Immunological Algorithm of Itescu et al for Predicting the Risk of High Grade Rejection Within 90 Days in a Cardiac Transplant Patient

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Itescu et al developed an algorithm based on immunologic findings that can be used to predict the risk of high grade rejection within 90 days for a patient with a cardiac transplant. This can help identify patients who may benefit from more aggressive management. The authors are from the College of Physicians and Surgeons of Columbia University in New York.

Patient selection: Cardiac transplant recipient with ISHLT (Billingham et al) grade 0 or 1A endomyocardial biopsy

Parameters:

(1) number of HLA-DR matches

(2) lymphocyte growth assay (LGA) - This involves culturing a biopsy fragment in a medium containing recombinant interleukin-2 and examined after 48 hours with a phase microscope, Any circumferential T-cell aggregation is considered positive.

(3) antibodies against non-donor specific MHC class II antigens (IgG anti-II)

HLA-DR Matches	LGA	IgG anti-II	Response Group
0	positive	positive	treat
0	positive	negative	continue frequent biopsy
0	negative	positive	continue frequent biopsy
0	negative	negative	continue frequent biopsy
1 or 2	positive	NA	continue frequent biopsy
1 or 2	negative	NA	rebiopsy in 90 days

from Figure 5, page 268

Response Group	Features
treat	high risk for progression; positive predictive value for high grade rejection in 90 days 86%
continue frequent biopsy schedule	moderate risk of progression
rebiopsy in 90 days	low risk for progression; negative predictive value for high grade rejection in 90 days 87%; positive predictive value 16%

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Immunological Algorithm of Itescu et al for Predicting the Risk of High Grade Rejection Within 90 Days in a Cardiac Transplant Patient

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