Steroid-free maintenance immunosuppression after heart transplantation

Steroids are routinely used in almost all immunosuppressive protocols after cardiac transplantation. The metabolic side effects of steroids are well known and could lead to significant morbidity and mortality in the posttransplant period. There is growing evidence to suggest that steroids may not be a requirement for adequate immunosuppression and that morbidity may be reduced by withdrawing steroids in select patients. We have reviewed our series of patients undergoing heart transplantation in whom steroids were weaned postoperatively.

We retrospectively reviewed all adult patients undergoing heart transplantation at our institution between November 1993 and April 2000 treated with a-triple-drug immunosuppressive regimen. Medications were recorded at discharge and at 6, 12, and 24 months posttransplant to determine the success of steroid weaning. Freedom from infection and rejection as well as overall survival was calculated using Kaplan-Meier methods.

By 24 months posttransplant, almost 70% of patients were receiving double-drug therapy. Survival for the entire group was excellent with 1-, 3-, and 5-year survival of 98%+/-2.0%, 93.2%+/-3.8%, and 88.3%+/-6.0%, respectively. Freedom from rejection at 6 months was 60.7%+/-6.5%, at 1 year was 60.7%+/-6.5%, and at 2 years was 58.5%+/-6.7%. Infectious complications were low with freedom from infection at 6 months of 78.5+/-5.5%, at 1 year of 76.5%+/-5.7%, and at 2 years of 72.0%+/-6.2%.

Our data suggest that an immunosuppressive regimen without long-term steroid administration results in excellent survival rates without an apparent increase in rejection or infectious complications.