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DOI: 10.1055/s-0029-1191592
Single shot ATG induction followed by postoperative CNI holiday: A renal sparing and safe strategy after heart transplantation!
Objective: To evaluate safety and efficacy of significant delay of postoperative CNI administration after single shot ATG induction.
Methods: 63 patients (ICM 23, DCM 36, other 4, age 54±14yrs) underwent orthotopic heart transplantation between Jan. 2004 and Aug. 2007. Preop. creatinine was 2.1±0.8mg/dl. Immunosuppression was induced by a single dosis ATG (Thymoglobulin 1.5mg/kg) with concommittant MMF (fixed dose of 2g/day) and steroids (taper from 1 to 0.1mg/kg/day) starting day one. Oral CyA or Tac was started only at 48–72 hours post HTx to reach target through levels only at postop. day 7–10. Postoperative monitoring included daily echocardiography, endomyocardial biopsy when indicated or before discharge.
Results: Perioperative mortality was 7/63 (11.1%) due to primary graft failure unrelated to rejection (n=3), sepsis/MOF (n=3) and mediastinitis (n=1). C0 level (HPLC) of CyA or Tac was 147±64/6.8±1.4at day 7 and 189±23/8.9±1.9at day 10 respectively. During the first postop. month only 1 patient required treatment for moderate acute rejection (ISHLT II) at day 10. Postop. creatinine peaked at 2.9±1.5, and decreased to 1.5±0.3mg/dl at discharge (day 28±25); only 3 patients (4.8%) required temporary hemofiltration. Incidence of viremia requiring preemptive therapy was 39.3% (22/56) during first year follow-up. No patient developed malignoma. Actuarial survival at 1 and 3 years is 83.6% and 81.8% respectively.
Conclusion: Single shot induction with ATG is potent enough to safely delay CNI administration translating into excellent perioperative renal function with <5% use of hemofiltration and avoids increased incidence of viral infection and malignoma.