Steroid-free maintenance immunotherapy: Minneapolis Heart Institute experience

M. R. Pritzker, K. D. Lake, T. J. Reutzel, F. M. Hoffman, C. R. Jorgensen, W. Pederson, R. W. Emery

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29 Scopus citations

Abstract

Recent advances in immunotherapy have resulted in improved survival after heart transplantation. The use of OKT3 as an induction agent has allowed the identification of a subset of patients who can be successfully withdrawn from prednisone and maintained on only cyclosporine and azathioprine. The latter regimen offers several theoretic advantages in terms of freedom from complications of long-term steroid therapy. To compare both the long-term efficacy and toxicity of steroid-free maintenance immunosuppression with triple-drug therapy, the medical records of 68 patients undergoing transplantation at the Minneapolis Heart Institute during a 3-year period (1988 through 1990) were reviewed. Thirty-six patients were treated with OKT3 induction immunotherapy, 29 were successfully tapered off prednisone by 114 ± 44 days after transplantation, whereas 32 patients were maintained on triple-drug therapy. The incidence of treated rejection was equivalent in both groups; however, the time to first rejection was longer in patients treated with OKT3/steroid-free maintenance (205 ± 214 vs 27 ± 17 days) (p = 0.02). Bacterial infections during the early posttransplant period were more common in the OKT3/steroid-free maintenance group (p = 0.008); however, fungal and viral infections were equally distributed between both groups. The incidence of hypertension was slightly higher in patients maintained on prednisone (67% vs 51%; p = 0.242). When compared with the triple-drug therapy group, patients withdrawn from prednisone gained less weight (4.1 ± 7.9 vs 6.8 ± 6.1 kg) but neither the increase in total kilograms (p = 0.17) nor the increase in percentage of ideal weight (9% ± 13% vs 14% ± 11%; p = 0.108) was significant. Weight gain after transplantation in percentage of ideal body weight was most closely related to patients' premorbid body mass index. Similarly, patients with hyperlipidemia before transplantation experienced a 15% increase in cholesterol levels and had higher lipid values after transplantation regardless of whether steroids were (298 ± 66 mg/dl) or were not used (247 ± 52 mg/dl) (p = 0.056). Patients receiving steroid maintenance without a history of previous lipid abnormalities experienced a 62% increase in cholesterol. The use of OKT3 induction immunotherapy, combined with aggressive early steroid withdrawal, appears to have short-term benefits, which produce early survival rates equivalent to or in excess of patients receiving triple-drug therapy. Continued patient follow-up will be necessary to determine if these early advantages translate into improved survival and reduced complications over a 5-year period.

Original languageEnglish (US)
Pages (from-to)415-420
Number of pages6
JournalJournal of Heart and Lung Transplantation
Volume11
Issue number2 II SUPPL.
StatePublished - 1992

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