IDENTIFICATION OF PATIENTS NOT REQUIRING ENDOMYOCARDIAL BIOPSIES LATEAFTER CARDIAC TRANSPLANTATION

Background. The risk for rejection is highest early, but graft rejecti on requiring intensified immunosuppression may be present even late af ter transplantation, Nonetheless, a considerable number of patients ar e absolutely free of rejection requiring intensified immunosuppression (Rej) late after transplantation. Therefore, we tried to identify pat ients who do not need endomyocardial biopsies greater than or equal to 2 years after transplantation and those who may benefit from long-ter m follow-up with routine endomyocardial biopsies. Methods. A total of 112 patients (age 45+/-12 years) had a follow-up with regular endomyoc ardial biopsies of greater than or equal to 3 years, A total of 4194 e ndomyocardial biopsies were performed (1364 greater than or equal to 2 years after transplantation). They were divided into three categories : rejection score=0, Texas 0-2 or International Society for Heart and Lung Transplantation (ISHLT) 0 or 1A; rejection score 1, Texas 3-4 or ISHLT 1B or 2; rejection score=2, Texas greater than or equal to 5 or ISHLT greater than or equal to 3A. Results. During the third and subse quent posttransplantation years, 31 of 112 (28%) patients had greater than or equal to 1 further Rej (total 51), Independent predictors iden tifying patients with Rej in multivariate analysis were age (odds rati o [OR]=0.96 per year, P<0.05), the sum of rejection score (OR=1.07 per score point, P<0.005) and the mean cyclosporine level in the first 2 years (OR=1.07 per % of upper therapeutic range, P<0.01), Fifty-eight (52%) patients with age >25 years, sum of rejection score less than or equal to 17, and mean cyclosporine level <90th percentile during the first 2 years would not have needed biopsies in the third and subseque nt years, whereas the other 48% had a risk of 54% to develop further R ej, In addition to predictors identifying patients with rejection, tim e after transplantation (OR=0.73 per year, P<0.005), cyclosporine leve l below therapeutic range (OR=2.15, P<0.05), and reduction of predniso ne (OR=2.64, P<0.05) were independent predictors at each endomyocardia l biopsy. Conclusions. Risk of Rej remained considerably high in appro ximately one third of our patients late after transplantation. In thes e, further surveillance biopsies appear justified, whereas half of the patients had no risk of Rej as long as immunosuppressive therapy was sufficient.