Pirche (predicted Indirectly Recognizable Hla Epitopes) Algorithm As A Possible Predictor Of Amr Following Heart Transplant
Giuseppe Fischetti, Lorenzo Giovannico, Antonio D'Errico Ramirez, Domenico Parigino, Vincenzo Santeramo, Luca Savino, Tomaso Bottio, Aldo D. Milano.
Azienda Ospedaliera Universitaria Policlinico di Bari, Bari, Italy.
BACKGROUND: PIRCHE-II is an algorithm used to estimate the risk for developing alloreactivity towards HLA mismatches. METHODS: A 35-year-old man with idiopathic dilated cardiomyopathy with several previous hospitalizations for heart failure is admitted to our unit for a new episode in August 2021. After evaluation, the patient was placed on the waiting list for transplant. The following month the patient underwent heart transplant. The donor had a compatible CDC crossmatch and was negative for anti-HLA antibodies. After 46 days, the patient was discharged at home in stable conditions after 2 negative endomyocardial biopsies (EMB): ISHLT’04 0. RESULTS: In January 2021, the patient was newly admitted for dyspnea and oliguria. Imaging revealed bilateral severe pleural effusion, biventricular cardiac disfunction; EMB showed acute rejection (ISHLT’04 3R). Panel-reactive antibody (PRA) screening found 93 % of class I PRA, 3 % of class II PRA with IgM and IgG donor-specific antibodies (DSA), C1q-positive.After 2 months, the patient was placed again on the transplant waitlist for a persistent severe biventricular disfunction, massive tricuspid regurgitation and diffuse myocardial fibrosis; class I PRA was decreasing (41 % in March 2022, 31 % in April 2022). Unfortunately, the patient died of infection before re-transplantation.After the event, which was recognized as AMR caused by class I DSA, a form rarely described in literature, we employed the PIRCHE (Predicted Indirectly Recognizable HLA Epitopes) algorithm to predict indirect donor-recipient alloreactivity: PIRCHE-II was 54. CONCLUSIONS: Is a high PIRCHE-II score a reliable predictor of AMR following heart transplant? More data and deeper understanding is surely needed. A correct after-transplant serologic monitoring is definitely needed to search for de-novo DSA.
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