Increased prevalence of autoimmune phenomena and greater risk for alloreactivity in female heart transplant recipients

Background-The influence of sex on alloreactivity and graft outcome after h eart transplantation was evaluated. Methods and Results-A retrospective review of 520 consecutive recipients of a primary cardiac allograft between 1992 and 2000 at a single center was p erformed. The influence of sex on alloreactivity, acute rejection, transpla nt-related coronary artery disease, and survival was determined. Statistica l methods included logistic regression analysis and Kaplan-Meier actuarial survival analysis. Female recipients had an increased prevalence before tra nsplant of idiopathic cardiomyopathy, antinuclear antibodies, and HLA-138, DR3 haplotypes. After transplant, female sex predicted shorter duration to a first rejection, higher cumulative rejection frequency, and earlier postt ransplant production of anti-HLA antibodies. Female recipients had higher e arly mortality rates (<6 months) that were due to infection. Fatal infectio ns correlated with 2-fold higher cyclosporine levels in female recipients. However, the incidence of transplant-related coronary artery disease develo ping beyond I year after transplant was lower in female than in male recipi ents. Conclusions-Females undergoing cardiac transplantation are more likely to m anifest features of an underlying autoimmune state. This may predispose to a higher posttransplant risk of allograft rejection and requirement for inc reased immunosuppression. Earlier diagnosis and management of alloreactivit y in female recipients before development of acute rejection and the use of more focused and less globally immunosuppressive agents during established rejections may have a significant effect on the clinical outcome of female cardiac allograft recipients.