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The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.

Assessment and management of allosensitization following heart transplant in adults

Published:December 19, 2022DOI:https://doi.org/10.1016/j.healun.2022.12.011
      Immunological injury to the allograft, specifically by antibodies to de novo donor specific human leukocyte antigen (dnDSA) and antibody mediated injury and rejection are the major limitations to graft survival after heart transplantation (HT). As such, our approach to allosensitization remains limited by the inability of contemporaneous immunoassays to unravel pathogenic potential of dnDSA. Additionally, the role of dnDSA is continuously evaluated with emerging methods to detect rejection. Moreover, the timing and frequency of dnDSA monitoring for early detection and risk mitigation as well as management of dnDSA remain challenging. A strategic approach to dnDSA employs diagnostic assays to determine relevant antibodies in conjunction with clinical presentation and injury/rejection of allograft to tailor therapeutics. In this review, we aim to outline contemporary knowledge involving detection, monitoring and management of dnDSA after HT. Subsequently, we propose a diagnostic and therapeutic approach that may mitigate morbidity and mortality while balancing adverse reactions from pharmacotherapy.

      KEYWORDS

      Abbreviations:

      AMR (antibody mediated rejection), CAV (cardiac allograft vasculopathy), CNI (calcineurin inhibitor), dnDSA (de novo donor specific antibody), EMB (endomyocardial biopsy), HLA (human leukocyte antigen), IVIg (intravenous immunoglobulin), HT (heart transplantation), LLPC (long lived plasma cell), MFI (mean fluorescence intensity), mTOR (mammalian target of rapamycin), nHLA-Ab (non-HLA-antibody), SAB (Single antigen bead)
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