Treatment of recurrent rejection in heart transplantation: cytolytic therapy or bolus steroids?

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Abstract
OBJECTIVES: The treatment of recurrent rejection in heart transplantrecipients has been a controversial issue for many years. The intent ofthis retrospective study was to perform a risk-benefit analysis betweentreatment strategies with bolus steroids only versus anti-thymocyteglobulins (RATG; 1.5 mg/kg q 4 days). METHODS: Between 1986 and 1993, 69 of425 patients (17 male, 52 female; mean age 44 +/- 11 years) who had morethan one rejection/patient per month (rej/pt per mo) in the first 3postoperative months were defined as recurrent rejectors. RESULTS:Repetitive methylprednisolone bolus therapy (70 mg/kg q 3 days) was givenin 27 patients (group M; 1.4 +/- 0.2 rej/pt per mo) and RATG therapy forone 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 thetwo study groups was comparable. The rejection-free interval (RFI)following RATG treatment in group A was 21.6 +/- 10 days and 22 +/- 11 ingroup M. In group M, 3 of 27 patients (11%) had a rejectiontreatment-related infection (2 bacterial; 1 viral) versus 6 of the 42patients of group A (14.2%; bacterial 1, viral 5). During postoperativemonths 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 periodcytolytic therapy for rejection was initiated in 8 of the remaining 21patients 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 notaffected by the type of initial treatment of recurrent rejection. Theactuarial freedom of graft atherosclerosis is comparable in the two groupswith 78% in group A versus 79% in group M free of graft atherosclerosis at3 years postoperatively. CONCLUSIONS: A comparison of cytolytic therapyversus repeated applications of bolus steroids for treatment of recurrentrejection reveals no significant difference in the long-term patientoutcome with respect to the incidence of future rejection episodes andsurvival.

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