Beyond rose colored glasses: the adaptive role of depressive and anxious symptoms among individuals with heart failure who were evaluated for transplantation.

The prospect of and the evaluative period for transplantation can be stressful for individuals with heart failure (HF). Little is known about the impact of psychosocial factors on service utilization and health outcomes. The current study examined the impact of depression, dysthymia, and anxiety on two-yr hospitalization and mortality among 96 individuals with HF who were evaluated for transplantation. Results revealed that only a small percentage of individuals endorsed sufficient symptomatology to meet criteria for a psychiatric, Axis I disorder (3.1% = anxiety; 2.1% = depression; 1.0% = dysthymia) although a significant proportion of the sample was prescribed an antidepressant or an anxiolytic (37%). Multivariable regression analysis was conducted to examine the association between significant independent demographic, medical, and psychiatric predictors and total duration of hospitalizations; logistic regression analysis was used to examine the relation between predictors and mortality. An increase in anxious symptoms was associated with a decrease in total number of days hospitalized during the two-yr period following the initial evaluation. Similarly, as depressive symptoms increased, risk of two-yr mortality decreased. Future research should assess communication between the patient and providers to further elucidate the potential relationship between psychiatric symptoms, service utilization/hospitalization, and mortality in this patient population.

Improving clinical practice: should we give influenza vaccinations to heart transplant patients?

BACKGROUND: Current practice recommends that immunosuppressed patients (pts) receive yearly influenza (flu) vaccinations. However, disparity exists between current recommendations and clinical practice regarding the decision to administer flu vaccinations to heart transplant (Tx) pts. The purpose of this study was to examine the common clinical practices and outcome characteristics in Tx pts in a multi-institutional database. We assess the incidence of rejection, infection and flu in the months after administration of flu vaccinations. METHODS: Between 1990 and 2001, 5,581 pts underwent Tx at 28 institutions. Pts who were >1 year post-Tx as of January 1, 2002 (N = 3,601) constituted the study group. RESULTS: During the years 2002 and 2003, 89% of the institutions administered flu vaccines, with 7 institutions requiring pts to be >3 months (N = 1), 6 months (N = 1) and 12 months (N = 5) post-Tx. All 25 centers that vaccinated pts used trivalent inactivated vaccines during the months of October through January. Three centers did not vaccinate Tx pts due to a purported association with increased allograft rejection. There were no significant differences in the total number of rejection episodes (0.4% vs 0.3%, p = 0.7), rejection episodes by month (January: 0.4% vs 0%, p = 0.2; February: 0.5% vs 1.5%, p = 0.08; March: 0.5% vs 0%, p = 0.14), all infections (0.7% vs 0.6%, p = 0.6) and viral infections (0.1% vs 0%, p = 0.17) between centers that administered flu vaccines and those that did not, respectively. The incidence of flu was low in both groups. CONCLUSIONS: Flu vaccinations can be given safely to heart transplant pts without an increased incidence of rejection or infection. This information provides clinicians with data to improve clinical practice.

Should status II patients be removed from the pediatric heart transplant waiting list? A multi-institutional study.

BACKGROUND: The survival benefit of cardiac transplantation (CTx) among Status 2 (stable outpatient) adult recipients has been questioned, but few studies have addressed this issue in pediatric patients. This study examined the following hypothesis: "Status 2 pediatric recipients have a survival benefit with CTx." METHODS: Between 1993 and 2003, 2,375 patients were listed for CTx at 24 institutions; 614 (26%) of these patients were Status 2. By multivariate competing outcomes hazard function analysis, death after listing and post-transplant survival were analyzed. RESULTS: A single-phase hazard function described the risk of death after listing, with 20% actual mortality within 2 months after Status 1 listing. The "natural history" of Status 2-listed patients was estimated by the risk of death, whereas waiting and risk of deterioration to Status 1 at CTx (weighted by the probability of death at 3 months after Status 1 listing). At 4 months after CTx, survival with CTx exceeded the predicted "natural Hx" survival in all diagnostic categories out to 4 years of follow-up. CONCLUSIONS: Pediatric patients currently listed as Status 2 have a survival benefit with transplant out to at least 4 years. A pediatric allocation system restricted to Status 1 patients could only be justified if the vast majority of such patients could be transplanted within 1 to 2 months.

Evolving trends in risk profiles and causes of death after heart transplantation: a ten-year multi-institutional study.

BACKGROUND: As therapeutic options evolve for advanced heart failure, the appropriate role for cardiac transplantation will require survival analyses that reflect changing trends in causes of death and patient and institutional risk profiles. Results from multi-institutional studies could be used to monitor progress in individual centers. METHODS: Between 1990 and 1999, 7290 patients undergoing cardiac transplantation in 42 institutions entered a formal outcomes study. Changing survival, causes of death, and patient risk profiles were analyzed. Multivariable risk-factor equations were applied to a single institution (300 primary heart transplants) to examine differences in risk-adjusted expected versus observed actuarial outcomes over time. RESULTS: Overall survival in the 42 institutions improved during the decade (P =.02). One- and 3-year cardiac transplant research database survival was as follows: era 1 (1990-1992), 84% and 76%, respectively; era 2 (1993-1995), 85% and 79%, respectively; and era 3 (1996-1999), 85% and 79%, respectively. Causes of death changed over time. Pretransplantation risk profiles increased over time (P =.0001), with increases in reoperations, devices, diabetes, severely ill recipients, pulmonary vascular resistance, sensitization, ischemic times, donor age, and donor inotropic support. Three-year actuarial survival in a single institution was 3% less than risk-adjusted predicted survival in era 1, 1% higher than predicted in era 2, and 7% higher than predicted in era 3. CONCLUSIONS: Survival after cardiac transplantation is gradually improving, despite increasing risk profiles. Further improvement requires periodic re-evaluation of risk profiles and causes of death to target areas of surveillance, therapy, and research. By using these methods, progress at individual institutions can be assessed in a time-related, risk-adjusted manner that also reflects changing institutional experience, expertise, or both.

Improvement in quality of life outcomes 2 weeks after left ventricular assist device implantation.

BACKGROUND: The successful use of left ventricular assist devices (LVADs) as a bridge to heart transplantation has prompted our examination of quality of life (QOL) outcomes. The purposes of this study are to describe QOL in patients 1 to 2 weeks after LVAD implantation and to compare QOL in a smaller cohort of patients from before to 1 to 2 weeks after surgery. METHODS: Data were collected from a convenience sample of 81 patients who completed booklets of questionnaires that measure domains of QOL 1 to 2 weeks after LVAD insertion and from 30 of 81 patients who completed booklets at both the pre-implantation and post-implantation periods. Patients completed booklets of 6 to 8 self-reporting instruments, with acceptable reliability and validity. Data were analyzed using descriptive and comparative statistics (chi-square, Mann-Whitney U and Wilcoxon signed ranks tests) with p = 0.01 considered statistically significant. RESULTS: One to 2 weeks after LVAD implantation, patients were quite satisfied with their lives, experienced moderately low amounts of stress, coped well, and perceived themselves as having good health and QOL, low symptom distress, and moderately low functional disability. Patients reported significantly better QOL, more satisfaction with health and functioning, and were significantly less distressed by symptoms from immediately pre-operatively to post-operatively. However, patients reported significantly more self-care disability and more dissatisfaction with socioeconomic areas of life from before to immediately after surgery. Psychological distress was low and did not change with time. CONCLUSION: Given that QOL improved from before to after LVAD implantation, our findings provide a springboard for investigation of the impact of LVADs on long-term QOL outcomes.

Spouse quality of life before and 1 year after heart transplantation.

These results indicate that overall perceived quality of life in spouses of heart transplant patients did not change significantly from the pretransplant period to 1 year posttransplantation. Conversely, specific factors influencing quality of life such as health, socioeconomic satisfaction, family satisfaction, coping styles, and the impact of the transplant experience on the spouses' life did change after transplantation. One year after heart transplantation, spouses reported less satisfaction with their health and socioeconomic status but more satisfaction with their family than they experienced before the transplant. In addition, spouses used less fatalistic, emotive, optimistic, and self-reliant coping styles after transplant than before. Lastly, spouses perceived the transplant experience more positively after the transplant than they did before the transplant. An ideal analysis would encompass data collected at more frequent periods pretransplantation and posttransplantation. The significant negative change found in the spouses' perceived health 1 year after transplant when compared with the spouses' perceived health before the transplant was based on a single-item question. A more comprehensive measure is needed to assess the health changes in the spouse that take place over time. This investigation highlights the importance of studying the impact that a catastrophic illness has on family members and the patient. As health care systems cut costs and streamline production, the needs of spouses and family members are more likely to be ignored. As a result, at some point in the future they could enter the health care arena as patients themselves. Early interventions are thus necessary to support family members of patients during the illness and throughout the recovery trajectory.

Are preoperative obesity and cachexia risk factors for post heart transplant morbidity and mortality: a multi-institutional study of preoperative weight-height indices. Cardiac Transplant Research Database (CTRD) Group.

BACKGROUND: The relationship between pre-transplant body weight and post-transplant outcome has only recently been identified using a single, indirect measure of weight (percent ideal body weight [PIBW]). The literature is equivocal regarding which index is the better indicator of body weight. The purpose of this study was to determine (1) if pre-heart transplant body weight, measured by body mass index (BMI) and PIBW, is associated with post-heart transplant morbidity and mortality and (2) if patient gender, age, and etiology of heart disease affect this association. METHODS: The sample included 4,515 patients who received a heart transplant from January 1, 1990-December 31, 1995 at 38 institutions participating in the Cardiac Transplant Research Database (CTRD). Patients were divided into groups according to their BMI and PIBW. Data were described using frequencies, measures of central tendency, Pearson correlation coefficients, stratified actuarial analyses and log rank tests for comparisons, and a multivariable risk factor analysis in the hazard domain. RESULTS: For all patients (n = 4,515), being <80% or >140% of IBW before heart transplant was a risk factor for increased mortality after heart transplant. The association between pre-heart transplant PIBW and post-heart transplant survival was affected by gender, age, and etiology of heart disease. In males, a higher PIBW was a significant risk factor for death early after transplant (p = .0003). Although not significant, there was a trend for a higher PIBW being a risk factor for death in females throughout the post transplant period (p = .07). No differences in cause of death were found for PIBW and BMI. In male and female recipients <55 years, being overweight pre-heart transplant was a risk factor for infection. In patients with pre-transplant ischemic heart disease, the greatest risk for infection was found in patients who were >140% of IBW. Pre-heart transplant BMI and PIBW were not associated with acute rejection or cardiac allograft arteriopathy after transplant. CONCLUSIONS: In conclusion, being cachectic or obese preoperatively is associated with decreased survival in all patients after heart transplantation. Being obese preoperatively is associated with increased infection after heart transplant in males and females <55 years and in patients with ischemic heart disease. Of the 2 indices of body weight used in this study, percent ideal body weight appears to be the better predictor of future morbidity and mortality following heart transplantation.

Preoperative psychosocial predictors of hospital length of stay after heart transplantation.

The effect of psychosocial factors on hospital length of stay (LOS) after heart transplantation has not been reported. This study examines relationships between preoperative psychosocial variables and LOS and identifies preoperative psychosocial predictors of LOS after transplant. A nonrandom sample of 307 patients at two medical centers completed a self-administered booklet of psychosocial measures. A chart review was also conducted. Psychosocial problems included anxiety, stress, and inadequate coping; questionable understanding of heart failure and treatment; substance abuse; and noncompliance. Self-care disability, a history of noncompliance, and more emotional disability predicted 8% of LOS. This supports the inclusion of psychosocial issues and functional disability in post-heart transplant clinical pathways.

Predictors of quality of life in patients at one year after heart transplantation.

BACKGROUND: A multivariate approach to the study of relationships between quality of life and demographic, physical, and psychosocial variables after heart transplantation has not been examined in a large, multi-site sample. The purpose of this study was to describe quality of life, examine relationships between quality of life and demographic, physical, and psychosocial variables, and identify predictors of quality of life in patients who were 1 year post heart transplantation. METHODS: Data were collected from a nonrandom sample of adult patients (n = 232) who were 1 year post heart transplantation at a Midwestern or Southern medical center. Nine self-administered instruments and chart review were used to gather data from patients. All tools had adequate psychometric support. Descriptive statistics, Pearson correlations, and step-wise multiple regression were used to analyze data. Level of significance was set at 0.05. RESULTS: Patients were most satisfied with the areas of quality of life regarding social interaction and least satisfied with their psychological state. Patients experienced an average amount of stress, were coping fairly well, reported overall good quality of life, and were very satisfied with the outcome of their transplant surgery. Nine out of 16 variables were significant predictors of quality of life and explained 66% of the variance in quality of life: less stress, more helpfulness of information from health care providers, better health perception, better compliance with the transplant regimen, more effective coping, less functional disability, less symptom distress, older age, and fewer complications. CONCLUSIONS: Predictors of quality of life at 1 year after heart transplantation were primarily psychological. Additional variance in quality of life was explained by physical, somatic sensation, demographic, and health status variables. Knowledge of these factors provides (1) information to identify patients who are at risk for poor quality of life at 1 year after heart transplantation and (2) direction for the development of interventions to improve quality of life.

Patient compliance at one year and two years after heart transplantation.

BACKGROUND: The purpose of this report is to determine the extent of difficulty following and self-reported compliance with prescribed activities at 1 year after heart transplantation, identify postoperative predictors of compliance at 1 year after transplantation, and compare difficulty following and compliance with the therapeutic regimen at 1 year versus 2 years after transplantation. METHODS: Data were collected from a nonrandom sample of 120 adult patients 1 year after heart transplantation and 76 of 120 patients 2 years after transplantation. Patients were 83% male, mean age 54 years, 86% were married, 28% were employed, and 91% were in NYHA class I at 1 year after transplantation. Data were collected from the Assessment of Problems with the Heart Transplant Regimen, Quality of Life Index, Heart Transplant Symptom Checklist, Sickness Impact Profile, Heart Transplant Stressor Scale, Jalowiec Coping Scale, Social Support Index, Heart Transplant Intervention Scale, Rating Question Form, and chart review. Data were analyzed via frequencies, multiple regression, paired t-tests, and the Wilcoxon matched-pairs signed-ranks test. RESULTS: At both 1 year and 2 years after transplantation, patients had almost no difficulty following the heart transplantation regimen and complied almost all of the time with taking medications, attending clinic, and completing scheduled tests. Patients complied less with following a diet, exercising, and taking their vital signs. Predictors of compliance at 1 year after heart transplantation differed by prescribed activity, explaining from 13% to 52% of variance (p < or = 0.0001). CONCLUSIONS: These findings indicate the need to continue the study of heart transplant recipient compliance longitudinally for individual prescribed activities and provide evidence and direction for the development of interventions to enhance patient compliance.

Quality of life 6 months after heart transplantation compared with indicators of illness severity before transplantation.

BACKGROUND: Quality of life is an important healthcare outcome to study. Quality of life after heart transplantation has not been compared with indicators of severity of illness before heart transplantation. OBJECTIVE: To compare differences in quality of life 6 months after heart transplantation with two preoperative indicators of severity of illness: New York Heart Association classification and United Network for Organ Sharing status. METHODS: Data were collected from a nonrandom sample of 219 adult patients who had received a heart transplant 6 months earlier. Patients were divided into groups on the basis of their New York Heart Association classification and United Network for Organ Sharing status immediately before transplantation. Instruments used were the Heart Transplant Symptom Checklist, Heart Transplant Stressor Scale, Rating Question Form, Quality of Life Index, Sickness Impact Profile, and Jalowiec Coping Scale. Data were analyzed with descriptive statistics, chi-square tests, and independent t tests. RESULTS: Quality of life 6 months after receiving a heart transplant varied with severity of illness before transplantation. These differences in quality of life were in the following domains: physical and occupational function, psychological state, and social interaction. Six months after receiving a heart transplant, patients who were more severely ill before transplantation were less satisfied with their lives, perceived that they were not doing as well, experienced more family-related stress, and used more negative coping strategies than did patients who were less severely ill preoperatively. CONCLUSIONS: These findings indicate the need for further study of quality of life in the transplant recipients who are the most critically ill in intensive care settings before surgery, to develop interventions to improve recipients' quality of life, and to evaluate effectiveness of those interventions longitudinally.

Serial measurements of interleukin-6, interleukin-8, tumor necrosis factor-alpha, and soluble vascular cell adhesion molecule-1 in the peripheral blood plasma of human cardiac allograft recipients.

BACKGROUND: Cardiac allograft rejection is largely an inflammatory response that, if allowed to proceed unchecked, will result in hemodynamic compromise or cardiogenic shock. Soluble mediators produced during an inflammatory response could potentially provide information regarding the initiation, progression, and outcome of a rejection episode. To test this hypothesis, we investigated the use of plasma cytokine measurements for interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor alpha (TNF alpha) in combination with measurements of soluble vascular cell adhesion molecule-1 (VCAM-1), an adhesion molecule, as a means for the detection of cardiac allograft rejection. METHODS: Serial enzyme-linked immunosorbent assays were performed on plasma samples collected from 29 patients three times per week during the first 8 weeks after transplantation. RESULTS: IL-6 plasma concentrations increased fivefold in the first week after transplantation (p < 0.001 vs pretransplantation levels) and thereafter remained at low levels for the next 6 weeks, with a small increase during the 8 weeks after transplantation (p = 0.006). In contrast, TNF-alpha, IL-8, and VCAM-1 levels remained low during the first 6 weeks after transplantation followed by a rise in mean VCAM-1 levels from 841 +/- 38 to 979 +/- 52 ng/ml at week 8. To determine the relationship of levels of each of the four soluble factors with rejection, the mean values obtained during the time interval 1 to 5 days before rejection were compared to mean values obtained during rejection and at other periods of no rejection (baseline). Cytokine levels were not predictive of rejection (no difference in levels 0 to 5 days before rejection versus baseline, p > 0.3 for IL-6, IL-8, TNF-alpha). However, VCAM-1 levels increased 0 to 5 days before rejection compared with baseline (914 +/- 40 vs 844 +/- 30 ng/ml, p = 0.06). CONCLUSIONS: IL-6 levels are increased immediately after heart transplantation. Circulating IL-6, IL-8, and TNF alpha levels do not predict rejection during the first 8 weeks after transplantation. Soluble VCAM-1 increases within 5 days before rejection and may potentially serve as a noninvasive marker for early rejection.

Symptom distress three months after heart transplantation.

BACKGROUND: Although symptoms of heart failure abate after heart transplantation, other symptoms caused by the surgery, immunosuppressant drugs, and complications can be new sources of symptom distress for patients after operation. METHODS: This two-site National Institutes of Health study compared symptom distress in 173 adult heart transplant recipients from before operation to 3 months after operation. The Heart Transplant Symptom Scale was used to measure 92 symptoms related to heart disease and heart failure, transplantation, medication side effects, and complications commonly found in this population. Analysis was via paired t tests with Bonferroni correction. Most patients (93%) were receiving a triple immunosuppressant regimen of cyclosporine, azathioprine, and prednisone. RESULTS: Total symptom distress decreased significantly (p = 0.013) from before operation to 3 months after heart transplantation. The 23 symptoms that decreased the most (p = 0.000) after operation accounted for a cumulative total reduction of 583% less symptom distress. These symptoms were primarily cardiopulmonary, neuromuscular, and emotional. The 10 symptoms that worsened the most (p = 0.000) after operation accounted for a cumulative total increase of 284% more symptom distress. These symptoms were primarily dermatologic, neurologic, and gastrointestinal and were all side effects of prednisone and cyclosporine. CONCLUSIONS: The net change in symptom distress resulted in 299% less symptom distress in this cohort at 3 months after heart transplantation. This significant improvement in symptom outcomes scientifically documents the effectiveness of heart transplantation in reducing symptoms of heart failure, along with accompanying emotional symptoms. These research findings therefore reinforce and support the positive symptom outcomes often reported anecdotally in clinical practice.

Improvement in quality of life in patients with heart failure who undergo transplantation.

BACKGROUND: Very few studies have examined quality of life longitudinally in heart failure patients from before or after heart transplantation. The purpose of this study was to compare quality of life of patients with heart failure at the time of listing for a heart transplant with that 1 year after the operation. Major dimensions of quality of life measured in this study were health, physical and emotional functioning, and psychosocial functioning. METHODS: A convenience sample of 148 patients (80% male and mean age 52 years) was recruited from a midwestern and southern medical center. Data were collected from chart review and six patient-completed instruments: the Heart Transplant Symptom Checklist, Sickness Impact Profile, Heart Transplant Stressor Scale, Jalowiec Coping Scale, Quality of Life Index, and Rating Question Form. Informed consent was obtained, and patients who agreed to participate in the study completed the booklet of self-administered instruments. Statistical analyses included frequencies, measures of central tendency, paired t-tests, and Wilcoxon signed-ranks tests. RESULTS: Total symptom distress decreased significantly overall from before to after heart transplantation (before = 0.19 versus after = 0.15, p < 0.0001). Patients rated themselves as having significantly poorer health while listed as a heart transplant candidate than at 1 year after surgery (before = 4.5 versus after = 7.5, p < 0.0001). Although the overall level of functional disability was fairly low before and 1 year after transplantation, patients still reported significant improvement after surgery (before = 0.21 versus 1 year after = 0.13, p < 0.0001). No significant differences were found in total stress, which was low to moderate (before = .026 versus 1 year after = 0.26, p = not significant), coping use (before = 0.48 versus 1 year after = 0.48, p = not significant), or coping effectiveness (before = 0.40) versus 1 year after = 0.42, p = not significant), from before to 1 year after heart transplantation. However, changes in types of symptoms, functional disability, stressors, and coping were noted over time. Overall satisfaction with life, which was fairly high at both time periods, increased significantly from the time of listing for a transplant to 1 year after surgery (before = 0.72 versus 1 year after = 0.82, p <0.0001), and overall quality of life improved significantly from before to after heart transplantation (before = 5.5 versus after = 7.8, p < 0.0001). CONCLUSIONS: End-stage heart failure patients had improved quality of life from before to 1 year after heart transplant due to less total symptom distress, better health perception, better overall functional status, more overall satisfaction with life, and improved overall quality of life. However, post-transplant patients still experienced some symptom distress, functional disability, and stress, but were coping well.

Impact of the heart transplant waiting process on spouses.

BACKGROUND: Practitioners working with candidates for heart transplants and their families know that the heart transplant waiting process is psychologically stressful and demanding. Spouses of heart transplant candidates struggle with multiple demands. Although many have studied the impact of heart transplantation on patients, only a few investigators have studied the impact of the heart transplant waiting period on spouses. METHODS: Using survey research methods, we studied the impact of the heart transplant wait on the lives of 85 spouses of heart transplant candidates from three sites using the following: Spouse Transplant Stressor Scale, Jalowiec Coping Scale, Family Inventory of Resources for Management, Quality of Life Index, a six-item rating scale, and a demographic form. RESULTS: One-third of the sample (30.6%) believed that the heart transplant waiting experience had a negative impact on their life, two-thirds (65.9%) believed it had a positive impact, and 3.5% believed that the heart transplant experience had no impact on their life. The longer the patient partner waited for a heart transplant, the more negative the impact was on the spouse's life (r = -0.23, p = 0.04). Spouses experiencing a negative impact from the heart transplant experience reported higher stressor scores (F = 3.74, p = 0.03), used more negative coping strategies (F = 3.69, p = 0.03), and had a lower quality of life (F = 3.28, p = 0.04). CONCLUSIONS: Spouses who reported a more negative impact from the heart transplant waiting experience were under more stress, used negative coping strategies, reported a lower quality of life, and had patient partners who waited longer for a heart.

Spouse stressors while awaiting heart transplantation.

OBJECTIVES: The objectives of this study were to identify common stressors experienced by spouses of heart transplantation (HT) candidates; to identify differences in stressors among spouses of HT candidates based on selected demographic variables; and to report preliminary psychometric data on the newly developed Spouse Transplant Stressor Scale. DESIGN: Comparative, cross-sectional survey. SAMPLE: Spouses of 85 HT candidates awaiting HT at midwestern and southeastern medical centers and a midwestern Department of Veterans Affairs hospital. MEASURES: Spouse Transplant Stressor Scale (Collins), an investigator-developed rating form and demographic data sheet. RESULTS: Spouses of HT candidates reported high levels of stress during the wait for a donor heart. Factors related directly to the transplantation experience were rated as the most stressful. Fear that the patient (partner) would die before a heart became available was the worst stressor for the spouses. Working spouses perceived more stressors related to responsibility, socioeconomics, and self. Stressors associated with the transplantation process itself were equally stressful for spouses who work and spouses who do not work.

Patterns of infection in the solid-organ transplant recipient.

Infection continues to be a major complication after transplantation. This article addresses common postoperative infections and how a complete preoperative and postoperative assessment of infections can affect the patient's morbidity and mortality. Prevention and treatment regimens for common infections that affect the immunosuppressed patient population also are discussed.

Utility of posttransplantation panel-reactive antibody measurements for the prediction of rejection frequency and survival of heart transplant recipients.

BACKGROUND AND METHODS: Seventy-six heart transplants in 73 patients were studied for the formation of lymphocytotoxic panel-reactive antibodies after transplantation. Treatment of patient serum with dithioerythritol was used to discriminate between antibodies of the immunoglobulin M and immunoglobulin G isotypes. Human leukocyte antigen specificities of immunoglobulin G panel reactive antibodies were determined by the pattern of reactivity with the cell panel used in the panel-reactive antibodies determinations. A total of 465 panel-reactive antibodies determinations were made during the first year after transplantation. RESULTS: Mean panel-reactive antibodies values were highest during the first posttransplantation month. Positive dithioerythritol-treated panel-reactive antibodies values were rare after the first month after transplantation. Multivariable analysis indicated that previous pregnancy and positive cytomegalovirus serologic analysis predicted a higher dithioerythritol-treated panel-reactive antibodies within the first 3 months. No decrease in actuarial survival, increase in cumulative rejection episodes, or increase in the incidence of coronary artery disease at 1 year was seen in patients with a standard panel-reactive antibodies greater than 10% or among patients with dithioerythritol-treated panel-reactive antibodies greater than 0%. A significant and major increase in rejection-related death or retransplantation occurred among 11 patients in whom donor human leukocyte antigen specific antibodies of the immunoglobulin G isotype were detected during the first posttransplantation year (p = 0.02). Two of the 11 patients died of refractory rejection and 3 and 6 months after transplantation, whereas one patient underwent retransplantation for refractory rejection at 13 months and subsequently died. CONCLUSIONS: (1) Posttransplantation serial standard panel-reactive antibodies or dithioerythritol-treated panel-reactive antibodies are not predictive of rejection-related mortality unless the specificity is determined to be antidonor HLA; (2) routine dithioerythritol-treated panel-reactive antibodies studies are advisable during the first month after transplantation, and, if positive (> 10%), antidonor human leukocyte antigen specificity should be determined; (3) detection of recipient immunoglobulin G anti-donor human leukocyte antigen antibodies after heart transplantation identifies a group at high risk for serious allograft rejection and should prompt more intensive rejection surveillance and consideration for additional immunotherapy.