Page 24 - Heart Transplant Protocol

Heart Function Service: Heart Transplant Protocols

Tacrolimus and MMF goals to be reviewed after each episode of rejection

Add antifungal, antiviral and PCP prophylaxis for 3 months after treatment for rejection with
exception of steroid pulse.
References: ISHLT Guidelines for the Care of Heart Transplant Recipients (2010).

Antibody Mediated Rejection Protocol

AMR has only been recognized as an entity in the last decade. It is often seen with CMR. Suspicion
should be raised in the context of significant donor specific antibodies (DSA) and if hemodynamic
compromise is present. Pericardial effusions may be found. It is common in the immediate post-
transplant period if the crossmatch was positive. If the patient undergoes a biopsy then the grading
system is used published by Berry et al. J Heart Lung Transplant 2013;32:1147–1162.

Treatment (see dosing/treatment course details below)

 Low Risk AMR
o Optimize immunosuppression
 Intermediate Risk AMR
o Consider pulse steroids and other immunosuppression

 High Risk AMR (pAMR 3 or rejection with hemodynamic compromise)
o Acute Setting Treatment:
 Pulse steroids
 Thymoglobulin
 Eculizumab 600- 1200 mg (consult with Medical Director for specific dosing)
 Consider plasmapheresis (1.5-2x)
o Biopsy once patient is stable
 If pAMR2 or greater
 Rituximab
 IVIG
 If pAMR2 or greater with DSA
 Consider additional Bortezomib

Updated November 9, 2017 24