How to deal with presensitized candidates for heart transplantation?

With increasing utilization of assist devices and adoption of calculated panel-reactive antibody (cPRA), the number of presensitized patients being listed for heart transplantation is increasing. An effort to standardize identification and management of such patients is paramount and recently initiated in the heart transplant community. The current review describes the basic concepts of presensitization and details the most relevant work including the latest advancements in this area.

More sensitive techniques in identifying presensitized patients have posed challenges in understanding the clinical relevance and implications of such testing. cPRA has been shown to benefit presensitized heart transplant patients. De-sensitization strategies have never been studied in a large clinical trial setting but a combination of plasmapheresis and intravenous immunoglobulin has been shown to be beneficial in small studies. Long-term positive outcomes of de-sensitization have been recently reported. Newer agents like alemtuzumab, bortezomib and complement inhibitors have been reported in case reports and series with promising results as de-sensitization strategy.

Data specific to strategies and therapies in heart transplantation are sparse and most knowledge stems from other organ transplantation. Consensus efforts to standardize care and also advance research in this area were initiated recently with hope for improving care for these patients.