Long-term survivors of pediatric heart transplantation: a multicenter report of sixty-eight children who have survived longer than five years

Quality of life and lifetime achievement in adult survivors of pediatric heart transplant

BACKGROUND

Survival in pediatric heart transplantation has improved since the first successful transplant over 35 years ago leading to increasing numbers of patients entering adulthood. We sought to examine quality of life and various lifetime achievements in our institutional population of long-term adult survivors of pediatric heart transplant.

METHODS

Participants ≥18 years of age who received a heart transplant as a pediatric patient (<18 years old), and who have survived ≥10 years post-transplant, completed two self-report surveys: (1) Ferrans and Powers QLI cardiac version which reports a measure of life satisfaction with a range of 0 (very dissatisfied) to 1 (very satisfied); and (2) CHONY Pediatric Heart Transplant Life Achievement Survey to examine lifetime achievement.

RESULTS

Sixty-two and sixty-five participants completed the Ferrans and Powers QLI cardiac version and CHONY Pediatric Heart Transplant Life Achievement Survey. The mean overall QLI was 0.75 ± 0.14 with the most satisfaction in the family domain. QLI scores were analyzed by age at initial transplant, gender, indication for transplant, and whether patients currently followed by pediatric or adult providers, with no statistically significant differences noted. Seventy-two percent of participants demonstrated stable employment or schooling. Around thirty percent of participants showed the ability to reach academic milestones including college and post-graduate education and ten percent to start their own families.

CONCLUSIONS

Our cohort of long-term adult survivors of pediatric heart transplant report a quality of life with scores thought to be reflective of a satisfactory quality of life, and many demonstrate achievement of major life milestones.

Progressive aortic root dilatation in pediatric heart transplant recipients

BACKGROUND

To determine prevalence, clinical implication, and risk factors for aortic root dilation (ARD) in pediatric heart transplant recipients.

METHODS

Serial echocardiograms were reviewed in all pediatric heart transplant recipients from 1999 to 2014 to assess maximal systolic diameter at the aortic annulus, aortic sinus, aortic sino-tubular (ST) junction, and ascending aorta. ARD was defined by a sinus/annulus ratio >1.56, ST junction/annulus ratio >1.28, and/or ascending aorta/annulus ratio >1.35.

RESULTS

A total of 147 subjects (53% male) were evaluated; 50% had congenital heart disease (CHD). Of the 74 with CHD, 38 had prior aortic arch reconstruction. The median age at transplant was 3 years (7 days-20.3 years) with a median duration of follow-up of 3.88 years (3 months-15 years). Prevalence of ARD significantly increased in the cohort from 15.6% at the initial echocardiogram to 49.6% at later follow-up (P<.0001). The median duration to development of ARD was 7.6 months. There were no significant differences in prevalence of ARD or days to maximum ratio based on the pretransplant diagnosis. Aortic regurgitation was very rare (7 with ≤mild) and did not correlate with ARD or require any interventions.

CONCLUSION

During intermediate follow-up, ARD commonly develops in children post-heart transplant, and prevalence increases with time after transplant. Within 1 year after transplant, almost 50% had developed abnormalities in aortic root size that were not apparent at the initial posttransplant echocardiogram. Preexisting CHD or need for prior arch reconstruction did not increase the risk of ARD.

Impact of Heart Transplantation on the Functional Status of US Children With End-Stage Heart Failure

Background:

There are limited data describing the functional status (FS) of children after heart transplant (HT). We sought to describe the FS of children surviving at least 1 year after HT, to evaluate the impact of HT on FS, and to identify factors associated with abnormal FS post-HT.

Methods:

Organ Procurement and Transplantation Network data were used to identify all US children <21 years of age surviving ≥1 year post-HT from 2005 to 2014 with a functional status score (FSS) available at 3 time points (listing, transplant, ≥1 year post-HT). Logistic regression and generalized estimating equations were used to identify factors associated with abnormal FS (FSS≤8) post-HT.

Results:

A total of 1633 children met study criteria. At the 1-year assessment, 64% were “fully active/no limitations” (FSS=10), 21% had “minor limitations with strenuous activity” (FSS=9); and 15% scored ≤8. In comparison with listing FS, FS at 1 year post-HT increased in 91% and declined/remained unchanged in 9%. A stepwise regression procedure selected the following variables for association with abnormal FS at 1 year post-HT: ≥18 years of age (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.2–2.7), black race (OR, 1.5; 95% CI, 1.1–2.0), support with ≥inotropes at HT (OR, 1.7; 95% CI, 1.2–2.5), hospitalization status at HT (OR, 1.5; 95% CI, 1.0–2.19), chronic steroid use at HT (OR, 1.5; 95% CI, 1.0–2.2), and treatment for early rejection (OR, 2.0; 95% CI, 1.5–2.7).

Conclusion:

Among US children who survive at least 1 year after HT, FS is excellent for the majority of patients. HT is associated with substantial improvement in FS for most children. Early rejection, older age, black race, chronic steroid use, hemodynamic support at HT, and being hospitalized at HT are associated with abnormal FS post-HT.

Rehospitalization after pediatric heart transplantation: Incidence, indications, and outcomes

We report the patterns of rehospitalization after pediatric heart transplant (Htx) at a single center. Retrospective review of 107 consecutive pediatric Htx recipients between January 22, 2007, and August 28, 2014, who survived their initial transplant hospitalization. The frequency, duration, and indications for all hospitalizations between transplant hospitalization discharge and September 30, 2015, were analyzed. A total of 444 hospitalization episodes occurred in 90 of 107 (84%) patients. The median time to first rehospitalization was 59.5 (range 1-1526) days, and the median length of stay was 2.5 (range 0-81) days. There were an average of two hospitalizations per patient in the first year following transplant hospitalization, declining to about 0.8 per patient per year starting at 3 years post-transplant. Admissions for viral infections were most common, occurring in 93 of 386 (24%), followed by rule out sepsis in 61 of 386 (16%). Admissions for suspected or confirmed rejection were less frequent, accounting for 41 of 386 (11%) and 31 of 386 (8%) of all admissions, respectively. Survival to discharge after rehospitalization was 97%. Hospitalization is common after pediatric Htx, particularly in the first post-transplant year, with the most frequent indications for hospitalization being viral illness and rule out sepsis. After the first post-transplant year, the risk for readmission falls significantly but remains constant for several years.

Lung Transplantation in Adolescents and Young Adults with Cystic Fibrosis

Context

Little is known about adolescents' and young adults' experience with cystic fibrosis while waiting for or after receiving a lung transplant. The psychological and psychosocial factors that may influence these patients' transplant outcomes are yet to be fully explored.

Objective

To explore the psychosocial impact of the lung transplant journey on adolescents and young adults with cystic fibrosis.

Design

A questionnaire-based pilot study was used to enable descriptive, comparative, and correlational analyses between pretransplant and posttransplant groups. Setting—A major lung transplant unit in Australia.

Participants

Twenty-seven patients (9 before and 18 after transplantation) participated in the study. The mean ages were 18.7 years (SD 4.2) and 22.6 years (SD 3.9) in the pretransplant and posttransplant groups, respectively.

Results

In all domains of the Short Form 36 except Mental Health and Social Functioning, the posttransplant group had significantly higher scores ( P < .05) compared to the pretransplant group. The Hospital and Anxiety and Depression Scale total Distress score in the posttransplant group was related to the number of rejection episodes ( r = 0.47, P = .049) as well as hospital admissions ( r = 0.51, P = .012). The number of rejection episodes was significantly related to patients' perceived level of self-efficacy ( P = .025), importance to health ( P = .001), and ease ( P = .10) of monitoring their symptoms.

Conclusion

This study provides some insight into the needs of adolescents and young adults with cystic fibrosis and the differences between those who are awaiting a transplant and those who have received a transplant. Assessing the young person's perceptions in relation to activities such as exercising, monitoring symptoms, and taking medications can give helpful insights into the transition phase, but require further research.

In My Shoes: Children's Quality of Life after Heart Transplantation

Background

Although heart transplantation has been offered for 2 decades to prolong the lives of children with end-stage heart disease, we know little about how these children view their lives, how they deal with their complicated medical regimen, and how the transplantation affects their quality of life.

Objectives

To examine the quality of life of school-aged heart transplant recipients and to identify the key factors they believe affect their quality of life.

Design

Focused ethnography.

Participants and Setting

Eleven children (7 girls, 4 boys) between the ages of 6 and 12 years (mean 9.1 years) who had received a transplant at least 6 months earlier were recruited from a large children's hospital.

Data Collection and Analysis

Semistructured interviews were conducted in private locations. Data were analyzed using content analysis and constant comparison.

Results

The children described their quality of life as “mostly good,” yet reported that life was “easy and not easy.” Ten factors that affected the children's quality of life were Doing Things/Going Places, Favorite School Activities, Hard Things About School, Being With Friends and Family, Doing Things/Going Places With Friends and Family, Interactions With Friends and Family, Taking Care of My Heart, My Body, The Transplant Team, and Other Health Problems. Based on similarities in meaning, these factors were combined into 3 themes: Doing What Kids Do, Being With Friends and Family, and Being a Heart Transplant Kid. The themes and factors can provide useful direction for interventions aimed at improving the quality of life for children after heart transplantation.

Pediatric Pulseless Ventricular Tachycardia: A Simulation Scenario for Fellows, Residents, Medical Students, and Advanced Practitioners

INTRODUCTION

Pulseless ventricular tachycardia is an uncommon presentation to the pediatric emergency department (ED) or the pediatric ICU (PICU); however, if unrecognized or inappropriately treated, it can lead to significant morbidity and mortality. This resource was created to simulate a high-acuity and low-frequency event targeting PICU fellows, pediatric emergency medicine fellows, pediatric residents, ED residents, medical students, and advanced nursing providers.

METHODS

This scenario details the case of a 12-year-old boy with a history of heart transplant who presents with the chief complaint of dizziness. He initially has multiple premature ventricular contractions and then progresses to pulseless ventricular tachycardia due to acute rejection. This simulation may be performed in a simulation lab or in situ in the ICU or ED. Necessary personnel include a simulation technician, instructors, and a nurse. A code cart and defibrillator with hands-free pads appropriate for the mannequin are needed supplies. Critical actions include cardiopulmonary resuscitation, defibrillation with three shocks, and administration of anti-arrhythmic. At the end of the scenario, a formal debriefing and learner assessment with structured feedback are performed.

RESULTS

Approximately 110 learners have completed this module during 18 separate sessions. Written evaluation from participants (n = 94) using a Likert scale (1 = not at all, 4 = to a great extent) shows that the objectives of the simulation are met to a great extent, with an average score of 3.8.

DISCUSSION

In conclusion, this resource advances learner knowledge and comfort when managing a pediatric patient with pulseless ventricular tachycardia, reviews appropriate management, and helps identify knowledge deficits in the management of these patients.

Aortic complications following pediatric heart transplantation: A case series and review

Aortic complications occur rarely after pediatric orthotopic heart transplantation, but are typically accompanied by catastrophic events. We describe the three cases of major aortic complications in our experience of 329 pediatric heart transplants. This case series and review highlight the important risk factors for aortic complications after heart transplantation.

High Risk of Graft Failure in Emerging Adult Heart Transplant Recipients

Emerging adulthood (17-24 years) is a period of high risk for graft failure in kidney transplant. Whether a similar association exists in heart transplant recipients is unknown. We sought to estimate the relative hazards of graft failure at different current ages, compared with patients between 20 and 24 years old. We evaluated 11 473 patients recorded in the Scientific Registry of Transplant Recipients who received a first transplant at <40 years old (1988-2013) and had at least 6 months of graft function. Time-dependent Cox models were used to estimate the association between current age (time-dependent) and failure risk, adjusted for time since transplant and other potential confounders. Failure was defined as death following graft failure or retransplant; observation was censored at death with graft function. There were 2567 failures. Crude age-specific graft failure rates were highest in 21-24 year olds (4.2 per 100 person-years). Compared to individuals with the same time since transplant, 21-24 year olds had significantly higher failure rates than all other age periods except 17-20 years (HR 0.92 [95%CI 0.77, 1.09]) and 25-29 years (0.86 [0.73, 1.03]). Among young first heart transplant recipients, graft failure risks are highest in the period from 17 to 29 years of age.

Renal function assessment in child and adolescent heart transplant recipients during routine cardiac catheterization

CKD identification after pediatric heart transplantation (PHT) is limited by inaccuracies in estimates of GFR. We hypothesized that GFR can be measured by a modified iohexol clearance protocol in PHT recipients and that the CKiD formula provides a better estimate of GFR than other estimating equations. A cross-sectional study of PHT recipients, ages 2-18 yr, undergoing coronary angiography was undertaken. The angiography dose of iohexol was divided by the area under the curve from three iohexol levels post-infusion to calculate GFR. Agreement between iGFR and multiple estimating equations (eGFR) was assessed. In 31 subjects, median age was 15.0 yr (IQR 7.6, 16.6). Mean iGFR was 93.8 (s.d. 22.5) mL/min/1.73 m(2) ; 16 (52%) had an iGFR <90 mL/min/1.73 m(2) . The full CKiD formula (mean eGFR 88.9, s.d. 14.9) had low bias (-5.0), narrowest 95% limits of agreement (-42.0, 32.1), highest 30% (94%) and 10% (52%) accuracy, and highest correlation coefficient (0.576) relative to iGFR. We describe a novel modified iohexol clearance method to assess GFR after PHT. Over half of the cohort had an iGFR <90, suggesting CKD. The full CKiD formula performs best with respect to bias, accuracy, and correlation.

Heart transplantation in pediatric population and in adults with congenital heart disease: long-term follow-up, critical clinical analysis, and perspective for the future

BACKGROUND

Heart transplantation is a treatment option for children as well as for adults with congenital heart disease.

OBJECTIVE

To report the experience of a tertiary center with heart transplant program in pediatric population and in adults with congenital heart disease.

PATIENTS AND METHODS

The study consisted of the evaluation of pediatric as well as adult patients undergoing heart transplantation for congenital heart disease. We evaluated the following indication and complications such as renal dialysis, graft vascular disease, tumors and survival.

RESULTS

From October 1992 to November 2013, 134 patients had transplantation, and there were 139 transplantations and 5 retransplantations. The immunosuppression regimen is based on calcineurin inhibitors and cytostatic drugs. The type of heart disease indicated for transplantation was cardiomyopathies in 70% and congenital heart disease in 30%. Of these 134 patients, 85 patients were alive. Actuarial survival is 77.4%, 69.6%, 59.3% at 1, 5, and 10 years after transplantation. Three patients underwent renal transplantation, 1 patient is in renal dialysis, and 8.2% of patients had post-transplant lymphoproliferative disease. Two patients had retransplantation for graft vascular disease; 1 of them required a simultaneous kidney transplant and died 30 days after the procedure and 1 patient is clinically well 2 years after retransplantation.

CONCLUSION

Heart transplantation in children and in adults with congenital heart disease is a promising therapeutic option and enables long-term survival for these patients.

Heart Transplantation in Pediatric and Congenital Heart Disease

Purpose:

To describe the indications and outcomes for pediatric patients and patients with congenital heart disease (CHD) undergoing heart transplantation (HT) in New Zealand.

Methods:

A retrospective audit of 253 patients who underwent HT from 1987 to end 2012 was undertaken. Thirty-seven patients were subdivided into two groups, those aged <18 years—pediatric heart disease (PHD) and those with CHD. Six patients aged <18 years were included in both the analyses. Demographic and clinical information were collected and outcomes established.

Results:

Overall actuarial survival of 37 patients with PHD or CHD was 92% at one year, 85% at five years, and 52% at ten years. The PHD group comprised 22 (8.7%) patients, median age 14 years (range 6-17), 14 (64%) male, with cardiomyopathy in 13, CHD in 6, and rheumatic heart disease in 3. At follow-up, 11 patients had died. Actuarial survival was 91% at one year and 79% at five years. Of the four patients with a mechanical assist device to bridge, three were transplanted and alive at follow-up. The CHD group comprised 21 (8.3%) patients, median age 25 years (range 6-48) and 19 (90%) were male. At follow-up, three patients had died. Actuarial survival was 95% at one year, 94% at five years, and 85% at ten years. All five patients with pre-HT Fontan circulation were alive a median of eight years following HT.

Conclusion:

Heart transplantation for carefully selected pediatric patients and patients with CHD can be successfully performed with favorable outcomes in a geographically isolated unit.

Long-term outcomes of children after solid organ transplantation

Solid organ transplantation has transformed the lives of many children and adults by providing treatment for patients with organ failure who would have otherwise succumbed to their disease. The first successful transplant in 1954 was a kidney transplant between identical twins, which circumvented the problem of rejection from MHC incompatibility. Further progress in solid organ transplantation was enabled by the discovery of immunosuppressive agents such as corticosteroids and azathioprine in the 1950s and ciclosporin in 1970. Today, solid organ transplantation is a conventional treatment with improved patient and allograft survival rates. However, the challenge that lies ahead is to extend allograft survival time while simultaneously reducing the side effects of immunosuppression. This is particularly important for children who have irreversible organ failure and may require multiple transplants. Pediatric transplant teams also need to improve patient quality of life at a time of physical, emotional and psychosocial development. This review will elaborate on the long-term outcomes of children after kidney, liver, heart, lung and intestinal transplantation. As mortality rates after transplantation have declined, there has emerged an increased focus on reducing longer-term morbidity with improved outcomes in optimizing cardiovascular risk, renal impairment, growth and quality of life. Data were obtained from a review of the literature and particularly from national registries and databases such as the North American Pediatric Renal Trials and Collaborative Studies for the kidney, SPLIT for liver, International Society for Heart and Lung Transplantation and UNOS for intestinal transplantation.

Outcomes following more than two decades of paediatric cardiac transplantation

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.

Aortic complications after pediatric cardiac transplantation in patients with a previous Norwood reconstruction

Despite increasing surgical success with staged palliation of hypoplastic left heart syndrome and its variants, some of these children eventually may require cardiac transplantation. Sixteen (7.8%) of 206 children ≤18 years old undergoing primary heart transplantation had a previous Norwood palliation. Two (12.5%) developed significant aortic problems after transplantation related to the initial homograft reconstruction of the aorta. Patient 1 developed acute graft failure requiring extracorporeal membrane oxygenator support post-transplant. During acute retransplantation 2 days later, the new donor aorta was sewn to a remnant of the initial donor aorta rather than to the heavily calcified reconstructed native aorta. Two months later, the patient required reoperation for acute airway compression from an aortic pseudoaneurysm caused by necrosis of the bridge of aortic tissue from the first transplant. Patient 2 had multiple balloon dilatations of recurrent coarctation after transplantation. Eighteen years post-transplant, during work-up for chronic fever and weight loss, computerized tomography showed a mycotic aneurysm of the reconstructed transverse aorta with contained rupture necessitating removal and replacement of the entire reconstructed aorta. Although uncommon, aortic complications in pediatric heart transplant patients with previous Norwood arch reconstruction can present with unusual manifestations requiring heightened vigilance.

Quality of life after pediatric solid organ transplantation

Long-term survival after pediatric solid organ transplantation is now the rule rather than the exception for increasing numbers of children with end-stage organ diseases. While transplantation restores organ function it does not necessarily return one to a normal life. Therefore, it is prudent to focus on assessment of not only traditional biologic outcomes but also the quality life for these children and their families. This article gives a brief overview of current definitions, conceptualizations, approaches to measurement of, and unique considerations in the evaluation of quality of life in children who have undergone solid organ transplant. Current understanding of quality of life in children who have undergone solid organ transplantation is reviewed, followed by limitations of current knowledge. Clinical implications are discussed and future research directions suggested.

Meta-analysis of medical regimen adherence outcomes in pediatric solid organ transplantation

BACKGROUND

Adherence to the medical regimen after pediatric organ transplantation is important for maximizing good clinical outcomes. However, the literature provides inconsistent evidence regarding prevalence and risk factors for nonadherence posttransplant.

METHODS

A total of 61 studies (30 kidney, 18 liver, 8 heart, 2 lung/heart-lung, and 3 with mixed recipient samples) were included in a meta-analysis. Average rates of nonadherence to six areas of the regimen, and correlations of potential risk factors with nonadherence, were calculated.

RESULTS

Across all types of transplantation, nonadherence to clinic appointments and tests was most prevalent, at 12.9 cases per 100 patients per year (PPY). The immunosuppression nonadherence rate was six cases per 100 PPY. Nonadherence to substance use restrictions, diet, exercise, and other healthcare requirements ranged from 0.6 to 8 cases per 100 PPY. Only the rate of nonadherence to clinic appointments and tests varied by transplant type: heart recipients had the lowest rate (4.6 cases per 100 PPY vs. 12.7-18.8 cases per 100 PPY in other recipients). Older age of the child, family functioning (greater parental distress and lower family cohesion), and the child's psychological status (poorer behavioral functioning and greater distress) were among the psychosocial characteristics significantly correlated with poorer adherence. These correlations were small to modest in size (r=0.12-0.18).

CONCLUSIONS

These nonadherence rates provide benchmarks for clinicians to use to estimate patient risk. The identified psychosocial correlates of nonadherence are potential targets for intervention. Future studies should focus on improving the prediction of nonadherence risk and on testing interventions to reduce risk.

Quality of life in adult survivors greater than 10 years after pediatric heart transplantation

BACKGROUND

This study assessed quality of life (QOL) in adult survivors of pediatric heart transplantation who survived > or = 10 years after transplantation.

METHODS

Prospective data were collected from heart transplant recipients who were aged > or = 18 years and had survived > or = 10 years after transplantation (transplantation between July 3, 1986, and April 4, 1997). QOL data were collected from patients using the Medical Outcomes Study 36-Item Short Form (SF-36) Health Survey. Clinical data were collected from medical records. Statistical analyses included frequencies and measures of central tendency.

RESULTS

Twenty-three patients (65% men, 91% white) completed the study. At the study initiation, they were a mean age of 9.0 +/- 7.1 years at transplantation, and were a mean age of 25.2 +/- 5.5 years (range, 18-34 years) and a mean of 16.2 +/- 3.0 years (range, 11-22 years) post-transplantation. Most were in school or working. Mean patient QOL scores from the SF-36v2 survey were 50.56 +/- 0.5 (range, 27.3-68.9) for physical health and 49.88 +/- 11.72 (range, 23.56-62.84) for mental health, similar to the general United States population. Late complications were frequent, including transplant coronary artery disease, 3; repeat heart transplantation, 2; post-transplantation lymphoproliferative disorder, 6; kidney transplantation, 5; acute late rejection, 5; and arrhythmias, 4.

CONCLUSION

This report of QOL in adult survivors of pediatric heart transplantation shows patient perception of physical and mental health is similar to the general population despite serious late complications. A multicenter study is planned to further evaluate QOL in this unique cohort.

Comparing parents' and children's views of children's quality of life after heart transplant

PURPOSE

The purpose of this focused ethnographic study was to explore the quality of life (QOL) of school-age heart-transplant recipients.

DESIGN AND METHODS

Semistructured interviews were conducted with 11 parent-child dyads. Data were analyzed using content analysis and constant comparison.

RESULTS

Participants identified key factors impacting the children's QOL including: participation in normal activities, normalcy, staying healthy, sources of strength and support, and struggles (parents' perspectives) and doing what kids do, being with family and friends, and being a heart transplant kid (children's perspectives).

PRACTICE IMPLICATIONS

Interventions focusing on the key factors identified by participants may impact the QOL of school-age heart-transplant recipients.

Subclinical atherosclerosis after heart and heart-lung transplantation in childhood

Children after heart transplantation are considered as at-risk patients for extracardiac atherosclerotic complications. Noninvasive ultrasound measurement of the common carotid artery (IMT) provides valid information about the endothelial structure of the vascular system. Twenty-two patients (17 male, mean age 12.4 +/- 4.5 yr) after heart and (5.7 +/- 4.5 yr) heart-lung transplantation were enrolled. The mean IMT was measured and compared with a control group (18 children, 10 male, mean age 11.8 +/- 1.8 yr) and to normative data. Transplanted children had a higher IMT than controls (0.453 +/- 0.003 vs. 0.424 +/- 0.002 mm, p < 0.001). IMT-SDS was increased as well (1.6 +/- 0.1 vs. 0.8 +/- 0, p < 0.001). Transplanted children had a higher LDL/HDL-ratio (2.2 +/- 0.2 vs. 1.2 +/- 0.1, p < 0.001). Time after transplantation, age at the time of transplantation, or medical therapy did not influence the findings. We found evidence for subclinical atherosclerosis in children after heart and heart-lung transplantation. Even if single atherosclerotic risk factors could not be identified, transplanted children seem to be at risk for atherosclerosis. Our findings support the recently published statement of the AHA-Expert panel: after heart transplantation atherosclerotic complications may occur with increased incidence. We propose the IMT-measurement in these patients as an easy method to assess the vascular status and to guide preventive measures.

Infectious, malignant, and autoimmune complications in pediatric heart transplant recipients

OBJECTIVE

To review clinical courses of pediatric heart transplant survivors after 5 years from transplantation for infections, lymphoproliferative, and autoimmune diseases.

STUDY DESIGN

A total of 71 patients were examined in 2 groups, infant recipients (underwent transplant <1 year of age, n = 38) and older recipients (underwent transplant >1 year, n = 33). All patients received comparable immunosuppression. Calculated occurrence rates were reported as means per 10 years of follow-up with SEs. Differences were examined by using Poisson regression.

RESULTS

Infant recipients had significantly higher (P < .001) occurrence rates of severe (mean, 2.04 +/- 0.5) and chronic infections (mean, 4.58 +/- 0.67) compared with older recipients (means, 0.37 +/- 0.19 and 1.87 +/- 0.70, respectively). Types of infections were similar to those in the general population with extremely rare opportunistic infections; however, they were more severe and resistant to treatment. Autoimmune disorders occurred at a frequency comparable with lymphoproliferative diseases and were observed in 7 of 38 infants (18%). Most common were autoimmune cytopenias.

CONCLUSIONS

Infant heart transplant recipients who survive in the long term have higher occurrence rates of infections compared with older recipients. Autoimmune disorders are a previously unrecognized morbidity in pediatric heart transplantation.

Chronic kidney disease after liver, cardiac, lung, heart-lung, and hematopoietic stem cell transplant

Patient survival after cardiac, liver, and hematopoietic stem cell transplant (HSCT) is improving; however, this survival is limited by substantial pretransplant and treatment-related toxicities. A major cause of morbidity and mortality after transplant is chronic kidney disease (CKD). Although the majority of CKD after transplant is attributed to the use of calcineurin inhibitors, various other conditions such as thrombotic microangiopathy, nephrotic syndrome, and focal segmental glomerulosclerosis have been described. Though the immunosuppression used for each of the transplant types, cardiac, liver and HSCT is similar, the risk factors for developing CKD and the CKD severity described in patients after transplant vary. As the indications for transplant and the long-term survival improves for these children, so will the burden of CKD. Nephrologists should be involved early in the pretransplant workup of these patients. Transplant physicians and nephrologists will need to work together to identify those patients at risk of developing CKD early to prevent its development and progression to end-stage renal disease.

Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research

Although for most children the process of atherosclerosis is subclinical, dramatically accelerated atherosclerosis occurs in some pediatric disease states, with clinical coronary events occurring in childhood and very early adult life. As with most scientific statements about children and the future risk for cardiovascular disease, there are no randomized trials documenting the effects of risk reduction on hard clinical outcomes. A growing body of literature, however, identifies the importance of premature cardiovascular disease in the course of certain pediatric diagnoses and addresses the response to risk factor reduction. For this scientific statement, a panel of experts reviewed what is known about very premature cardiovascular disease in 8 high-risk pediatric diagnoses and, from the science base, developed practical recommendations for management of cardiovascular risk.

The challenge of renal function in heart transplant children

Renal dysfunction may occur after pediatric heart transplantation and impacts on long-term prognosis. This study aims to review the incidence and mechanisms of chronic nephropathy following heart transplantation, and suggest therapeutic directions. The proportion of pediatric heart-transplant recipients with impaired renal function varies from 22 to 57%, and end-stage renal failure from 3 to 10%, depending on the method used for estimating the glomerular filtration rate. The pathophysiology of renal dysfunction is in part due to calcineurin inhibitor-induced renal vasoconstriction, through activation of the intrarenal renin-angiotensin system, TGF-beta1 upregulation and TGF-beta1 gene polymorphisms. Overproduction of angiotensin II, associated with angiotensin-converting-enzyme genotype, might be associated with poor prognosis and pharmacological factor gene polymorphisms, and may contribute to variation of calcineurine inhibitor exposure in the kidney. Strategies to prevent renal dysfunction include reducing calcineurine inhibitor exposure or delaying calcineurine inhibitor administration from the early post-transplant period. Calcium channel blockers and angiotensin-converting-enzyme inhibitors, blockade of angiotensin II, or anti-TGF-beta1 antibodies might limit nephrotoxicity. No accurate marker can predict the potential of renal lesions to develop. Lowering calcineurine inhibitors levels with immunosuppressive agents that are either less nephrotoxic or non-nephrotoxic should be formally studied. Of high interest is the impact of genetic polymorphism on the development of renal dysfunction.

Endothelial dysfunction and circadian blood pressure rhythmicity in young heart transplant recipients

Blood pressure variability correlates with circadian rhythmicity in endothelium-derived nitric oxide (NO) production in adults. Young, hypertensive orthotopic heart transplant (OHT) patients have functional abnormalities in NO-dependent signaling pathways that lead to reduced NO bioavailability and endothelial dysfunction. Following acute intravenous infusion of L: -arginine, the amino acid substrate for NO, OHT patients normalize blood pressure (BP) and endothelial function. However, the effects of chronic L: -arginine infusion on circadian BP rhythmicity and endothelial function in OHT patients have not been described. Six OHT patients (9-29 years old), and seven healthy control subjects (19-28 years old) were admitted for 48 hours. Systolic, diastolic, and mean blood pressures (MBP) were recorded hourly. Urine samples were obtained to measure nitrates/nitrites (NO(X)). Brachial artery flow-mediated vasodilatation (FMD; an index of endothelial function) and left ventricular ejection fraction (LVEF) were measured 0, 23, and 48 hours after admission. Intravenous L: -arginine HC1 was infused continuously beginning 24 hours after admission in all subjects. The incidence (50%) and degree (12.0 +/- 9.2%) of nocturnal MBP dipping was significantly less in OHT patients than control subjects. Furthermore, FMD was significantly reduced in OHT patients compared to controls (3.2 +/- 1.1 vs 7.2 +/- 3.1%, p = 0.01). L: -Arginine infusion had no significant effect on 24-hour MBP, LVEF, or nocturnal dipping status in any subject; however, L: -arginine normalized FMD in OHT patients (7.4 +/- 1.8%). Circadian BP variability and endothelial function are impaired in young cardiac transplant patients with medically controlled hypertension, and L: -arginine administration reverses endothelial dysfunction.

Cardiovascular Risk Reduction in High-Risk Pediatric Patients

Although for most children the process of atherosclerosis is subclinical, dramatically accelerated atherosclerosis occurs in some pediatric disease states, with clinical coronary events occurring in childhood and very early adult life. As with most scientific statements about children and the future risk for cardiovascular disease, there are no randomized trials documenting the effects of risk reduction on hard clinical outcomes. A growing body of literature, however, identifies the importance of premature cardiovascular disease in the course of certain pediatric diagnoses and addresses the response to risk factor reduction. For this scientific statement, a panel of experts reviewed what is known about very premature cardiovascular disease in 8 high-risk pediatric diagnoses and, from the science base, developed practical recommendations for management of cardiovascular risk.

Restrictive hemodynamics are present at the time of diagnosis of allograft coronary artery disease in children

Clinical recognition of allograft coronary artery disease (ACAD) is challenging. We examined whether right heart hemodynamics can aid its diagnosis in pediatric recipients. We retrospective analyzed hemodynamic data of recipients with ACAD versus age and date-of-transplant matched controls. From 1982-2001, 18 cases fulfilled study entry criteria. Median age at transplant was 12 years for subjects and 8 years for controls. Median time to diagnosis of ACAD was 65 months (14.5-124 months) and 67 months (16-140 months) to arteriography for controls. The median right ventricular end-diastolic pressure (RVEDP) at diagnosis was 11.0 vs. 6.0 mmHg for controls (p = 0.003). Pulmonary capillary wedge pressure (PCWP) at diagnosis was 14.0 vs. 8.0 mmHg for controls (p = 0.001). When subdivided by severity of ACAD, the difference was greater in the moderate/severe group. Compared to the previous catheterization (median interval 10 months for subjects, 12.0 for controls ), there was an increase of 4.0 mmHg in RVEDP in ACAD subjects (n = 13, p = .003) versus 0 mmHg in controls (p = 0.042), and an increase in PCWP of 5.5 in subjects (p = .002) versus 0 mmHg in controls (p = 0.066). The presence of elevated filling pressures plus an interim increase should alert to the presence of ACAD and help guide further investigation.

Treatment strategies in pediatric solid organ transplant recipients with calcineurin inhibitor-induced nephrotoxicity

Although short-term kidney allograft survival has improved significantly since the introduction of the calcineurin inhibitors (CNI) cyclosporine A (CsA) and tacrolimus, long-term transplant survival remains a major concern, chronic allograft nephropathy (CAN) being the principal reason for graft loss after the first post-transplant year. This is particularly major for pediatric renal transplant recipients because of their higher life expectancy compared with adults. The mechanisms leading to CAN are multiple, including acute and chronic alloimmune responses and nephrotoxicity of CNIs. CNI-induced nephrotoxicity is also a long-term concern in other pediatric solid organ transplant recipients, such as liver and heart. Prevention of allograft nephropathy requires a balance of maintaining adequate immunosuppression, while avoiding the toxic effects of CNIs. Regimens that are based on mycophenolate mofetil (MMF) alone or in combination with newer agents may allow for reduced reliance on CNIs and thus may represent an effective treatment paradigm for long-term maintenance of a renal allograft. From the available data it appears that the currently safest treatment strategy in pediatric renal and heart transplant recipients with CNI toxicity is an MMF-based therapy with low-dose CNIs +/- low-dose steroids, while in pediatric liver transplant recipients, CNI-free MMF-based immunosuppressive therapy with or without steroids appears feasible in a significant subset of patients. In renal transplant recipients, the benefit of a CNI-free MMF/steroid therapy on renal function is gained at the cost of increased rejection in a subset of patients, although the relative importance of rejection vs. overall renal function requires further clinical investigation. The introduction of mammalian target of rapamycin (mTOR) inhibitors provides an opportunity for unique CNI-sparing regimens that combine two antiproliferative agents (MMF and TOR inhibitors). It is possible that a sirolimus-based CNI-free immunosuppressive regimen in terms of renal transplant survival is superior to CNI minimization, where the detrimental effects of CNIs on allograft function and structure are still operative, albeit to a lesser degree. Substitution of CNIs by mTOR inhibitors is therefore promising, but requires validation in long-term studies in large cohorts.

Current issues in pediatric transplantation

Pediatric solid organ transplantation is so successful that >80% of children will survive to become teenagers and adults. Therefore, it is essential that these children maintain a good quality life, free of significant long-term side effects. While intensive immunosuppressive regimens (containing CsA, tacrolimus, MMF, and steroids) effectively reduce acute or chronic rejection, they can produce long-term side effects including viral infection, renal dysfunction, hypertension, and stunting. The development of effective methods of diagnosis, prevention, and treatment of CMV means that this is no longer a significant cause of mortality, but morbidity remains high. In contrast, infection rates of EBV remain high in EBV-negative pre-transplant patients. However, pre-emptive reduction of immunosuppression or treatment with rituximab or adoptive T-cell therapy is effective in preventing/treating post-transplant lymphoproliferative disease. Recent protocols have concentrated on reducing CsA immunosuppression, to prevent unacceptable cosmetic effects, and to reduce the hypertension, hyperlipidemia, and nephrotoxicity. Both CsA and tacrolimus cause a 30% reduction in renal function, with 4-5% of patients developing severe chronic renal failure. The use of IL-2 inhibitors for induction therapy with low-dose calcineurin inhibitors, in combination with renal-sparing drugs such as MMF or sirolimus for maintenance immunosuppression, should prevent significant renal dysfunction in the future. The concept of steroid-free immunosuppression with IL-2 inhibitors, tacrolimus, and MMF is an attractive option, which may reduce stunting and renal dysfunction. However, these regimens may be associated with the increased development of de-novo autoimmune hepatitis in 2-3% of children. The most important challenge to long-term survival in transplanted children is the management of non-adherence and other adolescent issues, particularly when transferring to adult units, as this is the time when many successful transplant survivors lose their grafts.

Pharmacotherapy of hyperlipidemia in pediatric heart transplant recipients: current practice and future directions

Lipoprotein abnormalities are fairly common after pediatric heart transplantation. Graft coronary artery disease (GCAD) limits long-term survival and has been linked to elevated serum triglyceride levels and decreased high-density lipoprotein levels. Histologically, GCAD represents intimal hyperplasia of the coronary vessel and is best imaged by intravascular ultrasound.A number of pharmacologic agents are available for the management of lipid disorders but experience with these drugs has mainly been in adults. HMG-CoA reductase inhibitors (statins) are currently used by many adult transplantation centers to alter lipid profiles in the hope of reducing GCAD. The use of statins among pediatric heart transplant centers is more limited. Although rhabdomyolysis is a concern with these agents, the incidence among individuals receiving immunosuppressant therapy is low. Aside from their lipid-lowering properties, statins may also protect against graft failure and rejection.

Longitudinal assessment of psychological functioning in children after heart or heart-lung transplantation

BACKGROUND

Despite the increasing numbers of pediatric heart and lung transplants being performed worldwide, longitudinal psychological evaluation of children and adolescents undergoing transplantation remains uncommon. The objective of this study was to assess psychological functioning in a group of patients at 12 months and 3 years after transplantation.

METHODS

Thirty-four children and adolescents (mean age at 12-month assessment: 7.9 years [range 1.3 to 15.3 years]) were evaluated after heart (n = 24) or heart-lung (n = 10) transplantation for congenital heart disease (CHD; n = 10), cystic fibrosis (n = 1), cardiomyopathy (CM; n = 21) or primary pulmonary hypertension (n = 2). Standardized measures were used to assess development, cognitive function, mood state and behavior at each test occasion.

RESULTS

Measures of developmental, cognitive and academic function were within the normal range with each test and showed stability over time. About 33% of patients had behavior problems at each test occasion, which is higher than the 10% reported for the normal population, but the prevalence of depression fell from 23% at 12 months to 13% at 3 years. Although there were no significant differences between heart and heart-lung recipients, children with a pre-transplant diagnosis of CHD had poorer scores on cognitive and behavioral parameters than those with CM. In particular, while the prevalence of behavior problems showed a slight decrease over time in the CM group, it increased from 33% at 12 months to 75% at 3 years in the CHD group.

CONCLUSIONS

A number of pediatric patients continue to have psychological difficulties 3 years after transplant. Initial diagnosis is an important factor in post-transplant psychological functioning, with a diagnosis of CHD appearing to be a risk factor for greater psychological morbidity, at least in the short and medium term. Further follow-up must address whether such differences persist in the longer term. Patients at risk for poorer psychological outcome need to be identified so that interventions can be implemented to reduce psychological morbidity.

Ten- and 20-year survivors of pediatric orthotopic heart transplantation

BACKGROUND

Pediatric heart transplantation is entering its third decade, allowing for the first time an analysis of a large group of true long-term survivors, specifically children who have survived > or =10 years post-transplantation.

METHODS

Fifty-two patients < or =18 years, who had undergone heart transplantation at Stanford between August 1974 and June 1993 and survived > or =10 years, were retrospectively reviewed.

RESULTS

Forty (77%) patients are currently alive. Thirteen survived >15 years and 5 >20 years (the longest being 26 years). Actuarial survival was 79.4% at 14 years and 53.1% at 20 years. Cardiomyopathy was the reason for transplantation in 71% and congenital heart disease (CHD) in 29%. At last evaluation, 71% were on a cyclosporine-based regimen and 23% a tacrolimus-based regimen; 33% were steroid-free. Twenty-seven percent were totally free from treatable rejection, 44% developed serious infections, 69% were receiving anti-hypertensives, and 8% required renal transplantation. Neoplasms occurred in 23%, graft coronary artery disease (CAD) in 31%, and 15% required re-transplantation. Of the 12 deaths, CAD was the most common cause (n = 4), followed by non-specific late graft failure (n = 3), infection (n = 2), rejection (n = 1), non-lymphoid cancer (n = 1) and lymphoid cancer (n = 1). Physical rehabilitation and return to normal lifestyle has been nearly 100%.

CONCLUSIONS

Heart transplantation in pediatric patients is compatible with true long-term survival with a growing cohort of children approaching their second and third decades. The gradual constant-phase decrease in survival noted in earlier studies appears to be continuing. Rejection and infection are low but persistent risks after the first years. Graft CAD and non-specific late graft dysfunction are the leading causes of death after 10 years. Rehabilitation is excellent.

Blood Pressure After Cardiac Transplantation in Childhood

BACKGROUND

There has been little formal study of blood pressure in children after cardiac transplantation.

METHODS

Twenty-four-hour and clinical blood pressure (BP) were measured in 28 children (>6 months after transplantation) and compared with a large amount of normal data.

RESULTS

Conventional (clinical) systolic BP (SBP) was elevated in 9 (32.1%) of 28 (95% confidence interval [CI] 15.8 to 52.3), and conventional diastolic BP (DBP) was elevated in 5 (17.8%) of 28 (95% CI 6.0 to 36.8). Mean 24-hour BP was >97.5 percentile in 2 (7.7%) of 26 (95% CI 0.9 to 25.1) for SBP and in 7 (28.0%) of 25 (95% CI 12.1 to 49.4) for DBP. In comparison with the control population, mean nighttime SBP was 8.9 mm Hg higher in the transplanted group (95% CI 4.8 to 13.1), but daytime and mean 24-hour SBP were similar. Mean day, night, and 24-hour DBP was significantly higher in the transplanted patients. The nighttime decrease in BP was significantly less than controls for SBP, but not for DBP. Conventional BP measurement was poorly predictive of 24-hour BP. There was a significant association between mean 24-hour SBP and interventricular septal thickness (r(2)=0.35; p=0.01). DBP was not associated with interventricular septal thickness (r(2)=0.07; p=0.20) but was significantly correlated with the time since transplantation (r=0.42; p=0.03 for conventional DBP and r=0.43; p=0.04 for 24-hour DBP).

CONCLUSIONS

The elevation of DBP in children after cardiac transplantation is unexplained. The elevation in nighttime SBP has possible important therapeutic implications and is not predicted by conventional (clinical) BP measurement.

Biological and psychological differences in the child and adolescent transplant recipient

Solid organ transplantation has become accepted therapy for the treatment of end-stage organ dysfunction in children. As early management of the pediatric transplant recipient has improved, important age-related differences in long-term patient outcomes have become apparent. Late morbidity and mortality can, in most cases, be attributed to the consequences of long-term immunosuppression: graft loss from under-immunosuppression or an increased incidence of cancer, hypertension, renal failure or diabetes from over-immunosuppression. Age-related differences in both biological and psychological factors play an important role in the optimization of therapy in the transplanted child. Important age-related differences have been demonstrated in all phases of pharmacokinetics: absorption, distribution, metabolism and elimination. Information regarding specific age-related pharmacokinetic differences is lacking for many immunosuppressive medications. Further study using physiologically based pharmacokinetic (PBPK) models will lead to more specific recommendations for age-based immunosuppression protocols. Non-adherence is common among solid organ transplant recipients of all ages and the consequences of non-adherence include increased rejection, late graft loss and death. The biological and psychological developmental changes that occur during adolescence place the transplanted adolescent at an even higher risk of non-adherence and poor outcome than other age groups. Further studies to elucidate the importance of both age-related pharmacokinetic and behavioral factors are needed to formulate therapeutic interventions that would improve adherence and patient outcomes.

Growing pains: non-adherence with the immunosuppressive regimen in adolescent transplant recipients

One-year graft and patient survival are better in adolescent transplant recipients (age 11-19 years) than in younger (age < 11 years) pediatric transplant recipients. However, several groups found that long-term outcomes (> i.e. 5 year post-transplant) in the adolescent age group are significantly worse than in younger transplant recipients. A behavioral factor that could explain an important part of the poorer clinical outcome in adolescent transplant recipients is non-compliance with medication taking. Adolescents, like all organ transplant recipients irrespective of their age, must adhere to a life-long immunosuppressive regimen in addition to other aspects of their therapeutic regimen. Therefore, adolescent transplant recipients, as all transplant patients, should be regarded as a chronically ill patient population in whom behavioral and psychosocial management is equally important as state-of-the-art medical management. This paper provides an overview of the current knowledge on prevalence, clinical consequences, and risk-factors for non-compliance with the immunosuppressive regimen in adolescent transplant recipients and offers some suggestions for adolescent-tailored interventions to improve medication adherence.

Improvement of Renal Function in Pediatric Heart Transplant Recipients Treated with Low-Dose Calcineurin Inhibitor and Mycophenolate Mofetil

BACKGROUND

Renal dysfunction is a major complication in heart transplant recipients treated with calcineurin inhibitors. The goal of the study was to investigate the effect of a reduction of calcineurin inhibitor dosage with the concomitant introduction of mycophenolate mofetil on both renal function and cardiac allograft function.

METHODS

Fourteen of 52 consecutive pediatric cardiac allograft recipients experienced a progressive decrease of renal function. A renal biopsy was performed before the dose of calcineurin inhibitors was reduced by 50% and azathioprine was replaced by mycophenolate mofetil. Renal function was evaluated by inulin clearance and maximal urinary osmolality before and yearly after the therapeutic changes. Acute rejection was monitored clinically, by echocardiography and endomyocardial biopsies.

RESULTS

Inulin clearance in the fourteen children decreased from 84.2 mL/min/1.73 m at one year posttransplantation to 46.5+/-9.6 mL/min/1.73 m at the time of the change in immunosuppressive therapy. Significant renal lesions were observed in the renal biopsies performed before the change. At 1 year, inulin clearance had increased by 67%. In six patients who had a second determination 2 years after the switch, inulin clearance was not significantly different from the value at 1 year. There were three reversible acute rejection episodes in three patients. The incidence of rejection episodes was not different from a control group of patients whose treatment was not changed.

CONCLUSION

The reduction of calcineurin inhibitor dosage and replacement of azathioprine by mycophenolate mofetil is a safe way to improve renal function in children with heart transplants and calcineurin inhibitor induced nephrotoxicity.

Ascending Aortic Aneurysm After Pediatric Heart Transplantation: Case Report of an Unusual Complication

A 28-month-old boy, weighing 11 kg, with severe dilated cardiomyopathy, was transplanted on December 1995. Hypertension and supraventricular tachycardia were detected in the immediate post-operative period, with favorable outcome. After 5 months of clinically asymptomatic follow-up, a dilation in the ascending aorta was observed on routine echocardiogram. Nuclear magnetic resonance imaging (NMRI) confirmed an ascending aortic aneurysm, with a diameter of 38 mm. An operation was performed, a bovine pericardium patch was sutured with reconstruction of the aortic wall, excluding the aneurysm. Good recovery was obtained and the child was discharged on Day 7 postoperatively. A post-operative echocardiogram showed absence of the aortic aneurysm and good surgical results. Another NMRI was done 5 months later, showing an intact ascending aorta. After 64 months, the patients clinical condition was confirmed as normal by echocardiogram. Surgical treatment was successful and the positive results have been maintained.

Beyond the first year after pediatric heart or heart-lung transplantation: Changes in cognitive function and behaviour

With the increasing use and improved survival rates of heart and lung transplantation as treatments for children with end-stage heart or lung disease, attention is focusing on the longer term psychological implications of these procedures. This paper focuses on the changes in cognitive development and behaviour in a group of 47 children who were seen 12 months and 2 yr after transplantation. There were 24 boys and 23 girls, mean age at transplantation was 8.3 yr (s.d. 5.3 yr), with a range of 0.3-15.1 yr. Assessments were made of developmental level, cognitive ability and problem behaviours, using previously validated measures, and comparisons were made with physically healthy children. For children under three and a half years of age there was a decrease over time in scores on all developmental parameters, with the change reaching significance on the scale assessing eye-hand coordination and on the overall IQ. Whilst all scores were within the normal range, they were at a significantly lower level than those of the healthy children. In contrast, there were no changes over time on any measures of cognitive or academic ability for older children, with correlations between 12 month and 2 yr scores being highly significant. The rate of behaviour problems at home at 12 months was 22%, compared with 34% at 2 yr post-transplant, which was higher than that found in the healthy children. Conversely, there was a drop in the prevalence of behaviour problems at school from 23% at 12 months to 9% at 2 yr. It is concluded that a significant minority of children and adolescents experience psychological difficulties 2 yr after transplant, with particular areas of concern focusing on development in the younger children and the occurrence of behaviour problems at home across the age-range.