Long-term outcomes of children after solid organ transplantation

Twin-to-Twin Heart Transplantation: A Unique Event With a 25-Year Follow-Up

Solid organ transplantation in pediatric patients has been a reality since 1954, when the first kidney transplantation was successfully performed between identical twins. We report the long-term outcomes, with more than 25 years of follow-up, in a patient born with hypoplastic left heart syndrome (HLHS) who received a heart transplant from a dizygotic twin. While we would not wish for this situation to reoccur, we hope that in reporting it, we can add to the discussion surrounding pediatric heart transplantation and the management of HLHS.

Living Donation Has a Greater Impact on Renal Allograft Survival Than HLA Matching in Pediatric Renal Transplant Recipients

BACKGROUND

Living donor (LD) kidney transplantation accounts for around half of all pediatric renal transplant recipients and results in improved renal allograft survival. The aim of this study was to determine the effect of HLA matching on deceased and LD renal allograft outcomes in pediatric recipients.

METHODS

Data were obtained from the UK Transplant Registry held by NHS Blood and Transplant on all children who received a donation after brain death (DBD) or LD kidney-only transplant between 2000 and 2011. HLA-A, HLA-B and HLA-DR mismatches were categorized into 4 levels and 2 groups. Data were fully anonymized.

RESULTS

One thousand three hundred seventy-eight pediatric renal transplant recipients were analyzed; 804 (58%) received a DBD donor kidney, 574 (42%) received an LD kidney. Five-year renal allograft survival was superior for children receiving a poorly HLA-matched LD kidney transplant (88%, 95% confidence interval [95% CI], 84-91%) compared with children receiving a well HLA-matched DBD kidney transplant (83%, 95% CI, 80-86%, log rank test P = 0.03). Five-year renal allograft survival was superior for children receiving an LD kidney with 1 or 2 HLA-DR mismatches (88%, 95% CI, 84-91%) compared with children receiving a DBD kidney with 0 HLA-DR mismatches (83%, 95% CI, 80-86%, log rank test P = 0.03).

CONCLUSIONS

In children, poorly HLA-matched LD renal transplant outcomes are not inferior when compared with well HLA-matched DBD renal transplants. It is difficult to justify preferentially waiting for an improved HLA-matched DBD kidney when a poorer HLA-matched LD kidney transplant is available.

The lack of Lazarus effect with proteasome inhibition

There have been marked improvements in the short- and long-term outcomes for children after renal transplantation over the past two decades with superior quality and quantity of life. It is encouraging to see increased patient and renal allograft survival rates with initially lower acute renal allograft rejection rates due to improved matching and immunosuppressive regimens. Unfortunately, longer-term renal allograft survival remains unchanged with chronic allograft injury from both immune and non-immune causes, resulting in chronic allograft dysfunction, morbidity from chronic kidney disease, and eventual renal allograft loss. Acute and chronic antibody-mediated rejection remains a clinical dilemma with a growing evidence base of its treatment, including proteasome inhibition using intravenous bortezomib. The future goal is to reduce chronic allograft dysfunction and make renal transplants last longer for pediatric renal transplant recipients who may require retransplantation during their childhood and adult lives, which can become successively more difficult due to sensitization.

[Mothers' perceptions of care practices for children who underwent heart transplantation]

OBJECTIVE

To learn mothers' perceptions of the main care practices that are to be administered after their children's heart transplantation, as well as the main difficulties they experience.

METHOD

A descriptive qualitative study conducted in March and April 2014, using the focus group technique for data gathering. Participants were 12 mothers who were monitoring their children in a hospital that is a reference for treating cardiopulmonary diseases. Speeches were recorded, transcribed, and organized around the care practices that the mothers performed after the children's heart transplantations, the mothers' main difficulties, their perceptions of their children's quality of life, and the use of educational materials to disseminate post-transplantation care practices. For data analysis, we used the content analysis technique.

RESULTS

The following were clarified: the schedule of immunosuppressive medication; food, environmental, and bodily and oral hygiene; the use of surgical masks; and keeping the children away from crowds.

CONCLUSION

The study contributed to the situational diagnosis of the care administered by the mothers of transplanted children.

Assessing allocation of responsibility for health management in pediatric liver transplant recipients

Given the increased risk for non-adherence and poor health outcomes in late adolescence, there is a need for better methods to evaluate and improve the transition process as adolescent patients are prepared to be independent adults. This study assessed the psychometrics and concurrent validity of a newly developed measure of AoR for health management in pediatric liver transplant patients. A total of 48 patients and 37 parents completed a 13-item measure of AoR. We performed an exploratory PCA on survey results and used component scores to assess the relationship between AoR and age, age at transplant, adherence, and health outcomes. Two primary components were identified: communication with the healthcare system and self-management tasks. Parent perception of adolescent responsibility for tasks related to communicating with the healthcare system was correlated, in younger patients, with increased non-adherence while responsibility for tasks related to self-management was correlated, in older patients, with decreased non-adherence. These results support AoR as a two-domain construct, and they provide targets for monitoring and intervention as adolescent patients advance toward transfer.

Vulnerability and Chronic Illness Management in Pediatric Kidney and Liver Transplant Recipients

Context—

Solid-organ transplant is the treatment of choice for end-stage organ failure and requires a transition from management of a life-threatening condition to a chronic illness. Despite research focusing on quality of life after transplant, there is a gap addressing the role of managing a chronic illness focusing on vulnerability and impact on family.

Objective—

Identify patient and family patterns of adaptation among kidney and liver transplant recipients in regard to (1) vulnerability, (2) impact of illness on the family, (3) family functioning, and (4) quality of life (parent and child report).

Design—

Cross-sectional study enrolling children 5 to 18 years old and their parent at a single time point after kidney or liver transplant. Validated self-report tools were completed.

Results—

In all, 47 participants (24 kidney and 23 liver) were recruited. Mean age at transplant was 4.0 (kidney) and 2.1 (liver) years. Mean age at report was 12.1 (kidney) and 7.1 (liver) years. Child vulnerability correlated negatively with (1) family impact in the kidney ( P < .05) and liver ( P < .05) transplant groups, (2) PedsQL subscales including Parent Emotional ( P < .05), Parent Social ( P < .01), Parent Psychosocial ( P < .01), Parent Physical ( P < .05), Parent School ( P < .05), and Child Social ( P < .01) in the kidney transplant group, (3) PedsQL Parent Emotional subscale ( P < .01) in the liver transplant group, and (4) Functional status ( P < .01) in the liver transplant group.

Conclusions—

Child vulnerability provides insight into quality of life and the impact of illness on the family and family functioning.

Common challenge topics in pediatric transplantation

This special issue is dedicated to the common challenge topics in pediatric transplantation. It contains 11 chapters, ranging from clinical research in pediatric transplantation to translational research (from bench to bedside). It includes comprehensive reviews from renowned scientists, clinicians and surgeons from five countries from the International Pediatric Transplantation Association (IPTA), Harvard University, the University of Miami and the University of São Paulo Medical School. The clinical management of specific issues, such as sensitized patients and ABO blood type-incompatible transplantation, is addressed. In addition, the challenges facing this patient population and the future perspectives for clinical research are discussed.