Update: 11/23/01
VANDERBILT PEDIATRIC HEART TRANSPLANTATION
Rejection Protocol
Mild rejection/Asymptomatic
1A
No change in therapy
1B
Consider Oral Pulse Steroids
Moderate rejection/Asymptomatic or mild symptoms
2
No change in therapy
3A
Pulse steroids; IV if early post-transplant; PO if late post-transplant
Moderate/severe rejection/Hemodynamically significant
3B
IV pulse steroids; Consider Thymoglobulin; Mechanical support as needed
4
IV pulse steroids; Thymoglobulin; Mechanical support as needed
“Guideline” regarding interpretation of ECHO scores:
It is important to know how ECHOs compare with past ECHOs for that patient and what the SF
is. This program only scores points for SF <28%, most transplants run SF>35-40%.
Clinical
symptoms
None
ECHO score 0-3
ECHO score > 4
No change in surveillance.
Change, possible
alternative cause
Very suspicious of
rejection
Admit, observe, repeat ECHO
< 24 hrs, consider biopsy.
Biopsy
Repeat ECHO < 24
hours
Treat for rejection
Treat for rejection
Optimize oral regimen whenever rejection occurs or is suspected.
H2 antagonist is added for ulcer prophylaxis during steroid therapy.
Biopsy should always be done prior to initiation of therapy beyond steroids, or for persistent
rejection, unless clinically too unstable for biopsy at presentation.
High dose IV Solumedrol (methylprednisolone) for symptomatic rejection or early moderate to
severe rejection:
125 mg BID x 3-4 days (<1 yr)
or
250 mg BID x 3-4 days (>1 yr to adolescent)
or
1 gram qd or 500 mg BID x 3-4 days (adolescent)
High dose PO Prednisone for asymptomatic, late moderate rejection (3A):
infant/child:
1 mg/kg/dose PO BID, rapid daily taper to 0.8, 0.6, 0.4 mg BID
then wean off over next 10 days.
adolescent:
50 mg PO BID, rapid daily taper to 40, 30, 20 BID, then decrease
by 1 mg/dose/day until twice daily maintenance dose of 10 mg
PO BID is attained at 2weeks, wean further as indicated.
Alternative PO Prednisone for asymptomatic, late (>60d) moderate rejection (3A):
infant/child:
1 mg/kg/dose PO BID x 3 days, then resume prior prednisone
dose.
adolescent:
100 mg PO QD x 3 days, then resume prior prednisone dose.
Thymoglobulin (ATG):
1.5-3.0 mg/kg/day QD for 5 days (up to 7-14 days; as short as 3 days).
See separate order sheet for details.