Tuesday, March 21, 2023
|
Therapy Class |
Therapy Name(s) |
|---|---|
|
Induction immunosuppression |
|
|
High-dose corticosteroids |
Prednisone, methylprednisolone |
|
Cytolytic therapy |
Anti-thymocyte Ig |
|
Interleukin-2 receptor inhibitor |
Basiliximab |
|
Maintenance immunosuppression |
|
|
Corticosteroids |
Prednisone, methylprednisolone |
|
Calcineurin inhibitors |
Tacrolimus, cyclosporine |
|
Cell-cycle inhibitors |
MMF, azathioprine |
|
Proliferation signal inhibitors |
Sirolimus, everolimus |
|
ACR treatment* |
|
|
High-dose corticosteroids |
Prednisone, methylprednisolone |
|
Cytolytic therapy† |
Anti-thymocyte Ig |
|
AMR treatment* |
|
|
High-dose corticosteroids |
Prednisone, methylprednisolone |
|
Cytolytic therapy† |
Anti-thymocyte Ig |
|
CD20 inhibitor |
Rituximab, obinutuzumab |
|
Proteosome inhibitor |
Bortezomib |
|
Complement inhibitor |
Eculizumab |
|
Ig |
Intravenous IgG |
|
Plasmapheresis |
|
Table 1. General Immunosuppressive Therapies Used After HT and for Rejection Treatment[1,8,9]
*Optimize maintenance immunosuppression and can add rejection treatment.
The failing graft may also be supported with inotropic agents and mechanical circulatory support.
|
ACR Grade |
2005 Scale |
1990 Scale |
|---|---|---|
|
No ACR |
0 R |
0 |
|
Mild |
1 R |
1A, 1B, 2 |
|
Moderate |
2 R |
3A |
|
Severe |
3 R |
3B, 4 |
Table 2. Comparison of 2005 and 1990 ACR Grading Scales[1,5,12]
|
Grade |
Definition |
Substrates |
|---|---|---|
|
pAMR 0 |
Negative for pathologic AMR |
Histologic and immunopathologic studies are both negative. |
|
pAMR 1 (H+) |
Histopathologic AMR alone |
Histologic findings are present and immunopathologic findings are negative. |
|
pAMR 1 (I+) |
Immunopathologic AMR alone |
Histologic findings are negative and immunopathologic findings are positive (CD68+ and/or C4d+). |
|
pAMR 2 |
Pathologic AMR |
Histologic and immunopathologic findings are both present. |
|
pAMR 3 |
Severe pathologic AMR |
Interstitial hemorrhage, capillary fragmentation, mixed inflammatory infiltrates, endothelial cell pyknosis, and/or karyorrhexis, and marked edema and immunopathologic findings are present. These cases may be associated with profound hemodynamic dysfunction and poor clinical outcomes. |
Table 3. The 2013 ISHLT Working Formulation for Pathologic Diagnosis of AMR in HT[6]
|
Major Complications |
Minor Complications |
|---|---|
|
Death (0%-0.07%) |
Chest pain (transient)(0%-1.8%) |
|
Cardiac perforation, hemopericardium, tamponade (0%-6.9%) |
Deep vein thrombosis(0.23%-3.8%) |
|
Pneumothorax, air embolism (0%-0.8%) |
Puncture site hematoma, nerve palsy (0%-0.64%) |
|
Thromboembolism (0%-0.32%) |
Hypotension, vasovagal syncope (0%-4.3%) |
|
Valvular trauma (0.02%-1.10%) |
Arterial trauma, vascular damage, fistulae (0.32%-2.80%) |
|
Severe arrhythmias, atrioventricular block (0%-11%) |
Table 4. Major and Minor Complications of EMB[22]
Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.
Disclosures for additional planners can be found here.
Professor of Medicine
University of Utah School of Medicine
Salt Lake City, Utah
This activity has been peer reviewed and the reviewer has no relevant financial relationships.
Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™
ABIM Diplomates - maximum of 1.00 ABIM MOC points
This activity is intended for cardiologists, transplant surgeons and other HCPs who work with patients who have received a heart transplant.
After participating in the activity, learners will understand current standards in cardiac allograft transplant monitoring and how novel, noninvasive modalities may impact the current standard of care.
Upon completion of this activity, participants will:
Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.
Disclosures for additional planners can be found here.
Professor of Medicine
University of Utah School of Medicine
Salt Lake City, Utah
This activity has been peer reviewed and the reviewer has no relevant financial relationships.
Medscape, LLC designates this enduring material for a maximum of 1.0
AMA PRA Category 1 Credit(s)™
. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.
For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]
There are no fees for participating in or receiving credit for this online educational activity. For information on applicability
and acceptance of continuing education credit for this activity, please consult your professional licensing board.
This activity is designed to be completed within the time designated on the title page; physicians should claim only those
credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the
activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.
Follow these steps to earn CME/CE credit*:
You may now view or print the certificate from your CME/CE Tracker. You may print the certificate, but you cannot alter it.
Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period, you can print
out the tally as well as the certificates from the CME/CE Tracker.
*The credit that you receive is based on your user profile.
CME / ABIM MOC Released: 3/23/2022
Valid for credit through: 3/23/2023
processing....
After participating in the activity, learners will understand current standards in cardiac allograft transplant monitoring and how novel, noninvasive modalities may impact the current standard of care.
Before you begin this activity, please assess your clinical knowledge by completing this brief survey. Answering these questions again after the activity will allow you to see what you learned and to compare your answers with those of your peers.
