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The removal of pathogenic substances by therapeutic plasma exchange (TPE), as a treatment for antibody-mediated rejection in cardiac transplant, has gain a way as a modern medical therapy. A multidisciplinary approach can be taken from TPE, but nephrologist must be the responsible for prescribing this therapy. Membrane filtration with TPE 2000 (Fig. 1), with an effective surface area of 0.35 m2 of polypropylene with ethylene oxide sterilization, targets a large-molecular-weight substances present in plasma as immunoglobulin. TPE could be offered as initial therapeutic intervention as it rapidly removes pathogenic substances as antibodies and cytokines from patients’ plasma. The technology is already in ICU: CRRT machines.
A 24-year-old woman, post cardiac transplantation 4 months prior to admission for dilated cardiomyopathy. She arrived to ER with progressive dyspnea, orthopnea and oliguria. VS: BP 91/64 mmHg, HR 120bpm, 24 RR, O2 sat 85%. Echocardiography: LVEF 20%, severe cardiac graft dysfunction with severe impairment of biventricular function TAPSE 0. A myocardial biopsy was performed. She presented pulseless electrical activity and ALS were performed for 2 minutes with success. Inotropic and vasopressors were started, orotracheal intubation was required and the patient was transferred to ICU. Biopsy results shows acute cellular rejection 2R. Positive for changes compatible with antibody-mediated rejection (AMR). A cardiorenal syndrome developed. Steroids and TPE were offered. 5 sessions of plasma exchange with TPE 2000 membrane were given, prescription with 1.5 plasma exchange, each one with albumin at 25% (Table 1). After TPE treatment there was a vasopressor reduction, inotropic withdrawal, and LVEF increase to 40% were achieve after treatment. The patient continues with immune suppressant therapy, and she is stable as she waits for the next step in regard of the heart failure and a possible second transplant. The cardiorenal syndrome improved.
Allograft dysfunction due to AMR is one of the worst complications post heart transplantations. Many therapies have been useful for these patients as: high-dose steroids, intravenous immunoglobulin and TPE. In this case we were able to evaluate the allograft disfunction previously to TPE, and subsequently we measure the allograft improvement which was from LVEF pre-TPE 20% to post-TPE 40%.
This can guide us to continue the research about TPE in AMR as there is no evidence-based guidelines that establish this therapy for patients as complex as this are. In Latin America is not a common practice in this type of patient, more research should be achieved.