Sepsis in heart transplant recipients: Is the new definition applicable?

The Editor,

Heart transplant recipients are at increased risk of infection and sepsis because of immunosuppression. Recently, in the February issue of JAMA, a new definition of sepsis has been published, which defines sepsis as “life-threatening organ dysfunction due to a dysregulated host response to infection.”[1] The immune system of heart transplant recipients, in the early postoperative period, is adapting to the new graft and immunosuppressant medications. It is neither completely suppressed nor active, a state which may be labeled as dysfunctional. Therefore, in the early postoperative period (<30 days) of heart transplant, it is only prudent to ignore the phrase “dysregulated host response” from the definition.

The definition that remains is “life-threatening organ dysfunction due to infection” which actually holds true in the setting of a heart transplant. The dilemma although remains do any life-threatening organ dysfunction and the positive documentation of an infection equates to sepsis? One common organ dysfunction after heart transplant is acute kidney injury (AKI) which is associated with high mortality in dialysis-dependent patients.[23] As per current definition, an infection manifesting in a recipient who already has AKI may not be labeled as sepsis until the existing AKI worsens and becomes life threatening, or a new life-threatening organ dysfunction occurs. The aforesaid discussion points that “life threatening” is the key word, and the sequence of events is important.

Heart transplant recipients follow a very steep downhill course once sepsis sets in and the duration between the evidence of infection and occurrence of sepsis may actually be very less. Therefore, it is prudent to recommend that “any organ dysfunction due to infection (life threatening or not)” should be managed as sepsis in heart transplant recipients.

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