Disfunción del injerto a largo plazo tras el trasplante cardiacoincidencia, causas y pronóstico

Abstract

OBJECTIVES: Late graft failure is a major cause of hospitalization and death among heart transplant recipients. Despite this is a common condition, there is little previously published information about its pathophysiology, incidence, clinical presentation, and prognostic implications. METHODS: We conducted a single-center, retrospective, observational study, based in a historical cohort of 547 patients who underwent heart transplantation in the Complejo Hospitalario Universitario de A Coruña from 1991 to 2014, and who survived the in-hospital postoperative period. Late graft failure was defined as the first hospital admission during long-term post-transplant follow-up. RESULTS: Over a mean follow-up period of 8.4 ± 6 years beyond the first hospital discharge, 178 (32.5%) patients were admitted due to new-onset late graft failure (incidence density rate: 3.6 cases per 100 patients-year, 95% Confidence Interval (CI) 3.1-4.2). By means of multivariable Cox´ s regression, pre-transplant diabetes, a higher transpulmonary gradient and a lower donor/recipient weight ratio were identified as independent predictors of late graft failure. Coronary allograft vasculopathy, acute rejection grade ≥1R, and antibody-mediated rejection grade pAMR ≥1 were identified in 50.6%, 44.9% and 19.2% patients admitted due to new-onset late graft failure. Left ventricular ejection fraction was ≥ 50% in 60.1% of these Retransplant-free survival 1, 5, 10 and 15 years after the diagnosis of new-onset late graft failure was 72.2%, 38.4%, 18.4%, and 7.5% respectively; the incidence density rate of re-hospitalization due to decompensated heart failure was 40.9 episodes per 100 patientsyears (CI 95% 36.6-46-6). The need for inotropes, the presence of coronary allograft vasculopathy, higher levels of serum creatinin, a reduced ejection fraction, and hyponatremia were independently associated with poorer outcomes in these individuals. In the subgroup of patients admitted due to late graft failure who showed evidence of acute rejection, the presence of signs of antibody-mediated rejection was associated with lower retransplant-free survival (p=0.038). CONCLUSIONS: Late graft failure is frequent in heart transplant recipients, and it is associated with poor survival. The most frequent underlying causes of late graft failure are coronary allograft vasculopathy and acute rejection.