Page 25 - Heart Transplant Protocol

Heart Function Service: Heart Transplant Protocols

Plasmapheresis procedure

 Alert pheresis attending through our paging system
 Place double lumen pheresis catheter & x-ray to confirm placement. 6-7FR catheter < 25 kg, 9FR
catheter > 25 kg
 Send labs per pheresis attending including: PT/INR, PTT, CBC, Fibrinogen and Ionized Calcium
 Send pre pheresis HLA Antibody assessment.
 The patient will be pheresed for 3-5 sessions (daily or every other day based on clinical course)
 Each session takes approximately 2-2.5 hours. The timing and the course will be modified on
individual patient needs. The procedure consists of 1.5-2x plasma volume exchanges per
session. Approximately 67-90% of IgG is removed during each pheresis session. The protein
removed is generally replaced with FFP and/or albumin. Platelets are expected to fall by
approximately 20% and should be followed closely. The citrated anticoagulant used during the
procedure can cause calcium to fall.

Medications
 Steroid Pulse Solumedrone pulse 10 mg/kg/daily x 3 doses
 Eculizumab See administration protocol
 IVIG 1-2 grams/kg/dose IV
 Rituximab 375mg/m2 IV; base subsequent doses (after 1st dose) on clinical findings (biopsy
results, HLA antibody profile) and CD19 results (hold dose if <20)
 Bortezomib 1.3 mg/m²/dose IV q 3 days x 4 doses (see administration protocol)

Infection Prophylaxis
 Ganciclovir 5mg/kg/dose IV q 24 hours x 14 days or valganciclovir 15mg/kg po daily for 3 months
 Nystatin 5-10 cc S/S TID for 3 months
 Bactrim 5mg/kg/dose daily, max 80 mg/dose for 3 months
 Patient needs a mask when exiting room

Monitoring post AMR Treatment:
 Donor specific antibodies post pheresis q 2-7 days while actively treating, followed by q 2 weeks
until biopsy cleared, followed by monthly until 6 month angiogram then space further
 Echocardiograms are performed based on clinical status
o Biopsy monitoring
o Repeat biopsy after AMR treatment in 4-6 weeks
o Coronary angiograms after AMR treatment in 6 months

Donor specific antibodies Post Transplant

Donor specific antibodies (DSA) can become apparent after transplantation even if they were not
detectable before and are associated with worse graft outcomes. Desensitization can thus be
undertaken to reduce donor specific antibodies arising post-transplant. The effectiveness of
desensitization depends upon the class and type of DSA. Class I antibodies appear to respond more

Updated November 9, 2017 25