CONSERVATIVE MANAGEMENT OF LATE REJECTION AFTER HEART-TRANSPLANTATION- A 10-YEAR ANALYSIS

Objective Immunosuppressive regimens for rejection after heart transpl antation have been modified to reduce infectious complications without diminishing rejection treatment efficacy. A review of a single instit utional series was performed to evaluate the influence of conservative management of grade 2 rejection on long-term outcomes after heart tra nsplantation. Methods Before 1990, patients with late (>3 months after transplant) grade 2 rejection were treated with supplemental immunosu ppressive drugs. Beginning in 1990, patients with late grade 2 rejecti on were treated conservatively by maintaining the current immunosuppre ssive regimen without additional therapy. The groups were compared for survival, incidence of subsequent rejection, and incidence of subsequ ent infection. Results One hundred twelve patients had one or more epi sodes of isolated, late grade 2 rejection; 39 (35%) were treated with supplemental immunosuppression (treated group) and 73 (65%) received n o additional therapy (nontreated group). The mean time from transplant ation to the first episode of isolated grade 2 rejection was 15.8 mont hs in the treated group and 17.8 months in the nontreated group. Graft survival at 5 and 10 years was 69% and 51%, respectively, in the trea ted group and 67% and 41%, respectively, in the nontreated group (p = 0.77). The rates for overall subsequent rejection were 0.031 episodes/ patient-month in the treated group and 0.029 episodes/patient-month in the nontreated group (p = 0.64). The rates for early rejection within 6 months of initial grade 2 rejection were 0.044 episodes/patient-mon th in the treated group and 0.035 episodes/patient-month in the nontre ated group (p = 0.56). The rates for overall subsequent infection were 0.018 episodes/patient-month in the treated group and 0.012 episodes/ patient-month in the nontreated group (p = 0.05). The rates for early infection within 6 months of initial grade 2 rejection a ere 0.070 epi sodes/patient-month in the treated group and 0.032 episodes/patient-mo nth in the nontreated group (p = 0.04). Group comparisons demonstrated a significantly lower incidence of infection in the nontreated group. Conclusions Conservative management of late grade 2 rejection neither adversely affects survival nor increases the incidence of subsequent short-term or long-term rejection. This approach lowers the early and late incidence of infection after rejection and may reduce other compl ications from aggressive supplemental immunosuppression.