Diagnosis and treatment of steroid resistant cellular rejection in heart transplant recipients--single center experience.
OBJECTIVE
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 > or = 3A (ISHLT) were considered a significant rejection, requiring treatment with 1 g i.v. 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 > or = 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.
Zakliczyński
Michał
M
Dept. of Cardiac Surgery & Transplantation, Silesian Center for Heart Disease, Zabrze, Poland. zaklimed@poczta.onet.pl
Nozyński
Jerzy
J
Zakliczyńska
Helena
H
Kozłowska
Katarzyna
K
Trzcińska
Iwona
I
Szewczyk
Marta
M
Konecka-Mrówka
Dominika
D
Foremny
Jerzy
J
Swierad
Marcin
M
Przybylski
Roman
R
Pisarska
Halina
H
Wojarski
Jacek
J
Durmała
Jacek
J
Zembala
Marian
M
D000293:Adolescent; D000328:Adult; D000961:Antilymphocyte Serum / Q000009:adverse effects / Q000627:therapeutic use; D016022:Case-Control Studies; D004351:Drug Resistance; D005260:Female; D006084:Graft Rejection / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D016027:Heart Transplantation; D006439:Hemodynamics / Q000187:drug effects; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D015994:Incidence; D007239:Infections / Q000209:etiology; D008297:Male; D008875:Middle Aged; D009026:Mortality; D009173:Mycophenolic Acid / Q000031:analogs & derivatives* / Q000627:therapeutic use; D012307:Risk Factors; D013256:Steroids / Q000627:therapeutic use*; D016019:Survival Analysis; D013601:T-Lymphocytes / Q000276:immunology
D000961:Antilymphocyte Serum; D007166:Immunosuppressive Agents; D013256:Steroids; D009173:Mycophenolic Acid