Acute cardiac allograft rejection: Treatment
- 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
Despite the use of potent immunosuppressive agents both immediately after cardiac transplantation and during long-term maintenance, acute rejection remains an important problem. The incidence of any rejection between discharge and one year has decreased from 30 percent for primary transplants in 2004 to 2006 to 25 percent in 2010 to 2011 . Acute cellular rejection is most likely to occur in the first three to six months, with the incidence declining significantly after this time .
The diagnosis of acute cellular cardiac allograft rejection is generally made by endomyocardial biopsy performed either routinely or because of suggestive symptoms.
ISHLT grading system — The endomyocardial biopsy is graded using the International Society for Heart and Lung Transplantation (ISHLT) nomenclature adopted in 1990 and revised in 2004 [3-5]. For acute cellular rejection :
●Grade 0 – No rejection
●Grade 1 R, mild – Interstitial and/or perivascular infiltrate with up to one focus of myocyte damage
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- ISHLT grading system
- DRUGS USED TO TREAT ACUTE CELLULAR REJECTION
- Antithymocyte globulin
- - Side effects
- Monoclonal OKT3 antibody
- TREATMENT OPTIONS FOR ACUTE REJECTION
- Hemodynamic compromise
- Grade 1 R
- Grade 2 R without hemodynamic compromise
- Severe or refractory rejection
- - Issues related to use of OKT3
- Antibiotic and antiviral prophylaxis
- Acute antibody-mediated (humoral) rejection
- RESISTANT OR RECURRENT REJECTION
- Total lymphoid irradiation
- Changes in maintenance immunosuppression
- - Methotrexate
- - Tacrolimus
- - Mycophenolate
- - Sirolimus
- - Everolimus
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS