Chang David H, Youn Jong-Chan, Dilibero Deanna, Patel Jignesh K, Kobashigawa Jon A
Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
Int J Heart Fail. 2020 Sep 29;3(1):15-30. doi: 10.36628/ijhf.2020.0034. eCollection 2021 Jan.
Heart transplant is the optimal treatment for selected patients with end-stage heart failure. Immunosuppression after heart transplantation has significantly reduced the incidence of rejection and improved patient outcomes with the routine use of calcineurin inhibitors. Antimetabolites and proliferation signal inhibitors add to the improvement in patient outcomes as well. The goal of induction therapy is to provide intense immunosuppression when the risk of allograft rejection is highest. Most maintenance immunosuppressive protocols employ a 3-drug regimen consisting of a calcineurin inhibitor, an antimetabolite agent and glucocorticoids. The management of rejection proceeds in a stepwise fashion based on the severity of rejection detected on biopsy and the patient's clinical presentation. This review will cover induction, maintenance, rejection therapy and some special considerations including sensitization, renal sparing protocol, and corticosteroid weaning. It will end in consideration of potential future directions in immunosuppressive strategies to promote patient and graft survival.
心脏移植是选定的终末期心力衰竭患者的最佳治疗方法。心脏移植后的免疫抑制通过常规使用钙调神经磷酸酶抑制剂，显著降低了排斥反应的发生率并改善了患者的预后。抗代谢物和增殖信号抑制剂也有助于改善患者的预后。诱导治疗的目标是在移植器官排斥风险最高时提供强化免疫抑制。大多数维持性免疫抑制方案采用由钙调神经磷酸酶抑制剂、抗代谢物药物和糖皮质激素组成的三联疗法。根据活检检测到的排斥反应严重程度和患者的临床表现，以逐步的方式进行排斥反应的管理。本综述将涵盖诱导治疗、维持治疗、排斥反应治疗以及一些特殊考虑因素，包括致敏、肾脏保护方案和糖皮质激素减量。最后将考虑免疫抑制策略未来潜在的发展方向，以提高患者和移植器官的存活率。
