Page 23 - Heart Transplant Protocol
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Heart Function Service: Heart Transplant Protocols

               ISHLT 0R, 1R
                     Usually does not require specific therapy

               ISHLT 2R

               Asymptomatic Patients

               Consider oral steroids 10 mg/kg (max 1 gram daily). For PO steroid pulse may consider dividing
               dose BID or TID for ease of administration. Total of 3 doses daily.

               Symptomatic Patients
               Solumedrone pulse 10mg/kg IV (maximum dose 1 gram IV), daily for 3 days

               Hemodynamic Compromise
               In addition to Solumedrone pulse give ATG for 5-7 days or until function is normalizing. Check
               daily CD3 counts & give ATG if CD3 >50

               Post Steroid Pulse treatment for 2R rejection:

                     Consider if maintenance steroids are necessary & if so for how long.
                     Repeat biopsy 2 weeks after therapy complete to assess for progression or to confirm
                       resolution of rejection.
                     For negative biopsy, continue with maintenance monitoring and maximize
                       immunosuppression (IS) as needed.

               Persistent Rejection Treatment:
               For persistent rejection or/and hemodynamic data which suggest worsening rejection, consider
               repeat steroid pulse as above or using ATG (thymo) or alemtuzumab (Campath).


               Grade 3R
               Diagnoses if wedge pressure more than 20, cardiac index less than 2 l/min/m2, or for clinically
               hemodynamically unstable patient or end organ damage or markedly decreased cardiac
               function by echocardiogram:

                   1.  Admission to CVICU
                   2.  Inotropic support as clinically indicated

                   3.  Thymoglobulin with daily CD3 count as per protocol
                   4.  Solumedrone pulse 10mg/kg IV (maximum dose 1 gram IV), daily for 3 days
                   5.  Have a high index of suspicion for antibody mediated rejection also being present and
                       consider additional AMR therapy (see below)
                   6.  After completion of therapy, repeat biopsy in 4 weeks
                   7.  Consider/Rule out TCAD










               Updated November 9, 2017                                                                    23
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