Steroid withdrawal after heart transplantation in adults

Corticosteroid use beyond 1-year post heart transplantation is associated with worse outcomes: A contemporary analysis of the ISHLT registry

Introduction

Immunosuppressive drugs ensure graft survival in heart transplantation (HT). However, prolonged use can lead to significant morbidity and mortality, and the optimal immunosuppressive regimen is unknown. We compared outcomes in adult HT recipients with or without steroid use in the large, international ISHLT Registry.

Methods

We included adults who underwent their first heart-only transplant between January 2010 and June 2018. We compared the risk-adjusted 2-, 3-, and 5-year survival as well as coronary allograft vasculopathy (CAV), treated rejection within 2 years, severe renal dysfunction, diabetes and malignancy rates between those with and without steroids by 1-year post-HT follow-up.

Results

We included 17,483 HT recipients, steroids were discontinued in 8750 (50.0%) recipients beyond 1-year post-HT. Unadjusted survival rates (conditional upon 1-year survival) were significantly lower in the cohort receiving steroids at 2-years (96.2% vs. 98.0%, p<0.001), 3-years (93.3% vs. 96.5% p<0.001), and 5-years (89.8% vs. 94.0%, p<0.001). After adjustment, continued steroid use remained associated with a significantly higher risk of 2-year (HR 1.92, 95% CI 1.60-2.31), 3-year (HR 1.88, 95% CI 1.63-2.16), and 5-year mortality (HR 1.64, 95% CI 1.47-1.82). Furthermore, continuing steroid was associated with a significantly higher prevalence of CAV (OR 1.09, 95% CI 1.01-1.18), diabetes (OR 1.24, 95% CI 1.12-1.36), 2-year treated rejection (OR 2.50, 95% CI 2.25-2.73), and severe renal dysfunction (OR 1.66, 95% CI 1.50-1.84) but no difference in malignancy rates (OR 0.85, 95% CI 0.70-1.04).

Conclusions

Steroid use beyond 1year post heart transplant was associated with significantly lower survival, and worsened morbidity among adult recipients. Whether this observation indicates steroid use is a marker of higher risk or worsens prognosis warrants prospective investigation.

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

The effect of changes in immunosuppressive therapy during the acute phase post-heart transplantation (HTx) on clinical outcomes remains unclear. This study aimed to investigate the effects of changes in immunosuppressive therapy by corticosteroid (CS) weaning and everolimus (EVR) initiation during the first year post-HTx on clinical outcomes. We analyzed 622 recipients registered in the Korean Organ Transplant Registry (KOTRY) between January 2014 and December 2021. The median age at HTx was 56 years (interquartile range [IQR], 45-62), and the median follow-up time was 3.9 years (IQR 2.0-5.1). The early EVR initiation within the first year post-HTx and maintenance during the follow-up is associated with reduced the risk of primary composite outcome (all-cause mortality or re-transplantation) (HR, 0.24; 95% CI 0.09-0.68; p < 0.001) and cardiac allograft vasculopathy (CAV) (HR, 0.39; 95% CI 0.19-0.79; p = 0.009) compared with EVR-free or EVR intermittent treatment regimen, regardless of CS weaning. However, the early EVR initiation tends to increase the risk of acute allograft rejection compared with EVR-free or EVR intermittent treatment.

Impact of varied immunosuppressive agents and posttransplant diabetes mellitus on prognosis among diverse transplant recipients (Experimental studies)

The success of solid organ transplantation (SOT) and the use of immunosuppressive agents offer hope to patients with end-stage diseases. However, the impact of posttransplant diabetes mellitus (PTDM) on SOT patients has become increasingly evident. In our study, we utilized the Scientific Registry of Transplant Recipients (SRTR) database to investigate the association between PTDM and patient survival in various types of organ transplantations, including liver, kidney, intestinal, heart, lung, and combined heart-lung transplantations (all P<0.001). Our findings revealed a negative effect of PTDM on the survival of these patients. Furthermore, we examined the effects of both generic and innovator immunosuppressive agents on the development of PTDM and the overall survival of different SOT populations. Interestingly, the results were inconsistent, indicating that the impact of these agents may vary depending on the specific type of transplantation and patient population. Overall, our study provides a comprehensive and systematic assessment of the effects of different immunosuppressive agents on prognosis, as well as the impact of PTDM on the survival of patients undergoing various types of SOT. These findings emphasize the need for further research and highlight the importance of optimizing immunosuppressive regimens and managing PTDM in SOT patients to improve their long-term outcomes.