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Comparison of cardiac rejection in heart and heart-lung transplantation
J C Baldwin1, P E Oyer, E B Stinson
1Department of Cardiovascular Surgery, Stanford University Medical Center, CA 94305.
Insights
Cardiac rejection is less common in heart-lung transplants compared to heart transplants. This may be due to immunosuppression protocols, including antithymocyte globulin, and inherent differences in rejection incidence.
Area of Science:
- Cardiology
- Transplantation Immunology
Background:
- Cardiac biopsy is crucial for diagnosing rejection in heart and heart-lung transplants.
- Pulmonary rejection can occur independently of cardiac rejection.
- Incidence of cardiac rejection might be lower in heart-lung transplantation than in heart transplantation.
Purpose of the Study:
- To compare the incidence of early cardiac rejection between heart transplant and heart-lung transplant recipients.
- To evaluate the impact of different immunosuppression protocols on rejection rates.
Main Methods:
- Prospective study of 40 heart and 9 heart-lung transplantations over 6 months (March-September 1986).
- Immunosuppression: Cyclosporine, azathioprine, and prednisone (tapered) for heart transplants; cyclosporine, azathioprine, and withheld steroids for 3 weeks plus rabbit antithymocyte globulin for heart-lung transplants.
- Cardiac rejection diagnosed by serial endomyocardial biopsy; cyclosporine levels monitored by radioimmunoassay.
Main Results:
- Early cardiac rejection was significantly less common in heart-lung transplant recipients compared to heart transplant recipients.
- Five early deaths in the heart transplant group (4 infection, 1 cerebrovascular accident).
- One late death from rejection in a heart transplant patient (241 days) and one from infection in a heart-lung transplant patient (99 days).
Conclusions:
- Cardiac rejection is notably less frequent after heart-lung transplantation than after heart transplantation.
- Prophylactic antithymocyte globulin may contribute to the lower rejection rates in heart-lung transplants.
- Rejection is likely inherently less common after heart-lung transplantation.
Abstract:
Cardiac biopsy remains the principal tool for diagnosis of rejection in heart and heart-lung transplantation. In rare instances pulmonary rejection may occur without cardiac rejection, but the overall incidence of cardiac rejection may be less with heart-lung transplantation than with heart transplantation. During the 6 months from March to September 1986, 40 heart transplantations and nine heart-lung transplantations were performed. Heart transplant patients received cyclosporine (8 to 10 mg/kg/day), azathioprine (1 to 2 mg/kg/day), and prednisone (0.8 mg/kg/day, with tapering). Heart-lung transplant patients received cyclosporine and azathioprine in the same dosages, but steroids were withheld for 3 weeks. Heart-lung transplant patients received three postoperative dosages of rabbit antithymocyte globulin (200 mg intramuscularly). There were five early deaths in the heart transplant group, four from infection and one from cerebrovascular accident. Since the initial rejection analysis presented here, one additional heart transplant patient died from rejection (241 days), and one heart-lung transplant patient died from infection (99 days). Cyclosporine levels were determined by radioimmunoassay, and cardiac rejection was diagnosed by serial endomyocardial biopsy. Early cardiac rejection is notably less common after heart-lung transplantation than after heart transplantation. Although the prophylactic antithymocyte globulin given in heart-lung transplantation may be important in this regard, rejection is probably inherently less common after heart-lung transplantation.