Author + information
- Alanna A. Morris, MD∗ ( and )
- Javed Butler, MD, MPH
- ↵∗Division of Cardiology, Emory University School of Medicine, 1462 Clifton Road Suite 520, Atlanta, Georgia 30322
We appreciate the interest shown by Dr. Deutsch and colleagues in our work (1) and their thoughtful comments regarding outcomes after heart transplantation (HT) as a function of race, panel reactive antibody (PRA) burden, and sensitization. We agree that existing data suggest the superiority of tacrolimus-based immunosuppressive regimens, particularly in black patients (2), with the proviso that blacks often require higher tacrolimus doses to reach therapeutic trough concentrations (3,4). Importantly, a recent analysis from the United Network for Organ Sharing (UNOS) database shows that a higher proportion of black HT recipients were receiving tacrolimus therapy than whites in recent years (5). We did not investigate differences in the use of various induction strategies, but previous studies have shown that induction immunosuppression using lymphocytolytic agents in the early perioperative period was associated with a survival benefit in younger black patients with ≥4 human leukocyte antigen (HLA) mismatches (6).
Dr. Deutsch and colleagues also correctly noted the insensitivity of standard Centers for Disease Control and Prevention (CDC)-based PRA testing compared to newer solid-phase or microsphere-based assays that have been increasingly used since the mid-1990s (7). Specific information regarding the technique used for HLA antibody detection was however not available in the UNOS database. To partially circumvent this issue, we limited our analysis to transplantations that were performed after 2000, hoping to capture the PRA results that were largely based on newer HLA platforms. Recent consensus guidelines in this regard published by the Transplantation Society provide state-of-the-art guidance in the clinical application of newer methods for HLA antibody detection when used in conjunction with conventional methods (8).
Clinical studies that further investigate the results of our study incorporating specific information on the various induction and maintenance immunosuppressive regimens used and the immunologic assays performed for assessment of sensitization status will be of great interest.
- American College of Cardiology Foundation
- Morris A.A.,
- Cole R.T.,
- Veledar E.,
- et al.
- Bray R.A.,
- Tarsitani C.,
- Gebel H.M.,
- Lee J.-H.