Acute cardiac allograft rejection: Diagnosis
- Howard J Eisen, MD
Howard J Eisen, MD
- Thomas J Vischer Professor of Medicine
- Drexel University College of Medicine
- Mariell Jessup, MD
Mariell Jessup, MD
- Professor of Medicine
- University of Pennsylvania School of Medicine
INCIDENCE AND OUTCOMES
Acute rejection is a common problem after heart transplantation, particularly early after transplantation. Most cases are due to cellular rejection. Antibody-mediated (noncellular, vascular, humoral) rejection is a less well understood and less easily diagnosed process, but potentially produces morbidity [1,2].
The 2009 report from the Registry of the International Society for Heart and Lung Transplantation (ISHLT) of patients with one-year follow-up between July 2004 and July 2008 found that 21 to 30 percent were treated for rejection during the first year after transplantation . This represents an underestimate for overall rejection, since the Registry did not collect data on mild rejection episodes (grade 1 R) or on antibody-mediated rejection. (See 'ISHLT grading system' below.) The 2014 registry report noted that the incidence of any rejection between discharge and one year decreased from 30 percent for primary transplants in 2004 to 2006, to 25 percent in 2010 to 2011. Furthermore, with the recognition that mild cellular rejection may not need acute treatment , the incidence of treated rejection decreased from 23 percent for primary transplants in 2004 to 2006, to 13 percent in 2010 to 2011 .
In the 2009 ISHLT report, among deaths occurring between January 1992 and June 2008, acute rejection accounted for 6 percent of deaths in the first 30 days, 12 percent from 31 days to one year, 10 percent from one year to three years, and less than 2 percent at more than five years . The contribution of rejection to post-transplant mortality has decreased over time [3,6]. This is primarily due to improvements in maintenance immunosuppression and in the diagnosis and treatment of rejection. Nevertheless, acute heart allograft rejection remains an important clinical problem. In the 2014 ISHLT registry report, acute rejection accounted for no more than 11 percent of deaths in the first three years, but acute and chronic immune injury are likely important contributors to graft failure, which remains a leading cause of death throughout follow-up .
This topic will review the risk factors for and the clinical features and diagnostic evaluation of acute cellular rejection in the heart transplant recipient. The treatment of acute rejection is discussed separately. (See "Acute cardiac allograft rejection: Treatment".)
Although acute cellular rejection is always a potential concern in a heart transplant recipient, the likelihood of a rejection episode is influenced by several factors, particularly the time after transplantation.
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- INCIDENCE AND OUTCOMES
- RISK FACTORS
- Time after transplantation
- Type of immunosuppression
- CLINICAL PRESENTATION
- Surveillance biopsy schedule
- Biopsy procedure
- - Complications
- Histologic findings of acute rejection
- ISHLT grading system
- - Acute cellular rejection
- - Nonrejection findings
- - Acute antibody-mediated (humoral) rejection
- NONINVASIVE DETECTION OF REJECTION
- Gene expression profiling
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS