Conservative management of late rejection after heart transplantation: a 10-year analysis

Immunosuppressive regimens for rejection after heart transplantation have been modified to reduce infectious complications without diminishing rejection treatment efficacy. A review of a single institutional series was performed to evaluate the influence of conservative management of grade 2 rejection on long-term outcomes after heart transplantation.

Before 1990, patients with late (>3 months after transplant) grade 2 rejection were treated with supplemental immunosuppressive drugs. Beginning in 1990, patients with late grade 2 rejection were treated conservatively by maintaining the current immunosuppressive regimen without additional therapy. The groups were compared for survival, incidence of subsequent rejection, and incidence of subsequent infection.

One hundred twelve patients had one or more episodes of isolated, late grade 2 rejection; 39 (35%) were treated with supplemental immunosuppression (treated group) and 73 (65%) received no additional therapy (nontreated group). The mean time from transplantation to the first episode of isolated grade 2 rejection was 15.6 months in the treated group and 17.8 months in the nontreated group. Graft survival at 5 and 10 years was 69% and 51 %, respectively, in the treated group and 67% and 41 %, respectively, in the nontreated group (p = 0.77). The rates for overall subsequent rejection were 0.031 episodes/patient-month in the treated group and 0.029 episodes/patient-month in the nontreated group (p = 0.64). The rates for early rejection within 6 months of initial grade 2 rejection were 0.044 episodes/patient-month in the treated group and 0.035 episodes/patient-month in the nontreated group (p = 0.56). The rates for overall subsequent infection were 0.018 episodes/patient-month in the treated group and 0.012 episodes/patient-month in the nontreated group (p = 0.05). The rates for early infection within 6 months of initial grade 2 rejection were 0.070 episodes/patient-month in the treated group and 0.032 episodes/patient-month in the nontreated group (p = 0.04). Group comparisons demonstrated a significantly lower incidence of infection in the nontreated group.

Conservative management of late grade 2 rejection neither adversely affects survival nor increases the incidence of subsequent short-term or long-term rejection. This approach lowers the early and late incidence of infection after rejection and may reduce other complications from aggressive supplemental immunosuppression.