Corticosteroid use beyond 1-year post heart transplantation is associated with worse outcomes: A contemporary analysis of the ISHLT registry.

INTRODUCTION

Immunosuppressive drugs ensure graft survival in heart transplantation (HT). However, prolonged use can lead to significant morbidity and mortality, and the optimal immunosuppressive regimen is unknown. We compared outcomes in adult HT recipients with or without steroid use in the large, international ISHLT Registry.

METHODS

We included adults who underwent their first heart-only transplant between January 2010 and June 2018. We compared the risk-adjusted 2-, 3-, and 5-year survival as well as coronary allograft vasculopathy (CAV), treated rejection within 2 years, severe renal dysfunction, diabetes and malignancy rates between those with and without steroids by 1-year post-HT follow-up.

RESULTS

We included 17,483 HT recipients, steroids were discontinued in 8750 (50.0%) recipients beyond 1-year post-HT. Unadjusted survival rates (conditional upon 1-year survival) were significantly lower in the cohort receiving steroids at 2-years (96.2% vs. 98.0%, p<0.001), 3-years (93.3% vs. 96.5% p<0.001), and 5-years (89.8% vs. 94.0%, p<0.001). After adjustment, continued steroid use remained associated with a significantly higher risk of 2-year (HR 1.92, 95% CI 1.60-2.31), 3-year (HR 1.88, 95% CI 1.63-2.16), and 5-year mortality (HR 1.64, 95% CI 1.47-1.82). Furthermore, continuing steroid was associated with a significantly higher prevalence of CAV (OR 1.09, 95% CI 1.01-1.18), diabetes (OR 1.24, 95% CI 1.12-1.36), 2-year treated rejection (OR 2.50, 95% CI 2.25-2.73), and severe renal dysfunction (OR 1.66, 95% CI 1.50-1.84) but no difference in malignancy rates (OR 0.85, 95% CI 0.70-1.04).

CONCLUSIONS

Steroid use beyond 1year post heart transplant was associated with significantly lower survival, and worsened morbidity among adult recipients. Whether this observation indicates steroid use is a marker of higher risk or worsens prognosis warrants prospective investigation.