Acute rejection in the long-term cardiac transplant survivor. Clinical diagnosis, treatment and significance.

Thirty-two of 59 patients undergoing cardiac transplantation at Stanford University Medical Center since January, 1968, have survived longer than three months. In 19 of these long-term survivors 47 episodes of late acute rejection occurred. In the first two months post-transplantation the incidence of acute rejection is one episode per 20.5 patient days, but between four and 12 months post-transplantation decreases to one episode per 200 patient days. Late acute rejection episodes are usually clinically mild and can be detected by electrocardiographic changes, evidence of mild graft dysfunction and characteristic histologic changes in tissue obtained by transvenous endomyocardial biopsy. Out-patient treatment with increased oral prednisone has successfully reversed 70% of these late acute rejection episodes, with the other 30% requiring more aggressive therapy. Late acute rejection or complications related to its treatment have contributed to the death of three long-term survivors and has been implicated as a causative factor in the development of graft coronary atherosclerosis in six patients in the earlier part of our series. However, the occurrence of acute rejection in the long-term cardiac transplant patient does not preclude good graft function and patient survival in the majority of patients.