[HEART TRANSPLANTATION: HUMORAL REJECTION - A CASE REPORT]

Allograft rejection is a major challenge in the treatment of heart transplant recipients. The rejection is pathophysiological categorized into cellular rejection, mediated by lymphocytes and antibody-medicated rejection (AMR). We will focus on this case report on AMR, mediated by recipient antibodies, directed against donor antigens on the allograft's vascular endothelium, mostly HLA-group antigens. These antibodies mount an inflammatory response, myocardial damage, and eventually myocardial dysfunction and cardiac allograft vasculopathy (CAV). The diagnosis of AMR is based on pathological findings, both histological and immune-histochemical on myocardial biopsy and serology of recipient donor-specific antibodies. The key principles of AMR treatment are removal or neutralization of the pathological antibodies, prevention of de-novo antibodies production and inhibition of lymphocyte-dependent inflammatory pathways. First-line treatment options include high dose corticosteroids, anti-thymocyte globulin, intravenous immunoglobulin, plasmapheresis and rituximab. We present a case-repost of a 48-year-old male, who underwent a successful orthotopic heart transplantation, and one and half years later, developed a severe AMR with diffuse CAV. It was manifested as progressive heart failure and recurrent coronary events. The patient was treated with first line medications mentioned above, and due to lack of sufficient response he was also treated with photopheresis and bortezomib, but to no avail. More aggressive treatments, with doubtful efficacy, were not feasible due to the patient's grave condition and he eventually died.