Skip to main content
PMC home page
Annals of Surgery logoLink to Annals of Surgery
. 1998 Sep;228(3):395–401. doi: 10.1097/00000658-199809000-00012

Conservative management of late rejection after heart transplantation: a 10-year analysis.

J R Doty 1, P L Walinsky 1, J D Salazar 1, D E Alejo 1, P S Greene 1, W A Baumgartner 1
PMCID: PMC1191499  PMID: 9742922

Abstract

OBJECTIVE: Immunosuppressive regimens for rejection after heart transplantation have been modified to reduce infectious complications without diminishing rejection treatment efficacy. A review of a single institutional series was performed to evaluate the influence of conservative management of grade 2 rejection on long-term outcomes after heart transplantation. METHODS: Before 1990, patients with late (>3 months after transplant) grade 2 rejection were treated with supplemental immunosuppressive drugs. Beginning in 1990, patients with late grade 2 rejection were treated conservatively by maintaining the current immunosuppressive regimen without additional therapy. The groups were compared for survival, incidence of subsequent rejection, and incidence of subsequent infection. RESULTS: One hundred twelve patients had one or more episodes of isolated, late grade 2 rejection; 39 (35%) were treated with supplemental immunosuppression (treated group) and 73 (65%) received no additional therapy (nontreated group). The mean time from transplantation to the first episode of isolated grade 2 rejection was 15.6 months in the treated group and 17.8 months in the nontreated group. Graft survival at 5 and 10 years was 69% and 51 %, respectively, in the treated group and 67% and 41 %, respectively, in the nontreated group (p = 0.77). The rates for overall subsequent rejection were 0.031 episodes/patient-month in the treated group and 0.029 episodes/patient-month in the nontreated group (p = 0.64). The rates for early rejection within 6 months of initial grade 2 rejection were 0.044 episodes/patient-month in the treated group and 0.035 episodes/patient-month in the nontreated group (p = 0.56). The rates for overall subsequent infection were 0.018 episodes/patient-month in the treated group and 0.012 episodes/patient-month in the nontreated group (p = 0.05). The rates for early infection within 6 months of initial grade 2 rejection were 0.070 episodes/patient-month in the treated group and 0.032 episodes/patient-month in the nontreated group (p = 0.04). Group comparisons demonstrated a significantly lower incidence of infection in the nontreated group. CONCLUSIONS: Conservative management of late grade 2 rejection neither adversely affects survival nor increases the incidence of subsequent short-term or long-term rejection. This approach lowers the early and late incidence of infection after rejection and may reduce other complications from aggressive supplemental immunosuppression.

Full text

PDF
395

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Anguita M., López-Rubio F., Arizón J. M., Latre J. M., Casares J., López-Granados A., Mesa D., Giménez D., Torres F., Concha M. Repetitive nontreated episodes of grade 1B or 2 acute rejection impair long-term cardiac graft function. J Heart Lung Transplant. 1995 May-Jun;14(3):452–460. [PubMed] [Google Scholar]
  2. Billingham M. E. Dilemma of variety of histopathologic grading systems for acute cardiac allograft rejection by endomyocardial biopsy. J Heart Transplant. 1990 May-Jun;9(3 Pt 2):272–276. [PubMed] [Google Scholar]
  3. Brunner-La Rocca H. P., Sütsch G., Schneider J., Follath F., Kiowski W. Natural course of moderate cardiac allograft rejection (International Society for Heart Transplantation grade 2) early and late after transplantation. Circulation. 1996 Sep 15;94(6):1334–1338. doi: 10.1161/01.cir.94.6.1334. [DOI] [PubMed] [Google Scholar]
  4. Fishbein M. C., Bell G., Lones M. A., Czer L. S., Miller J. M., Harasty D., Trento A. Grade 2 cellular heart rejection: does it exist? J Heart Lung Transplant. 1994 Nov-Dec;13(6):1051–1057. [PubMed] [Google Scholar]
  5. Hutter J. A., Wallwork J., English T. A. Management of rejection in heart transplant recipients: does moderate rejection always require treatment? J Heart Transplant. 1990 Mar-Apr;9(2):87–91. [PubMed] [Google Scholar]
  6. Kemnitz J. Grade 2 cellular heart rejection: does it exist?: Yes! J Heart Lung Transplant. 1995 Jul-Aug;14(4):800–801. [PubMed] [Google Scholar]
  7. Lloveras J. J., Escourrou G., Delisle M. B., Fournial G., Cerene A., Bassanetti I., Durand D. Evolution of untreated mild rejection in heart transplant recipients. J Heart Lung Transplant. 1992 Jul-Aug;11(4 Pt 1):751–756. [PubMed] [Google Scholar]
  8. Nakhleh R. E., Jones J., Goswitz J. J., Anderson E. A., Titus J. Correlation of endomyocardial biopsy findings with autopsy findings in human cardiac allografts. J Heart Lung Transplant. 1992 May-Jun;11(3 Pt 1):479–485. [PubMed] [Google Scholar]
  9. Nielsen H., Sørensen F. B., Nielsen B., Bagger J. P., Thayssen P., Baandrup U. Reproducibility of the acute rejection diagnosis in human cardiac allografts. The Stanford Classification and the International Grading System. J Heart Lung Transplant. 1993 Mar-Apr;12(2):239–243. [PubMed] [Google Scholar]
  10. Sharples L. D., Cary N. R., Large S. R., Wallwork J. Error rates with which endomyocardial biopsy specimens are graded for rejection after cardiac transplantation. Am J Cardiol. 1992 Aug 15;70(4):527–530. doi: 10.1016/0002-9149(92)91202-f. [DOI] [PubMed] [Google Scholar]
  11. Spratt P., Sivathasan C., Macdonald P., Keogh A., Chang V. Role of routine endomyocardial biopsy to monitor late rejection after heart transplantation. J Heart Lung Transplant. 1991 Nov-Dec;10(6):912–914. [PubMed] [Google Scholar]
  12. White J. A., Guiraudon C., Pflugfelder P. W., Kostuk W. J. Routine surveillance myocardial biopsies are unnecessary beyond one year after heart transplantation. J Heart Lung Transplant. 1995 Nov-Dec;14(6 Pt 1):1052–1056. [PubMed] [Google Scholar]
  13. Winters G. L., Loh E., Schoen F. J. Natural history of focal moderate cardiac allograft rejection. Is treatment warranted? Circulation. 1995 Apr 1;91(7):1975–1980. doi: 10.1161/01.cir.91.7.1975. [DOI] [PubMed] [Google Scholar]
  14. Winters G. L., McManus B. M. Consistencies and controversies in the application of the International Society for Heart and Lung Transplantation working formulation for heart transplant biopsy specimens. Rapamycin Cardiac Rejection Treatment Trial Pathologists. J Heart Lung Transplant. 1996 Jul;15(7):728–735. [PubMed] [Google Scholar]
  15. el-Gamel A., Doran H., Rahman A., Deiraniya A., Campbell C., Yonan N. Clinical importance of grade 2 cellular heart rejection. J Heart Lung Transplant. 1996 Mar;15(3):319–321. [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES