397 Although treatments for cardiac allograft rejection varies among institutions, intravenous steroid therapy is frequently administered for"moderate" 3A rejection. Oral steroid bolus followed by tapering doses has been studied and found to be effective. To determine the efficacy of oral steroid bolus without a taper for the treatment of asymptomatic 3A cardiac allograft rejection, a retrospective analysis was performed on all consecutive cardiac transplant recipients transplanted between Jan 1995 through Dec 1997. Of 230 recipients, 113 were treated for 197 new episodes of 3A rejection. Treatment consisted of 100 mg of prednisone for 3 consecutive days followed by resuming the pre-rejection steroid dose. The treated episodes were analyzed as success (S) if follow up biopsy (at 1-2 weeks) were Grade 0, 1A, 1B, or 2; treatment was counted as failure (F) if follow-up biopsy showed Grade 3A or higher. The 113 patients included 89 (79%) males; mean age was 51.9 ± 11.1 years (range 19-68; median 54). Thirty-one patients (28%) had left ventricular assist device as a bridge to transplant (LVAD BTT). Of the 197 3A rejections treated solely with a three-day bolus of oral steroids, 146 episodes (74%) responded. A comparison of the success rates among those patients who received oral pulse treatment>90 days post transplant versus recipients who required treatments earlier revealed the response rates to be 88% versus 69%, respectively (p=0.007). Comparing response rate for the patients who received treatment >60 days to those who were treated earlier showed a slight decreased in the responder rate to 84% (versus 68%, p=0.02). Among patients treated for moderate rejection before and after 30 days of transplant, there was a significant decrease in the response rate to 69% and 78%, respectively (p=ns). The mean age of the recipients showed a trend to be lower among the failure group (49± 13 years) than the success group (53 ± 10 years) (p=0.07). Having LVAD BTT did not significantly affect the treatment outcome after an oral pulse for a moderate grade rejection. The response rates were 66%, for the patients who received LVAD BTT, versus 77% for those not bridged (p=ns). There was no difference between the two groups in regards to gender, the mean dose of cyclosporine (4.9 (F) vs. 4.5 (S) mg/kg/day), the mean dose of prednisone (19 (F) 18 (S) mg/day) or the mean dose of azathioprine (1.7 (F) vs. 1.9 (S) mg/kg/day). We also compared the difference in the cost between the oral and IV therapies. The total cost of three-day outpatient nursing supervised IV steroid therapy was $861.48; for three-day oral prednisone, it was $6.88. In conclusion, oral steroid bolus therapy is an effective and economical way to treat asymptomatic moderate grade cardiac allograft rejections especially after the immediate post transplant period.Table
Thirty-four patients with history of congestive heart failure, dilated cardiomyopathy, and biopsy-proven lymphocytic myocarditis were treated for six months with immunosuppressive agents (prednisone and azathioprine) in addition to standard therapy for congestive heart failure. Seventy-three percent had improvement or resolution of the lymphocytic infiltrate, whereas 27% had persistent infiltrates. Improvement in myocardial histologic findings was unpredictable and did not correlate with age, gender, duration of symptoms, initial functional class, severity of left ventricular dysfunction, intensity of initial inflammatory infiltrate, or degree of myocardial cell injury. Histologic response was associated with significant improvement in left ventricular ejection fraction, but not cardiothoracic ratio, left ventricular dimensions, or survival. Functional class improved equally whether patients' disease did or did not respond to the treatment, and was not necessarily associated with objective improvement in cardiac function. Immunosuppressive therapy resulted in serious or fatal side effects in 24% of patients. Overall long-term survival was 79% at one year and 76% at two years. Poor survival was related to left ventricular ejection fraction less than 20%, male sex, age less than 50 years, and marked left ventricular dilation, but not to myocardial histologic findings. These findings indicate that the potential benefits nu the risks of immunosuppressive therapy must be weighed carefully in the individual patient.
Objective: To assess levels of and factors associated with depression and negative affect 5 years after heart transplant (HT). Participants: 370 adults 5 years post-HT. Outcome Measures: Cardiac Depression Scale and the Positive and Negative Affect Schedule (PANAS). Research Method: Stepwise multiple regression analyses were used to test 32 potential demographic, medical, functional, and psychosocial factors in adjustment. Results: Predictor variables accounted for 53% of the variance of depression scores and 45% of the variance of PANAS negative affect scores. The best predictors (p .001) for depression were neurological symptoms, younger age, lower recreational functioning, and lower satisfaction with emotional support, and the best predictors for negative affect were neurological symptoms, lower mobility functioning, and perceived uncertainty about health. Depression scores were lower than norms for nontransplanted heart failure patients, and negative affect levels were comparable to those of the general population. Conclusions: The findings indicate normal long-term adjustment among HT recipients. Several factors associated with negative emotions, including younger age, have not been identified in previous research.
355 Background: Recently, multiple opportunistic infections and severe hypogammaglobulinemia have been noted in several heart transplant recipients on tacrolimus (FK), mycophenolate (MMF) and prednisone combination therapy. Objectives: To determine if FK/MMF is more likely to produce low IgG than cyclosporine (cyclo)/MMF. Methods: 105 patients received heart transplants between 9/1/97 and 8/31/98. Total IgG/A/M levels were obtained at 3 and 6 months post-transplant and when clinically indicated. Results: Of 53/105 pts who had IgG levels performed, 14/53 had been treated with FK/MMF and 37/53 received cyclo/MMF. 8/14 (57%) of the FK group had a total IgG < 500 with 4/14 (28.6%) having severely low IgG (<310.) By contrast, 9/37 (24.3%) of the cyclo/MMF group had IgG<500, with 1/37 (2.7%) being <310. Of the 5 pts with IgG<310, 4/5 were FK/MMF treated and 4/5 had CMV (3 tissue-invasive) as well as other infections including nocardiosis, aspergillosis, and Acinetobacter bacteremia. None of these 5 were CMV D + /R−; all were treated with CMVIG and decreased immunosuppression as well as antimicrobials. (Table)TableConclusions: Hypogammaglobulinemia is more common than previously recognized in MMF-treated heart transplant recipients. Moderate to severe hypogammaglobulinemia may be more likely in FK/MMF than cyclo/MMF treated patients. Monitoring total IgG levels in FK/MMF treated patients may allow for early intervention through reduction of immunosuppression, Ig replacement, and intensified antimicrobial pre-emptive therapy.
