Thoracic organ transplantation in children. The Sahlgrenska University Hospital experience

On the basis of the experience acquired from more than 350 thoracic organ transplantations in adults, the outcome of thoracic organ transplantations in the paediatric age group (0-17 years of age) performed consecutively from 1989 to 1998 at our centre was reviewed. Heart transplantation was performed in 27 patients, heart-lung in 6 and bilateral lung transplantation in 2 patients. The preoperative diagnosis included dilated cardiomyopathy in 17 patients, congenital heart defects in 8, hypertrophic cardiomyopathy in 2, cystic fibrosis in 1 and secondary and primary pulmonary hypertension in 5 and 2 patients, respectively. The median age at transplantation and the follow-up period were 12.7, range 0.3-18.2, and 4, range 0.1-9.2 years, respectively. No early deaths occurred after heart transplantation, but one patient died of coronary artery disease 4.8 years after transplantation. One early death occurred one week after heart-lung transplantation as a result of bleeding complications, and another patient died of obliterative bronchiolitis and pulmonary infection 2.5 years after surgery. The remaining patients are alive and have been functionally rehabilitated. In conclusion, despite a relatively small centre volume, paediatric thoracic organ transplantations can be performed with good short- and medium-term survival and good functional status can be achieved by deriving knowledge and experience from transplantations in adults and by collaboration between the various professionals involved in the caring process.

[Practice guidelines of the Spanish Society of Cardiology. Cardiac and heart-lung transplants]

Cardiac transplantation is the only therapy that is able to substantially modify the natural evolution of patients with severe heart failure, along with angiotensin converting enzyme inhibitors. Nevertheless, because of the limited number of donors, its impact is scarce compared to the magnitude of the problem. Up to the end of 1998, 48,541 orthotopic cardiac transplantations and about 2,510 heart and both lung transplantations have been registered throughout the world. In Spain 2,780 procedures have been performed in the last 15 years. The survival expectations for a transplanted patient is 75% after the first year and 60% the following 5 years. The average duration of the graft is 8 years and 6 months. Cardiac transplantation is indicated for young and middle-age patients with irreversible cardiac process in bad clinical condition, with no other possibility of medical or surgical management and with a limited life expectancy. The major debate when choosing this therapy appears with the critical patients, patients older than 65 years, and some patients with systemic diseases. The great demand of transplantation obliges the teams to enlarge the criteria for donors' acceptance. At the same time, the increase of the knowledge about the transmission of some infections, mainly viral, forces to review those criteria day-to-day. The use of different immunosuppressive strategies pursues the control of rejection. The most commonly used is the so-called triple therapy (cyclosporine-azathioprine and steroids). The use of antilymphocytic antibodies such as cytolytic induction treatment is not unanimously accepted. Some of the new immunosuppressive agents such as myphenolate-mofetil and tacrolimus seem to offer advantages mainly due to their greater potency. Since transplantation is a limited procedure, of which its practise has an effect on the whole health system of a country, a perfect planning and adequacy of the Centers is compulsory, as well as the setting-up of clear rules for the use of donors and priority of transplantation. Finally, the patient must be informed clearly and comprehensively at length of the risks, limitations and expectations of these complex procedures.

[Lung transplantations--methods, indications and results 1986-1998]

The National Hospital is the national centre for organ transplantation in Norway, and heart-lung-transplantation was introduced at the hospital in 1986. In this report, methods, patient selection and the current expectations of the various forms of lung transplantation are described. Heart-lung transplantation and bilateral lung transplantation have been used in patients in which a diseased heart or a native lung left behind would create serious problems in the postoperative period, thus we select patients to unilateral lung transplants whenever it is feasible. Due to a severe lack of lung transplants, and based on results of heart-lung and lung transplantation at other transplantation centres, we apply different upper age limits to the various transplantation procedures. 98 lung transplantations have been performed at Rikshospitalet, 96 of them after 1990; 15 heart-lung transplantations, 66 single lung transplantations in 61 patients, and 17 bilateral, sequential lung transplantations. 30 day mortality is 15%. One and five years recipient survival is 70% and 34% after heart-lung transplantation, 66% and 48% after single lung transplantation, and 81% and 63% after bilateral lung transplantation. Significant bronchial complications occurred in 7% of all anastomosis performed. The results are similar to data from The International Registry for Heart and Lung Transplantation. Lung transplantation is not developed to the same level as other forms of organ transplantation. Organ shortage is the most critical factor for further development of the lung transplantation programme.

The UNOS OPTN waiting list and donor registry

1. On October 31, 1998, there were 62,994 registrants on the combined UNOS waiting list. Of these, 66% were awaiting kidney transplantation, and 18% were awaiting liver transplantation. 2. The majority of patients on the UNOS waiting list on October 31, 1998 were blood type O (52%), White (60%) and male (58%). 3. Median waiting times (MWTs) have increased steadily for nearly every organ since 1988, especially for liver, kidney, and lung registrants. 4. For patients added to the waiting list in 1996. MWTs to transplant were longest for heart-lung registrants (742 days). The shortest waiting times for this cohort were among heart registrants (223 days). No median could be calculated for kidney registrants added in 1996. 5. Death rates per patients waiting at risk declined during 1988-1997. Death rates were higher for patients awaiting life-saving organs (liver, heart, lung, heart-lung) than for non-lifesaving organs (kidney, pancreas, kidney-pancreas). 6. There were 5,478 cadaveric and 3,820 living donors recovered in 1997, a 34% and 109% increase over those recovered in 1988. 7. Large increases were seen in the number of liver (45-84%), pancreas (14-24%), and lung (3-15%) donors between 1988-1997. 8. The number of cadaveric donors aged 50 or older has increased from 12% of all donors in 1988 to 28% of all donors in 1997. 9. The typical cadaveric donor in 1997 was a white male with ABO blood type O, between the ages of 18-34. In 1997, a typical living donor was a white female with ABO blood type O between the ages of 35-49. 10. Between 1988-1997, the percentage of minority donation increased for cadaveric donors (17-24%), and for living donors (23-27%). 11. The number of living donors who were either spouses or unrelated to the recipient increased from 4% in 1988 to 15% in 1997.

Worldwide thoracic organ transplantation: a report from the UNOS/ISHLT International Registry for Thoracic Organ Transplantation

1. The number of heart transplant operations performed in the US decreased by 52 procedures between 1996 (2,344) and 1997 (2,292). The number of lung transplants increased by 118 in 1997 (928). 2. The most frequently reported indication for heart transplantation in the US was coronary artery disease (44.9%). For other thoracic transplants, the most frequently reported indications included cystic fibrosis (36.8%) for double-lung, emphysema/COPD (53.8%) for single-lung and congenital disease (33.9%) for heart-lung transplants. The most frequently reported diagnoses for thoracic transplantation outside the US included cardiomyopathy (50.4%) for heart, cystic fibrosis (31.3%) for double-lung, idiopathic pulmonary fibrosis (32.4%) for single-lung and primary pulmonary hypertension (23.3%) for heart-lung transplants. 3. US heart transplant recipients were predominately male (77.4%), over age 50 (55.9%) and white (82.1%). In contrast, US lung transplant recipients were predominantly female (51.9%), between ages 35-64 (73.4%) and white (89.5%). No meaningful variance from the US recipient demographic profile was noted for the non-US recipients during the same time period. 4. Mean ischemic time showed minimal change for hearts (2 minutes), a sharp increase for heart-lungs (29.5 minutes) and a decrease for lungs (11 minutes) from 1997-1998. 5. The one-year survival rates for thoracic transplants performed in the US were 83.2% for heart, 75.7% for lung and 34.1% for heart-lung in 1997. Five-year survival rates for US thoracic transplants were 66% for heart and 46.4% for lung for transplants performed in 1993. 6. Long-term patient survival rates were: 29.5% at 14 years for heart, 19.4% at 9 years for lung and 26.2% at 11 years for heart-lung recipients. 7. The most important risk factor for mortality of US heart recipients at one month, one year and conditionally at 5 years after transplantation was receipt of a previous heart transplant. Significant short-term risk factors included recipient age and ischemic time. Substantial long-term risk factors included older donor age and donor race. 8. The factors having the most significant impact on lung mortality at all time points were related to either the patient's medical condition (e.g.x, in the ICU prior to transplant, requiring mechanical ventilation) or diagnosis. 9. Mechanical ventilation and previous transplant had the largest impact on heart-lung mortality. 10. For heart and lung recipients, the major cause of rehospitalization during the first year after transplantation was infection alone.

Lung transplant waiting list: differential outcome of type of end-stage lung disease, one year after registration

BACKGROUND

Donor lung scarcity, distinct natural courses of the different types of end-stage lung diseases, and lung allocation schemes demand appropriate candidate acceptance for a lung transplant and time of listing. This study was undertaken to investigate the association between type of end-stage lung disease and outcome, 1 year after a lung transplant candidate was put on the waiting list.

METHODS

From 1990 to 1995, 1376 adult patients were registered for a first lung (n = 1006) or heart-lung (n = 370) transplantation in Eurotransplant. All patients were followed for at least 1 year. For each type of end-stage lung disease (cystic fibrosis, pulmonary fibrosis, emphysema, pulmonary hypertension, congenital heart disease, and other), chances of transplantation, of death on the waiting list, and of removal for other reasons, 1 year after listing, were calculated with the competing risks method. A multivariate Cox regression model was used to assess the influence of the type of end-stage lung disease on the waiting list outflow among other prognostic variables.

RESULTS

Lung transplant candidates with emphysema and with pulmonary fibrosis had the highest chance of a transplant; however, patients with pulmonary fibrosis had also the highest probability of dying while waiting, while the emphysema patients and those with the type "other" had the lowest probability. In the multivariate analysis, the type of end-stage lung disease appeared as an independent prognostic factor for both outcomes. Compared to the patients with cystic fibrosis (reference group), only patients with pulmonary fibrosis had a significantly higher chance of a transplant (RR = 1.50); the lowest chance of death for the emphysema and the "other" patients was confirmed (RR = 0.53 and RR = 0.51, respectively). Recipient size, ABO blood group, country and epoch of listing also had a significant impact on the transplant chance, while country of listing and recipient age were the other factors independently influencing the chance of dying on the waiting list. On the heart-lung waiting list, the type of end-stage lung disease solely affected the chance of death prior to transplant. Compared with cystic fibrosis, pulmonary fibrosis had a significantly higher risk (RR = 2.93), closely followed by pulmonary hypertension (RR = 2.57). Factors crucial for the chance of a heart-lung transplant were recipient size, ABO blood group and country of listing.

CONCLUSIONS

The type of end-stage lung disease is a distinctive factor for predicting survival on the lung and heart-lung transplant waiting list, and should be taken into account whenever assessing waiting list outcomes. When developing lung allocation schemes, it is medically justified to incorporate the type of end-stage lung disease.

Worldwide thoracic organ transplantation: a report from the UNOS/ISHLT International Registry for thoracic organ transplantation

1. The number of heart transplant operations performed in the United States has decreased by 16 procedures between 1995 (2,360) and 1996 (2,344). Following a period of rapid growth from 1990 (203) through 1995 (871), there was a decrease of 71 lung transplant procedures between 1995 (871) and 1996 (800). 2. The most frequently reported indication for heart transplantation in the US was coronary artery disease (44.88%). For other thoracic transplants, the most frequently reported indications included cystic fibrosis (31.85%) for double lung, emphysema/COPD (55.88%) for single lung and congenital heart disease (48.72%) for heart-lung transplants. The most frequently reported diagnoses for thoracic transplantation outside the US included cardiomyopathy (47.4%) for heart, cystic fibrosis (33.0%) for double lung, idiopathic pulmonary fibrosis (29.1%) for single lung and primary pulmonary hypertension (23.4%) for heart-lung transplants. 3. US heart transplant recipients were predominantly male (77.6%), older than age 50 (55.4%) and white (82.3%). In contrast, US lung transplant recipients were predominantly female (52.1%), aged 35-64 (73.5%) and white (89.5%). No significant variance from the US recipient demographic profile was noted for non-US recipients in this analysis. 4. The mean donor age for heart and lung transplants has risen slightly with an increase in mean age of 3.12 years for heart donors and 4.72 years for lung donors from 1987-1997. 5. The one-year survival rate for thoracic transplants performed in the US was 84.8% for heart, 70.1% for lung and 73.4% for heart-lung in 1996. Five-year survival for US thoracic transplants was 66.5% for heart and 43.2% for lung transplants performed in 1992. 6. There was little change in heart transplant survival based on transplant era (1987-89, 1990-92 and 1993-95). Lung recipients transplanted in the 1993-95 era showed a 16% increase in survival compared with those transplanted in the 1987-89 era at the 48-month time point. 7. The most important risk factor for US heart recipients at one month, one year, and conditionally at 5 years after transplantation was receipt of a previous heart transplant. Other substantial long-term risk factors included donor age and non-white, non-black recipient. 8. The most important risk factors for mortality in US lung recipients were the order of the transplant (primary or repeat) and the patient's medical condition at time of transplant. Diagnosis, recipient age and recipient race were highly influential risk factors for conditional 5-year mortality. 9. For heart and lung recipients, the major cause of hospitalization during the first 2 years after transplantation was infection.

Thoracic transplantation in 1998

Thoracic transplantation has been a clinical option for patients with end-stage heart and lung disease for three decades. Heart, lung, and combined heart-lung transplantations are no longer experimental procedures; they are a standard part of the treatment algorithm for selected patients with end-stage heart and lung disease. This article summarizes the current status of heart, lung, and heart-lung transplantations and provides an insight into the future of this field.

Lung transplantation for cystic fibrosis--a single center experience over 8 years

OBJECTIVE

Colonization of the lung and mediastinal lymph nodes with multi-resistant bacteria, diabetes and malnutrition represent potential risk factors for lung transplantation in cystic fibrosis. We therefore reviewed our experience in this patient population.

METHODS

Between December 1988 and March 1997, 219 lung and heart-lung transplantations were performed at our institution. Of these, 39 procedures were done in 35 patients with cystic fibrosis. All candidates (mean age 26 years) were oxygen dependent (preoperative mean PO2: 44.8 +/- 9.1 Torr, preoperative mean PCO2: 53.4 +/- 10.5 Torr, one patient on respirator). Of the primary operations, 34 were performed as bilateral sequential lung transplants, one as a heart-lung transplantation.

RESULTS

Mean duration on respirator for survivors was 3.1 (1-12) days, mean ICU and hospital stay were 4.7 (1-13) and 28 (12-79) days, respectively. The 3-month mortality rate was 5.7% (two patients died due to acute graft failure on days 36 and 73). Other causes of death in the follow-up were cerebral bleeding (one patient) and chronic graft failure (three patients). The survival rates were 91% at 1 year, 83% at 3 years and 76% at 5 years. In eight patients, a bronchiolitis obliterans syndrome (BOS) developed (in four cases grade 3). The freedom of BOS (grade 1 or more) at 1, 3 and 5 years was 87, 79 and 55%, respectively. Four retransplantations were performed. Of the 29 patients alive, only seven are physically limited.

CONCLUSION

Bilateral lung transplantation for cystic fibrosis allows for acceptable early- and long-term results. Postoperative survival is not impaired by infection, diabetes and malnutrition. Long-term functional outcome seems to be comparable to lung transplantation in patients without infectious pulmonary disease.

Pregnancy after heart or heart-lung transplantation: a series of 10 pregnancies

OBJECTIVE

To evaluate pregnancy after heart or heart-lung transplantation in France.

DESIGN

A questionnaire survey of all French centres performing heart and heart-lung transplants provided an exhaustive registry on pregnancy after transplantation.

METHODS

A questionnaire was sent to 36 centres. Anonymous reports on transplantation and subsequent pregnancies between 1984 and 1996 were analysed.

RESULTS

Of 1290 heart and 120 heart-lung transplantation performed during the study period, 10 pregnancies (seven after heart transplantation and three after heart-lung transplantation) were reported in nine women who were delivered of 11 infants. High blood pressure complicated nine pregnancies and severe pre-eclampsia occurred in two. One woman developed Kaposi sarcoma of the cervix. Delivery at 35 weeks gestation (27-39) was by caesarean section in 50% cases. Mean birthweight was 1990 g (700-2880g) and 50% of the infants had a birthweight < tenth centile. One infant developed cardiomyopathy as a condition inherited from her mother, and congenital hepatitis B was diagnosed in another.

CONCLUSIONS

Pregnancy after heart and heart-lung transplantation is feasible and can be successful, but this should be planned when cardiac and respiratory functions are stable. Adequate obstetrical and genetic counselling should be provided.

[Pregnancy after heart and heart-lung transplantation. Apropos of 10 cases and review of the literature]

INTRODUCTION

A survey of all French Centres performing heart and heart lung transplant provided an exhaustive registry of pregnancy after transplantation.

MATERIAL AND METHODS

A questionnaire was sent to 36 Centres. Anonymous reports of transplantation and subsequent pregnancies which occurred between 1984 and 1994 were analyzed.

RESULTS

Among 1290 heart and 120 heart lung transplantations performed during the study period 10 pregnancies were reported in 9 patients (6 after heart transplantation and 3 heart-lung transplantation) who gave birth to 11 neonates. The interval between the transplantation and the pregnancy is 23.1 months (range: 10-39). High blood pressure complicated nine pregnancies and severe preeclampsia occurred in two cases. Immunosuppressive therapy was i) Cyclosporine alone (n = 1), ii) i with corticosteroid therapy (n = 7), iii) ii with azathioprine (n = 2). One patient developed Kaposi sarcoma of the cervix. Delivery at 35 (27-39) weeks' gestation was by caesarean section in 50% of the cases. Mean birthweight was 1990 gm (range: 700-2880) and 50% of the neonates were below the tenth centile. One child developed cardiomyopathy as diagnosed in her mother and another one was diagnosed with congenital hepatitis B by absence of prophylaxis at birth. All the patients are alive at this time.