in detecting rejecting patients or identifying those at low risk of rejection, although BNP change over longer periods of time can predict significant rejection [28–30].

for cellular rejection. Moreover, this scenario makes clinical trial design in this area chal­lenging. Though potentially dynamic, hemo­dynamics from right heart catheterization can help determine the appropriate hospital setting for treatment of HTx rejection. Critically ill patients with hemodynamic compromise rejec­tion (HCR) have elevated filling pressures and low cardiac output/cardiac index and should be cared for in an intensive care unit (ICU). These patients may need inotropes to maintain adequate cardiac output/cardiac index and may require vasopressors to maintain adequate blood pressure. High dose intravenous (IV) corticos­teroids are the first line of treatment for sympto­matic ACR. For patients with HCR, the addition of cytolytic therapy with anti-thymocyte globu­lin (ATG) is recommended. Maintaining or rais­ing the target calcineurin inhibitor (CNI) trough goal should be considered in conjunction with treatment of ACR. Once the acute phase of treatment with IV corticosteroids (±IV cytol­ytic therapy) is completed, an oral steroid taper should follow. Consideration of the change of anti-metabolite to proliferation signal inhibitor (PSI) can occur in the hospital or at outpatient discharge follow-up, depending on a number of clinical factors. After the initiation of high dose IV corticosteroids, appropriate antibiotic proph­ylaxis should be prescribed for approximately 3 months. Trimethoprim-sulfamethoxazole (Bactrim) can be prescribed to prevent pneu­mocystis jiroveci and nocardia infections. Valganciclovir (Valcyte) can be prescribed to prevent viral infections, including cytomegalo­virus (CMV). Clotrimazole (Mycelex) can be used to prevent fungal infections, including oral thrush. Repeat surveillance EMB should follow in 2–4 weeks after the diagnosis and initiation of treatment for ACR.