title: A Proposal for Early Dosing Regimens in Heart Transplant Patients Receiving Thymoglobulin and Calcineurin Inhibition.
abstract: There is currently no consensus regarding the dose or duration of rabbit antithymocyte globulin (rATG) induction in different types of heart transplant patients, or the timing and intensity of initial calcineurin inhibitor (CNI) therapy in rATG-treated individuals. Based on limited data and personal experience, the authors propose an approach to rATG dosing and initial CNI administration. Usually rATG is initiated immediately after exclusion of primary graft failure, although intraoperative initiation may be appropriate in specific cases. A total rATG dose of 4.5 to 7.5 mg/kg is advisable, tailored within that range according to immunologic risk and adjusted according to immune monitoring. Lower doses (eg, 3.0 mg/kg) of rATG can be used in patients at low immunological risk, or 1.5 to 2.5 mg/kg for patients with infection on mechanical circulatory support. The timing of CNI introduction is dictated by renal recovery, varying between day 3 and day 0 after heart transplantation, and the initial target exposure is influenced by immunological risk and presence of infection. Rabbit antithymocyte globulin and CNI dosing should not overlap except in high-risk cases. There is a clear need for more studies to define the optimal dosing regimens for rATG and early CNI exposure according to risk profile in heart transplantation.
authors: University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
authors: Markus J
authors: MJ
authors: Barten
authors: Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany.
authors: Uwe
authors: U
authors: Schulz
authors: Department of Cardiac and Thoracic Surgery, Johann-Wolfgang-Goethe University, Frankfurt am Main, Germany.
authors: Andres
authors: A
authors: Beiras-Fernandez
authors: Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.
authors: Michael
authors: M
authors: Berchtold-Herz
authors: Department of Cardiovascular Surgery, Heinrich Heine University, Düsseldorf, Germany.
authors: Udo
authors: U
authors: Boeken
authors: Department of Cardiac Surgery, Heart Center Leipzig, University Hospital Leipzig, Leipzig, Germany.
authors: Jens
authors: J
authors: Garbade
authors: Department of Cardiac and Thoracic Surgery, University of Regensburg, Regensburg, Germany.
authors: Stephan
authors: S
authors: Hirt
authors: Kerckkoff Clinic, Bad Nauheim, Germany.
authors: Manfred
authors: M
authors: Richter
authors: Cardiac Surgery Clinic, University of Heidelberg, Heidelberg, Germany.
authors: Arjang
authors: A
authors: Ruhpawar
authors: Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors: Jan Dieter
authors: JD
authors: Schmitto
authors: Department of Cardiac, Thoracic and Vascular Surgery, German Heart Institute, Berlin, Germany.
authors: Felix
authors: F
authors: Schönrath
authors: Clinic of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany.
authors: Rene
authors: R
authors: Schramm
authors: Department of Cardiac Surgery, Children's Hospital, Zürich, Switzerland.
authors: Martin
authors: M
authors: Schweiger
authors: Clinic for Cardiovascular Surgery, University Hospital Zürich, Zurich, Switzerland.
authors: Markus
authors: M
authors: Wilhelm
authors: Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
authors: Andreas
authors: A
authors: Zuckermann