Management of Patients With Preformed Reactive Antibodies Who Are Awaiting Cardiac Transplantation

Patients with elevated levels of preformed reactive antibodies to HLA antigens have higher rates of organ rejection than do patients without such antibodies. Consequently, before proceeding with transplantation, many medical centers do prospective cross-matching, that is, mix lymphocytes from the organ donor with sera from the prospective organ recipient, to determine whether a higher rejection rate or an immediate episode of rejection will occur. The problem has been compounded by the increased frequency of preformed reactive antibodies in patients with ventricular assist devices who are awaiting cardiac transplantation. Performing a prospective cross-match can be time-consuming and often is impossible because of the unstable condition of the organ donor or travel logistics, leading to increased costs for transplantation and longer waiting times for recipients. A variety of treatments are used in cardiac transplantation programs in attempts to reduce the concentration of preformed reactive antibodies. Each of these treatments has accompanying complications and considerations for the transplant team. Each treatment must also be assessed for therapeutic response. Options for managing patients with preformed antibodies and a case report are presented.