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Roh J, Hwang JH, Park S, Lee H, Park EM, Lee HW, Lee JY, Shim J, Choi K, Kang HJ. Investigation of the efficacy and safety of wild- type and triple-gene knockout pig RBC transfusions in nonhuman primates. Front Immunol 2024; 15:1418249. [PMID: 38994362 PMCID: PMC11236543 DOI: 10.3389/fimmu.2024.1418249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/13/2024] [Indexed: 07/13/2024] Open
Abstract
Introduction Decreasing rates of blood donation and close margins between blood supply and demand pose challenges in healthcare. Genetically engineered pig red blood cells (pRBCs) have been explored as alternatives to human RBCs for transfusion, and triple-gene knockout (TKO) modification improves the compatibility of pRBCs with human blood in vitro. In this study, we assessed the efficacy and risks of transfusing wild-type (WT)- and TKO-pRBCs into nonhuman primates (NHPs). Methods Blood from O-type WT and TKO pigs was processed to produce pRBCs for transfusion, which were transfused or not into NHPs (n=4 per group: WT, TKO, and control) after 25% total blood volume withdrawal: their biological responses were compared. Hematological, biochemical, and immunological parameters were measured before, immediately after, and at intervals following transfusion. Two months later, a second transfusion was performed in three NHPs of the transfusion group. Results Transfusion of both WT- and TKO-pRBCs significantly improved RBC counts, hematocrit, and hemoglobin levels up to the first day post-transfusion, compared to the controls. The transfusion groups showed instant complement activation and rapid elicitation of anti-pig antibodies, as well as elevated liver enzyme and bilirubin levels post-transfusion. Despite the higher agglutination titers with WT-pRBCs in the pre-transfusion crossmatch, the differences between the WT and TKO groups were not remarkable except for less impairment of liver function in the TKO group. After the second transfusion, more pronounced adverse responses without any hematological gain were observed. Conclusions WT- and TKO-pRBC transfusions effectively increased hematologic parameters on the first day, with rapid clearance from circulation thereafter. However, pRBC transfusion triggers strong antibody responses, limiting the benefits of the pRBC transfusion and increasing the risk of adverse reactions.
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Affiliation(s)
- Juhye Roh
- Department of Laboratory Medicine, Hallym University College of Medicine and Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Jeong Ho Hwang
- Animal Model Research Group, Jeonbuk Branch Institute, Korea Institute of Toxicology, Jeongeup, Republic of Korea
| | - Sangkeun Park
- Department of Laboratory Medicine, Hallym University College of Medicine and Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Haneulnari Lee
- Department of Laboratory Medicine, Hallym University College of Medicine and Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Eun Mi Park
- Department of Laboratory Medicine, Hallym University College of Medicine and Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Hye Won Lee
- Department of Laboratory Medicine, Hallym University College of Medicine and Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Ju Young Lee
- Animal Model Research Group, Jeonbuk Branch Institute, Korea Institute of Toxicology, Jeongeup, Republic of Korea
| | - Joohyun Shim
- Department of Transgenic Animal Research, Optipharm Inc., Cheongju, Republic of Korea
| | - Kimyung Choi
- Department of Transgenic Animal Research, Optipharm Inc., Cheongju, Republic of Korea
| | - Hee Jung Kang
- Department of Laboratory Medicine, Hallym University College of Medicine and Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
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Bansal N, West LJ, Simmonds J, Urschel S. ABO-incompatible heart transplantation-evolution of a revolution. J Heart Lung Transplant 2024:S1053-2498(24)01561-4. [PMID: 38604353 DOI: 10.1016/j.healun.2024.03.019] [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: 02/28/2024] [Revised: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 04/13/2024] Open
Abstract
In the 1990s, neonates born with severe congenital heart disease faced more than 50% mortality awaiting an ABO-compatible (ABOc) transplant donor. This desperate situation, together with knowledge of gaps in the adaptive immune system in early childhood, led to the clinical exploration of intentional ABO-incompatible (ABOi) heart transplantation. In 2001, West et al. reported the first series of 10 infants in Canada. Since then, consideration of ABOi heart donors has become the standard of care for children awaiting transplantation in the first few years of life, resulting in reduced wait times and better organ utilization with noninferior post-transplant outcomes compared to ABOc recipients. This state-of-the-art review discusses the clinical development and evolution, underlying and resulting immunological aspects, current challenges, and future directions of ABOi heart transplantation.
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Affiliation(s)
- Neha Bansal
- Pediatric Cardiology, Mount Sinai Kravis Children's Hospital, New York, New York
| | - Lori J West
- Department of Pediatrics, University of Alberta/Stollery Children's Hospital, Edmonton, Alberta, Canada; Alberta Transplant Institute, Edmonton, Alberta, Canada
| | - Jacob Simmonds
- Pediatric Cardiology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Simon Urschel
- Department of Pediatrics, University of Alberta/Stollery Children's Hospital, Edmonton, Alberta, Canada; Alberta Transplant Institute, Edmonton, Alberta, Canada
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3
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Milligan C, Daly KP. ABO-Incompatible Heart Transplantation: Where Science, Society, and Policy Collide. J Card Fail 2024; 30:486-487. [PMID: 37598901 DOI: 10.1016/j.cardfail.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/10/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Caitlin Milligan
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin P Daly
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
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4
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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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Krauss A, West LJ, Conway J, Khoury M, Nahirniak S, Halpin A, Al Aklabi M, Urschel S. Successful ABO incompatible heart transplantation after desensitization therapy in an older child. Pediatr Transplant 2023; 27:e14459. [PMID: 36597218 DOI: 10.1111/petr.14459] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/08/2022] [Accepted: 12/14/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND ABO-incompatible heart transplantation (HTx) has become a standard procedure for children below 2 years of age due to an immunologically immature immune system and associated low isohemagglutinin titers. METHODS We report a case of an ABO-incompatible HTx (recipient blood group O, donor blood group A) at the age of 5 years and 11 months with a fully matured immune system and previously high isohemagglutinin titers that diminished as a result of human leucocyte antigen (HLA) desensitization therapy with rituximab and immunoglobulins. RESULTS The anti-A titer at the time of HTx was 1:16 with post-transplant isoagglutinin titers never exceeding 1:4 without any signs of rejection with now 3 years of post-HTx follow-up. CONCLUSIONS ABO isohemagglutinin titers should be routinely assessed in children undergoing desensitization therapy since ABOi transplantation can be considered in selected cases to expand the donor pool with the option of crossing the ABO barrier to find a better-matched allograft.
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Affiliation(s)
- Annemarie Krauss
- Division of Pediatric Cardiology at the University of Alberta, Deutsches Herzzentrum, Berlin, Germany
| | - Lori J West
- Departments of Pediatrics, Surgery, Medical Microbiology/Immunology and Laboratory Medicine/Pathology, University of Alberta, Alberta Transplant Institute, Edmonton, Alberta, Canada.,Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada
| | - Jennifer Conway
- Division of Pediatric Cardiology at the University of Alberta, Edmonton, Alberta, Canada
| | - Michael Khoury
- Division of Pediatric Cardiology at the University of Alberta, Edmonton, Alberta, Canada
| | - Susann Nahirniak
- Department of Laboratory Medicine and Pathology, University of Alberta and Alberta Precision Laboratories, Edmonton, Alberta, Canada
| | - Anne Halpin
- Department of Laboratory Medicine and Pathology, University of Alberta and Alberta Precision Laboratories, Edmonton, Alberta, Canada
| | - Mohammed Al Aklabi
- Division of Pediatric Cardiac Surgery, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Simon Urschel
- Division of Pediatric Cardiology at the University of Alberta, Edmonton, Alberta, Canada
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 108] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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7
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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8
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Gil-Jaurena JM, Camino M, Calle C, Pardo C, Pita A, Pérez-Caballero R. Trasplante cardiaco con incompatibilidad de grupo. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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9
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ABO-Incompatible Heart Transplant in Infants: A UNOS Database Review. Ann Thorac Surg 2021; 112:589-594. [DOI: 10.1016/j.athoracsur.2020.06.073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 06/15/2020] [Accepted: 06/17/2020] [Indexed: 11/20/2022]
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Urschel S, Ballweg JA, Cantor RS, Koehl DA, Reinhardt Z, Zuckerman WA, Dipchand AI, Kanter KR, Sparks J, McCoy M, Kirklin JK, Carlo WF. Clinical outcomes of children receiving ABO-incompatible versus ABO-compatible heart transplantation: a multicentre cohort study. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 5:341-349. [PMID: 33743201 DOI: 10.1016/s2352-4642(21)00023-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/07/2021] [Accepted: 01/14/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND ABO-incompatible heart transplantation increases donor availability in young children and is evolving into standard of care in children younger than 2 years. Previous smaller studies suggest similar outcomes to ABO-compatible heart transplantation, but persisting alterations of the immune system in ABO-incompatible recipients might increase the risk of some infections or benefit the graft owing to reduced HLA reactivity. We aimed to assess long-term outcomes in young children after they received ABO-incompatible or ABO-compatible heart transplantation. METHODS In this multicentre, prospective cohort study, we analysed data from the Pediatric Heart Transplant Society registry to compare children who received ABO-incompatible or ABO-compatible heart transplantation before age 2 years between Jan 1, 1999, and June 30, 2018. Given significantly different clinical demographics between the two groups, we also matched each ABO-incompatible recipient to two ABO-compatible recipients using propensity score matching. We assessed patient and graft survival, coronary allograft vasculopathy, malignancy, acute rejection (any episode resulting in augmentation of immunosuppression), and infections (requiring intravenous antibiotic or antiviral therapy or life-threatening infections treated with oral therapy). FINDINGS We included 2206 children who received a heart transplant before age 2 years, with 11 332·6 patient-years of cumulative observation time. Children who received an ABO-incompatible transplant (n=364) were younger and a larger proportion had congenital heart disease and ventilator and mechanical circulatory support than the ABO-compatible recipients (n=1842). After matching, only differences in blood group (more O in ABO-incompatible and more AB in ABO-compatible groups) and use of polyclonal induction therapy with anti-thymocyte globulins persisted. The two matched groups had similar post-transplantation graft survival (p=0·74), freedom from coronary allograft vasculopathy (p=0·75), and malignancy (p=0·51). ABO-incompatible recipients showed longer freedom from rejection (p=0·0021) in the overall cohort, but not after matching (p=0·48). Severe infections (p=0·0007), bacterial infections (p=0·0005), and infections with polysaccharide encapsulated bacteria (p=0·0005) that share immunological properties with blood group antigens occurred less frequently after ABO-incompatible heart transplantation. INTERPRETATION ABO-incompatible heart transplantation for children younger than 2 years is a clinically safe approach, with similar survival and incidences of rejection, coronary allograft vasculopathy, and malignancy to ABO-compatible recipients, despite higher-risk pre-transplant profiles. ABO-incompatible transplantation was associated with less bacterial infection, particularly encapsulated bacteria, suggesting that the acquired immunological changes accompanying ABO tolerance might benefit rather than jeopardise transplanted children. FUNDING Pediatric Heart Transplant Society.
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Affiliation(s)
- Simon Urschel
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
| | - Jean A Ballweg
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NB, USA
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Devin A Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zdenka Reinhardt
- Department of Paediatric Cardiology and Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Warren A Zuckerman
- Division of Pediatric Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Anne I Dipchand
- Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Kirk R Kanter
- Emory University School of Medicine, Atlanta, GA, USA
| | - Joshua Sparks
- Norton Children's Hospital, University of Louisville, Louisville, KY, USA
| | - Marie McCoy
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar F Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
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11
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A current era analysis of ABO incompatible listing practice and impact on outcomes in young children requiring heart transplantation. J Heart Lung Transplant 2020; 39:627-635. [DOI: 10.1016/j.healun.2020.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/24/2020] [Accepted: 02/06/2020] [Indexed: 12/19/2022] Open
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12
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Abstract
Heart transplantation is a standard treatment for selected paediatric patients with end-stage heart disease. With improvement in surgical techniques, organ procurement and preservation strategies, immunosuppressive drugs, and more sophisticated monitoring strategies, survival following transplantation has increased over time. However, rejection, infection, renal failure, post-transplant lymphoproliferative disease and post-transplant cardiac allograft vasculopathy still preclude long-term survival. Therefore, continued multidisciplinary scientific efforts are needed for future gains. This review focuses on the current status, outcomes and ongoing challenges including patient selection, indications and contraindications, national and international survivals, post-transplant complications and quality of life.
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13
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Abstract
Donors for pediatric heart transplantation are accepted based on variety of donor factors. There is wide variability in practice across centers and lack of evidence to guide standardized approach for some donor characteristics. This article reviews current practice and evidence for donor evaluation in pediatric heart transplantation.
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Affiliation(s)
- Nikki Singh
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Muhammad Aanish Raees
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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14
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Abstract
PURPOSE OF REVIEW To provide an international perspective and current review of pediatric heart transplantation (PHTx). RECENT FINDINGS Waitlist survival and long-term outcomes in PHTx continue to improve. Strategies to maximize donor pool utilization include ABO incompatible listing for infants and expanded donor-to-recipient weight ranges. However, there is a high degree of practice variation internationally, from listing strategies and donor acceptance practices to chronic immunosuppression regimens, long-term graft surveillance, and consideration for retransplantation. SUMMARY Common indications for PHTx include end-stage congenital heart disease and cardiomyopathy. Current median graft survival among PHTx recipients ranges from 13 to 22 years. Common morbidities include infection, rejection, renal dysfunction, coronary allograft vasculopathy, and posttransplant lymphoproliferative disease. International registry data, collaborative initiatives to standardize management, and multicenter studies continue to improve knowledge and advancement of the field.
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15
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Pediatric heart transplantation: long-term outcomes. Indian J Thorac Cardiovasc Surg 2019; 36:175-189. [PMID: 33061202 DOI: 10.1007/s12055-019-00820-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 03/15/2019] [Accepted: 03/19/2019] [Indexed: 12/26/2022] Open
Abstract
Pediatric heart transplant has become the standard of care for end-stage heart disease in children throughout the world. The number of transplants has grown dramatically since the first transplant was performed, and over the last two decades, outcomes have consistently improved with progression in knowledge enhancing the clinical course and outcomes of these patients. Short-term outcomes in the most recent era have been excellent resulting in a renewed focus towards medium- and long-term outcomes. This article will review the most up-to-date literature on overall heart transplantation outcomes and specific long-term outcomes including rejection, cardiac allograft vasculopathy, graft failure, infection, renal dysfunction, malignancy, and the need for re-transplantation. The article also explores the post-transplantation outcomes of special populations, including Fontan patients, ABO-incompatible recipients, sensitized recipients, extracorporeal membrane oxygenation, and ventricular assist devices. The article concludes with a look at transition from pediatric to adult care and medication adherence, which are becoming major issues related to long-term outcomes as post-transplant survival increases.
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16
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Dean CL, Sullivan HC, Stowell SR, Fasano RM, West LJ, Robitaille N, Josephson CD. Current state of transfusion practices for ABO-incompatible pediatric heart transplant patients in the United States and Canada. Transfusion 2018; 58:2243-2249. [DOI: 10.1111/trf.14775] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 04/15/2018] [Accepted: 04/16/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Christina L. Dean
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine; Emory University School of Medicine
| | - Harold C. Sullivan
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine; Emory University School of Medicine
| | - Sean R. Stowell
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine; Emory University School of Medicine
| | - Ross M. Fasano
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine; Emory University School of Medicine
- Departments of Hematology and Clinical Pathology; Children's Healthcare of Atlanta; Atlanta Georgia
| | - Lori J. West
- Department of Pediatrics; Alberta Transplant Institute, Stollery Children's Hospital, University of Alberta; Edmonton Alberta Canada
| | - Nancy Robitaille
- Division of Hematology-Oncology, Department of Pediatrics; CHU Sainte-Justine; Montreal Quebec Canada
| | - Cassandra D. Josephson
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine; Emory University School of Medicine
- Departments of Hematology and Clinical Pathology; Children's Healthcare of Atlanta; Atlanta Georgia
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17
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Abstract
PURPOSE OF REVIEW Pediatric heart transplants continue to be the therapy of choice for children with end stage heart failure. The interplay of limited donor supply, improvement in ventricular assist device (VAD) technology and utilization, and a focus on optimizing long-term outcomes make it critically important for practitioners to be aware of an evolving diagnostic and therapeutic arsenal. RECENT FINDINGS Data suitable to define best practices for pediatric heart transplantation consist of an amalgam of small single center series, registry reviews and judicious inference from adult studies. Large-scale prospective pediatric studies are essentially nonexistent; the pediatric heart transplant study group continues to be highly productive while new collaboratives are emerging. SUMMARY Outcomes for pediatric transplants continue to improve. Technology and innovation continue to drive shifts in management. Improvements in VAD support along with refinement of solid-phase assays require clinicians to develop a deeper understanding of pre and post transplant management of donor-specific antibodies and antibody-mediated rejection. Expertise in retransplantation and the care of adults with congenital heart disease will be critical in the future.
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18
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Abstract
Pediatric heart transplantation is standard of care for children with end-stage heart failure. The diverse age range, diagnoses, and practice variations continue to challenge the development of evidence-based practices and new technologies. Outcomes in the most recent era are excellent, especially with the more widespread use of ventricular assist devices (VADs). Waitlist mortality remains high and knowledge of risk factors for death while waiting and following transplantation contributes to decision-making around transplant candidacy and timing of listing. The biggest gap impacting both waitlist and overall survival remains mechanical support options for infants and patients with single ventricle physiology. Though acute rejection has decreased progressively, both diagnosis and management of antibody-mediated rejection has become increasingly challenging and complex, as has the ability to understand the implication of anti-HLA antibodies detected both pre- and post-transplantation-including when and how to intervene. Trends in immunosuppression protocols include more use of induction therapy and steroid avoidance or withdrawal protocols. Common long-term morbidities include renal insufficiency, which can be mitigated with surveillance and renal-sparing strategies, and infections. Functional outcomes are excellent, but significant psychosocial challenges exist in relation to neurodevelopment, non-adherence, and transition from child-centered to adult-centered care. Cardiac allograft vasculopathy (CAV) remains a barrier to long-term survival, though it is more apparent that objective evidence of an impact on the allograft is important with regards to impact on outcomes. Retransplantation is rare in pediatric heart transplant recipients. Pediatric heart transplantation continues to evolve in order to address the challenges of the diverse group of patients that reach end-stage heart failure during childhood.
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Affiliation(s)
- Anne I Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Canada
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19
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Eculizumab for Thrombotic Microangiopathy Associated with Antibody-Mediated Rejection after ABO-Incompatible Kidney Transplantation. Case Rep Transplant 2017; 2017:3197042. [PMID: 29445563 PMCID: PMC5763091 DOI: 10.1155/2017/3197042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 11/16/2017] [Indexed: 12/27/2022] Open
Abstract
Thrombotic microangiopathy is a form of antibody-mediated rejection (ABMR): it is the main complication of ABO-incompatible (ABOi) kidney transplantation (KT). Herein, we report on two cases of ABMR with biological and histological features of thrombotic microangiopathy (TMA) that were treated by eculizumab after ABOi KT. The first patient presented with features of TMA at postoperative day (POD) 13. Because of worsening biological parameters and no recovery of kidney function, despite seven sessions of immunoadsorption, a salvage therapy of eculizumab was started on POD 23. Kidney function slightly improved during the first 4 months after transplantation. Eculizumab was stopped at month 4. However, kidney function worsened progressively, leading to dialysis at month 13 after transplantation. The second patient presented with features of TMA at POD 1. In addition to immunoadsorption therapy, eculizumab was started on POD 6. Kidney function improved. Eculizumab was stopped on POD 64 and immunoadsorption sessions were stopped on POD 102. At the last follow-up (after 9 months), eGFR was at 43 mL/min/1.73 m2. Our case reports show the beneficial effect of eculizumab to treat ABMR after ABOi KT. However, it should be given early after diagnosing TMA associated with ABMR.
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20
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Simpson KE, Canter C. Can we push the boundaries of ABO-incompatible pediatric heart transplantation? J Heart Lung Transplant 2017; 37:433-434. [PMID: 28756122 DOI: 10.1016/j.healun.2017.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 12/19/2022] Open
Affiliation(s)
- Kathleen E Simpson
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Charles Canter
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA.
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21
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Abstract
PURPOSE OF REVIEW ABO-incompatible (ABOi) heart transplantation (HTx) in young children has evolved from an experimental approach to a standard allocation option in many countries. Clinical and immunological research in ABOi transplantation has revealed insight into the immature immune system and its role in superior graft acceptance in childhood and antigen-specific tolerance. RECENT FINDINGS Multicenter experience has confirmed equal actuarial survival, freedom from rejection, and graft vasculopathy comparing ABOi with ABO-compatible HTx. Observations of reduced antibody production and B-cell immunity toward the donor blood group have been confirmed in long-term follow-up. Mechanisms contributing to tolerance in this setting involve the interplay between B-cells and the complement system and the development of B-cell memory. Better characterization of the ABH polysaccharide antigens has improved diagnostic methods and clinical assessment of blood group antibodies. Boundaries regarding age, immune maturity, and therapeutic interventions to extend the applicability of ABOi HTx have been explored and resulted in data that may be useful for HTx patients beyond infancy and ABOi transplantation of other organs. Tolerance of ABH antigens possibly extends to HLA response. SUMMARY The review provides insight into the clinical evolution of ABOi HTx and associated immunologic discoveries. Current experiences and boundaries are discussed together with recent and potential future developments for utilization in other patient and age groups.
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Stites E, Le Quintrec M, Thurman JM. The Complement System and Antibody-Mediated Transplant Rejection. THE JOURNAL OF IMMUNOLOGY 2016; 195:5525-31. [PMID: 26637661 DOI: 10.4049/jimmunol.1501686] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Complement activation is an important cause of tissue injury in patients with Ab-mediated rejection (AMR) of transplanted organs. Complement activation triggers a strong inflammatory response, and it also generates tissue-bound and soluble fragments that are clinically useful markers of inflammation. The detection of complement proteins deposited within transplanted tissues has become an indispensible biomarker of AMR, and several assays have recently been developed to measure complement activation by Abs reactive to specific donor HLA expressed within the transplant. Complement inhibitors have entered clinical use and have shown efficacy for the treatment of AMR. New methods of detecting complement activation within transplanted organs will improve our ability to diagnose and monitor AMR, and they will also help guide the use of complement inhibitory drugs.
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Affiliation(s)
- Erik Stites
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045; and
| | - Moglie Le Quintrec
- Department of Nephrology and Renal Transplantation, Lapeyronie Hospital, 34295 Montpellier Cedex 5, France
| | - Joshua M Thurman
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045; and
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23
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Abstract
PURPOSE OF REVIEW The phenomenon of tolerance induced during immunologic immaturity has been explored for more than 60 years. Although direct application of neonatal tolerance to organ transplantation in human newborns is limited, exploiting discrete components of neonatal immaturity is proving fruitful. RECENT FINDINGS Two reviews comprehensively considered features and impact of neonatal tolerance as described in the 1950s. Recent imaging studies in mice demonstrated complex functional interactions especially of donor regulatory T cells with emerging neonatal immune components. The propensity of the developing immune system toward tolerance rather than immunity to non-self carbohydrates in ABO-incompatible transplantation was shown using glyconanotechnology tools to have exquisite specificity, and is associated with age-related changes in the B-cell compartment and complement components. Discarded infant thymus was found to be a source of abundant therapeutic regulatory T cells. Erythroid precursors transiently present in newborn mice and humans were shown to have immunosuppressive properties that may contribute to a tolerogenic environment. SUMMARY Neonatal tolerance has profound impact on immunology well beyond transplantation. Continued exploration of mechanisms underlying the malleability of the developing immune system and exploitation of particular components are leading to tools for immune manipulation beyond infancy.
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Peng E, Kirk R, Wrightson N, Duong P, Ferguson L, Griselli M, Butt T, O'Sullivan JJ, MacGowan GA, Crossland D, Schueler S, Hasan A. An Extended Role of Continuous Flow Device in Pediatric Mechanical Circulatory Support. Ann Thorac Surg 2016; 102:620-7. [PMID: 27130250 DOI: 10.1016/j.athoracsur.2016.02.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/16/2015] [Accepted: 02/01/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mechanical circulatory support in the pediatric population is currently limited to pulsatile ventricular assist devices (VAD). In recent years, the use of durable, newer generation, continuous flow devices have increased substantially among adults with end-stage heart failure. We examined the extended role of this device in the pediatric population (aged less than 18 years). METHODS Between 2010 and 2015, 12 patients (median age 7.1 years; range, 3.7 to 17.0; one third of patients were aged 5 years or less) received a HeartWare ventricular assist device (HVAD; HeartWare, Framingham, MA), 11 for cardiomyopathy and 1 for posttransplant rejection. Right VAD support (n = 5; 42%) was provided by a short-term device (Levitronix, Zurich, Switzerland). RESULTS Overall, 1 patient died (day 638), 8 patients (67%) underwent transplantation, 1 patient (8.3%) recovered, and 2 patients (17%) remain on HVAD. The mean length of support was 150 days (range, 16 to 638). Four patients (33.3%) were discharged home (all left VAD). In the left VAD group (n = 7), 3 patients subsequently received transplants (days 185, 201, and 234, respectively), 1 recovered (day 149), 1 died (day 638), 1 remained on HVAD (day 198), and 1 needed conversion to biventricular assist device (BIVAD [day 73]). In the BIVAD group (n = 5), right VAD was weaned in 3 (60%), all subsequently received transplants, and 2 remained on BIVAD support until transplant (days 16 and 17, respectively). One BIVAD patient required conversion to central cannulation for longer-term support. Four BIVAD patients (80%) were in Interagency Registry for Mechanically Assisted Circulatory Support level 1 before VAD compared with 2 (29%) in the left VAD group (p = not significant). The actuarial survival rate was 100% at 1 year with no neurologic events. CONCLUSIONS The third-generation, continuous flow device can provide durable support in the pediatric population. The selection strategy for patients who benefit most from the device continues to evolve. It is anticipated that a smaller design in the future will benefit an even wider pediatric population with heart failure.
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Affiliation(s)
- Ed Peng
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Richard Kirk
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Neil Wrightson
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Phuoc Duong
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Lee Ferguson
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Massimo Griselli
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Tanveer Butt
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - John J O'Sullivan
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Guy A MacGowan
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - David Crossland
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Stephan Schueler
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Asif Hasan
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom.
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