Oral steroid pulse without taper for the treatment of asymptomatic moderate cardiac allograft rejection

Background: The most frequently administered treatment for asymptomatic ISH LT Grade 3A cardiac allograft rejection is intravenous steroids or oral ste roid pulse with a taper. This study analyzes the efficacy of 3-day 100-mg c ourse of prednisone without a tapered regimen for the treatment of asymptom atic moderate cardiac allograft rejection. Methods: All new episodes of asymptomatic ISHLT Grade 3A rejections were tr eated with oral steroid pulse without taper, consisting of 100 mg of predni sone for 3 consecutive days followed by resuming the pre-rejection steroid dose on the fourth day. We retrospectively reviewed the histologic response of all treated episodes among all cardiac transplant recipients transplant ed between January 1995 through December 1997 who were treated with triple therapy consisting of cyclosporine, azathioprine and steroids. Patients rec eiving additional or alternative immunosuppressives were excluded from the study. The treated episodes were analyzed as responders if the follow-up bi opsy were Grade 0, 1A, 1B, or 2; treatment was counted as non-responders if the follow-up biopsy showed Grade 3A or higher. Results: Of 230 cardiac transplant recipients, 100 patients received a 3-da y 100 mg course of prednisone without taper for 174 new episodes of asympto matic ISHLT Grade 3A rejection. The overall response rate was 75% (130/174 rejection episodes). A significant difference in the response rate was obse rved depending on the number of days post transplant. A comparison of the s uccess rates among rejections which occurred > 90 days post transplant vers us < 30 days revealed responses to be 88% versus 70% (p = 0.02); for reject ions treated > 60 days post transplant versus < 30 days showed success rate s of 84% versus 70% (p = 0.04). The mean age of the recipient revealed a tr end to be lower among the non-responder group (49 +/- 12 years versus 53 +/ - 9 years, p = 0.07). Having left ventricular assist device as a bridge to transplant did not significantly affect the treatment outcome. The response rates were 69% for the patients who required the assist device versus 77% for those not bridged (p = ns). There was no significant difference in the gender or the baseline immunosuppressive doses between the responders and n on-responders. The cost of a 3-day outpatient, visiting nurse supervised in travenous steroid therapy versus 3 days of oral prednisone was $861 vs $6.8 8. Conclusion: Oral steroid pulse without taper is an effective and economical way to treat asymptomatic moderate grade cardiac allograft rejection. A 3- day course of 100 mg of prednisone without taper should be considered as fi rst line of therapy for clinically stable form of moderate cardiac allograf t rejection occurring > 60 days post transplant.