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Hypertension in Pediatric Solid Organ Transplant Recipients. Curr Hypertens Rep 2023; 25:51-60. [PMID: 36862274 DOI: 10.1007/s11906-023-01237-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE OF REVIEW To review the current literature regarding hypertension (HTN) following pediatric solid organ transplant (SOTx), including definition, prevalence, risk factors, outcomes, and treatment. RECENT FINDINGS In recent years several new guidelines for the definition, monitoring, and management of pediatric HTN have been published, but with no specific recommendations regarding SOTx recipients. HTN remains highly prevalent, yet underdiagnosed and undertreated in kidney transplant (KTx) recipients, especially when ambulatory blood pressure monitoring (ABPM) is utilized. There are little data regarding its prevalence in other SOTx recipients. HTN in this population is multifactorial and is associated with HTN status prior to Tx, demographic factors (age, sex, and race), weight status, and immunosuppression protocol. HTN is associated with subclinical cardiovascular (CV) end-organ damage, including left ventricular hypertrophy (LVH) and arterial stiffness, yet there are no recent data regarding its long-term outcomes. There are also no updated recommendations regarding the optimal management of HTN in this population. Given its high prevalence and the young age of this population facing years at increased CV risk, post-Tx HTN requires more clinical attention (routine monitoring, frequent application of ABPM, better BP control). Additional research is needed for a better understanding of its long-term outcomes as well as its treatment and treatment goals. Much more research is needed regarding HTN in other pediatric SOTx populations.
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Bogle C, Cantor R, Koehl D, Lochridge J, Kirklin JK, Barnes A, Wallis G, Amdani S, Ameduri R, Pahl E, Simpson KE, Blume ED. Obesity and dyslipidemia predict cardiac allograft vasculopathy and graft loss in children and adolescents post-heart transplant: A PHTS multi-institutional analysis. Pediatr Transplant 2022; 26:e14244. [PMID: 35122464 DOI: 10.1111/petr.14244] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 01/03/2022] [Accepted: 01/24/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Obesity and dyslipidemia afflict children of all ages. We explored the prevalence of obesity and dyslipidemia in pediatric heart transplant (HT) recipients and its effects on cardiac allograft vasculopathy (CAV) and survival. METHODS This study included primary HT recipients (≤18 years) transplanted between 01/1996 and 12/2018 included in the Pediatric Heart Transplant Society database. Obesity was categorized according to WHO/CDC guidelines and dyslipidemia according to the National Cholesterol Education Program. Kaplan-Meier analyses for CAV and graft loss stratified for BMI and lipid panels were generated and risk factors identified using multivariate analyses. RESULTS Among 6291 HT patients (median age [range] at HT = 4.3 [0.6-12.8] years; 45% Female; 68% White), 56% had a normal BMI at HT. Obese patients at HT had an increased risk for graft loss (HR 1.19, 95% CI 1.01-1.4, p = .04). Poor total cholesterol (TC), LDL-C, and TG were associated with the risk of both CAV (HR 1.79, p < .0001; HR 1.65, p = .0015; HR 1.53, p < .0001, respectively) and graft loss (HR 1.58, p = .0008; HR 1.22, p = .04; HR 1.43, p = .0007, respectively). CONCLUSIONS Pediatric patients who are obese at the time of HT and dyslipidemic at 1 year post-HT are at an increased risk for CAV and graft loss. Preventative interventions may reduce morbidity and mortality among this cohort.
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Affiliation(s)
- Carmel Bogle
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ryan Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jillien Lochridge
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Aliessa Barnes
- Division of Pediatric Cardiology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Gonzalo Wallis
- Division of Pediatric Cardiology, Levine Children's Hospital, Atrium Health, Charlotte, North Carolina, USA
| | - Shahnawaz Amdani
- Division of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Rebecca Ameduri
- Division of Pediatric Cardiology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Elfriede Pahl
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Kathleen E Simpson
- Division of Cardiology, University of Colorado Anschutz Medical Center, Children's Hospital of Colorado, Aurora, Colorado, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
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Power A, Baez Hernandez N, Dipchand AI. Rejection surveillance in pediatric heart transplant recipients: Critical reflection on the role of frequent and long-term routine surveillance endomyocardial biopsies and comprehensive review of non-invasive rejection screening tools. Pediatr Transplant 2022; 26:e14214. [PMID: 35178843 DOI: 10.1111/petr.14214] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/25/2021] [Accepted: 11/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite significant medical advances in the field of pediatric heart transplantation (HT), acute rejection remains an important cause of morbidity and mortality. Endomyocardial biopsy (EMB) remains the gold-standard method for diagnosing rejection but is an invasive, expensive, and stressful process. Given the potential adverse consequences of rejection, routine post-transplant rejection surveillance protocols incorporating EMB are widely employed to detect asymptomatic rejection. Each center employs their own specific routine rejection surveillance protocol, with no consensus on the optimal approach and with high inter-center variability. The utility of high-frequency and long-term routine surveillance biopsies (RSB) in pediatric HT has been called into question. METHODS Sources for this comprehensive review were primarily identified through searches in biomedical databases including MEDLINE and Embase. RESULTS The available literature suggests that the diagnostic yield of RSB is low beyond the first year post-HT and that a reduction in RSB intensity from high-frequency to low-frequency can be done safely with no impact on early and mid-term survival. Though there are emerging non-invasive methods of detecting asymptomatic rejection, the evidence is not yet strong enough for any test to replace EMB. CONCLUSION Overall, pediatric HT centers in North America should likely be doing fewer RSB than are currently performed. Risk factors for rejection should be considered when designing the optimal rejection surveillance strategy. Noninvasive testing including emerging biomarkers may have a complementary role to aid in safely reducing the need for RSB.
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Affiliation(s)
- Alyssa Power
- Department of Pediatrics, UT Southwestern Medical Center and Children's Medical Center, Dallas, Texas, USA
| | - Nathanya Baez Hernandez
- Department of Pediatrics, UT Southwestern Medical Center and Children's Medical Center, Dallas, Texas, USA
| | - Anne I Dipchand
- Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada
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Ross FJ, Vu EL, Fang ZA, Resheidat A, Mossad EB, Mittnacht AJC. Selected 2019 Highlights in Congenital Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2020; 34:2022-2027. [PMID: 32418836 DOI: 10.1053/j.jvca.2020.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 04/07/2020] [Indexed: 11/11/2022]
Abstract
This article is a review of the highlights of pertinent literature published in 2019, which is of interest to the pediatric cardiac anesthesiologist. After a search of the United States National Library of Medicine PubMed database, several topics emerged in which significant contributions were made in 2019. The authors of this manuscript considered the following topics noteworthy and were included in this review: advances in pediatric heart transplantation, blood management in pediatric cardiac surgery, the impact of nutrition on outcomes in congenital heart surgery, and the use of vasopressin in patients after Fontan palliation.
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Affiliation(s)
- Faith J Ross
- Department of Anesthesiology, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Eric L Vu
- Department of Anesthesiology, Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Zhe A Fang
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children Toronto, Ontario, Canada
| | - Ashraf Resheidat
- Division of Pediatric Cardiovascular Anesthesia, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Emad B Mossad
- Division of Pediatric Cardiovascular Anesthesia, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Alexander J C Mittnacht
- Department of Anesthesiology, Westchester Medical Center, New York Medical College, Valhalla, NY.
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Wong TC, Keebler ME. Cardiac Magnetic Resonance Parametric Mapping Following Heart Transplantation: Moving Beyond Acute Rejection and Coronary Allograft Vasculopathy Assessment. JACC Cardiovasc Imaging 2020; 13:1531-1533. [PMID: 32305482 DOI: 10.1016/j.jcmg.2020.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 02/21/2020] [Accepted: 02/24/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Timothy C Wong
- Department of Medicine, Division of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Cardiovascular Magnetic Resonance Center, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Mary E Keebler
- Department of Medicine, Division of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Advanced Heart Failure and Transplantation, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Cell-free DNA donor fraction analysis in pediatric and adult heart transplant patients by multiplexed allele-specific quantitative PCR: Validation of a rapid and highly sensitive clinical test for stratification of rejection probability. PLoS One 2020; 15:e0227385. [PMID: 31929557 PMCID: PMC6957190 DOI: 10.1371/journal.pone.0227385] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 12/17/2019] [Indexed: 02/06/2023] Open
Abstract
Lifelong noninvasive rejection monitoring in heart transplant patients is a critical clinical need historically poorly met in adults and unavailable for children and infants. Cell-free DNA (cfDNA) donor-specific fraction (DF), a direct marker of selective donor organ injury, is a promising analytical target. Methodological differences in sample processing and DF determination profoundly affect quality and sensitivity of cfDNA analyses, requiring specialized optimization for low cfDNA levels typical of transplant patients. Using next-generation sequencing, we previously correlated elevated DF with acute cellular and antibody-mediated rejection (ACR and AMR) in pediatric and adult heart transplant patients. However, next-generation sequencing is limited by cost, TAT, and sensitivity, leading us to clinically validate a rapid, highly sensitive, quantitative genotyping test, myTAIHEART®, addressing these limitations. To assure pre-analytical quality and consider interrelated cfDNA measures, plasma preparation was optimized and total cfDNA (TCF) concentration, DNA fragmentation, and DF quantification were validated in parallel for integration into myTAIHEART reporting. Analytical validations employed individual and reconstructed mixtures of human blood-derived genomic DNA (gDNA), cfDNA, and gDNA sheared to apoptotic length. Precision, linearity, and limits of blank/detection/quantification were established for TCF concentration, DNA fragmentation ratio, and DF determinations. For DF, multiplexed high-fidelity amplification followed by quantitative genotyping of 94 SNP targets was applied to 1168 samples to evaluate donor options in staged simulations, demonstrating DF call equivalency with/without donor genotype. Clinical validation studies using 158 matched endomyocardial biopsy-plasma pairs from 76 pediatric and adult heart transplant recipients selected a DF cutoff (0.32%) producing 100% NPV for ≥2R ACR. This supports the assay’s conservative intended use of stratifying low versus increased probability of ≥2R ACR. myTAIHEART is clinically validated for heart transplant recipients ≥2 months old and ≥8 days post-transplant, expanding opportunity for noninvasive transplant rejection assessment to infants and children and to all recipients >1 week post-transplant.
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Riggs KW, Morales DLS. Invited Commentary. Ann Thorac Surg 2018; 107:171-172. [PMID: 30118705 DOI: 10.1016/j.athoracsur.2018.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 07/08/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Kyle W Riggs
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229.
| | - David L S Morales
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229
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