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Ann Thorac Surg 1994;58:999-1004
© 1994 The Society of Thoracic Surgeons
Division of Thoracic and Cardiovascular Surgery, Surgical Center, Hanmover Medical School, Hannover, Germany
* Address reprint requests to Dr Hausen, Abteilung für Thorax-, Herz- und Gefäβchirurgie, Zentrum Chirurgie, Org. Nr. 6210, Medizinische Hochschule Hannover, D-30623 Hannover, Germany.
The toxicity of long-term immunosuppressive therapy has become a major concern in long-term follow-up of heart transplant recipients. In this respect the quality of renal function is undoubtedly linked to cyclosporin A (CsA) drug levels. In cardiac transplantation, specific CsA trough levels have historically been maintained between 250 and 350 µg/L in many centers without direct evidence for the necessity of such high levels while using triple-drug intmunosuppression. This retrospective analysis compares the incidence of acute and chronic graft rejection as well as overall mortality between groups of patients with high (250 to 350 µg/L) and low (150 to 250 µg/L) specific CsA trough levels. A total of 332 patients who underwent heart transplantation between October 1985 and October 1992 with a minimum follow-up of 30 days were included in this study (46 women and 276 men; aged, 44± 12 years; mean follow-up, 1,122 ± 777 days). Standard triple-drug immunosuppression included firstyear specific CsA target trough levels of 250 to 300 µg/L. Patients were grouped according to their average creatinine level in the first postoperative year (group I, 1;30 µmol/L, n = 234; group II, 3
130 µmol/L, n = 98). The overall 5-year survival excluding the early 30-day mortality was 92% (group I, 216/232) and 91% (group II, 89/98) with 75% of the mortality due to chronic rejection. The rate of rejection for the entire follow-up period was similar in both groups (first yean group I, 3.2 ± 2.6 rejection/patient/year; group II, 3.6± 2.7 rejection/ patient/year; p = not significant). The CsA levels were significantly lower in group II patients (CsA level: group 1,240± 58 µg/L versus group II, 197± 51 µg/L; p < 0.05). The results show that in patients with preoperatively or perioperatively compromised renal function specific CsA levels can be lowered safely to less than 200 µg/L without an increased risk for acute or chronic graft rejection. This reduction often is associated with preservation or even improvement of renal function.
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