TREATMENT OF RECURRENT REJECTION IN HEART-TRANSPLANTATION - CYTOLYTICTHERAPY OR BOLUS STEROIDS

Objectives. The treatment of recurrent rejection in heart transplant r ecipients has been a controversial issue for many years. The intent of this retrospective study was to perform a risk-benefit analysis betwe en treatment strategies with bolus steroids only versus anti-thymocyte globulins (RATG; 1.5 mg/kg q 4 days). Methods. Between 1986 and 1993, 69 of 425 patients (17 male, 52 female; mean age 44 +/- 11 years) who had more than one rejection/patient per month (rej/pt per mo) in the first 3 postoperative months were defined as recurrent rejectors. Resu lts. Repetitive methylprednisolone bolus therapy (70 mg/kg q 3 days) w as given in 27 patients (group M; 1.4 +/- 0.2 rej/pt per mo) and RATG therapy for one of the rejection episodes of the 42 remaining patients (group A; 1.5 +/- 0.2 rej/pt per mo). The quality of triple drug immu nosuppression in the two study groups was comparable. The rejection-fr ee interval (RFI) following RATG treatment in group A was 21.6 +/- 10 days and 22 +/- 11 in group M. In group M, 3 of 27 patients (11%) had a rejection treatment-related infection (2 bacterial; 1 viral) versus 6 of the 42 patients of group A (14.2%; bacterial 1, viral 5). During postoperative months 3-24, 0.15 +/- 0.12 rej/pat per mo were observed in group M and 0.21 +/- 0.13 rej/pat per mo in group A (n.s.). In this 21-month period cytolytic therapy for rejection was initiated in 8 of the remaining 21 patients of group M (38%) and 15 of the remaining 37 patients of group A (40.5%). The absolute survival and the individual causes of death were not affected by the type of initial treatment of recurrent rejection. The actuarial freedom of graft atherosclerosis i s comparable in the two groups with 78% in group A versus 79% in group M free of graft atherosclerosis at 3 years postoperatively. Conclusio ns. A comparison of cytolytic therapy versus repeated applications of bolus steroids for treatment of recurrent rejection reveals no signifi cant difference in the longterm patient outcome with respect to the in cidence of future rejection episodes and survival.