Steroid use in heart transplant patients in Spain in the current era: a multicenter survey

Abstract

Objective: Steroid withdrawal (SW) from maintenance therapy in heart transplant patients is still a controversial subject. We designed a questionnaire to ascertain the attitudes and procedures of a number of Spanish heart transplant units (16) regarding the use/withdrawal of steroids as part of the immunosuppressive maintenance therapy.

Materials and methods: We sent an 11-item questionnaire to the clinical director in charge of each unit. The questionnaire was completed and returned by 14 units.

Results: In 21.5% of the centers SW was performed in all patients, while 78.5% of the centers only performed SW in selected patients. In 57% of units SW was performed at 12 months posttransplantation and between 6 and 12 months in the rest. Fewer than 20% of patients were steroid-free in 46% of units while in 23% of units this proportion was >50%. In 11 units, the minimum prednisone dose administered was <or=5 mg/d. More than 80% used the following selection criteria for SW: no acute rejection episodes (ARE) in the first 3 to 6 months, low immunological risk, and concomitant immunosuppression. The main expected benefits were: a decrease in the incidence of diabetes, bone problems, and obesity, and improved dyslipidemia, hypertension, and overweight. Twenty-eight percent of units performed an endomyocardial biopsy (EMB) before SW, while 3 units also repeated it after SW. In most cases (72%), an EMB was always performed at 1 month after withdrawal. In a low percentage of cases (<30%), all units had to reintroduce steroids in the maintenance regimen due to an ARE (73%).

Conclusions: Most heart transplant units (78.5%) performed SW at 1 year after transplantation in selected patients: those without an ARE in the first 3 to 6 months and those with low immunological risk. The main benefits were to avoid or reduce diabetes and bone problems, and to a lesser extent, overweight, hypertension, and hypercholesterolemia. In <30% of patients steroids had to be reintroduced due to an ARE.