Steroid withdrawal after heart transplantation in adults

Abstract

Corticosteroids (CSs) are a key component of immunosuppressive treatment after heart transplantation (HTx). While effectively preventing acute rejection, several adverse effects including diabetes, hypertension, osteoporosis, and hyperlipidemia are associated with long-term use. As these complications may impair long-term outcome in HTx recipients, withdrawal of CSs is highly desirable, however, no uniform approach exists. Previous experience suggests that CS withdrawal can be accomplished without an increase in the incidence of acute rejection and even carrying a survival benefit. Also, common complications related to long-term CS use appear to be less frequent following CS discontinuation. Recipients who successfully discontinue CSs, however, likely belong to an immuneprivileged subset of patients with low risk of post-transplant complications. Available studies evaluating CS withdrawal are highly heterogeneous and consensus on optimal timing and eligibility for withdrawal is lacking. Efforts to improve the understanding of optimal CS withdrawal strategy are of great importance in order to safely promote CS weaning in eligible patients and thereby alleviate the adverse effects of long-term CS use on post-transplant outcomes. The purpose of this review was to evaluate different protocols of CS withdrawal after HTx in terms of clinical outcomes and to explore criteria for successful CS withdrawal.

Impact of Everolimus Initiation and Corticosteroid Weaning During Acute Phase After Heart Transplantation on Clinical Outcome: Data from the Korean Organ Transplant Registry (KOTRY)

“…Briefly, recipients enrolled in heart transplant cohort of the KOTRY are followed up at 1, 6, 12, 24, 36, 48, 60, and 120 months to monitor for rejection and screen for adverse events post-HTx according to the heart transplant cohort protocol. We annually collected the data including [1] the recipient's vital signs and comorbidities [2]; the information about prescribed medications and changes to medications including immunosuppressants [3]; a laboratory test [4]; PRA (panel reactive antibody) I & II [5]; DSA (donor specific antibodies) [6]; echocardiographic assessment [7]; recent events (death, rejection, cardiac allograft vasculopathy, renal replacement therapy or re-transplantation); and [8] posttransplantation complications (rejection, malignancy, diabetes mellitus, hypertension, stroke, infection, skeletal complication, and renal impairment).…”

“…Advanced maintenance regimens consisting of immunosuppressive agents and therapeutic drug monitoring post-HTx contribute to the increased success of HTx by reducing the risk of rejection [3,4]. However, temporal changes of regimens or dosages in immunosuppressive agents are still associated with a risk of acute rejection after transplantation, while inappropriate administration leads to adverse drug effects [5][6][7]. Therefore, the principal goal of immunosuppressive therapy is to balance the prevention of allograft rejection and adverse immunotherapeutic effects [8].…”