ABO-incompatible cardiac transplantation in pediatric patients with high isohemagglutinin titers

BACKGROUND: ABO-incompatible (ABOi) cardiac transplantation is now used widely in infants with isohemagglutinin titers < 1:4, but there is increasing evidence that ABOi transplantation can also be used in children with significantly higher titers. We reviewed our high-titer ABOi transplants and report our results here. METHODS: Patients who underwent ABOi cardiac transplantation from 2000 to 2013 with pre-existing isohemagglutinin titers of >= 1:16 were identified from departmental databases. Outcomes were reviewed using medical and laboratory records. RESULTS: Thirty patients underwent ABOi cardiac transplantation between 2000 and 2013. Twelve (40%) had pre-transplant isohemagglutinin titers of >= 1:16 and were included for further study. Median age was 14.9 (range 9.8 to 107.3) months and median weight was 9.6 (range 7.6 to 25) kg. Five (42%) were male. Pre-transplant diagnosis was cardiomyopathy in 8 of 12 (67%) and congenital heart disease in 4 of 12 (33%). Highest pre-transplant isohemagglutinin titer was 1:256 in 2 patients. Four patients (33%) had early antibody-mediated rejection (AMR), all within 15 days post-transplant. Management included use of rituximab, bortezomib, immunoadsorption and eculizumab. Three patients died but no deaths were associated with high isohemagglutinin titers. CONCLUSIONS: ABOi cardiac transplantation in patients with isohemagglutinin titers >= 1:16 is possible. AMR may occur early and immunoadsorption has proven effective at decreasing antibody titers. (C) 2015 International Society for Heart and Lung Transplantation. All rights reserved.