Corticosteroid withdrawal after heart transplantation

Abstract

SINCE the mid-1980s, the standard immunosuppressive regimen in heart transplantation has been the so-called triple therapy with cyclosporine (CyA), azathioprine, and prednisone. However, the substantial morbidity of chronic corticosteroid administration has prompted the use of ever-decreasing doses of prednisone for maintenance immunosuppression. Yacoub et al at the Harefield Hospital in London are credited with the initial report of successful withdrawal of corticosteroids in heart transplants in 1985. Since then, several transplant groups have implemented this practice showing that, some time after transplantation, prednisone can be successfully withdrawn in a significant proportion of patients. Long-term follow-up of these patients has also shown the lack of an increased incidence of mortality and morbidity related to rejection. However, the transplant community seems to be reluctant to adopt this practice, probably because of the concern that the absence of significant problems with rejection has not been firmly established. In fact, the 1998 ISHLT Registry Report shows that more than 75% of patients are still on prednisone 3 years after transplantation. The purpose of this paper is to review the current information in this field. Although many short series of patients succesfully withdrawn from steroids are available in the literature, we will mainly focus on reports in adult heart transplantation with more than 100 patients and a sufficiently extended follow-up period. Also, we will report our own experience (Hospital Universitario “Valdecilla,” Santander, Spain) with corticosteroid withdrawal in 132 adult heart transplant patients.