Heart transplantation and antibody-mediated rejection

Rejection limits the long-term survival of the transplanted heart. A major type of rejection of the cardiac allograft is termed antibody-mediated rejection (AMR). The definition of AMR has evolved; however, it remains a challenging diagnosis for transplant clinicians. Improved assays have defined a program of immunological responses that are deleterious and constitute AMR. The International Society for Heart and Lung Transplantation (ISHLT) initially established the clinical and pathologic criteria for the diagnosis of AMR in heart transplantation. These criteria were refined in 2006, and more recently in 2013 as a result of a consensus conference on AMR led by the International Society of Heart and Lung Transplantation (ISHLT) (Table 32.1). The latter report by the 2013 ISHLT task force provides the most comprehensive recommendations for the assessment of AMR to date (Berry et al., J Heart Lung Transpl, 32(12): 1147-1162, 2013). More recently, a scientific statement was published by the American Heart Association to provide recommendations based on the recent consensus conferences and to facilitate standardization of management (Colvin, et al. Circulation, 131(18): 1608-1639, 2015). This is necessary, as current management tends to be center-specific and based on prior experience, which has small numbers of patients. In this chapter, we emphasize the current knowledge, the diagnosis, and management strategies for AMR in the cardiac transplant recipient.