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% |
Specialty: Cardiology, Surgery, general