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Risk/benefit ratio of perioperative OKT3 in cardiac transplantation
M R Johnson1, G M Mullen, E J O'Sullivan
1Department of Medicine, Loyola University Medical Center, Maywood, Illinois.
Insights
Perioperative OKT3 in cardiac transplant patients increases infections, particularly cytomegalovirus, without improving rejection rates or survival. This study suggests reconsidering its use in triple-drug immunosuppression regimens.
Area of Science:
- Immunology
- Transplantation Medicine
- Clinical Pharmacology
Background:
- Cardiac transplantation requires effective immunosuppression to prevent rejection.
- The role of perioperative anti-T cell therapy, such as OKT3, in optimizing outcomes is debated.
- Triple-drug immunosuppression is a standard post-transplant regimen.
Purpose of the Study:
- To evaluate the risk-benefit ratio of perioperative OKT3 in cardiac transplant recipients on triple-drug immunosuppression.
- To compare rejection rates, infection incidence, and patient survival between patients receiving OKT3 and those not receiving anti-T cell therapy.
Main Methods:
- Retrospective comparison of two groups of cardiac transplant patients.
- Group 1 received perioperative OKT3 (n=33); Group 2 received no perioperative anti-T cell therapy (n=46).
- Data analyzed for rejection, infection rates, and patient survival.
Main Results:
- No significant difference in total or treated rejection rates, or time to first rejection.
- The OKT3 group experienced a higher incidence of total infections (0.8 vs 0.3 per patient/month) and intravenously treated infections (0.5 vs 0.1 per patient/month).
- Cytomegalovirus infection occurred in 46% of the OKT3 group versus 22% in the control group (p=0.025). Patient survival did not differ.
Conclusions:
- Perioperative OKT3 in cardiac transplant patients on triple-drug immunosuppression increases infection risk, especially cytomegalovirus.
- This increased infection risk does not correlate with decreased or delayed rejection.
- The use of perioperative OKT3 in this context does not improve patient survival.
Abstract:
To evaluate the risk/benefit ratio of perioperative OKT3 in cardiac transplant patients receiving triple-drug immunosuppression, patients who underwent cardiac transplantation between July 1, 1988 and December 31, 1989 (n = 33) and who received perioperative OKT3 were retrospectively compared with patients who underwent transplantation between January 1, 1990 and June 30, 1991 (n = 46), and who received no perioperative anti-T cell therapy. To allow similar follow-up, data were analyzed through June 30, 1990 for the OKT3 group and through December 31, 1991 for the no anti-T cell therapy group. Patients in the no anti-T cell therapy group waited longer for a donor organ; other pretransplant characteristics did not differ. The azathioprine dose 1 month after transplant was higher in the no anti-T cell therapy group (144 +/- 63 mg vs 109 +/- 55 mg, p = 0.016); other post-transplant immunosuppression was similar. The incidence of total and treated rejection and the time to the first rejection did not differ between the groups. The OKT3 group had a higher number of infections (0.8 +/- 0.9 vs 0.3 +/- 0.3, p = 0.006) and intravenously treated infections (0.5 +/- 0.6 vs 0.1 +/- 0.2, p = 0.004) per patient per month. Cytomegalovirus infection developed in 46% of the OKT3 group versus 22% of the no anti-T cell therapy group (p = 0.025). Patient survival did not differ between the groups. Thus, an immunosuppressive regimen that includes perioperative OKT3 increases infections, especially cytomegalovirus infections, without decreasing or delaying rejection or increasing survival.