The Meaning of Mild Rejection During Corticosteroid Weaning in Heart Transplant Recipients.

Abstract

398 Corticosteroid weaning after heart transplant has increased in popularity and has been performed early and late (> 6 months) after heart transplantation. The actual weaning schedule has varied from program to program (over 1 week to 5 months). Some heart transplant programs will reinstitute corticosteroids if routine endomyocardial biopsy during weaning reveals mild rejection. However, it has not been established whether mild rejection progresses to a more severe form of rejection at a higher rate during corticosteroid weaning. To answer this question, we reviewed 165 heart transplant patients between April 1989 and July 1997 who were undergoing corticosteroid weaning beginning at 6 months after transplant and decreasing by 1 mg per month from a 5 mg baseline dose. Only endomyocardial biopsy grades of ≥3A were treated with reinstitution of corticosteroids at high doses. During this corticosteroid-weaning period, there were a total of 835 endomyocardial biopsies performed. Of the total, 558 were grade 0, 238 were grade 1A, 9 were grade 1B, 25 were grade 2, 4 were grade 3A, and 1 was grade 3B. The 4 patients with grade 3A rejection had either grade 0 or grade 1A on their previous endomyocardial biopsies. The patient with grade 3B rejection had previous endomyocardial biopsy demonstrating grade 1B rejection. This meant 1/9 (11%) grade 1B rejections and only 2/238 (0.8%) grade 1A rejection progressed to ≥ grade 3A rejection. Four patients were withdrawn from the corticosteroid-weaning protocol due to LVEF decreasing to ≤ 45% (range 20-45%) and all 4 patients had either grade 0 or grade 1A on their endomyocardial biopsy at the time of removal from the corticosteroid-weaning protocol. Other patients were not successfully weaned due to adverse effects of weaning including myalgias, headaches, arthritis, and fatigue. Corticosteroid weaning was successful in 83.6% of patients. Conclusion: Corticosteroid weaning late after heart transplantation is successful in a majority of patients. Endomyocardial biopsies during the steroid-weaning protocol revealing grade 1A mild rejection rarely progress to a more severe from of rejection and therefore do not support removing the patient from the corticosteroid-weaning protocol. Endomyocardial biopsy grade 1B rejection during corticosteroid weaning should have close observation with follow-up endomyocardial biopsy.