student research day - Case Western Reserve University School of ...

Carey Faber
Early Outcomes using a Steroid-Avoidance Immune Suppression Protocol in Non-neonatal Heart
Transplant Recipients
Carey Faber, Tajinder (TP) Singh MD, MSc; Gerard Boyle MD; Sarah Worley MS and Gerard Boyle MD
Department of Pediatric Cardiology, Congestive Heart Failure and Transplant
Cleveland Clinic Foundation and Children’s Hospital Boston
Purpose: Chronic oral steroid use is a key ingredient of maintenance immune suppression (IS) in heart
transplant (HT) patients (pts) and is associated with increased morbidity. In a 2-center study, we analyzed
early clinical outcomes in 40 consecutive pediatric (non-neonatal) HT pts managed with a steroid avoidance
protocol.
Methods: Eligible HT pts (non-sensitized pts, n=35, selected pts with mild sensitization and negative
crossmatch, n=5) entered a steroid avoidance IS protocol consisting of induction therapy (thymoglobulin
pre-treated with steroids) for a median duration of 5-days (3-6 days) followed by 2 drug tacrolimus-based,
steroid-free IS. The primary outcome variable was freedom from moderate rejection (ISHLT 2R or antibody
mediated rejection, AMR).
Results: Median age of pts was 8 yrs (1 month-22 yrs) who were followed for a median duration of 15
months (1-38 months). Indication for HT was congenital heart disease in 11 (28%) and myocardial disease
in 29 (72%). Median ICU stay post-HT was 6 days and hospital stay 19 days. Moderate rejection episodes
occurred in 4 pts (cellular rejection in one and AMR in 3 pts). Freedom from moderate rejection was 97% at
6 months and 89% at 1 year post-HT. Seven pts were treated for CMV antigenemia (6 asymptomatic,
detected on monitoring) and one patient for post-transplant lymphoproliferative disease. In 6 pts (15%)
steroids were either continued after first 5 days post-HT or restarted. One of these 6 pts received
maintenance steroids post-rejection episode. Post-HT survival was 92% at 6 months and 88% at 12 and 24
months. Four deaths occurred; 3 early hospital deaths due to multi-organ failure and one 8 months post-HT
due to AMR.
Conclusions: An IS protocol of induction followed by steroid avoidance was associated with low incidence
of moderate rejection during the first year after heart transplant in young HT recipients.
Supported by NIH T35 Training Grant (HL082544)
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