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Mantell BS, Azeka E, Cantor RS, Carlo WF, Chrisant M, Dykes JC, Hoffman TM, Kirklin JK, Koehl D, L'Ecuyer TJ, McAllister JM, Prada-Ruiz AC, Richmond ME. The Fontan immunophenotype and post-transplant outcomes in children: A multi-institutional study. Pediatr Transplant 2023; 27:e14456. [PMID: 36591863 DOI: 10.1111/petr.14456] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 09/17/2022] [Accepted: 10/07/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients after Fontan palliation represent a growing pediatric population requiring heart transplant (HTx) and often have lymphopenia (L) and/or hypogammaglobinemia that may be exacerbated by protein-losing enteropathy (PLE, P). The post-HTx effects of this altered immune phenotype are not well studied. METHODS In this study of the Pediatric Heart Transplant Society Registry, 106 Fontan patients who underwent HTx between 2005 and 2018 were analyzed. The impact of lymphopenia and PLE on graft survival, infection, rejection, and malignancy was analyzed at 1 and 5 years post-HTx. RESULTS The following combinations of lymphopenia and PLE were noted: +L+P, n = 37; +L-P, n = 23; -L+P, n = 10; and -L-P, n = 36. Graft survival between the groups was similar within the first year after transplant (+L+P: 86%, +L-P: 86%, -L+P: 87%, -L-P: 89%, p = .9). Freedom from first infection post-HTx was greatest among -L-P patients compared to patients with either PLE, lymphopenia, or both; with a 22.1% infection incidence in the -L-P group and 41.4% in all others. These patients had a significantly lower infection rate in the first year after HTx (+L+P: 1.03, +L-P: 1, -L+P: 1.3, -L-P: 0.3 infections/year, p < .001) and were similar to a non-single ventricle CHD control group (0.4 infections/year). Neither freedom from rejection nor freedom from malignancy 1 and 5 years post-HTx, differed among the groups. CONCLUSIONS Fontan patients with altered immunophenotype, with lymphopenia and/or PLE, are at increased risk of infection post-HTx, although have similar early survival and freedom from rejection and malignancy. These data may encourage alternative immunosuppression strategies and enhanced monitoring for this growing subset of patients.
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Affiliation(s)
- Benjamin S Mantell
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center of NewYork-Presbyterian, New York, New York, USA
| | - Estela Azeka
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Waldemar F Carlo
- Division of Pediatric Cardiology, Children's of Alabama, Birmingham, Alabama, USA
| | - Maryanne Chrisant
- The Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, Florida, USA
| | - John C Dykes
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| | - Timothy M Hoffman
- Division of Pediatric Cardiology, North Carolina Children's Hospital, Chapel Hill, North Carolina, USA
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Thomas J L'Ecuyer
- Division of Pediatric Cardiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jennie M McAllister
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center of NewYork-Presbyterian, New York, New York, USA
| | - Adriana C Prada-Ruiz
- Division of Pediatric Cardiology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Marc E Richmond
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center of NewYork-Presbyterian, New York, New York, USA
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Ahmed H, Lee J, Bernstein D, Rosenthal D, Dykes J, Lee D, Barkoff L, Weinberg K, Hollander SA, Chen S. Increased risk of infections in pediatric Fontan patients after heart transplantation. Pediatr Transplant 2023; 27:e14421. [PMID: 36303275 DOI: 10.1111/petr.14421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 09/16/2022] [Accepted: 09/22/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Infectious complications are a major cause of morbidity and mortality after HT. Fontan patients may be more susceptible to post-HT infections. METHODS This was a single-center, retrospective cohort analysis of pediatric patients undergoing HT for FF physiology or DCM, who underwent induction with ATG. The primary endpoint was an infection in the first 180 days post-HT, defined as positive (1) blood/urine/respiratory culture; (2) viral PCR; (3) skin or wound infection; and/or (4) culture-negative infection if ≥5 days of antibiotics were completed. Secondary endpoints included (1) cell counts after ATG; (2) PTLD; and (3) rejection (≥Grade 2R ACR or pAMR2) in the first 180 days post-HT. RESULTS A total of 59 patients (26 FF, 33 DCM) underwent HT at 14.7 (IQR 10.6, 19.5) and 11.7 (IQR 1.4, 13.6) years of age, respectively. The median total ATG received was 7.4 (IQR 4.9, 7.7) vs 7.5 (IQR 7.3, 7.6) mg/kg (p = NS) for FF and DCM patients, respectively. Twenty-three patients (39%) developed an infection 180 days post-HT, with a higher rate of infection in FF patients (54% vs 27%, p = .03). Adjusted for pre-transplant absolute lymphocyte count, FF patients had a higher risk of infection at 30 days post-HT (OR 7.62, 95% CI 1.13-51.48, p = .04). There was no difference in the incidence of PTLD (12% vs 0%; p = .08) or rejection (12% vs 21%; p = .49). CONCLUSION Compared to DCM patients, FF patients have a higher risk of infection. Modifications to induction therapy for FF patients should be considered.
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Affiliation(s)
- Humera Ahmed
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Joanne Lee
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Daniel Bernstein
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - David Rosenthal
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - John Dykes
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Donna Lee
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Lynsey Barkoff
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kenneth Weinberg
- Division of Hematology-Oncology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sharon Chen
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
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Zafar F, Lubert AM, Trout AT, Katz DA, Palermo JJ, Opotowsky AR, Lorts A, Chin C, Powell AW, Villa CR, Anwar N, Morales DL, Dillman JR, Alsaied T. Abdominal CT and MRI Findings of Portal Hypertension in Children and Adults with Fontan Circulation. Radiology 2022; 303:557-565. [PMID: 35289663 DOI: 10.1148/radiol.211037] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Portal hypertension in the Fontan circulation is a function of elevated systemic venous pressure and liver fibrosis. Purpose To quantify the prevalence of radiologic evidence of portal hypertension and elevated VAST score (one point each for varices, ascites, splenomegaly, and thrombocytopenia) of 2 or greater in children and adults with Fontan circulation and to determine the association with hemodynamics and adverse outcomes. Materials and Methods This was a retrospective study of individuals with Fontan circulation who underwent abdominal MRI or CT for focal liver lesion surveillance between January 2012 and December 2019. Portal hypertension was defined as the presence of at least two of the following: varices, ascites, or splenomegaly. Fontan deterioration was defined as a composite of heart failure signs or symptoms requiring diuretic escalation, placement of a ventricular assist device, heart transplant, or death. Relationships between variables and the composite end point were assessed using univariable and multivariable logistic regression. Results A total of 123 patients (age range, 9-55 years; 32 children) were evaluated (median age, 23 years; IQR, 17-30 years; 63 male patients). Median time since diagnosis of Fontan circulation was 16 years (IQR, 12-23 years). Twenty-five of the 123 patients (20%) had radiologic evidence of portal hypertension, and 34 (28%) had a VAST score of 2 or greater. Fontan deterioration occurred in 25 of the 123 patients (20%); median follow-up duration was 0.4 year (IQR, 0.1-3.1 years). Compared with patients who had Fontan circulation without deterioration, patients with Fontan deterioration were more likely to have moderate or severe ventricular systolic dysfunction (P < .01), moderate or severe atrioventricular valve regurgitation (P < .01), higher Fontan pressure (P = .01), radiologic evidence of portal hypertension (P < .01), and VAST score of 2 or greater (P < .01). Conclusion Radiologic evidence of portal hypertension at abdominal imaging in children and adults with Fontan circulation was associated with higher venous pressures and an increased risk for Fontan deterioration. These characteristics may be used to identify patients who warrant comprehensive hemodynamic evaluation. © RSNA, 2022.
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Affiliation(s)
- Faizeen Zafar
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Adam M Lubert
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Andrew T Trout
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - David A Katz
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Joseph J Palermo
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Alexander R Opotowsky
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Angela Lorts
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Clifford Chin
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Adam W Powell
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Chet R Villa
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Nadeem Anwar
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - David L Morales
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Jonathan R Dillman
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Tarek Alsaied
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
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