Acute cellular rejection can be defined as any clinical event requiring treatment by a significant increase in immunosuppression. During the first year following heart transplantation, the average patient will have 1.3 ± 0.7 episodes of acute cellular rejection. Identifiable risk factors for early acute cellular rejection include female sex and young age of the donor. The endomyocardial biopsy has served as the gold standard for diagnosing allograft rejection since its introduction in 1973. In 1990, a formulation standardizing the grading of endomyocardial biopsies for the degree of cardiac rejection was established ( Table... .6). Endomyocardial biopsies are generally performed every 1 to 2 months during the first year, when rejection risk is greatest. Arrhythmias or new evidence of congestive heart failure should alert the physician to possible acute cellular rejection. Treatment of significant rejection episodes begins with pulse doses of corticosteroids for 3 days (methylprednisolone 500-1000 mg/day) followed by augmented primary immunosuppression. Steroid refractory acute cellular rejection has been treated with variable success by a variety of methods including lymphocytotoxic therapy and total lymphoid irradiation.
Table 6 Standardized grading system for classifying cellular rejection on endomyocardial biopsy specimens
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