Combined Dialitic Therapy in the Treatment of Vascular Rejection After Heart Transplantation L. Ahualli, V. Picone, M. Ran˜ o, R. Sabbatiello, M. Pattin, A. Vallejos, R. Barcellos, P. Trecco, T.O. Steward Harris, L. Romeo, C. Parisi, N. Jacob, E. Maiolo, R. Schiavelli, D. Radlovachki, and D. Davreux PRESENTATION OF THE CASE A 60-YEAR-OLD female patient has a history of severe arterialhypertension of renovascular etiology, right renalartery stenosis successfully treated with angioplasty (1995),mild to moderate mitral stenosis, rheumatic fever etiology,multiparous, symptomatic for dysphea in func- tionalclass III–IV (NYHA), panelreactive antibody (⫺), and multiple episodesof heart failure. She underwent orthotopic heart transplanton April 2, 2000,from a 16- year-old male donor who died from a firearm wound in skull,with relationship weight/R ⫽ 1,2; ischemic time, 124 minutes. She experienced arterial hypotension during the first 24 hours, accompanied by clinical symptoms (R3 right and left,bibasalcrepitantrales,hemodynamic [AD, 23; PCP, 30; IC, 1.8 L/min/m 2 ], echocardiographic [severe impairmentof systolic-diastolic function of left ventricle, dilation and severe impairment of function right ventricle, mitral valve low flow and severe pericardial effusion]). Endomyocardial biopsy was performed showing severe interstitial edema, prominence of endothelial cells (Fig 1), hemorrhagicfocz (Fig 2), leadingto the diagnosisof vascular rejection. Plasmapheresis with immunoabsorption in sequence was initiated and continued on days 1, 2, 4, and 6; venovenous hemofiltration was performed from days 3 to 8 due to acute renal failure caused by low cardiac output syndrome, as well as treatmentwith polyclonalantibodies(ATG Thymo- globulin,Merieux) for 8 days. Upon the recovery of the diuresis the creatinine decreased to 2.5 mg/dL, (and treat- mentwas initiated with cyclosporine 5 mg/kg/min orally, trying to reach a trough level between 300 to 400 ng/dL, as From the Heart Transplant Department, Nefrology and Renal TransplantUnit, “Hospital General de Agudos Dr Cosme Argerich,” Government of the City of Buenos Aires, Buenos Aires, Argentina. Address reprint requests to L. Ahualli,MD, Republica Arabe Siria, 1953 1. Piso Dpto 3, C1425EYI Capital Federal, Argentina. Fig 1. Vascularrejection.Inter- stitial edema and endothelial swelling (HE originalmagnifica- tion 40⫽). © 2002 by Elsevier Science Inc. 0041-1345/02/$–see front matter 655 Avenue of the Americas, New York, NY 10010 PII S0041-1345(01)02710-5 Transplantation Proceedings, 34, 157–160 (2002) 157