This handout is for adhf in cardiac transplant recipient (cav / acr / amr). Your care team identified this based on: heart transplant recipient with new dyspnea / orthopnea / edema (concern for rejection or cav).
Other reasons your team may use this plan: unexplained troponin or bnp rise in transplant recipient (rejection screen); new lvef reduction on surveillance echo in transplant recipient; positive donor-specific antibody (dsa) titer + clinical decompensation → amr concern.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| methylprednisolone | 1000 mg IV daily × 3 days (pulse therapy) | IV | daily × 3 | ISHLT 2010 (Stewart PMID 21177015) — pulse steroids first line for ≥2R ACR; also adjunct in AMR |
| mycophenolate mofetil | 1000–1500 mg PO BID (continue maintenance; do not hold for rejection) | PO | BID | ISHLT 2023 maintenance triple therapy (CNI + MMF + steroids); continue during rejection treatment |
| tacrolimus | Maintain trough 8–12 ng/mL early post-transplant; 5–10 ng/mL late; AVOID over-reduction | PO | BID | KDIGO transplant 2009 — narrow therapeutic window; sub-therapeutic trough is the most modifiable rejection driver |
| rituximab | 375 mg/m² IV weekly × 4 | IV | weekly × 4 | AMR B-cell depletion; ISHLT 2013 AMR working formulation |
| immune globulin (IVIG) | 1–2 g/kg IV (split over 2–5 days) | IV | one course (often combined with plasmapheresis) | AMR neutralization of circulating DSA; combined with plasmapheresis per ISHLT 2013 |
| torsemide | 20–40 mg IV/PO | IV/PO | daily–BID | Decongestion; preferred over furosemide if gut edema (TRANSFORM-HF Mentz JAMA 2023); avoid NSAIDs |
Plan: Cardiac transplant ADHF — rejection / CAV phenotype-based regimen (ISHLT 2010 + 2023; KDIGO transplant 2009)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Guideline: ISHLT 2010 ACR grading + ISHLT 2013 AMR working formulation + ISHLT 2023 update + KDIGO transplant 2009