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Transplantation |

Combination Therapy With Plasmapheresis, IVIG, and Rituximab Provides Benefit in the Management of Early Antibody Mediated Rejection in Lung Transplant in a Pilot Cohort

Keri Townsend, PharmD; Miae Kim, PharmD; Isabelle Wood, BS; Steve Boukedes, BS; Indira Guleria, PhD; Phillip Camp, MD; Souheil El-Chemaly, MD; Edgar Milford, MD; Anil Chandraker, MD; Hilary Goldberg, MD
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Brigham & Women's Hospital, Boston, MA


Chest. 2013;144(4_MeetingAbstracts):1018A. doi:10.1378/chest.1704606
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Abstract

SESSION TITLE: Post-Transplant Complications

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Monday, October 28, 2013 at 07:30 AM - 09:00 AM

PURPOSE: Antibody Mediated Rejection (AMR) is increasingly recognized as a risk factor for poor graft survival after transplantation. Various treatment regimens have shown benefit in renal and cardiac transplant. We sought to evaluate our experience as little has been reported on the effectiveness of therapy in lung transplant.

METHODS: We evaluated all lung transplant recipients at our institution between January 2008 and August 2012 to determine incidence of treated AMR as well as response to therapy. Response was defined based on improvement or stabilization of diagnostic features of AMR, including: pre-existing and de novo class I & II Donor Specific Antibody (DSA) as detected by Luminex, pathologic markers of AMR, and clinical status.

RESULTS: Incidence of treated AMR was 7% (10/142). AMR was most commonly diagnosed using a combination of pre-treatment positive circulating DSA, as well as clinical evidence of allograft dysfunction suggestive of AMR. Ten patients were treated for 17 cases of AMR with plasmapheresis, IVIG +/- rituximab. The median number of rounds of therapy was 1.5. Half of the patients treated experienced stabilization or improvement. Overall mortality at six months post AMR treatment was 40%. While circulating DSA prior to transplant was not different between groups, development of de novo DSA at MFI>3000 post-transplant was more prevalent in the non-responder group (60% vs. 20%). Non-responders tended to have more advanced allograft dysfunction at time of treatment initiation, requiring ventilation and/or oxygen supplementation more frequently than responders (4 vs. 2). Despite a higher median number of treatments in the non-responder group (2 vs.1), mortality was markedly worse in this group (4 vs. 0).

CONCLUSIONS: Surveillance for circulating DSA after transplant was an important tool in assessing risk for development of AMR in our study. When initiated early, combination plasmapheresis, IVIG +/- rituximab was an effective treatment in this pilot cohort.

CLINICAL IMPLICATIONS: Routine monitoring for DSA post-transplant may assist in earlier detection and successful treatment of AMR using combination plasmapheresis, IVIG +/- rituximab.

DISCLOSURE: The following authors have nothing to disclose: Keri Townsend, Miae Kim, Isabelle Wood, Steve Boukedes, Indira Guleria, Phillip Camp, Souheil El-Chemaly, Edgar Milford, Anil Chandraker, Hilary Goldberg

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