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Right arrow Transplantation - heart

J Thorac Cardiovasc Surg 2005;130:528-537
© 2005 The American Association for Thoracic Surgery

Cardiothoracic Transplantation

Early outcomes in human lung transplantation with Thymoglobulin or Campath-1H for recipient pretreatment followed by posttransplant tacrolimus near-monotherapy

Kenneth R. McCurry, MD a , * , Aldo Iacono, MD b , Adrianna Zeevi, PhD a , b , c , d , Samuel Yousem, MD c , Alin Girnita, MD d , Shahid Husain, MD b , Diana Zaldonis, BSN a , Bruce Johnson, MD b , Brack G. Hattler, MD a , Thomas E. Starzl, MD, PhD a , d

a Department of Surgery, The University of Pittsburgh Medical Center, Pittsburgh, Pa
b Department of Medicine, The University of Pittsburgh Medical Center, Pittsburgh, Pa
c Department of Pathology, The University of Pittsburgh Medical Center, Pittsburgh, Pa
d Thomas E. Starzl Transplantation Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pa

Received for publication April 20, 2004; revisions received September 8, 2004; accepted for publication September 30, 2004.

* Address for reprints: Kenneth R. McCurry, MD, 200 Lothrop St, Suite C-700, Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213 (Email: mccurrykr{at}upmc.edu).

OBJECTIVES: Acute and chronic rejection remain unresolved problems after lung transplantation, despite heavy multidrug immunosuppression. In turn, the strong immunosuppression has been responsible for mortality and pervasive morbidity. It also has been postulated to interdict potential mechanisms of alloengraftment.

METHODS: In 48 lung recipients we applied 2 therapeutic principles: (1) recipient pretreatment with antilymphoid antibody preparations (Thymoglobulin [SangStat, Fremont, Calif] or Campath [alemtuzumab; manufactured by ILEX Pharmaceuticals, LP, San Antonio, Tex; distributed by Berlex Laboratories, Richmond, Calif]) and (2) minimal posttransplant immunosuppression with tacrolimus monotherapy or near-monotherapy. Our principal analysis was of the events during the critical first 6 posttransplant months of highest immunologic and infectious disease risk. Results were compared with those of 28 historical lung recipients treated with daclizumab induction and triple immunosuppression (tacrolimus-prednisone-azathioprine).

RESULTS: Recipient pretreatment with both antilymphoid preparations allowed the use of postoperative tacrolimus monotherapy with prevention or control of acute rejection. Freedom from rejection was significantly greater with Campath than with Thymoglobulin (P = .03) or daclizumab (P = .05). After lymphoid depletion with Thymoglobulin or Campath, patient and graft survival at 6 months was 90% or greater. Patient and graft survival after 9 to 24 months is 84.2% in the Thymoglobulin cohort, and after 10 to 12 months, it is 90% in the Campath cohort. There has been a subjective improvement in quality of life relative to our historical experience.

CONCLUSION: Our results suggest that improvements in lung transplantation can be accomplished by altering the timing, dosage, and approach to immunosuppression in ways that might allow natural mechanisms of alloengraftment and diminish the magnitude of required maintenance immunosuppression.




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