METHOTREXATE AS RESCUE ADJUNCTIVE IMMUNOTHERAPY IN INFANT AND ADULT HEART-TRANSPLANTATION

Methotrexate may be a useful adjunct to more conventional immunosuppression in heart transplantation, but experience is limited. We report our findings in 18 patients aged 19 days to 64 years, who were treated with methotrexate. Five patients were less than 1 year of age; 11 patients were over 16 years of age. Indications could be divided in two groups. Seven patients were treated with methotrexate as rescue therapy for unresolving acute grade 3 rejection or for early recurrence after one rejection episode that had been treated with steroids and antilymphocyte serum. All infants were treated with methotrexate for life-threatening rejection. Methotrexate was given as an adjunct to conventional treatment in six patients for mild rejection, which occurred while steroids were being decreased or in patients with relative contraindications to high-dose steroids. One grade 3b rejection could not be reversed with methotrexate and led to the patient's death 3 months later. One grade 1b rejection only temporarily improved and was actually reversed with high-dose steroids after 4 months. All other rejections were rapidly reversed with the use of methotrexate. Tolerance of methotrexate has been very good with transient leukopenia in four patients, with ulcerative stomatitis in one patient, and with transient elevation of liver enzymes in two patients. We conclude that methotrexate is a valuable rescue/adjunctive immunotherapeutic agent that is capable of altering heart rejection with considerable safety and efficacy.