European Journal of Cardio-Thoracic Surgery, Vol 10, 905-910, Copyright © 1996 by European Association for Cardio-thoracic Surgery
Treatment of recurrent rejection in heart transplantation: cytolytic therapy or bolus steroids?
B Hausen, S Demertzis, R Rohde, B Gohrband, T Wahlers, K Pethig and HJ Schafers
Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Germany.
OBJECTIVES: The treatment of recurrent rejection in heart transplant
recipients has been a controversial issue for many years. The intent of
this retrospective study was to perform a risk-benefit analysis between
treatment strategies with bolus steroids only versus anti-thymocyte
globulins (RATG; 1.5 mg/kg q 4 days). METHODS: Between 1986 and 1993, 69 of
425 patients (17 male, 52 female; mean age 44 +/- 11 years) who had more
than one rejection/patient per month (rej/pt per mo) in the first 3
postoperative months were defined as recurrent rejectors. RESULTS:
Repetitive methylprednisolone bolus therapy (70 mg/kg q 3 days) was given
in 27 patients (group M; 1.4 +/- 0.2 rej/pt per mo) and RATG therapy for
one of the rejection episodes of the 42 remaining patients (group A; 1.5
+/- 0.2 rej/pt per mo). The quality of triple drug immunosuppression in the
two study groups was comparable. The rejection-free interval (RFI)
following RATG treatment in group A was 21.6 +/- 10 days and 22 +/- 11 in
group M. In group M, 3 of 27 patients (11%) had a rejection
treatment-related infection (2 bacterial; 1 viral) versus 6 of the 42
patients of group A (14.2%; bacterial 1, viral 5). During postoperative
months 3-24, 0.15 +/- 0.12 rej/pat per mo were observed in group M and 0.21
+/- 0.13 rej/pat per mo in group A (n.s.). In this 21-month period
cytolytic therapy for rejection was initiated in 8 of the remaining 21
patients of group M (38%) and 15 of the remaining 37 patients of group A
(40.5%). The absolute survival and the individual causes of death were not
affected by the type of initial treatment of recurrent rejection. The
actuarial freedom of graft atherosclerosis is comparable in the two groups
with 78% in group A versus 79% in group M free of graft atherosclerosis at
3 years postoperatively. CONCLUSIONS: A comparison of cytolytic therapy
versus repeated applications of bolus steroids for treatment of recurrent
rejection reveals no significant difference in the long-term patient
outcome with respect to the incidence of future rejection episodes and
survival.
