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Dipchand AI, Webber SA. Pediatric heart transplantation: Looking forward after five decades of learning. Pediatr Transplant 2024; 28:e14675. [PMID: 38062996 DOI: 10.1111/petr.14675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/17/2023] [Accepted: 11/24/2023] [Indexed: 02/07/2024]
Abstract
Heart transplantation has become the standard of care for pediatric patients with end-stage heart disease throughout the world. Since the first transplant was performed in 1967, the number of transplants has grown dramatically with 13 449 pediatric heart transplants being reported to The International Society of Heart and Lung Transplant (ISHLT) between January 1992 and June 30, 2018. Outcomes have consistently improved over the last few decades, specifically short-term outcomes. Most recent survival data demonstrate that recipients who survive to 1-year post-transplant have excellent long-term survival with more than 60% of those who were transplanted as infants being alive 25 years later. Nonetheless, the rates of graft loss beyond the first year have remained relatively constant over time; driven primarily by our poor understanding and lack of treatments for chronic allograft vasculopathy (CAV). Acute rejection, CAV, graft failure, and infection continue to be the major causes of death within the first 5 years post-transplant. In addition, renal dysfunction, malignancy, and the need for re-transplantation remain as significant issues that require close follow-up. Looking forward, key challenges include improving donor utilization rates (including donation after cardiac death (DCD) and the use of ex vivo perfusion devices), the development of non-invasive biomarkers for rejection, efforts to mitigate the long-term effects of immunosuppression, and prevention of CAV. It is not possible to cover the entire evolution of pediatric heart transplantation over the last five decades, but in this review, we hope to touch on key observations, lessons learned, and practice changes that have advanced the field, as well as glance ahead to the next decade.
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Affiliation(s)
- Anne I Dipchand
- Department of Paediatrics, Head, Heart Transplant, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Steven A Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Pediatrician-in-Chief, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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2
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Hartje-Dunn C, Blume ED, Bastardi H, Daly KP, Fynn-Thompson F, Gauvreau K, Singh TP. Medium-term Outcomes in Pediatric Heart Transplant Recipients Managed Using a Steroid Avoidance Immune Suppression Protocol. Transplantation 2024; 108:e8-e14. [PMID: 37788365 DOI: 10.1097/tp.0000000000004820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
BACKGROUND Short-term outcomes using steroid avoidance immune suppression are encouraging in pediatric heart transplant (HT) recipients at low risk of antibody-mediated rejection. We assessed medium-term outcomes in pediatric HT recipients initiated on a steroid avoidance protocol at our institution using surveillance biopsies. METHODS All primary HT recipients during 2006-2020 who did not have a donor-specific antibody were eligible for immune suppression consisting of 5-d Thymoglobulin/steroid induction followed by a tacrolimus-based, steroid-free regimen. We assessed freedom from graft failure (death or retransplant), acute rejection, posttransplant lymphoproliferative disease, and cardiac allograft vasculopathy. RESULTS Overall, 150 of 181 primary HT recipients were eligible for steroid avoidance regimen. Their median age was 8.7 y, 41% had congenital heart disease, 23% were sensitized, and 35% were on a mechanical support. The median follow-up was 6.1 y. Eleven patients (8%) were on maintenance steroids at discharge and 13% at 1 y. Graft survival was 94% at 1 y and 87% at 5 y. Freedom from rejection was 73% at 1 y and 64% at 5 y. Freedom from posttransplant lymphoproliferative disease was 96% at 1 y and 95% at 5 y. Freedom from moderate cardiac allograft vasculopathy was 94% at 5 y. Eight patients developed diabetes. Estimated glomerular filtration rate was <60 mL/min/1.73 m 2 in 5% of the cohort at 5 y. CONCLUSIONS Pediatric HT recipients at low risk of antibody-mediated rejection have excellent medium-term survival and relatively low incidence of posttransplant morbidities when managed using a steroid avoidance immune suppression protocol.
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Affiliation(s)
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Heather Bastardi
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Kevin P Daly
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Biostatistics, Harvard School of Public Health, Boston, MA
| | - Tajinder P Singh
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
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3
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Mylonas KS, Soukouli I, Avgerinos DV, Boletis JN. Current immunosuppression strategies in pediatric heart transplant. Immunotherapy 2022; 14:663-667. [PMID: 35510326 DOI: 10.2217/imt-2021-0352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
| | - Ioanna Soukouli
- Department of Nephrology & Renal Transplantation, Laiko General Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | | | - John N Boletis
- Department of Nephrology & Renal Transplantation, Laiko General Hospital, National & Kapodistrian University of Athens, Athens, Greece
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4
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Laks JA, Dipchand AI. Cardiac allograft vasculopathy: A review. Pediatr Transplant 2022; 26:e14218. [PMID: 34985793 DOI: 10.1111/petr.14218] [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: 06/08/2021] [Revised: 11/11/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Heart transplantation has become the standard of care for pediatric patients with end-stage heart disease, and outcomes have consistently improved over the last few decades. CAV, however, remains a leading cause of morbidity and mortality in heart transplantation and is the leading cause of death beyond 3 years post-transplantation. We sought out to provide an in-depth overview of CAV in the pediatric heart transplant population. METHODS Database searches were conducted in both Medline and Embase on the topic of cardiac vasculopathy in pediatric heart transplant recipients. The search used five broad concept terms: heart transplant; pediatric; CAV; diagnosis, prognosis, and risk factors; and guidelines and reviews. References were captured if there was at least one term in each of the concepts. The search was limited to articles in the English language. RESULTS A total of 148 articles were identified via the literature search with further articles identified via review of references. Pediatric data regarding the etiology and development of CAV remain limited although knowledge about the immune and non-immune factors playing a role are increasing. CAV continues to be difficult to detect with many invasive and non-invasive methods available, yet their effectiveness in the detection of CAV remains suboptimal. There remains no proven medical intervention to treat or reverse established CAV disease, and CAV is associated with high rates of graft loss once detected. However, several medications are used in hopes of preventing, slowing progression, or modifying the outcomes. CONCLUSION This review provides a comprehensive overview of CAV, discusses its clinical presentation, risk factors, diagnostic tools used to identify CAV in the pediatric population, and highlights the current therapeutic options and the need for ongoing research.
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Affiliation(s)
- Jessica A Laks
- Heart Institute, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Anne I Dipchand
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
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5
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Ubeda Tikkanen A, Berry E, LeCount E, Engstler K, Sager M, Esteso P. Rehabilitation in Pediatric Heart Failure and Heart Transplant. Front Pediatr 2021; 9:674156. [PMID: 34095033 PMCID: PMC8170027 DOI: 10.3389/fped.2021.674156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/20/2021] [Indexed: 11/20/2022] Open
Abstract
Survival of pediatric patients with heart failure has improved due to medical and surgical advances over the past decades. The complexity of pediatric heart transplant patients has increased as medical and surgical management for patients with congenital heart disease continues to improve. Quality of life in patients with heart failure and transplant might be affected by the impact on functional status that heart failure, heart failure complications or treatment might have. Functional areas affected might be motor, exercise capacity, feeding, speech and/or cognition. The goal of rehabilitation is to enhance and restore functional ability and quality of life to those with physical impairments or disabilities. Some of these rehabilitation interventions such as exercise training have been extensively evaluated in adults with heart failure. Literature in the pediatric population is limited yet promising. The use of additional rehabilitation interventions geared toward specific complications experienced by patients with heart failure or heart transplant are potentially helpful. The use of individualized multidisciplinary rehabilitation program that includes medical management, rehabilitation equipment and the use of physical, occupational, speech and feeding therapies can help improve the quality of life of patients with heart failure and transplant.
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Affiliation(s)
- Ana Ubeda Tikkanen
- Department of Pediatric Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA, United States
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, MA, United States
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States
| | - Emily Berry
- Department of Physical Therapy and Occupational Therapy Services, Boston Children’s Hospital, Boston, MA, United States
| | - Erin LeCount
- Department of Physical Therapy and Occupational Therapy Services, Boston Children’s Hospital, Boston, MA, United States
| | - Katherine Engstler
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, MA, United States
| | - Meredith Sager
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, MA, United States
- Augmentative Communication Program, Boston Children’s Hospital, Boston, MA, United States
| | - Paul Esteso
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
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6
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Sisson TM, Padilla LA, Hubbard M, Smith S, Pearce FB, Collins JL, Carlo WF. Impact of induction strategy change on first-year rejection in pediatric heart transplantation at a single center-From postoperative basiliximab to either postoperative anti-thymocyte globulin or preoperative basiliximab. Clin Transplant 2021; 35:e14314. [PMID: 33838071 DOI: 10.1111/ctr.14314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/27/2020] [Accepted: 03/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Our pediatric heart transplant center transitioned from post-bypass basiliximab (BAS) induction to either anti-thymocyte globulin (ATG) or pre-bypass BAS. The purpose of this study was to compare first-year rejection rates before and after this change. METHODS A single-center retrospective analysis was conducted of pediatric heart transplant recipients from 2010 to 2019. Primary outcome was first-year rejection. Bivariate analysis, Kaplan-Meier curves, and multivariable regression were performed across eras. RESULTS Forty-three early era patients (55%) received post-bypass BAS, and 35 late era patients (45%) received pre-bypass BAS (n = 17) or ATG (n = 18). First-year rejection decreased in the late era (31% vs 53%, p = .05). This finding was more pronounced after excluding infants (38% vs 73%, p = .006). Late era was associated with a decreased likelihood of rejection (all cohort OR 0.19, 95% CI 0.05-0.66; infants excluded OR 0.17, 95% CI 0.04-0.61). No differences in post-transplant lymphoproliferative disease, donor-specific antibody, or infection were observed. CONCLUSIONS Fewer late era patients receiving ATG or pre-bypass BAS induction had first-year rejection compared to the early era patients receiving standard post-bypass BAS induction. This programmatic shift in induction strategy was readily achievable and potentially effective in reducing first-year rejection.
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Affiliation(s)
| | - Luz A Padilla
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Sally Smith
- Children's of Alabama Heart Transplant Program, Birmingham, AL, USA
| | - Frank Bennett Pearce
- Children's of Alabama Heart Transplant Program, Birmingham, AL, USA.,Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL, USA
| | - Jacqueline Leslie Collins
- Children's of Alabama Heart Transplant Program, Birmingham, AL, USA.,Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL, USA
| | - Waldemar F Carlo
- Children's of Alabama Heart Transplant Program, Birmingham, AL, USA.,Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL, USA
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7
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Lunze FI, Singh TP, Gauvreau K, Molloy MA, Blume ED, Berger F, Colan SD. Comparison of tissue Doppler imaging and conventional echocardiography to discriminate rejection from non-rejection after pediatric heart transplantation. Pediatr Transplant 2020; 24:e13738. [PMID: 32525246 DOI: 10.1111/petr.13738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 02/14/2020] [Accepted: 04/17/2020] [Indexed: 11/30/2022]
Abstract
TDI is considered superior to conventional echocardiography for detecting changes in graft function during rejection in adults but has not demonstrated after pediatric OHT. We retrospectively analyzed echocardiograms performed within 24 hours of biopsy in 122 recipients with median age of 8.7 years. Using biopsy findings as the gold standard, we compared paired rejection and non-rejection echocardiograms using each patient as their own control. We included pairs of LV dimensions, FS, volumes, mass, mass/volume, sphericity, wall stress, SSI, SVI, and TDI velocities in this comparison. C-statistic was used to assess discrimination for individual echo variables and combinations of variables. Overall, 647 non-rejection and 24 rejection biopsy-echo pairs were identified. There was a significant decline in TDI velocities and their Z-scores during rejection but not in conventional variables (P ≤ .005). The variable that best discriminated rejection from non-rejection was LV S', with C-statistic = 0.93. Conventional echo variables performed less well with C-statistic range 0.65-0.67 for LV EF, shortening fraction, and mass. TDI is superior to conventional echocardiography measures for discriminating rejection from non-rejection. The use of newer non-invasive parameters to detect myocardial dysfunction and shifting the paradigm of rejection surveillance to detection of non-rejection together provide a promising approach to reducing the need for biopsy in pediatric heart recipients.
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Affiliation(s)
- Fatima I Lunze
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Institute, Berlin, Germany.,Departments of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Tajinder P Singh
- Departments of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Departments of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Kimberlee Gauvreau
- Departments of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Meaghan A Molloy
- Departments of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth D Blume
- Departments of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Departments of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Felix Berger
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Institute, Berlin, Germany.,Departments of Pediatrics, Charité-Medical School, Berlin, Germany
| | - Steven D Colan
- Departments of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Departments of Pediatrics, Harvard Medical School, Boston, MA, USA
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8
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Das BB, Chan KC, Winchester RW, Zakrzewski M, Niu J. Correlation of gene expression profiling score, cardiac hemodynamics and echocardiographic parameters in asymptomatic, rejection-free pediatric heart transplant recipients. Pediatr Transplant 2020; 24:e13673. [PMID: 32067334 DOI: 10.1111/petr.13673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 01/21/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To correlate gene expression profiling scores obtained by AlloMap® with cardiac hemodynamics, cardiac allograft vasculopathy (CAV), and echocardiographic parameters in asymptomatic, rejection-free pediatric heart transplant (HT) recipients. METHODS Single-institution retrospective study of 210 AlloMap scores obtained concomitantly with cardiac catheterization and echocardiogram from 55 children during follow-up after cardiac transplantation. RESULTS The median age at HT was 5.1 years (range, 0.9-14.1), with 29 males and 26 females. AlloMap scores were high in <2 years vs ≥2 years of age at the time of HT (P = .001), and trending higher with time after HT (R2 = .04, P = .004). There was no significant difference in scores between ACR grades 0 and 1R or CAV. There was mild to modest correlation of AlloMap scores with the mean right atrial pressure (P = .002), and pulmonary capillary wedge pressure (P = .02), but no correlation was found with LV SF% (P = .3), LV EF% (P = .5), or RV FAC % (P = .8). CONCLUSIONS Our study provides preliminary data that the AlloMap score must be studied carefully before it can be used in children, particularly in those under 2 years of age. Monitoring of serial scores for each patient could potentially reflect changes in allograft performance that may determine indications for catheterization and biopsy which needs to be validated in future studies.
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Affiliation(s)
- Bibhuti B Das
- Pediatric Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, Florida.,Baylor College of Medicine, Texas Children's Hospital Austin Specialty Care, Austin, Texas
| | - Kak-Chen Chan
- Pediatric Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - Robert W Winchester
- Pediatric Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - Megan Zakrzewski
- Pediatric Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - Jianli Niu
- Office of Human Research, Memorial Healthcare System, Hollywood, Florida
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9
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Extracorporeal Membrane Oxygenation Support After Heart Transplantation in Children-Outcomes of a Single Center Cohort. Pediatr Crit Care Med 2020; 21:332-339. [PMID: 31658187 DOI: 10.1097/pcc.0000000000002192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation is used for postcardiotomy low cardiac output but is less established following heart transplantation. We characterized outcomes for children supported with extracorporeal membrane oxygenation after heart transplantation. DESIGN Single-center retrospective study. SETTING Large pediatric cardiac referral center. PATIENTS All patients who received heart transplantation and were cannulated to extracorporeal membrane oxygenation between 1995 and 2016. INTERVENTIONS Primary outcome measure was mortality 12 months postextracorporeal membrane oxygenation. Patient characteristics were analyzed for association with outcome according to early graft failure (extracorporeal membrane oxygenation ≤ 7 d after heart transplantation), or late graft failure. MEASUREMENTS AND MAIN RESULTS There were 246 heart transplants during the study period and 50 extracorporeal membrane oxygenation runs in 44 patients. Median time from transplant to extracorporeal membrane oxygenation was 1 day (range, 0-11.7 yr), with early graft failure in 28 patients (median 1, range 0-2 d) and 22 extracorporeal membrane oxygenation runs in 20 late graft failure patients (median, 0.8 yr; range, 8 d to 11.7 yr), including four patients with prior extracorporeal membrane oxygenation for early graft failure. Twenty-six patients (59%) survived to hospital discharge, and survival 12 months postextracorporeal membrane oxygenation was 24 patients (55%), lower in those with late graft failure (40% vs 67%; p 0.02). Independent risk factors for 12-month mortality were congenital heart disease, higher pulmonary vascular resistance indexed to body surface area (> 2.2 Woods U/m), and higher creatinine. Higher panel reactive antibody levels were associated with 12-month mortality in the late graft failure group only. CONCLUSIONS Extracorporeal membrane oxygenation can be effectively used to rescue patients with graft dysfunction after heart transplantation but is associated with high early mortality. Factors associated with mortality within 12 months include presence of congenital heart disease, renal dysfunction, elevated pulmonary vascular resistance indexed to body surface area and in those supported with extracorporeal membrane oxygenation late after heart transplantation, significant human leukocyte antigen sensitization.
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10
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Association of Clinical Rejection Versus Rejection on Protocol Biopsy With Cardiac Allograft Vasculopathy in Pediatric Heart Transplant Recipients. Transplantation 2020; 104:e31-e37. [DOI: 10.1097/tp.0000000000002983] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Lamour JM, Mason KL, Hsu DT, Feingold B, Blume ED, Canter CE, Dipchand AI, Shaddy RE, Mahle WT, Zuckerman WA, Bentlejewski C, Armstrong BD, Morrison Y, Diop H, Iklé DN, Odim J, Zeevi A, Webber SA. Early outcomes for low-risk pediatric heart transplant recipients and steroid avoidance: A multicenter cohort study (Clinical Trials in Organ Transplantation in Children - CTOTC-04). J Heart Lung Transplant 2019; 38:972-981. [PMID: 31324444 PMCID: PMC8359669 DOI: 10.1016/j.healun.2019.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/12/2019] [Accepted: 06/16/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Immunosuppression strategies have changed over time in pediatric heart transplantation. Thus, comorbidity profiles may have evolved. Clinical Trials in Organ Transplantation in Children-04 is a multicenter, prospective, cohort study assessing the impact of pre-transplant sensitization on outcomes after pediatric heart transplantation. This sub-study reports 1-year outcomes among recipients without pre-transplant donor-specific antibodies (DSAs). METHODS We recruited consecutive candidates (<21 years) at 8 centers. Sensitization status was determined by a core laboratory. Immunosuppression was standardized as follows: Thymoglobulin induction with tacrolimus and/or mycophenolate mofetil maintenance. Steroids were not used beyond 1 week. Rejection surveillance was by serial biopsy. RESULTS There were 240 transplants. Subjects for this sub-study (n = 186) were non-sensitized (n = 108) or had no DSAs (n = 78). Median age was 6 years, 48.4% were male, and 38.2% had congenital heart disease. Patient survival was 94.5% (95% confidence interval, 90.1-97.0%). Freedom from any type of rejection was 67.5%. Risk factors for rejection were older age at transplant and presence of non-DSAs pre-transplant. Freedom from infection requiring hospitalization/intravenous anti-microbials was 75.4%. Freedom from rehospitalization was 40.3%. New-onset diabetes mellitus and post-transplant lymphoproliferative disorder (PTLD) occurred in 1.6% and 1.1% of subjects, respectively. There was no decline in renal function over the first year. Corticosteroids were used in 14.5% at 1 year. CONCLUSIONS Pediatric heart transplantation recipients without DSAs at transplant and managed with a steroid avoidance regimen have excellent short-term survival and a low risk of first-year diabetes mellitus and PTLD. Rehospitalization remains common. These contemporary observations allow for improved caregiver and/or patient counseling and provide the necessary outcomes data to help design future randomized controlled trials.
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Affiliation(s)
- Jacqueline M Lamour
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, New York, New York.
| | | | - Daphne T Hsu
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, New York, New York
| | - Brian Feingold
- Departments of Pediatrics and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Elizabeth D Blume
- Department of Pediatric Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Charles E Canter
- Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - Anne I Dipchand
- Department of Paediatrics, Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robert E Shaddy
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - William T Mahle
- Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Warren A Zuckerman
- Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York
| | - Carol Bentlejewski
- Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York
| | | | | | - Helena Diop
- Rho Federal Systems Division, Chapel Hill, North Carolina
| | - David N Iklé
- Rho Federal Systems Division, Chapel Hill, North Carolina
| | - Jonah Odim
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Steven A Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
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12
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Abstract
BACKGROUND Significant inter-centre variability in the intensity of endomyocardial biopsy surveillance for rejection following paediatric cardiac transplantation has been reported. Our aim was to determine if low-intensity biopsy surveillance with two scheduled biopsies in the first year would produce outcomes similar to published registry outcomes. METHODS A retrospective study of paediatric recipients transplanted between 2008 and 2014 using a low-intensity biopsy protocol consisting of two surveillance biopsies at 3 and 12-13 months in the first post-transplant year, then annually thereafter. Additional biopsies were performed based on echocardiographic and clinical surveillance. Excluded were recipients that were re-transplanted or multi-organ transplanted or were followed at another institution. RESULTS A total of 81 recipients in the first 13 months after transplant underwent an average of 2 (SD ± 1.3) biopsies, 24 ± 6.8 echocardiograms, and 17 ± 4.4 clinic visits per recipient. During the 13-month period, 19 recipients had 24 treated rejection episodes, with the first at an average of 2.8 months post-transplant. The 3-, 12-, 36-, and 60-month conditional on discharge graft survival were 100%, 98.8%, 98.8%, and 90.4%, respectively, comparable to reported figures in major paediatric registries. At a mean follow-up of 4.7 ± 2.1 years, four patients (4.9%) developed cardiac allograft vasculopathy, three (3.7%) developed a malignancy, and seven (8.6%) suffered graft loss. CONCLUSION Rejection surveillance with a low-intensity biopsy protocol demonstrated similar intermediate-term outcomes and safety measures as international registries up to 5 years post-transplant.
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13
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Cardiac transplantation in children. BJA Educ 2019; 19:105-112. [DOI: 10.1016/j.bjae.2019.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2019] [Indexed: 11/30/2022] Open
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14
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Wagner SJ, Turek JW, Maldonado J, Staron M, Edens RE. Less Is More in Post Pediatric Heart Transplant Care. Ann Thorac Surg 2018; 107:165-171. [PMID: 30071234 DOI: 10.1016/j.athoracsur.2018.06.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 05/24/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Historically, steroids and endomyocardial biopsies have, respectively, been part of standard immunosuppression for preventing cardiac transplant rejection and monitoring for rejection. However, these treatments come with numerous adverse effects. Some transplant programs have questioned whether the risks and costs outweigh the benefits or whether they may interfere with patient outcomes. METHODS Pediatric cardiac transplantations over 15 years (n = 49) were examined in a single-center retrospective study. Two groups of patients were formed: group 1 received induction steroids and underwent routine protocol biopsy (n = 18), and group 2 neither received steroids nor underwent routine biopsy (n = 13). RESULTS The 1-year survival rate was similar between the two approaches: group 1 survival was 94% and group 2 survival was 92%. However, differences between the two groups were observed for comorbidities. Group 1 had 11 patients that exhibited rejection, and group 2 had only 1 patient (p = 0.003). Group 2 had fewer cases of posttransplant hypertension (p = 0.001) and insulin dependence (p = 0.02). CONCLUSIONS This study suggests a less-invasive posttransplant approach that avoids biopsies and steroids was safely implemented in this single center. Both groups had similar survival. However, group 2 had statistically significant less posttransplant rejection, hypertension, and diabetes. Overall, this study shows no increased risk associated with steroid and biopsy avoidance in posttransplant patients, but with some clear benefits.
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Affiliation(s)
- Samantha J Wagner
- Department of Pediatrics, Stead Family Children's Hospital, University of Iowa, Iowa City, Iowa
| | - Joseph W Turek
- Department of Surgery, Stead Family Children's Hospital, University of Iowa, Iowa City, Iowa
| | - Jennifer Maldonado
- Department of Pediatrics, Stead Family Children's Hospital, University of Iowa, Iowa City, Iowa
| | - Michelle Staron
- Department of Pediatrics, Stead Family Children's Hospital, University of Iowa, Iowa City, Iowa
| | - R Erik Edens
- Department of Pediatrics, Stead Family Children's Hospital, University of Iowa, Iowa City, Iowa.
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Butts RJ, Dipchand AI, Sutcliffe D, Bano M, Dimas V, Morrow R, Das B, Kirk R. Comparison of basiliximab vs antithymocyte globulin for induction in pediatric heart transplant recipients: An analysis of the International Society for Heart and Lung Transplantation database. Pediatr Transplant 2018; 22:e13190. [PMID: 29878688 DOI: 10.1111/petr.13190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2018] [Indexed: 11/28/2022]
Abstract
This study aims to compare 2 common induction strategies, basiliximab and ATG. Analysis of the ISHLT transplant registry was performed. The database was queried for pediatric heart transplants from January 1, 2000, to June 30, 2015, who had received induction with basiliximab or ATG. Primary end-point was graft survival. Secondary end-points included 1-year survival and 1-year conditional survival. There were 3158 heart transplants who received induction with basiliximab or ATG. The ATG cohort was younger, more likely to have congenital heart disease or be a retransplant, have a higher PRA, longer ischemic time, and been transplanted earlier in the study period (all P<.01). There was no difference in graft loss in the basiliximab cohort compared to the ATG cohort (HR 1.18 P=.06). On conditional 1-year survival analysis, basiliximab induction was associated with graft loss (HR=1.35 95% CI 1.1-1.7, P<.01), and in the propensity-matched cohort, the basiliximab cohort was more likely to experience rejection prior to discharge (P=.04). Infection prior to discharge was more common in the antithymocyte cohort. Induction with ATG is associated with improved late graft survival compared to basiliximab.
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Affiliation(s)
- Ryan J Butts
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anne I Dipchand
- Hospital for Sick Children, University of Toronto, Toronto, ON, USA
| | - David Sutcliffe
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Maria Bano
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vivian Dimas
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert Morrow
- Children's Medical Center of Dallas, Dallas, TX, USA
| | - Bibhuti Das
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Richard Kirk
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Schweiger M, Zuckermann A, Beiras-Fernandez A, Berchtolld-Herz M, Boeken U, Garbade J, Hirt S, Richter M, Ruhpawar A, Schmitto JD, Schönrath F, Schramm R, Schulz U, Wilhelm MJ, Barten MJ. A Review of Induction with Rabbit Antithymocyte Globulin in Pediatric Heart Transplant Recipients. Ann Transplant 2018; 23:322-333. [PMID: 29760372 PMCID: PMC6248300 DOI: 10.12659/aot.908243] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Pediatric heart transplantation (pHTx) represents only a small proportion of cardiac transplants. Due to these low numbers, clinical data relating to induction therapy in this special population are far less extensive than for adults. Induction is used more widely in pHTx than in adults, mainly because of early steroid withdrawal or complete steroid avoidance. Antithymocyte globulin (ATG) is the most frequent choice for induction in pHTx, and rabbit antithymocyte globulin (rATG, Thymoglobulin®) (Sanofi Genzyme) is the most widely-used ATG preparation. In the absence of large, prospective, blinded trials, we aimed to review the current literature and databases for evidence regarding the use, complications, and dosages of rATG. Analyses from registry databases suggest that, overall, ATG preparations are associated with improved graft survival compared to interleukin-2 receptor antagonists. Advantages for the use of rATG have been shown in low-risk patients given tacrolimus and mycophenolate mofetil in a steroid-free regimen, in sensitized patients with pre-formed alloantibodies and/or a positive donor-specific crossmatch, and in ABO-incompatible pHTx. Registry and clinical data have indicated no increased risk of infection or post-transplant lymphoproliferative disorder in children given rATG after pHTx. A total rATG dose in the range 3.5–7.5 mg/kg is advisable.
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Affiliation(s)
- Martin Schweiger
- Department of Cardiac Surgery, Children's Hospital, Zürich, Switzerland
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | | | - Udo Boeken
- Department of Cardiovascular Surgery, Heinrich Heine University, Düsseldorf, Germany
| | - Jens Garbade
- Department of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Stephan Hirt
- Department of Cardiac and Thoracic Surgery, University of Regensburg, Regensburg, Germany
| | | | - Arjang Ruhpawar
- Cardiac Surgery Clinic, University of Heidelberg, Heidelberg, Germany
| | - Jan Dieter Schmitto
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Felix Schönrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, and DZHK (German Center for Cardiovascular Research), Berlin, Germany
| | - Rene Schramm
- Clinic of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| | - Uwe Schulz
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Markus J Wilhelm
- Clinic for Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Markus J Barten
- University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Corticosteroid Weaning in Stable Heart Transplant Patients: Guidance by Serum Cortisol Level. J Transplant 2018; 2018:3740395. [PMID: 29670764 PMCID: PMC5835262 DOI: 10.1155/2018/3740395] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/16/2018] [Accepted: 01/23/2018] [Indexed: 12/03/2022] Open
Abstract
Background Despite earlier studies describing the feasibility of steroid weaning in heart transplant patients, the majority of patients are maintained on steroid therapy for life. We examined a strategy based on a single morning serum cortisol measurement. Methods We assigned stable posttransplant patients, who were maintained on tacrolimus, mycophenolate mofetil, and corticosteroids, into one of two groups based on a screening morning cortisol level. Patients with a cortisol < 8 micrograms/deciliter were assigned to a “maintenance” group and the others were assigned to the weaning group and steroids were tapered off over 4–6 weeks. Patients were monitored on subsequent office visits for adrenal insufficiency and allograft rejection. Results Thirty-one patients were enrolled (6 patients in the maintenance group and 25 in the steroid-weaning group). Mean follow-up was 10.2 ± 4 years for the weaning group and 9.0 ± 4.9 years in the maintenance group (p = 0.6). No cases of rejection were noted, nor did any patient resume steroid treatment following discontinuation. Conclusion Steroids can be safely discontinued in stable heart transplant patients with an AM serum cortisol ≥ 8 micrograms/deciliter with appropriate outpatient follow-up. In this study, no patient suffered late rejection or clinically noted adrenal insufficiency.
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Effect of Induction Therapy on Graft Survival in Primary Pediatric Heart Transplantation: A Propensity Score Analysis of the UNOS Database. Transplantation 2017; 101:1228-1233. [PMID: 27362312 DOI: 10.1097/tp.0000000000001285] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The use of induction therapy in pediatric heart transplantation has increased. The aim of this study was to investigate the effects of induction therapy on graft survival. METHODS The United Network for Organ Sharing database was queried for isolated pediatric heart transplants from January 1, 1994, to December 31, 2013. Propensity scores for induction treatment were calculated by estimating probability of induction using a logistic regression model. Transplants were then matched between induction treatment groups based on the propensity score, reducing potential biases. Using only propensity score matched transplants, the effect of induction therapy on graft survival was investigated using Cox-proportional hazards. Subgroup analyses were performed based on age, race, recipient cardiac diagnosis, HLA, and recipient panel-reactive antibody (PRA). RESULTS Of 4565 pediatric primary heart transplants from 1994 to 2013, 3741 had complete data for the propensity score calculation. There were 2792 transplants successfully matched (induction, n = 1396; no induction, n = 1396). There were no significant differences in transplant and pretransplant covariates between induction and no induction groups. In the Cox-proportional hazards model, the use of induction of was not associated with graft loss (hazard ratio [HR], 0.88; 95% confidence interval [95% CI], 0.75-1.01; P = 0.07). In subgroup analyses, induction therapy may be associated with improved survival in patients with PRA greater than 50% (HR, 0.57; 95% CI, 0.34-0.97) and congenital heart disease (HR, 0.78; 95% CI, 0.64-0.96). CONCLUSIONS Induction therapy is not associated with improved graft survival in primary pediatric heart transplantation. However, in pediatric heart transplant recipients with PRA greater than 50% or congenital heart disease, induction therapy is associated with improved survival.
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Schweiger M, Stiasny B, Immer F, Bürki C, Schmiady M, Dave H, Cavigelli-Brunner A, Kretschmar O, Cannizzaro V, Hübler M. Cardiac transplantation in a neonate-First case in Switzerland and European overview. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12935] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Martin Schweiger
- Division of Congenital Cardiovascular Surgery; University Children's Hospital Zurich; Zurich Switzerland
- Children's Research Centre; University Children's Hospital Zurich; Zurich Switzerland
| | - Brian Stiasny
- Children's Research Centre; University Children's Hospital Zurich; Zurich Switzerland
- Division of Pediatric Cardiology; University Children's Hospital Zurich; Zurich Switzerland
| | | | - Christoph Bürki
- Children's Research Centre; University Children's Hospital Zurich; Zurich Switzerland
- Department of Anesthesiology; University Children's Hospital Zurich; Zurich Switzerland
| | - Martin Schmiady
- Division of Congenital Cardiovascular Surgery; University Children's Hospital Zurich; Zurich Switzerland
- Children's Research Centre; University Children's Hospital Zurich; Zurich Switzerland
| | - Hitendu Dave
- Division of Congenital Cardiovascular Surgery; University Children's Hospital Zurich; Zurich Switzerland
- Children's Research Centre; University Children's Hospital Zurich; Zurich Switzerland
| | - Anna Cavigelli-Brunner
- Children's Research Centre; University Children's Hospital Zurich; Zurich Switzerland
- Division of Pediatric Cardiology; University Children's Hospital Zurich; Zurich Switzerland
| | - Oliver Kretschmar
- Children's Research Centre; University Children's Hospital Zurich; Zurich Switzerland
- Division of Pediatric Cardiology; University Children's Hospital Zurich; Zurich Switzerland
| | - Vincenzo Cannizzaro
- Children's Research Centre; University Children's Hospital Zurich; Zurich Switzerland
- Department of Intensive Care Medicine and Neonatology; University Children's Hospital Zurich; Zurich Switzerland
| | - Michael Hübler
- Division of Congenital Cardiovascular Surgery; University Children's Hospital Zurich; Zurich Switzerland
- Children's Research Centre; University Children's Hospital Zurich; Zurich Switzerland
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Elboudwarej O, Phan D, Patel JK, Liou F, Aintablian T, Osborne A, Yu Z, Reinsmoen N, Kobashigawa JA. Corticosteroid wean after heart transplantation-Is there a risk for antibody formation? Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12916] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2017] [Indexed: 11/28/2022]
Affiliation(s)
| | - Derek Phan
- Cedars-Sinai Heart Institute; Los Angeles CA USA
| | | | - Frank Liou
- Cedars-Sinai Heart Institute; Los Angeles CA USA
| | | | | | - Zhe Yu
- Cedars-Sinai Heart Institute; Los Angeles CA USA
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21
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Impact of Rabbit Antithymocyte Globulin Dose on Long-term Outcomes in Heart Transplant Patients. Transplantation 2016; 100:685-93. [PMID: 26457604 DOI: 10.1097/tp.0000000000000950] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Optimal dosing strategies have not been established for rabbit antithymocyte globulin (rATG) after heart transplantation, and there is currently wide variability in rATG regimens with respect to both dose and duration. METHODS In a retrospective, single-center analysis, 523 patients undergoing heart transplantation during 1996 to 2009 were stratified by cumulative rATG dose: less than 4.5 mg/kg (group A), 4.5 to 7.5 mg/kg (group B) or greater than 7.5 mg/kg (group C). RESULTS Survival at 1 year after transplantation was 80% in group A, 90% in group B, and 88% in group C (P = 0.062). Incidence of acute rejection per 1000 patient-years was significantly higher in group A (hazards ratio [HR], 54.8; 95% confidence interval [95% CI], 33.9-83.8) compared to groups B (19.6; 95% CI, 11.4-31.4) and C (23.6; 95% CI, 17.5-31.3). Incidence of severe infection 10 years after transplantation was higher in group C (45%) than groups A (37%) or B (23%) (P < 0.001); cytomegalovirus infection rates were 35%, 20% and 23%, respectively (P = 0.009). Multivariable Cox regression showed an HR of 0.51 (95% CI, 0.25-1.02) for acute rejection with group B versus group A, and 0.54 (95% CI, 0.33-0.88; P = 0.013) for severe infection. The rate of malignancy per 1000 patient-years was higher in groups B (13.85) and C (14.95) than group A (7.83). CONCLUSIONS These retrospective data suggest that a cumulative rATG dose of 4.5 to 7.5 mg/kg may offer a better risk-benefit ratio than lower or higher doses, with acceptable rates of infection and posttransplant malignancy. Prospective trials are needed.
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A Proposal for Early Dosing Regimens in Heart Transplant Patients Receiving Thymoglobulin and Calcineurin Inhibition. Transplant Direct 2016; 2:e81. [PMID: 27500271 PMCID: PMC4946520 DOI: 10.1097/txd.0000000000000594] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 04/10/2016] [Indexed: 12/19/2022] Open
Abstract
There is currently no consensus regarding the dose or duration of rabbit antithymocyte globulin (rATG) induction in different types of heart transplant patients, or the timing and intensity of initial calcineurin inhibitor (CNI) therapy in rATG-treated individuals. Based on limited data and personal experience, the authors propose an approach to rATG dosing and initial CNI administration. Usually rATG is initiated immediately after exclusion of primary graft failure, although intraoperative initiation may be appropriate in specific cases. A total rATG dose of 4.5 to 7.5 mg/kg is advisable, tailored within that range according to immunologic risk and adjusted according to immune monitoring. Lower doses (eg, 3.0 mg/kg) of rATG can be used in patients at low immunological risk, or 1.5 to 2.5 mg/kg for patients with infection on mechanical circulatory support. The timing of CNI introduction is dictated by renal recovery, varying between day 3 and day 0 after heart transplantation, and the initial target exposure is influenced by immunological risk and presence of infection. Rabbit antithymocyte globulin and CNI dosing should not overlap except in high-risk cases. There is a clear need for more studies to define the optimal dosing regimens for rATG and early CNI exposure according to risk profile in heart transplantation.
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Immune Therapy. Pediatr Crit Care Med 2016; 17:S69-76. [PMID: 26945331 DOI: 10.1097/pcc.0000000000000626] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In this Consensus Statement, we review the etiology and pathophysiology of inflammatory processes seen in critically ill children with cardiac disease. Immunomodulatory therapies aimed at improving outcomes in patients with myocarditis, heart failure, and transplantation are extensively reviewed. DATA SOURCES The author team experience and along with an extensive review of the medical literature were used as data sources. DATA SYNTHESIS The authors synthesized the data in the literature to present current immumodulatory therapies. For each drug, the physiologic rationale, mechanism of action, and pharmacokinetics are synthesized, and the evidence in the literature to support the therapy is discussed. CONCLUSIONS Immunomodulation has a crucial role in the treatment of certain pediatric cardiac diseases. Immunomodulatory treatments that have been used to treat myocarditis include corticosteroids, IV immunoglobulin, cyclosporine, and azathioprine. Contemporary outcomes of pediatric transplant recipients have improved over the past few decades, partly related to improvements in immunomodulatory therapy to prevent rejection of the donor heart. Immunosuppression therapy is commonly divided into induction, maintenance, and acute rejection therapy. Common induction medications include antithymocyte globulin, muromonab-CD3, and basiliximab. Maintenance therapy includes chronic medications that are used daily to prevent rejection episodes. Examples of maintenance medications are corticosteroids, cyclosporine, tacrolimus, sirolimus, everolimus, azathioprine, and mycophenolate mofetil. Rejection of the donor heart is diagnosed either by clinically or by biopsy and is treated with intensification of immunosuppression.
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Ansari D, Höglund P, Andersson B, Nilsson J. Comparison of Basiliximab and Anti-Thymocyte Globulin as Induction Therapy in Pediatric Heart Transplantation: A Survival Analysis. J Am Heart Assoc 2015; 5:JAHA.115.002790. [PMID: 26722127 PMCID: PMC4859398 DOI: 10.1161/jaha.115.002790] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Basiliximab and anti‐thymocyte globulin are widely used drugs for induction therapy after pediatric heart transplantation. The aim of this study was to determine whether any differences could be observed between basiliximab and anti‐thymocyte globulin, with respect to long‐term mortality, in a population of pediatric cardiac transplant recipients. Methods and Results An analysis of pediatric heart transplant patients (aged <18 years) from the United Network for Organ Sharing database was conducted that compared patients receiving basiliximab with those that received anti‐thymocyte globulin for the risk of all‐cause mortality. Secondary endpoints included death attributable to graft failure, cardiovascular causes, infection, or malignancy. Of the 2275 patients, 685 received basiliximab and 1590 anti‐thymocyte globulin. One‐year survival was similar for both groups; however, at 5 and 10 years, basiliximab was associated with poorer long‐term survival (68% versus 76% at 5 years [P<0.001] and 49% versus 65% at 10 years [P<0.001], respectively). Basiliximab was associated with higher risk of death attributable to graft failure (P=0.013), but not death attributable to cardiovascular causes (P=0.444), infection (P=0.095), or malignancy (P=0.392). After multivariate analysis, use of basiliximab (versus use of anti‐thymocyte globulin) remained significantly associated with all‐cause mortality (hazard ratio, 1.27; 95% confidence interval, 1.02–1.57; P=0.030). Conclusions In pediatric heart transplant patients, use of basiliximab for induction therapy was associated with an increased risk of mortality, when compared with those receiving anti‐thymocyte globulin.
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Affiliation(s)
- David Ansari
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University and Skåne University Hospital, Lund, Sweden (D.A., J.N.)
| | - Peter Höglund
- Department of Laboratory Medicine Lund, Clinical Chemistry and Pharmacology, Lund University, Lund, Sweden (P.)
| | - Bodil Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden (B.A.)
| | - Johan Nilsson
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University and Skåne University Hospital, Lund, Sweden (D.A., J.N.)
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Auerbach SR, Kukreja M, Gilbert D, Bastardi H, Feingold B, Knecht K, Kaufman BD, Brown RN, Miyamoto SD. Maintenance steroid use at 30 days post-transplant and outcomes of pediatric heart transplantation: A propensity matched analysis of the Pediatric Heart Transplant Study database. J Heart Lung Transplant 2015; 34:1066-72. [DOI: 10.1016/j.healun.2015.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 02/19/2015] [Accepted: 03/16/2015] [Indexed: 10/23/2022] Open
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Mohty M, Bacigalupo A, Saliba F, Zuckermann A, Morelon E, Lebranchu Y. New directions for rabbit antithymocyte globulin (Thymoglobulin(®)) in solid organ transplants, stem cell transplants and autoimmunity. Drugs 2015; 74:1605-34. [PMID: 25164240 PMCID: PMC4180909 DOI: 10.1007/s40265-014-0277-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the 30 years since the rabbit antithymocyte globulin (rATG) Thymoglobulin® was first licensed, its use in solid organ transplantation and hematology has expanded progressively. Although the evidence base is incomplete, specific roles for rATG in organ transplant recipients using contemporary dosing strategies are now relatively well-identified. The addition of rATG induction to a standard triple or dual regimen reduces acute cellular rejection, and possibly humoral rejection. It is an appropriate first choice in patients with moderate or high immunological risk, and may be used in low-risk patients receiving a calcineurin inhibitor (CNI)-sparing regimen from time of transplant, or if early steroid withdrawal is planned. Kidney transplant patients at risk of delayed graft function may also benefit from the use of rATG to facilitate delayed CNI introduction. In hematopoietic stem cell transplantation, rATG has become an important component of conventional myeloablative conditioning regimens, following demonstration of reduced acute and chronic graft-versus-host disease. More recently, a role for rATG has also been established in reduced-intensity conditioning regimens. In autoimmunity, rATG contributes to the treatment of severe aplastic anemia, and has been incorporated in autograft projects for the management of conditions such as multiple sclerosis, Crohn’s disease, and systemic sclerosis. Finally, research is underway for the induction of tolerance exploiting the ability of rATG to induce immunosuppresive cells such as regulatory T-cells. Despite its long history, rATG remains a key component of the immunosuppressive armamentarium, and its complex immunological properties indicate that its use will expand to a wider range of disease conditions in the future.
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Affiliation(s)
- Mohamad Mohty
- Department of Hematology and Cellular Therapy, CHU Hôpital Saint Antoine, 184, rue du Faubourg Saint Antoine, 75571, Paris Cedex 12, France,
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Rangel UV, Gomes Junior SCDS, Costa AMAM, Moreira MEL. Variables associated with peripherally inserted central catheter related infection in high risk newborn infants. Rev Lat Am Enfermagem 2014; 22:842-7. [PMID: 25493681 PMCID: PMC4292672 DOI: 10.1590/0104-1169.3481.2488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 07/08/2014] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE: to relate the variables from a surveillance form for intravenous devices in high
risk newborn infants with peripherally inserted central catheter related
infection. METHODOLOGY: approximately 15 variables were studied, being associated with peripherally
inserted central catheter related infection, this being defined by blood culture
results. The variables analyzed were obtained from the surveillance forms used
with intravenous devices, attached to the medical records of newborn infants
weighing between 500 and 1,499 g. The statistical association was defined using
the Chi-squared and Student t tests. The study was approved by the Research Ethics
Committee of the Instituto Fernandes Figueira under process N. 140.703/12. RESULTS: 63 medical records were analyzed. The infection rate observed was 25.4%. Of the
variables analyzed, only three had a statistically-significant relationship with
the blood culture - the use of drugs capable of inhibiting acid secretion,
post-natal steroid use, and undertaking more than one invasive procedure (p-value
of 0.0141, 0.0472 and 0.0277, respectively). CONCLUSION: the absence of significance of the variables of the form may be related to the
quality of the records and to the absence of standardization. It is recommended
that the teams be encouraged to adhere to the protocol and fill out the form.
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28
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Zuckermann A, Schulz U, Deuse T, Ruhpawar A, Schmitto JD, Beiras-Fernandez A, Hirt S, Schweiger M, Kopp-Fernandes L, Barten MJ. Thymoglobulin induction in heart transplantation: patient selection and implications for maintenance immunosuppression. Transpl Int 2014; 28:259-69. [PMID: 25363471 PMCID: PMC4359038 DOI: 10.1111/tri.12480] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 09/18/2014] [Accepted: 10/24/2014] [Indexed: 01/12/2023]
Abstract
Clinical data relating to rabbit antithymocyte globulin (rATG) induction in heart transplantation are far less extensive than for other immunosuppressants, or indeed for rATG in other indications. This was highlighted by the low grade of evidence and the lack of detailed recommendations for prescribing rATG in the International Society for Heart and Lung Transplantation (ISHLT) guidelines. The heart transplant population includes an increasing frequency of patients on mechanical circulatory support (MCS), often with ongoing infection and/or presensitization, who are at high immunological risk but also vulnerable to infectious complications. The number of patients with renal impairment is also growing due to lengthening waiting times, intensifying the need for strategies that minimize calcineurin inhibitor (CNI) toxicity. Additionally, the importance of donor-specific antibodies (DSA) in predicting graft failure is influencing immunosuppressive regimens. In light of these developments, and in view of the lack of evidence-based prescribing criteria, experts from Germany, Austria, and Switzerland convened to identify indications for rATG induction in heart transplantation and to develop an algorithm for its use based on patient characteristics.
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Affiliation(s)
- Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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Abstract
BACKGROUND Maintenance steroid (MS) use in pediatric heart transplantation (HT) varies across centers. The purpose of this study was to evaluate the impact of steroid-free maintenance immunosuppression (SF) on graft outcomes in pediatric HT. METHODS Patients younger than 18 years in the United States undergoing a first HT during 1990 to 2010 were analyzed for conditional 30-day graft loss (death or repeat HT) and death based on MS use by multivariable analysis. A propensity score was then given to each patient using a logistic model, and propensity matching was performed using pre-HT risk factors, induction therapy, and nonsteroid maintenance immunosuppression. Kaplan-Meier graft and patient survival probabilities by MS use were then calculated. RESULTS Of 4894 patients, 3962 (81%) were taking MS and 932 (19%) SF. Of the 4530 alive at 30 days after HT, 3694 (82%) and 836 (18%) were in the MS and SF groups, respectively. Unmatched multivariable analysis showed no difference in 30-day conditional graft survival between MS and SF groups (hazard ratio=1.08, 95% confidence interval=0.93-1.24; P=0.33). Propensity matching resulted in 462 patients in each MS and SF group. Propensity-matched Kaplan-Meier survival analysis showed no difference in graft or patient survival between groups (P=0.3 and P=0.16, respectively). CONCLUSIONS We found no difference in graft survival between SF patients and those taking MS. An SF regimen in pediatric HT avoids potential complications of steroid use without compromising graft survival, even after accounting for pre-HT risk factors.
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Baraldo M, Gregoraci G, Livi U. Steroid-free and steroid withdrawal protocols in heart transplantation: the review of literature. Transpl Int 2014; 27:515-29. [PMID: 24617420 PMCID: PMC4229061 DOI: 10.1111/tri.12309] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Revised: 01/11/2013] [Accepted: 03/06/2014] [Indexed: 01/05/2023]
Abstract
Corticosteroids (CSs) are still the mainstay of induction, rescue, and maintenance in heart transplantation (HTx). However, their use is associated with significant and well-documented side effects usually related to the dose administered and the duration of therapy. Moreover, CSs interfere with the recipient's quality of life and with the active process of graft tolerance. Physicians have been exploring ways to avoid or reduce CSs in association with other immunosuppressive drugs, minimizing side effects and costs. The regimens are classified as steroid-free or steroid withdrawal protocols. The studies analyzed in this review come to similar conclusions as benefits and adverse consequences: steroid-free protocols should be advisable and mandatory in pediatric patients, insulin-dependent diabetes mellitus (IDDM), presence of infection, familial metabolic disorders/obesity, severe osteoporosis, and in the elderly. On the other hand, steroid withdrawal can be successfully achieved in 50-80%, with late better than early withdrawal, no increase in rejection-related mortality, no adverse impact on survival, and probably a better quality of live. Safety and efficacy can certainly be improved by an individualized approach to the transplant recipient.
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Affiliation(s)
- Massimo Baraldo
- Department of Experimental and Clinical Medicine, Medical School, University of Udine, Udine, Italy; SOC Institute of Clinical Pharmacology, University-Hospital Santa Maria della Misericordia, Udine, Italy
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31
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Laster ML, Fine RN. Growth following solid organ transplantation in childhood. Pediatr Transplant 2014; 18:134-41. [PMID: 24438347 DOI: 10.1111/petr.12219] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2013] [Indexed: 11/28/2022]
Abstract
One of the ultimate goals of successful transplantation in pediatric solid organ transplant recipients is the attainment of optimal final adult height. This manuscript will discuss the attainment of height following solid organ transplantation in pediatric recipients of kidney, liver, heart, lung, and small bowel transplantation. Age is a primary factor with younger recipients exhibiting the greatest immediate catch up growth. Graft function is a significant contributory factor with a reduction in glomerular filtration rate correlating with poor growth in kidney recipients and the need for re-transplantation with impaired growth in liver recipients. The known adverse impact of steroids on growth has led to modification of steroid dosage and even to steroid withdrawal and steroid avoidance. In kidney and liver recipients, this has been associated with the development on occasion of acute rejection episodes. In infant heart transplantation, avoidance of maintenance corticosteroid immunosuppression is associated with normal growth velocity in the majority of patients. With marked improvement in patient and graft survival rates in pediatric organ graft recipients, it is timely that the quality of life issues, such as normal adult height, receive paramount attention. In general, normal growth post-transplantation should be an achievable goal that results in normal adult height for many solid organ transplantation recipients.
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Affiliation(s)
- M L Laster
- LAC+USC Medical Center, Los Angeles, CA, USA
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32
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Thrush PT, Gossett JG, Costello JM, Matthews KL, Nubani R, Bhagat H, Backer CL, Pahl E. Role for immune monitoring to tailor induction prophylaxis in pediatric heart recipients. Pediatr Transplant 2014; 18:79-86. [PMID: 24283506 DOI: 10.1111/petr.12193] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2013] [Indexed: 01/29/2023]
Abstract
UNLABELLED rATG is used for HTx induction but is costly and associated with infection and PTLD. HYPOTHESIS Tailoring rATG induction with CD3 monitoring results in less infection, reduced costs, and similar rejection. Retrospective review of HTx recipients receiving rATG induction. Control cases received "usual" rATG dosing (1.5 mg/kg/day typically × 5 days). Starting in October 2009, absolute CD3 monitoring (target <25 cells/mm(3) ) guided rATG dosing (study cases). Outcomes included first-year incidence of infection/rejection, direct costs of therapy, and incidence of PTLD/death. Study cases (n = 32) received fewer doses of rATG (median 4 vs. 5, p < 0.001) and less total rATG (median 3.2 vs. 7.4 mg/kg, p < 0.001) compared with controls (n = 17). There was no difference in incidence of infection, rejection, or patient survival during the first year post-HTx. There was one early death in both groups and one late case of PTLD in the control group. Drug savings were significant (median drug cost per patient $2718 vs. $4756, p < 0.001). CD3-tailored rATG induction in HTx recipients is associated with reduced drug costs and similar rates of rejection/infection. Longer follow-up will determine whether extended benefits are associated with this induction monitoring strategy.
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Affiliation(s)
- Philip T Thrush
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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33
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Tissue Doppler imaging for rejection surveillance in pediatric heart transplant recipients. J Heart Lung Transplant 2013; 32:1027-33. [PMID: 23937884 DOI: 10.1016/j.healun.2013.06.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 06/13/2013] [Accepted: 06/20/2013] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Most transplant centers perform serial cardiac biopsies for rejection surveillance in pediatric heart transplant (HT) recipients. We sought to assess tissue Doppler imaging (TDI) findings during biopsy specimen-proven rejection in pediatric HT recipients and to develop TDI criteria for absence of rejection with high predictive accuracy. METHODS We included the 122 HT recipients in follow-up at our center (median age at HT, 8.7 years). We identified all echocardiograms with adequate TDI data performed within 24 hours of a cardiac biopsy during 2005 to 2011. Rejection was defined as Grade ≥ 2R cellular rejection or antibody-mediated rejection. Paired comparisons of TDI velocities were made using patients' baseline velocities as the control. RESULTS Overall, 647 specimen-pairs were identified where there was no rejection at baseline. In 24 of these, the second biopsy specimen demonstrated rejection. Using receiver operating characteristic curve analysis of percentage change from baseline, we identified < 15% decline in left ventricular (LV) S' velocity and < 5% decline in LV A' velocity to individually predict non-rejection with > 99% accuracy. When joint criteria were used, the predictive accuracy was 100%, and no rejection event was misclassified. More than 75% of TDI pairs met these criteria for non-rejection. CONCLUSIONS Biopsy specimen-proven rejection is associated with a significant decline in biventricular TDI velocities from baseline in pediatric HT recipients. By using well-defined TDI criteria to predict non-rejection, a substantial proportion of planned biopsies may be deferred or avoided at minimal risk to pediatric HT recipients.
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34
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Chen CK, Dipchand AI. The current state and key issues of pediatric heart transplantation. INDIAN JOURNAL OF TRANSPLANTATION 2013. [DOI: 10.1016/j.ijt.2013.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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35
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Marshall CD, Richmond ME, Singh RK, Gilmore L, Beddows K, Chen JM, Addonizio LJ. A comparison of traditional versus contemporary immunosuppressive regimens in pediatric heart recipients. J Pediatr 2013; 163:132-6. [PMID: 23391044 DOI: 10.1016/j.jpeds.2012.12.075] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 12/11/2012] [Accepted: 12/21/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To assess the differences in rejection and infection complications between the most common contemporary immunosuppression regimen in pediatric heart transplantation (cytolytic induction, tacrolimus based) and classic triple-therapy (cyclosporine based without induction). STUDY DESIGN We performed a retrospective, historical-control, observational study comparing outcomes in patients who underwent traditional immunosuppression (control group, n = 64) with those for whom the contemporary protocol was used (n = 39). Episodes of rejection, viremia (cytomegalovirus or Epstein-Barr virus), serious bacterial or fungal infections, anemia or neutropenia requiring treatment in the first year after heart transplantation, and 1-year survival were compared between traditional and contemporary immunosuppression groups. RESULTS The 2 groups were similar with respect to baseline demographics. There were no differences in risk of cytomegalovirus, Epstein-Barr virus, or bacterial or fungal infections in the first year post-transplantation. Patients in the contemporary group were more likely to need therapy for anemia (51% vs 14%, P < .001) or neutropenia (10% vs 0%, P = .019). However, more contemporary protocol patients were rejection-free in the first year post-transplantation (63% vs 41%, P = .03). Overall graft survival was similar between groups (P = .15). CONCLUSIONS A contemporary immunosuppression regimen using tacrolimus, mycophenolate mofetil, and induction was associated with less rejection in the first year, with no difference in the risk of infection but greater risk of anemia and neutropenia requiring treatment. Long-term follow-up on these patients will evaluate the impact of the immunosuppression regimen on survival.
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Affiliation(s)
- Clement D Marshall
- Division of Pediatric Cardiology, Columbia University, College of Physicians and Surgeons, New York, NY 10032, USA
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36
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Crespo Leiro MG, Bonet LA, Paniagua Martín MJ, Gómez Bueno M, Escribano P, González Vilchez F, Rodríguez Lambert JL, Brossa Loidi V, Lage Gallé E, Delgado Jiménez J. Steroid withdrawal during 5 years following heart transplantation, and the relationship between steroid dosage at 1-year follow-up and complications during the next 2 years: results from the RESTCO study. Transplant Proc 2013; 44:2631-4. [PMID: 23146478 DOI: 10.1016/j.transproceed.2012.09.104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Little information is available regarding the controversial issue of steroid withdrawal following heart transplantation (HT), or instead in the incidence of adverse steroid effects at dosages typically employed in Spain. METHODS We analyzed the 5-year follow-up records of 1209 patients (82.5% men, aged ≥ 18 years) who underwent HT between 2000 and 2005 and survived at least 1 month in 13 Spanish centers. The incidences of first steroid withdrawal before 1, 3, and 5 years post-HT were expressed as Kaplan-Meier probability estimates. Three patient groups defined in accordance with steroid dosage at 1-year follow-up (0, ≤ 5, and >5 mg/d; groups A, B, and C, respectively) were compared with regard to the incidence of de novo hypertension, diabetes, and bone fractures over the following 2 years. RESULTS The 5-year incidence of withdrawal was 28%, 21% of whom required reintroduction of steroids. Kaplan-Meier probabilities of withdrawal before 1, 3, and 5 years post-HT were 8.8% (95% confidence interval ([CI] 7.3%-10.7%), 27.8% (CI 25.2%-30.6%), and 30.2% (CI 27.5%-33.2%), respectively. At 1-year follow-up, 9.9% of patients were steroid-free, 28.9% were taking ≤ 5 mg/d, and 61.3% >5 mg/d. The 2-year incidence of de novo hypertension increased significantly (P = .012) from 13.5% to 29.6% to 35.3% in groups A, B, and C respectively. These groups did not differ significantly in regard to the 2-year incidence of diabetes or bone fractures. CONCLUSIONS Reintroduction of steroids was required by 21% of the 28% of Spanish HT patients who has been weaned from steroids within 5 years of HT. The incidence of de novo hypertension between 1 and 3 years post-HT increased with steroid dosage at 1-year follow-up. De novo diabetes and bone fractures showed no similar significant association.
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Affiliation(s)
- M G Crespo Leiro
- Complejo Hospitalario, Universitario de A Coruña, A Coruña, Spain.
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37
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Cahoon WD, Ensor CR, Shullo MA. Alemtuzumab for cytolytic induction of immunosuppression in heart transplant recipients. Prog Transplant 2013. [PMID: 23187050 DOI: 10.7182/pit2012241] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To review available evidence about the safety and efficacy of alemtuzumab for induction of immunosuppression in heart transplant recipients. DATA SOURCES Searches of MEDLINE, EMBASE, and Cochrane databases were conducted. Key search terms included alemtuzumab, Campath-1H, CD52, lymphocyte, cytolytic, induction, immunosuppression, rejection, and cardiac transplantation. Additional pertinent data were identified through a search of abstracts from major transplant meetings. STUDY SELECTION AND DATA EXTRACTION All English-language articles and abstracts identified from the data sources were evaluated. All primary data were eligible for inclusion if they evaluated the safety or efficacy of alemtuzumab for induction of immunosuppression in heart transplant patients. One retrospective cohort, 1 case series, 1 case-control series, and 1 open-label trial were identified and included for review. DATA SYNTHESIS Acute cellular rejection occurs in 40% to 70% of heart transplant recipients within the first 6 months after transplant and is associated with significant morbidity and mortality. Depleting and nondepleting antibodies have displayed positive outcomes in inducing immunosuppression; however, the ideal induction strategy that balances efficacy and toxicity remains elusive. Alemtuzumab, a cytolytic anti-CD52 antibody, has been used to induce immunosuppression in kidney, pancreas, liver, intestine, and lung transplant recipients, and its use in heart transplant has been investigated. Studies of use of alemtuzumab to induce immunosuppression in heart transplant patients have shown low rates of rejection; however, it has not been directly compared with other immunosuppression-inducing agents and safety data are limited. CONCLUSIONS Although alemtuzumab may be a practical option for inducing immunosuppression, data are insufficient to recommend its routine use in deference to more established agents. Large, randomized clinical trials with extended durations of follow-up must be conducted to characterize its efficacy and safety further.
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Affiliation(s)
- William D Cahoon
- Virginia Commonwealth University Health System, Richmond, VA, USA.
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Schumacher KR, Gajarski RJ. Postoperative care of the transplanted patient. Curr Cardiol Rev 2013; 7:110-22. [PMID: 22548034 PMCID: PMC3197086 DOI: 10.2174/157340311797484286] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 06/09/2011] [Accepted: 06/29/2011] [Indexed: 11/22/2022] Open
Abstract
The successful delivery of optimal peri-operative care to pediatric heart transplant recipients is a vital determinant of their overall outcomes. The practitioner caring for these patients must be familiar with and treat multiple simultaneous issues in a patient who may have been critically ill preoperatively. In addition to the complexities involved in treating any child following cardiac surgery, caretakers of newly transplanted patients encounter multiple transplant-specific issues. This chapter details peri-operative management strategies, frequently encountered early morbidities, initiation of immunosuppression including induction, and short-term outcomes.
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Lunze FI, Colan SD, Gauvreau K, Chen MH, Perez-Atayde AR, Blume ED, Singh TP. Cardiac Allograft Function During the First Year after Transplantation in Rejection-Free Children and Young Adults. Circ Cardiovasc Imaging 2012; 5:756-64. [DOI: 10.1161/circimaging.112.976613] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Allograft dysfunction is a common finding early after heart transplant (HT). We sought to assess the recovery of left (LV) and right ventricular (RV) function during the first year after HT in children and young adults using pulsed-wave tissue Doppler imaging.
Methods and Results—
We analyzed serially performed echocardiography in 44 pediatric HT recipients (median age: 7.3 years at HT) who remained rejection-free during the first year post-transplant. Age-based normative values for systolic (
S
′), early-diastolic (
E
′), and late-diastolic (
A
′) velocities obtained using pulsed-wave tissue Doppler imaging in 380 healthy children were used to transform patient data into
z
scores. Pulsed-wave tissue Doppler imaging studies ≤10 days post-HT demonstrated biventricular systolic and diastolic dysfunction with most prominent impairment in RV systolic function (
S
′
z
score −2.7±0.8), RV early-diastolic filling (
E
′
z
score −2.3±1.1), and LV early-diastolic filling (
E
′
z
score −2.3±1.1). LV systolic function (
S
′
z
score) and late-diastolic filling (
A
′
z
score) improved to normal in 11 to 30 days, LV early-diastolic filling (
E
′
z
score) in 4 to 6 months, and RV early-diastolic filling in 6 to 9 months (
P
<0.001 for all on longitudinal analysis). However, RV systolic function (RV
S
′
z
score −1.2±1.1) remained impaired 1-year post-transplant. Analysis of serial cardiac catheterization studies showed that RV and LV filling pressures were elevated early post-HT and declined gradually during the first year post-transplant.
Conclusions—
Pediatric HT recipients have biventricular dysfunction using pulsed-wave tissue Doppler imaging early after HT with most significant impairment in RV systolic function and RV and LV early-diastolic filling. Although other aspects of LV and RV function normalize in 6 to 9 months, RV systolic function remains abnormal 1 year-post-transplant.
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Affiliation(s)
- Fatima I. Lunze
- From the Departments of Cardiology (F.I.L., S.D.C., K.G., M.H.C., E.D.B., T.P.S.), Medicine (M.H.C.), and Pathology (A.R.P-A.), Boston Children’s Hospital, Boston, MA; Departments of Pediatrics (S.D.C., E.D.B., T.P.S.), and Pathology (A.R.P-A.), Harvard Medical School, Boston, MA; and Department of Biostatistics, Harvard School of Public Health (KG), Boston, MA
| | - Steven D. Colan
- From the Departments of Cardiology (F.I.L., S.D.C., K.G., M.H.C., E.D.B., T.P.S.), Medicine (M.H.C.), and Pathology (A.R.P-A.), Boston Children’s Hospital, Boston, MA; Departments of Pediatrics (S.D.C., E.D.B., T.P.S.), and Pathology (A.R.P-A.), Harvard Medical School, Boston, MA; and Department of Biostatistics, Harvard School of Public Health (KG), Boston, MA
| | - Kimberlee Gauvreau
- From the Departments of Cardiology (F.I.L., S.D.C., K.G., M.H.C., E.D.B., T.P.S.), Medicine (M.H.C.), and Pathology (A.R.P-A.), Boston Children’s Hospital, Boston, MA; Departments of Pediatrics (S.D.C., E.D.B., T.P.S.), and Pathology (A.R.P-A.), Harvard Medical School, Boston, MA; and Department of Biostatistics, Harvard School of Public Health (KG), Boston, MA
| | - Ming Hui Chen
- From the Departments of Cardiology (F.I.L., S.D.C., K.G., M.H.C., E.D.B., T.P.S.), Medicine (M.H.C.), and Pathology (A.R.P-A.), Boston Children’s Hospital, Boston, MA; Departments of Pediatrics (S.D.C., E.D.B., T.P.S.), and Pathology (A.R.P-A.), Harvard Medical School, Boston, MA; and Department of Biostatistics, Harvard School of Public Health (KG), Boston, MA
| | - Antonio R. Perez-Atayde
- From the Departments of Cardiology (F.I.L., S.D.C., K.G., M.H.C., E.D.B., T.P.S.), Medicine (M.H.C.), and Pathology (A.R.P-A.), Boston Children’s Hospital, Boston, MA; Departments of Pediatrics (S.D.C., E.D.B., T.P.S.), and Pathology (A.R.P-A.), Harvard Medical School, Boston, MA; and Department of Biostatistics, Harvard School of Public Health (KG), Boston, MA
| | - Elizabeth D. Blume
- From the Departments of Cardiology (F.I.L., S.D.C., K.G., M.H.C., E.D.B., T.P.S.), Medicine (M.H.C.), and Pathology (A.R.P-A.), Boston Children’s Hospital, Boston, MA; Departments of Pediatrics (S.D.C., E.D.B., T.P.S.), and Pathology (A.R.P-A.), Harvard Medical School, Boston, MA; and Department of Biostatistics, Harvard School of Public Health (KG), Boston, MA
| | - Tajinder P. Singh
- From the Departments of Cardiology (F.I.L., S.D.C., K.G., M.H.C., E.D.B., T.P.S.), Medicine (M.H.C.), and Pathology (A.R.P-A.), Boston Children’s Hospital, Boston, MA; Departments of Pediatrics (S.D.C., E.D.B., T.P.S.), and Pathology (A.R.P-A.), Harvard Medical School, Boston, MA; and Department of Biostatistics, Harvard School of Public Health (KG), Boston, MA
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Clinical Pharmacokinetics and Pharmacodynamics of Prednisolone and Prednisone in Solid Organ Transplantation. Clin Pharmacokinet 2012; 51:711-41. [DOI: 10.1007/s40262-012-0007-8] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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41
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Stendahl G, Bobay K, Berger S, Zangwill S. Organizational structure and processes in pediatric heart transplantation: a survey of practices. Pediatr Transplant 2012; 16:257-64. [PMID: 22244347 DOI: 10.1111/j.1399-3046.2011.01636.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Despite emerging literature on pediatric heart transplantation, there continues to be variation in current practices. The degree of variability among heart transplant programs has not been previously characterized. The purpose of this study was to evaluate organizational structure and practices of pediatric heart transplant programs. The UNOS database was queried to identify institutions according to volume. Coordinators from 50 institutions were invited to participate with a 70% response rate. Centers were grouped by volume into four categories. Some institutional practices were dominated by clear volume trends. Ninety-five percent of larger centers routinely transplant patients with known antibody sensitization and report a broader range and acuity of recipients. Ninety-four percent report problems with non-adherence. Sixty-nine percent of centers routinely require prospective crossmatches. There was dramatic variation in the use of steroids across all centers. Sixty-five percent of centers transition adolescents to an adult program. Prophylaxis protocols were also highly inconsistent. This survey provided a comprehensive insight into current practices at pediatric heart transplant programs. The results delineated remarkably variable strategies for routine aspects of care. Analysis of divergence along with uniformity across protocols is a valuable exercise and may serve as a stepping-stone toward ongoing cooperation and clarity for evidence-based practice protocols.
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Affiliation(s)
- Gail Stendahl
- Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA.
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Abstract
OPINION STATEMENT Outcomes following cardiac transplantation in childhood continue to improve. Advances in immunosuppressive therapy over the past two decades likely have contributed to this trend. The evolution in the management of immunosuppression in children has been based on clinical experience rather than on evidence-based medicine; indeed, there have been no pivotal randomized controlled trials of any form of immunosuppression in pediatric thoracic transplantation. Important trends in immunosuppressive therapy and transplant outcomes have been obtained from large transplant registries. Several trends have been identified since the last review of this topic in this journal. First, there is increased knowledge of the pharmacodynamics and pharmacokinetics of immunosuppressive drugs in children, with notable advances in the field of pharmacogenomics. These studies help explain individual variations in drug exposure, efficacy, and adverse events. They also help explain racial and ethnic variations in drug metabolism and efficacy. Second, there have been clear trends in the use of specific immunosuppressive medications. Use of induction therapy, especially polyclonal T cell-depleting antibody preparations, has increased significantly in recent years. The calcineurin inhibitor (CNI) tacrolimus is being used as the cornerstone of maintenance therapy in lieu of cyclosporine in more and more centers. Mounting evidence suggests that use of adjunctive agents (notably mycophenolate mofetil [MMF]) may improve outcomes, including survival, suggesting that monotherapy with CNIs is not the ideal maintenance therapy. Despite its increased cost, MMF has largely replaced azathioprine as the adjunctive agent of choice. Inhibitors of the mammalian target of rapamycin (i.e., sirolimus and everolimus) have not yet assumed a major place as adjunctive agents, as their safety and efficacy have not been well established in children. With the improvements in immunosuppressive therapy, the justification for routine corticosteroid use is far from clear, and many centers have shown excellent outcomes with complete steroid avoidance. Third, there is increasing interest in the importance of anti-HLA antibodies as important risk factors for adverse graft and patient outcomes. This is generating intense interest in treatments that target B cells and plasma cells. Finally, there is increasing realization that the "one size fits all" approach to immunosuppressive therapy is an obsolete concept and that the ultimate goal is to tailor immunosuppressive therapy to the needs of the individual patient. The development of reliable biomarkers of the patient's immune response to the allograft will be essential for optimal individualized immunosuppressive management.
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43
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Chinnock RE, Bailey LL. Heart transplantation for congenital heart disease in the first year of life. Curr Cardiol Rev 2011; 7:72-84. [PMID: 22548030 PMCID: PMC3197092 DOI: 10.2174/157340311797484231] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 06/13/2011] [Accepted: 06/30/2011] [Indexed: 01/24/2023] Open
Abstract
Successful infant heart transplantation has now been performed for over 25 years. Assessment of long term outcomes is now possible. We report clinical outcomes for322 patients who received their heart transplant during infancy. Actuarial graft survival for newborn recipients is 59% at 25 years. Survival has improved in the most recent era. Cardiac allograft vasculopathy is the most important late cause of death with an actuarial incidence at 25 years of 35%. Post-transplant lymphoma is estimated to occur in 20% of infant recipients by25 years. Chronic kidney disease grade 3 or worse is present in 31% of survivors. The epidemiology of infant heart transplantation has changed through the years as the results for staged repair improved and donor resources remained stagnant. Most centers now employ staged repair for hypoplastic left heart syndrome and similar extreme forms of congenital heart disease. Techniques for staged repair, including the hybrid procedure, are described. The lack of donors is described with particular note regarding decreased donors due to newer programs for appropriate infant sleep positioning and infant car seats. ABO incompatible donors are a newer resource for maximizing donor resources, as is donation after circulatory determination of death and techniques to properly utilize more donors by expanding the criteria for what is an acceptable donor. An immunological advantage for the youngest recipients has long been postulated, and evaluation of this phenomenon may provide clues to the development of accommodation and/or tolerance.
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Affiliation(s)
- Richard E Chinnock
- Departments of Pediatrics, Loma Linda University School of Medicine Pediatric Heart Transplant Program Loma Linda University Children's Hospital Loma Linda, CA, USA.
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44
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Urschel S, Rieck BD, Birnbaum J, Dalla Pozza R, Rieber N, Januszewska K, Fuchs A, West LJ, Netz H, Belohradsky BH. Impaired cellular immune response to diphtheria and tetanus vaccines in children after thoracic transplantation. Pediatr Transplant 2011; 15:272-80. [PMID: 21272167 DOI: 10.1111/j.1399-3046.2010.01468.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Safety and immunogenicity of diphtheria and tetanus booster vaccination were evaluated in 28 children after thoracic transplantation. Adverse events were documented in a patient diary. Blood was collected prior to and four wk after vaccination. Specific antibody concentrations were measured by ELISA. Lymphocytes were investigated for expression of activation markers (CD25, HLA-DR) by flow cytometry and proliferation assays with and without stimulation. Post-vaccination antibody titers were higher than prevaccination (p < 0.001), with more patients having protective antibody levels against diphtheria (p < 0.02) and tetanus (p < 0.001). There was no increased proliferation in non-stimulated or stimulated cultures after vaccination. The number of T-lymphocytes activated by the vaccination antigens was similar pre- and post-vaccination, whereas HLA-DR-expression on stimulated and non-stimulated CD4(+) T-cells increased significantly. Increase in antibodies was negatively correlated with tacrolimus dose, and impaired cellular immunity was associated with higher tacrolimus dose and steroid use. Adverse events were similar to the general population; serious adverse events and rejection did not occur. Vaccination with inactivated vaccines can be performed safely in immunosuppressed children after thoracic transplantation and induces protective antibody levels in the majority of patients. Impaired induction of specific cellular immunity is correlated with intensity of immunosuppression and may explain reduced sustainability of antibodies.
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Affiliation(s)
- Simon Urschel
- Department of Pediatric Cardiology and Intensive Care, Klinikum Grosshadern, Ludwig Maximilians University, Munich, Germany.
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Irving CA, Kirk R, Parry G, Hamilton L, Dark JH, Wrightson N, Griselli M, Hasan A. Outcomes following more than two decades of paediatric cardiac transplantation. Eur J Cardiothorac Surg 2011; 40:1197-202. [PMID: 21493085 DOI: 10.1016/j.ejcts.2011.02.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 02/03/2011] [Accepted: 02/08/2011] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE There have been significant changes in the field of paediatric cardiac transplantation over the last two decades. We report experience of over 22 years from a single UK transplant centre. METHODS A total of 189 orthotopic cardiac transplants were performed in 182 children aged <18 years between March 1987 and March 2009 in our institution. Patients were identified and outcomes reviewed using the cardiopulmonary transplant database and hospital medical records. RESULTS 182 patients underwent cardiac transplantation, mean age 8.3 years (0.1-17.9 years), 91 (50%) male. Mean follow-up time was 9.0 years (0.3-22.3 years). 117 patients (64%) had a diagnosis of cardiomyopathy, 65 (36%) had congenital heart disease. There was no significant difference in age at transplant between the group with cardiomyopathy and the group with congenital heart disease. 32 patients (17.6%) were on mechanical support prior to transplant. Three (1.6%) patients have required long-term renal replacement therapy post transplant, and 16 (8.8%) developed post-transplant lymphoproliferative disease. Survival was 93% at 30 days, 89% at 1 year, 85% at 5 years, 70% at 10 years and 67% at 15 years with a decrease in mortality over time. Seven patients (3.8%) were re-transplanted. CONCLUSIONS Outcomes following cardiac transplantation in childhood are improving with increased experience. There has been a reduction in 30-day mortality over time.
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Affiliation(s)
- Claire A Irving
- Department of Paediatric Cardiothoracic Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.
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Gajarski RJ, Blume ED, Urschel S, Schechtman K, Zheng J, West LJ, Altamirano L, Miyamoto S, Naftel DC, Kirklin JK, Zamberlan MC, Canter CE. Infection and malignancy after pediatric heart transplantation: The role of induction therapy. J Heart Lung Transplant 2011; 30:299-308. [DOI: 10.1016/j.healun.2010.09.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 09/04/2010] [Accepted: 09/22/2010] [Indexed: 01/24/2023] Open
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Impact of different long-term maintenance immunosuppressive therapy strategies on patients' outcome after heart transplantation. Transpl Immunol 2010; 23:93-103. [PMID: 20434559 DOI: 10.1016/j.trim.2010.04.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Revised: 04/13/2010] [Accepted: 04/21/2010] [Indexed: 01/09/2023]
Abstract
The introduction of cyclosporine in the early 1980s meant a decisive improvement in post-transplant outcomes for all solid-organ transplants and, in particular, it allowed heart transplantation to emerge as a viable therapeutic option for patients with end-stage cardiac failure. Many factors, including recipient and donor selection, organ preservation and the technical aspects of the transplant itself, influence post-operative outcomes following heart transplantation but the continued need to treat the recipient's immune response plays a key role in determining long-term outcomes. Thereby interactions between immunosuppressive drugs used in different combinations play an important role in patients' outcome. After more than two decades, significant controversy still exists as to the best immunosuppressive regimen for long-term maintenance. During the 1990s and 2000s, newer immunosuppressive medications, specifically, tacrolimus, mycophenolate mofetil, sirolimus, everolimus and the IL-2 receptor blockers (daclizumab and basiliximab), were introduced that allow the clinician several options to try to minimize side effects and maximize the desired therapeutic effects. The side effects involve direct organ toxicity (e.g. renal and hepatic dysfunction), metabolic disturbances, (e.g. diabetes, hyperlipidemia and hypertension), neurotoxicity, and several other significant adverse events, such as cholestasis and myelosuppression. Newer immunosuppressive drugs can impair wound healing, induce lung toxicity and produce various cytopenic states. Steroids continue to plague patients with their well-known side effects. This article reviews the current data on the benefits and risks of the various therapeutic regimens available, which are analyzed under three main themes: calcineurin inhibitor based therapies, calcineurin minimization protocols and calcineurin free regimens.
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