight North American centers. At transplantation, subjects were categorized as nonsensitized or sensitized (presence of ≥1 HLA antibody with MFI ≥1000 using single antigen beads). Sensitized subjects were further classified as complement-dependent cytotoxicity crossmatch (CDC-crossmatch) positive or negative and as donor-specific antibodies (DSA) positive or negative. Immunosuppression was standardized. CDC-crossmatch-positive subjects also received perioperative antibody removal, maintenance corticosteroids, and intravenous immunoglobulin. The primary endpoint was the 1 year incidence rate of a composite of death, retransplantation, or rejection with hemodynamic compromise. 317 subjects were screened, 290 enrolled and 240 transplanted (51 with pretransplant DSA, 11 with positive CDC-crossmatch). The incidence rates of the primary endpoint did not differ statistically between groups; nonsensitized 6.7% (CI: 2.7%, 13.3%), sensitized crossmatch positive 18.2% (CI: 2.3%, 51.8%), sensitized crossmatch negative 10.7% (CI: 5.7%, 18.0%), P = .2354. The primary endpoint also did not differ by DSA status. Freedom from antibody-mediated and cellular rejection was lower in the crossmatch positive group and/or in the presence of DSA. Follow-up will determine if acceptable outcomes can be achieved long-term.

KEYWORDS:

alloantibody; clinical research/practice; crossmatch; heart transplantation/cardiology; pediatrics; rejection: antibody-mediated (ABMR)

PMID:
29673058
DOI:
10.1111/ajt.14876
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