Impact and outcomes after desensitization therapy in highly sensitized heart transplant candidates

The efficacy and posttransplant outcomes of desensitization therapy in highly sensitized heart transplantation (HT) candidates are unknown. In this retrospective cohort study, 57 HT candidates with pre-HT calculated panel reactive antibody (cPRA) level of >50% for anti-human leukocyte antigen antibodies with mean fluorescence intensity >10 000, who were treated with desensitization therapy, were identified. Posttreatment cPRA was determined for all patients, and follow-up data and outcomes were determined from review of the medical record. Bortezomib/plasmapheresis, and rituximab or obinutuzumab with intravenous immunoglobulin led to significant decreases in cPRA calculated for antibodies with mean fluorescence intensity >10 000 and/or C1q-positive antibodies. After desensitization, 40 patients received HT during the follow-up period. Of the transplanted patients, 17 patients experienced elimination or a decrease in donor-specific antibodies that allowed them to receive an HT that would not have been possible prior to desensitization therapy. Transplanted patients had higher rates of antibody-mediated rejection than the general national HT population, but similar 5-year survival and rates of cardiac allograft vasculopathy or graft dysfunction. Safety outcomes, including malignancy and infections, occurred at acceptable rates. Thus, desensitization therapies for highly sensitized HT candidates help to broaden the donor pool and facilitate HT.