Treatment of rejection depends on the type and severity of the pathologic grade as well as clinical symptoms and the presence of hemodynamic changes (see table).
Patients with grade 1 rejection without hemodynamic changes are often not treated but followed closely for progression. Rejection often resolves spontaneously, avoiding the risks of additional immunosuppression. Grade 3 and 4 rejection, in comparison, requires significant changes in therapy. These episodes of rejection are usually treated with high doses of intravenous or oral steroids for 3 days, followed by a rapid steroid taper. Steroid-resistant episodes are treated with OKT3, a mouse monoclonal antibody to the CD3 molecule, which is part of a multi-molecular complex found on mature C cells.
International Society of Heart and Lung Transplantation Scale for Cardiac Rejection
What is peripheral vascular disease (PVD)?
This term peripheral vascular disease is usually used to describe atherosclerotic peripheral arterial disease. Other names for this condition are peripheral arterial disease and arteriosclerosis obliterans.
How is claudication different from other types of leg pain?
Claudication is the characteristic symptom of PVD. It is an intermittent pain which results from inadequate tissue perfusion during exercise. It consists of three essential features:
The pain is always experienced in a functional muscle unit (calf, buttock, thigh, etc.).
It is reproducibly precipitated by exercise.
It is promptly relieved by rest.
Claudication does not necessarily have to be pain; it can be cramping, weakness, or numbness.
An elderly woman complains of calf pain that occurs when she walks more than two blocks. She has a normal pulse in the dorsalis pedis and posterior tibial arteries. Does she have claudication?
Possibly. Several conditions share the characteristic onset of leg pain with exercise, including arterial embolism, muscle phosphorylase deficiency, drug toxicity (vasospasm), as well as nonvascular causes such as arthritis and lumbar disc disorders. They can be differentiated from PVD by the reproducibility of pain (recurs consistently after the same amount and type of activity in PVD), means of pain relief, and presence of distal pulses (reduced in PVD).
The patient should be asked what she does to relieve the pain”sit down, stand up, slow down? Does the pain develop in other activities? In this case, the patient can relieve the pain only by sitting down, and the pain sometimes develops after she stands too long. These differences suggest pseudoclaudification, which is from spinal stenosis. Spinal stenosis causes a pain very similar to claudication that is relieved by sitting or bending over, but not by standing up straight (as it is in PVD). The presence of normal distal pulses also makes PVD less likely.