Corticosteroid wean after heart transplantation-Is there a risk for antibody formation?

Background: Corticosteroid withdrawal after heart transplantation is limited to select immune-privileged patients but it is not known whether this predisposes patients to a higher risk for sensitization. Methods: A total of 178 heart transplant recipients had panel-reactive antibody (PRA) measurements at transplant and every 6 months and were monitored for rejection with protocol endomyocardial biopsies. Corticosteroid withdrawal was initiated at 6 months post-transplant in select patients. Results: Patients successfully weaned off prednisone (SPW; n= 103) had lower PRA compared to those maintained on prednisone (MP; n= 51) at pretransplant (34% vs 63%), 6 months (18% vs 49%), 12 months (19% vs 51%), and 18 months (15% vs 47%) after transplant (P<. 05). Among 68 nonsensitized patients at transplant in the SPW group, seven (10%) developed de novo PRA at 12 months, compared to four of 19 (21%) of MP patients. Freedom from any treated rejection (97% vs 69% vs 67%), acute cellular rejection (100% vs 86% vs 71%), and antibody-mediated rejection (100% vs 88% vs 88%; all P=. 001) at 2 years was higher in SPW compared to MP and those who failed prednisone wean, respectively. Conclusion: Few patients successfully weaned off prednisone after heart transplant develop de novo circulating antibodies but are not at increased risk for developing rejection.