Current State of Drug Therapies for Antibody Mediated Rejection After Heart Transplantation.

Abstract

Antibody mediated rejection (AMR) continues to be a significant and challenging complications following heart transplantation (OHT), contributing significantly to morbidity and mortality. Despite its clear clinical impact, there is no clear consensus on optimal treatment strategies due to a paucity of prospective clinical trials and the immunological nuances of this rejection phenotype. Therapeutic plasma exchange and intravenous immune globulin remain the cornerstones of a majority of AMR protocols. However, there is growing evidence of the use of additional therapies that target more specific antibody mechanisms. Anti-CD20 antibodies, proteasome inhibitors, anti-CD38 antibodies, IL-6 receptor antagonists, and complement inhibitors have been used to reverse AMR and mitigate its deleterious consequences. However, these medications come with their own nuances and considerations for use. Therefore, the purpose of this review article will be to provide practical "how-to" information on the utilizations of these agents, including prescribing, dosing strategies, monitoring approaches, and duration of treatment. Additionally, a key focus will be placed on adverse effects profiles associated with AMR treatment with these novel agents through monitoring and risk mitigation approaches to ensure patient safety. In this way, this review aims to serve as a comprehensive and practical guide for clinicians, synthesizing existing data on both standard and emerging AMR therapies to improve patient outcomes following heart transplantation.