Managing Contemporary AMR with a 4-Tiered Treatment Protocol: A Single-Center Experience

• Published in: The Journal of heart and lung transplantation Vol. 41; no. 4; p. S412
• Main Authors: Choe, J., Habal, M.V., Restaino, S.W., Latif, F., Clerkin, K.J., Yuzefpolskaya, M., Sayer, G., Uriel, N., Jennings, D.L.
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01-04-2022
• ISSN: 1053-2498; 1557-3117
• DOI: 10.1016/j.healun.2022.01.1036

Much remains unknown about the optimal diagnosis and treatment of antibody-mediated rejection (AMR) after heart transplant (HT). With limited literature available to guide treatment decisions, center-specific protocol often dictate local practice. Here we describe the results of a 4-tiered AMR treatment protocol at our center.
In March 2020, a new 4-tiered treatment protocol for AMR was developed at Columbia University. Tier 1, which centers around thymoglobulin, is the most intense and is reserved for those with severe graft dysfunction (Figure 1). Tier 2 involves plasmapheresis and bortezomib and is used for non-severe graft dysfunction. Tier 3 is for patients with preserved graft function but biopsy-proven AMR, while tier 4 is used for new or rising DSA. The primary endpoint is survival at last follow up, while key secondary endpoints include freedom from recurrent AMR and resolution of DSA. Drug side effects and rates of subsequent infection in the 6 months post treatment were also gathered.
A total of 20 patients were included (Median age = 56.9 years old, % male = 75%, time from HT = 3.85 years). Five patients received tier 1 treatment, and four were alive at last follow up, with none free from recurrent AMR. Nine patients were treated with tier 2, all were alive at last follow up, while four were free from recurrent AMR. Six patients were treated with tier 3, and five were alive at last follow up, while four were free from recurrent AMR. If true, DSA became undetectable in 8/20 patients with four patients in the tier 3 group. Overall, there were 7 patients that experienced infection within 6 months of treatment.
Early data suggest the potential need for augmented maintenance suppression post AMR treatment, as many patients treated in tier 1 and tier 2 experienced recurrent AMR as well as rebound DSA post AMR treatment. Further studies are warranted to support the results of this study.