Page 19 - Heart Transplant Protocol

Heart Function Service: Heart Transplant Protocols

Mycophenolate Mofetil (Cellcept)
o Mycophenolate Mofetil (Cellcept)- IV to PO 1:1
2
 Starting dose of 300 mg/m BID - goal of 600 mg/m BID (max dose 1500 mg)
2
 Check dose is appropriate if WBC > 6 or consider withholding if neutropenic.
 Consider change primarily to Sirolimus if intolerable GI side effects.

Prograf (Tacrolimus)
o Prograf (Tacrolimus or FK506)
 0.1 to 0.2 mg/kg/day PO BID
 Goal Levels
 Post-operative – 3mths: 10-13 ng/ml, obtain levels daily until stable
 3 – 6 months: 8-11 ng/ml
 6-12 months: 6-9 ng/ml
 >12 months: 5-8 ng/ml
 Following acute rejection episode, Prograf goal to be re-addressed on a
case by case basis.

Sirolimus (Rapamycin)
o Resistant rejection: combined Prograf + Sirolimus goal 10-12
o Standard dual therapy: combined Prograf + Sirolimus 8-10 (predominance of
Sirolimus especially in setting of CNI nephropathy)

Azathioprine (Imuran)
o Indicated in Mycophenolate Mofetil and Sirolimus intolerance
o Start 2 mg/kg/day
o Reduce dose for ANC <500
o Wean dose for WBC <4,000 or anemia
o Check that patient is on appropriate dose if WBC > 6K

Cyclosporine
o Goal Levels
 200-250 < 3 months post-transplant (goal to keep closer to 250)
 150-200 3-12 months post-transplant
 50-100 > 1 year

Rejection

Traditionally rejection has been separated into either cellular or humoral (antibody mediated). While
undoubtedly rejection may be purely one or the other, most times there is an element of both.
Rejection is often diagnosed on the basis of clinical findings, assessment of donor specific antibodies and
echocardiography as the patient is often too unstable for cardiac biopsy. A biopsy may be helpful to
direct treatment. Although biopsy is recognized as the “gold standard” for diagnosis the myocardial

Updated November 9, 2017 19