Treatment and Outcomes of Patients with International Society of Heart and Lung Transplantation (ISHLT) Grade 2 Rejection After Heart Transplant

Abstract

Introduction Treatment guidelines for asymptomatic acute cellar rejection of ISHLT grade 2 (2R ACR) are dictated by clinical judgement and patient risk. In higher risk cases, a course of intravenous (IV) corticosteroids may be recommended, while in others a short course of oral steroids is given. There is also variability in pathologic rejection grading on endomyocardial biopsy. We aimed to determine if treatment choice predicts outcomes in 2R ACR patients. Methods We reviewed all patients with biopsy-proven 2R ACR following heart transplantation at our institution from 2012-2016. Treatment strategies were classified as IV corticosteroids or “other” (ie, pulse oral corticosteroids or adjustment of baseline immunosupprants.) These two strategies were compared for time to re-hospitalization, time to recurrence of ≥2R ACR, development of cardiac allograft vasculopathy or renal insufficiency, and 1-year survival. Results Among 305 heart transplant recipients, 73 patients developed 117 separate episodes of 2R ACR. 37 patients (51%) received IV corticosteroids and were more likely to be hospitalized (24% versus 3%) for treatment. However, the two strategy groups did not differ in time to re-hospitalization (46% versus 33%, p=0.78) (Fig 1), time to recurrence (98 days versus 51 days, p=0.48), development of cardiac allograft vasculopathy (67% versus 57%, p=0.47) or renal insufficiency (58% versus 65%, p=0.634). Admission for infection was the reason for re-hospitalization in 19% vs 3% of cases. Additionally there was no difference in 1-year survival (95% versus 94%, p=0.45) (Fig 2). Conclusions While this study is limited by a small cohort, results suggests there is no significant difference in outcomes among patients treated with either aggressive IV steroids versus adjustment of oral immunosuppressants, including oral corticosteroids. Aggressive treatment may not be needed for biopsy proven 2R ACR in patients without hemodynamic compromise.