Diagnosis and Treatment of Steroid Resistant Cellular Rejection in Heart Transplant Recipients – Single Center Experience
Michal Zakliczynski, Jerzy Nozynski, Helena Zakliczynska, Katarzyna Kozlowska, Iwona Trzcinska, Marta Szewczyk, Dominika Konecka-Mrówka, Jerzy Foremny, Marcin Swierad, Roman Przybylski, Halina Pisarska, Jacek Wojarski, Jacek Durmala, Marian Zembala
Ann Transplant 2003; 8(1): 25-36
Objectives: Aim of the study was to assess frequency and risk factors of steroid resistant cellular rejection (SRR) in heart transplant recipients, to determine methods of its treatment, and to evaluate influence of steroid resistant rejection and method of its treatment on short- and long-term results. Methods: All pts. received cyclosporine-A, azathioprine and prednisone. Biopsy results‡3A (ISHLT) were considered a significant rejection, requiring treatment with 1g iv. methylprednizolone for 3 days followed by oral prednisone. SRR was recognized in case of biopsy-proven progression of rejection, lack of improvement in 2 consecutive biopsies, or increasing hemodynamic compromise despite treatment of biopsy-proven rejection. 146 pts. eligible for the study were divided into: study group – 15 pts. with SRR (10%), and control group – 131 pts. SRR was treated with: cytolytic therapy – ATG (10 pts.), mycophenolate mofetil (3 pts.) or steroids (2 pts.). Number of biopsies‡3A, cumulative biopsy score, average biopsy result, effectiveness of SRR treatment, side effects of therapy, and survival were analysed. Results: All parameters characterizing rejection were significantly higher in the study group. No risk factors of SRR were found. In 6 pts. with SRR and hemodynamic compromise (all treated with ATG) improvement was observed in 4 pts, while death occurred in 2 pts. There were no deaths in pts. without hemodynamic compromise – none of 3 methods of treatment was superior, however ATG increased the infection risk. Survival in the 1st year was significantly lower in the study group (67% vs. 89% in the control group). Conclusions: SRR is recognized in about 10% of heart transplant recipients, increasing risk of death in the 1st year after surgery. Cytolytic therapy increases risk of infection, and should be avoided in pts. without hemodynamic compromise.
Keywords: Heart Transplantation, Immunosuppression, Cytolytic Therapy, Steroid Resistant Acute Cellular Rejection