Impact of anti-HLA antibody desensitization in pediatric heart transplantation

Results from a Pediatric Heart Transplant Society (PHTS)–Pediatric Health Information System (PHIS) linkage analysis, evaluating the impact of anti-human leukocyte antigen (HLA) sensitization, panel reactive antibody (PRA) testing, and desensitization (DS) strategies in pediatric heart transplant recipients (N = 3,229), were published in Pediatric Transplantation by Nandi et al. Recipients with available Class I and II HLA PRA data were stratified into low (≤10%), medium (>10% to <median PRA among sensitized patients), or high (≥median PRA for sensitized patients). The study assessed associations between PRA category, DS strategies, and post-transplant outcomes. 

Key data: Patients with low PRA at listing demonstrated greater 10-year graft survival compared with those with high PRA (p < 0.05). Low PRA was also associated with higher survival through 12 months (Class I, p = 0.0005; Class II, p < 0.0001), greater freedom from rejection through 1 year (both p < 0.0001), and improved 10-year freedom from cardiac allograft vasculopathy (CAV; Class I, p = 0.05; Class II, p = 0.006) compared with medium and high PRA categories. DS was not associated with reduction from a high PRA category to a lower PRA category (Class I, p = 0.747; Class II, p = 0.053). There was no difference in 10-year survival according to PRA category reduction status for either Class I or II (Class I, p = 0.36; Class II, p = 0.22). 

Key learning: Higher PRA was associated with poorer post-transplant outcomes in pediatric heart transplantation. Although DS strategies were not significantly associated with reductions in PRA category, changes in Class II PRA between listing and transplantation may have prognostic relevance.