5-Year Outcome of Patients Weaned off Corticosteroids after Heart Transplantation: Is There a Downside?

Abstract

A large number of heart transplant patients are weaned off corticosteroids within the first year after heart transplantation. These patients are selected as they do not have rejection or graft dysfunction. In addition, these patients have not developed donor-specific antibodies (DSAs) and therefore are viewed as being immune-privileged. However, it has not been well established whether these patients have enhanced 5-year outcome compared to patients who remain on prednisone. Between 2010 and 2014, we assessed 292 heart transplant patients who were successfully weaned off prednisone. These patients were compared to a contemporaneous cohort (n=173) of patients who had not undergone steroid weaning. Patients who were initiated on steroid weaning but failed were excluded. Endpoints include 5-year survival, 5-year freedom from cardiac allograft vasculopathy (CAV, stenosis ≥30% by angiography), 5-year freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), 5-year freedom from left ventricular dysfunction (LVEF ≤40%) or infection, and 1-year freedom from any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). Patients who were successfully weaned off prednisone had significantly greater freedom from 1-year any treated rejection and 5-year freedom from left ventricular dysfunction. Those weaned off prednisone had comparable survival, freedom from CAV, NF-MACE, and infection to those not weaned off corticosteroids. Steroid weaning is associated with long-term maintenance of normal cardiac function and may indeed represent an immune-privileged state. There does not appear to be any notable shortcoming to steroid weaning.