TREATMENT OF STEROID-RESISTANT AND RECURRENT ACUTE CARDIAC TRANSPLANTREJECTION WITH A SHORT-COURSE OF ANTIBODY THERAPY

The purpose of this study was to assess the efficacy of short courses of OKT3 and ATG, respectively, for steroid resistant or recurrent acut e allograft cardiac rejection (AR). Between June 1988 and March 1994, 101 heart transplant patients were treated with a quadruple sequential immunosuppression protocol (ATG, azathioprine, CsA, and prednisone). AR was diagnosed by endomyocardial biopsy (EMB), and patients with sco res >2 (ISHLT) received pulse methylprednisolone, 500 mg i.v. on 3 con secutive days. In cases of steroid-resistant or recurrent AR, OKT3 (5 mg/d) or ATG (1.5-2.5 mg/kg/d), was administered for 5-7 d instead of the usual 10-14 d course. OKT3 (17 courses; 10 steroid resistant, 7 re current AR; 5.3+/-0.7 doses) was given to 16 patients (4F/12M, 45+/-11 yr), 29-269 d after transplantation. ATG (8 courses; 5 steroid resist ant, 3 recurrent AR; 4.9+/-0.6 doses) was given to 8 patients (1F/7M, 53+/-7 yr), 23-503 d after transplantation. Successful treatment of AR with a score <2 at the first and second EMB after treatment was 88% a nd 88% with OKT3, and 87.5% and 100% with ATG, respectively. Throughou t follow up (50+/-22 months after OKT3; 49+/-28 months after ATG), the re was a trend towards lower incidence of subsequent AR after ATG (25% vs. 69%, P=0.09), and similar incidence of infections, graft atherosc lerosis and mortality. No cases of lymphoproliferative disorder were o bserved, We conclude that short courses of OKT3 or ATG are safe and ef fective for the treatment of steroid resistant or recurrent AR, with a similar incidence of complications. These results may have cost-effec tiveness implications and need to be confirmed in a randomized study.