Efficacy of a Standardized Regimen of Therapeutic Plasma Exchange and IVIG for Treatment of Antibody-Mediated Rejection in Lung Transplant Recipients

Antibody-mediated rejection (AMR) in lung transplantation has been associated with poor long-term clinical course and is a risk factor for chronic lung allograft dysfunction and graft loss. Appropriate management of AMR is necessary to improve graft survival in lung transplant recipients. There is currently no standardized approach to the treatment of lung AMR, and practices vary by institution. We sought to examine the efficacy of a standardized protocol of plasma exchange (PLEX) and IVIG in decreasing donor-specific antibodies (DSAs) and improving AMR in lung transplant recipients. A retrospective chart review was conducted on all lung transplant recipients who completed a course of PLEX per UT Southwestern AMR protocol between January 2012 and December 2019 for diagnosis of AMR. Data were collected on the patient clinical course, treatment regimen, pre-PLEX DSA, post-PLEX DSA, follow-up (> 1-month post-PLEX) DSA, and pre-and post-PLEX biopsy, when available. Of 527 patients who underwent lung transplantation during the study period, 56 (11%) received an acute course of PLEX every other day per protocol for AMR of lung transplant. Forty (71%) of 56 patients had one episode of AMR requiring PLEX; 16 patients (29%) had repeat episodes of AMR within 6 weeks to 47 months of the first episode. Most patients showed improvement in AMR on biopsy (69%) and a decline in DSA (68%). Our data suggest that treatment with combined PLEX and IVIG protocol appears effective for treating lung AMR.