Low-dose oral prednisone in the treatment of acute cardiac allograft rejection not associated with hemodynamic compromise

The standard therapy for acute cardiac allograft rejection is intravenous methylprednisolone, usually in doses of about 3 gm per treatment. Treatment is undertaken in most cases solely on the basis of a histologic diagnosis of rejection, irrespective of hemodynamic status. To reduce total corticosteroid dose and administer therapy in an outpatient environment, low-dose oral prednisone protocols were developed for the treatment of acute rejection in the absence of important hemodynamic compromise. A high-dose oral prednisone pulse (2 gm total for the average 75 kg male patient) was used in the first month. Thereafter a series of low-dose oral prednisone pulses were used (range, 0.5 to 1.0 gm total for the average 75 kg male patient). Of 85 transplant recipients at risk, 188 rejection episodes were treated over a 1477 total patient-months of follow-up. The high-dose oral pulse resulted in successful therapy (no subsequent therapy required) in 34 of 65 treatments (52%). The low-dose oral pulse was successful in treating 80 of 123 treatments (65%). This approach to acute rejection did not appear to adversely affect patient or graft outcome based on progression of stable to unstable hemodynamics, survival (84% and 82%, 1- and 2-year actuarial survival, respectively), or left ventricular ejection fraction (0.56 ± 0.09 and 0.54 ± 0.08, at 1 and 2 years, respectively). There did not appear to be discriminating factors that determined the therapeutic outcome, other than the higher failure rate within 1 month of transplant. We conclude that acute allograft rejection in the absence of important hemodynamic compromise responds to lower-than-conventional doses of corticosteroids in the majority of cases.