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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; 43:1514-1520. [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] [MESH Headings] [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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2
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Peled Y, Ducharme A, Kittleson M, Bansal N, Stehlik J, Amdani S, Saeed D, Cheng R, Clarke B, Dobbels F, Farr M, Lindenfeld J, Nikolaidis L, Patel J, Acharya D, Albert D, Aslam S, Bertolotti A, Chan M, Chih S, Colvin M, Crespo-Leiro M, D'Alessandro D, Daly K, Diez-Lopez C, Dipchand A, Ensminger S, Everitt M, Fardman A, Farrero M, Feldman D, Gjelaj C, Goodwin M, Harrison K, Hsich E, Joyce E, Kato T, Kim D, Luong ML, Lyster H, Masetti M, Matos LN, Nilsson J, Noly PE, Rao V, Rolid K, Schlendorf K, Schweiger M, Spinner J, Townsend M, Tremblay-Gravel M, Urschel S, Vachiery JL, Velleca A, Waldman G, Walsh J. International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024. J Heart Lung Transplant 2024:S1053-2498(24)01679-6. [PMID: 39115488 DOI: 10.1016/j.healun.2024.05.010] [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: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 08/18/2024] Open
Abstract
The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.
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Affiliation(s)
- Yael Peled
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel.
| | - Anique Ducharme
- Deparment of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Michelle Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Neha Bansal
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Diyar Saeed
- Heart Center Niederrhein, Helios Hospital Krefeld, Krefeld, Germany
| | - Richard Cheng
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Brian Clarke
- Division of Cardiology, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Fabienne Dobbels
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Maryjane Farr
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX; Parkland Health System, Dallas, TX, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN, USA
| | | | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona Sarver Heart Center, Tucson, Arizona, USA
| | - Dimpna Albert
- Department of Paediatric Cardiology, Paediatric Heart Failure and Cardiac Transplant, Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Alejandro Bertolotti
- Heart and Lung Transplant Service, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Michael Chan
- University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Sharon Chih
- Heart Failure and Transplantation, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Monica Colvin
- Department of Cardiology, University of Michigan, Ann Arbor, MI; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Maria Crespo-Leiro
- Cardiology Department Complexo Hospitalario Universitario A Coruna (CHUAC), CIBERCV, INIBIC, UDC, La Coruna, Spain
| | - David D'Alessandro
- Massachusetts General Hospital, Boston; Harvard School of Medicine, Boston, MA, USA
| | - Kevin Daly
- Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - Carles Diez-Lopez
- Advanced Heart Failure and Heart Transplant Unit, Department of Cardiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Anne Dipchand
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Melanie Everitt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alexander Fardman
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Marta Farrero
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - David Feldman
- Newark Beth Israel Hospital & Rutgers University, Newark, NJ, USA
| | - Christiana Gjelaj
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew Goodwin
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Kimberly Harrison
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eileen Hsich
- Cleveland Clinic Foundation, Division of Cardiovascular Medicine, Cleveland, OH, USA
| | - Emer Joyce
- Department of Cardiology, Mater University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Tomoko Kato
- Department of Cardiology, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Daniel Kim
- University of Alberta & Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Me-Linh Luong
- Division of Infectious Disease, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Haifa Lyster
- Department of Heart and Lung Transplantation, The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Johan Nilsson
- Department of Cardiothoracic and Vascular Surgery, Skane University Hospital, Lund, Sweden
| | | | - Vivek Rao
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Katrine Rolid
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kelly Schlendorf
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Joseph Spinner
- Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Madeleine Townsend
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Maxime Tremblay-Gravel
- Deparment of Medicine, Montreal Heart Institute, Université?de Montréal, Montreal, Quebec, Canada
| | - Simon Urschel
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jean-Luc Vachiery
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Angela Velleca
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Georgina Waldman
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - James Walsh
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane; Heart Lung Institute, The Prince Charles Hospital, Brisbane, Australia
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Iskander C, Nwankwo U, Kumanan KK, Chiwane S, Exil V, Lowrie L, Tan C, Huddleston C, Agarwal HS. Comparison of Morbidity and Mortality Outcomes between Hybrid Palliation and Norwood Palliation Procedures for Hypoplastic Left Heart Syndrome: Meta-Analysis and Systematic Review. J Clin Med 2024; 13:4244. [PMID: 39064284 PMCID: PMC11277754 DOI: 10.3390/jcm13144244] [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: 04/30/2024] [Revised: 06/20/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
Background/Objectives: Hybrid palliation (HP) procedures for hypoplastic left heart syndrome (HLHS) are increasing. Our objective was to compare mortality and morbidity following HP and NP (Norwood palliation) procedures. Methods: Systematic review and meta-analysis of HLHS patients of peer-reviewed literature between 2000 and 2023. Mortality and/or heart transplantation in HP versus NP in the neonatal period, interstage period, and at 1, 3 and 5 years of age, and morbidity including completion of Stage II and Stage III palliation, unexpected interventions, pulmonary artery pressures, right ventricle function, neurodevelopmental outcomes and length of hospital stay were evaluated. Results: Twenty-one (meta-analysis: 16; qualitative synthesis: 5) studies evaluating 1182 HLHS patients included. HP patients had higher interstage mortality (RR = 1.61; 95% CI: 1.10-2.33; p = 0.01) and 1-year mortality (RR = 1.22; 95% CI: 1.03-1.43; p = 0.02) compared to NP patients without differences in 3- and 5-years mortality. HP procedure in high-risk HLHS patients had lower mortality (RR = 0.48; 95% CI: 0.27-0.87; p = 0.01) only in the neonatal period. HP patients underwent fewer Stage II (RR = 0.90; 95% CI: 0.81-1.00; p = 0.05) and Stage III palliation (RR = 0.78; 95% CI: 0.69-0.90; p < 0.01), had more unplanned interventions (RR = 3.38; 95% CI: 2.04-5.59; p < 0.01), and longer hospital stay after Stage I palliation (weighted mean difference = 12.88; 95% CI: 1.15-24.62; p = 0.03) compared to NP patients. Conclusions: Our study reveals that HP, compared to NP for HLHS, is associated with increased morbidity risk without an improved survival rate.
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Affiliation(s)
- Christopher Iskander
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Ugonna Nwankwo
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Krithika K. Kumanan
- Advanced Data Health Institution, Saint Louis University, Saint Louis, MO 63104, USA;
| | - Saurabh Chiwane
- Division of Pediatric Critical Care Medicine, Loma Linda University, Loma Linda, CA 92354, USA;
| | - Vernat Exil
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Lia Lowrie
- Division of Pediatric Critical Care Medicine, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA;
| | - Corinne Tan
- Department of Pediatric Cardio-Thoracic Surgery, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.T.); (C.H.)
| | - Charles Huddleston
- Department of Pediatric Cardio-Thoracic Surgery, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.T.); (C.H.)
| | - Hemant S. Agarwal
- Division of Pediatric Critical Care Medicine, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA;
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Hollander SA, Chen S, Dykes J, Kaufman BD, Lee E, Wujcik K, Profita E, Schmidt J, Rosenthal DN. A comprehensive, multifaceted strategy to increase pediatric donor heart utilization. J Heart Lung Transplant 2024:S1053-2498(24)01707-8. [PMID: 38945282 DOI: 10.1016/j.healun.2024.06.015] [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: 02/21/2024] [Revised: 06/18/2024] [Accepted: 06/24/2024] [Indexed: 07/02/2024] Open
Abstract
BACKGROUND In 2016, we initiated a quality improvement endeavor to increase pediatric heart offer acceptance. This study assessed the effect of these interventions at our center. METHODS We evaluted pre- and postimplementation cohorts (January 1, 2008-December 31, 2016 vs January 1, 2017-July 1, 2023) comparing donor heart utilization. Six interventions were iterated over time to increase offer acceptance ("extended criteria"): ABO-incompatible transplant, ex vivo perfusion for distanced donors, 3-dimensional total cardiac volume (TCV) assessment, acceptance of hepatitis-C or Severe Acute Respiratory Syndrome Coronavirus 2 infected donors, and institutional culture change favoring consideration of donors previously considered unacceptable. Outcomes studied included annual HT volume, median waitlist duration, sequence number at acceptance, and post-transplant clinical outcomes. RESULTS During the study period, annual transplant volume increased from 16/year to 25/year pre- and postimplementation. Three hundred thirteen of 389 (80%) listed patients were transplanted. Waitlist duration shortened postimplementation (p = 0.01), as did the percentage of accepted heart offers utilizing at least 1 extended criterion (p < 0.001). Institutional culture change and TCV assessment had the largest impact on donor heart utilization (p = 0.04 and p < 0.001). There was no difference in post-HT intubation or intensive care unit days (p = 0.05-0.9), though post-transplant hospitalization duration (p < 0.001) increased. Post-transplant survival was unaffected by the use of extended criteria hearts (p = 0.3). CONCLUSIONS We report a successful longitudinal, multifaceted effort to increase organ offer utilization, with institutional culture change and TCV assessments most impactful. The use of extended criteria hearts was not associated with inferior survival.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California.
| | - Sharon Chen
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - John Dykes
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Beth D Kaufman
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Ellen Lee
- Procurement Services, Stanford Medicine Children's Health, Palo Alto, California
| | - Kari Wujcik
- Solid Organ Transplant Services, Stanford Medicine Children's Health, Palo Alto, California
| | - Elizabeth Profita
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Julie Schmidt
- Solid Organ Transplant Services, Stanford Medicine Children's Health, Palo Alto, California
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
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Amdani S, Deshpande SR, Liu W, Urschel S. Impact of the Pediatric ABO Policy Change on Listings, Transplants, and Outcomes for Children Younger Than 2 Years Listed for Heart Transplantation in the United States. J Card Fail 2024; 30:476-485. [PMID: 37328049 DOI: 10.1016/j.cardfail.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND We assessed the impact of the liberalized ABO pediatric policy change on candidate characteristics and outcomes for children undergoing heart transplant (HT). METHODS AND RESULTS Children <2 years undergoing HT with ABO strategy reported at listing and HT from December 2011 to November 2020 to the Scientific Registry of Transplant Recipients database were included. Characteristics at listing, HT, and outcomes during the waitlist and post-transplant were compared before the policy change (December 16, 2011 to July 6, 2016), and after the policy change (July 7, 2016 to November 30, 2020). The percentage of ABO-incompatible (ABOi) listings did not increase immediately after the policy change (P = .93); however, ABOi transplants increased by 18% (P < .0001). At listing, both before and after the policy change, ABOi candidates had higher urgency status, renal dysfunction, lower albumin, and required more cardiac support (intravenous inotropes, mechanical ventilation) than those listed ABO compatible (ABOc). On multivariable analysis, there were no differences in waitlist mortality between children listed as ABOi and ABOc before the policy change (adjusted hazard ratio [aHR] 0.80, 95% confidence interval [CI] 0.61-1.05, P = .10) or after the policy change (aHR 1.2, 95% CI 0.85-1.6, P = .33). Post-transplant graft survival was worse for ABOi transplanted children before the policy change (aHR 1.8, 95% CI 1.1-2.8, P = .014), but not significantly different after the policy change (aHR 0.94, 95% CI 0.61-1.4, P = .76). After the policy change, ABOi listed children had significantly shorter waitlist times (P < .05). CONCLUSIONS The recent pediatric ABO policy change has significantly increased the percentage of ABOi transplantations and decreased waitlist times for children listed ABOi. This change in policy has resulted in broader applicability and actual performance of ABOi transplantation with equal access to ABOi or ABOc organs, and thus eliminated the potential disadvantage of only secondary allocation to ABOi recipients.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio.
| | - Shriprasad R Deshpande
- Department of Cardiology, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Wei Liu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Simon Urschel
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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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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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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Richmond ME, Conway J, Kirklin JK, Cantor RS, Koehl DA, Lal AK, McDonald N, Gajarski R, Lin KY, Singh RK, Fenton M, Asante-Korang A, Amdani S, Auerbach SR, Everitt MD. Three decades of collaboration through the Pediatric Heart Transplant Society Registry: A journey through registry data with a highlight on children with single ventricle anatomy. Pediatr Transplant 2024; 28:e14615. [PMID: 37811686 DOI: 10.1111/petr.14615] [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: 03/16/2023] [Revised: 08/08/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND The Pediatric Heart Transplant Society (PHTS) Registry was founded 30 years ago as a collaborative effort among like-minded providers of this novel life-saving technique for children with end-stage heart failure. In the intervening decades, the data from the Registry have provided invaluable knowledge to the field of pediatric heart transplantation. This report of the PHTS Registry provides a comprehensive look at the data, highlighting both the longevity of the registry and one unique aspect of the PHTS registry, allowing for exploration into children with single ventricle anatomy. METHODS The PHTS database was queried from January 1, 1993 to December 31, 2019 to include pediatric (age < 18 years) patients listed for HT. For our analysis, we primarily analyzed patients by era. The early era was defined as children listed for HT from January 1, 1993 to December 31, 2004; middle era January 1, 2005 to December 31, 2009; and recent era January 1, 2010 to December 31, 2019. Outcomes after listing and transplant, including mortality and morbidities, are presented as unadjusted for risk, but compared across eras. RESULTS Since 1993, 11 995 children were listed for heart transplant and entered into the PHTS Registry with 9755 listed during the study period. The majority of listings occurred within the most recent era. Waitlist survival improved over the decades as did posttransplant survival. Other notable changes over time include fewer patients experiencing allograft rejection or infection after transplant. Waitlist and posttransplant survival have changed dramatically in patients with single ventricle physiology and significantly differ by stage of single ventricle palliation. SUMMARY Key points from this PHTS Registry summary and focus on patients with single ventricle congenital heart disease in particular, include the changing landscape of candidates and recipients awaiting heart transplant. There is clear improvement in waitlist and transplant outcomes for children with both cardiomyopathy and congenital heart disease alike.
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Affiliation(s)
- Marc E Richmond
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Jennifer Conway
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Devin A Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ashwin K Lal
- Division of Pediatric Cardiology, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Nancy McDonald
- Department of Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| | - Robert Gajarski
- Division of Cardiology, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Kimberly Y Lin
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rakesh K Singh
- Hassenfeld Children's Hospital, New York University Grossman School of Medicine, New York, New York, USA
| | - Matthew Fenton
- Great Ormond Street Hospital for Children NHS Foundation Trust and Cardiothoracic Transplant Unit, London, UK
| | | | - Shahnawaz Amdani
- Division of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Scott R Auerbach
- Division of Cardiology, Children's Hospital of Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Melanie D Everitt
- Division of Cardiology, Children's Hospital of Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
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Bernaldo-de-Quirós E, Camino M, Martínez-Bonet M, Gil-Jaurena JM, Gil N, Hernández-Flórez D, Fernández-Santos ME, Butragueño L, Dijke IE, Levings MK, West LJ, Pion M, Correa-Rocha R. First-in-human therapy with Treg produced from thymic tissue (thyTreg) in a heart transplant infant. J Exp Med 2023; 220:e20231045. [PMID: 37906166 PMCID: PMC10619578 DOI: 10.1084/jem.20231045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/30/2023] [Accepted: 10/06/2023] [Indexed: 11/02/2023] Open
Abstract
Due to their suppressive capacity, regulatory T cells (Tregs) have attracted growing interest as an adoptive cellular therapy for the prevention of allograft rejection, but limited Treg recovery and lower quality of adult-derived Tregs could represent an obstacle to success. To address this challenge, we developed a new approach that provides large quantities of Tregs with high purity and excellent features, sourced from thymic tissue routinely removed during pediatric cardiac surgeries (thyTregs). We report on a 2-year follow-up of the first patient treated worldwide with thyTregs, included in a phase I/II clinical trial evaluating the administration of autologous thyTreg in infants undergoing heart transplantation. In addition to observing no adverse effects that could be attributed to thyTreg administration, we report that the Treg frequency in the periphery was preserved during the 2-year follow-up period. These initial results are consistent with the trial objective, which is to confirm safety of the autologous thyTreg administration and its capacity to restore the Treg pool.
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Affiliation(s)
- Esther Bernaldo-de-Quirós
- Laboratory of Immune-Regulation, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain
| | - Manuela Camino
- Department of Pediatric Cardiology, Hospital Gregorio Marañón, Madrid, Spain
| | - Marta Martínez-Bonet
- Laboratory of Immune-Regulation, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain
| | | | - Nuria Gil
- Department of Pediatric Cardiology, Hospital Gregorio Marañón, Madrid, Spain
| | - Diana Hernández-Flórez
- Laboratory of Immune-Regulation, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain
| | | | - Laura Butragueño
- Pediatric Intensive Care Unit, Hospital Gregorio Marañón, Madrid, Spain
| | - I. Esmé Dijke
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
- Canadian Donation and Transplantation Research Program Investigator, Edmonton, Canada
- Alberta Transplant Institute, Edmonton, Canada
| | - Megan K. Levings
- Canadian Donation and Transplantation Research Program Investigator, Edmonton, Canada
- Department of Surgery and School of Biomedical Engineering, University of British Columbia, BC Children’s Hospital, Vancouver, Canada
| | - Lori J. West
- Canadian Donation and Transplantation Research Program Investigator, Edmonton, Canada
- Alberta Transplant Institute, Edmonton, Canada
- Department of Pediatrics, University of Alberta/Stollery Children’s Hospital, Edmonton, Canada
| | - Marjorie Pion
- Laboratory of Immune-Regulation, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain
| | - Rafael Correa-Rocha
- Laboratory of Immune-Regulation, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain
- Canadian Donation and Transplantation Research Program Investigator, Edmonton, Canada
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10
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Lee JY, Kidambi S, Zawadzki RS, Rosenthal DN, Dykes JC, Nasirov T, Ma M. Weight Matching in Infant Heart Transplantation: A National Registry Analysis. Ann Thorac Surg 2023; 116:1241-1248. [PMID: 35835207 PMCID: PMC10321673 DOI: 10.1016/j.athoracsur.2022.05.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 04/26/2022] [Accepted: 05/31/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Infants account for a significant proportion of pediatric heart transplantation but also suffer from a high waitlist mortality. Donor oversizing by weight-based criteria is common practice in transplantation and is prevalent in this group. We sought to analyze the impact of oversizing on outcomes in infants. METHODS Infant heart transplantations reported to the United Network for Organ Sharing from January 1994 to September 2019 were retrospectively analyzed. 2384 heart transplantation recipients were divided into quintiles (Q1-Q5) on the basis of donor-to-recipient weight ratio (DRWR). Multivariate Cox regression was used to estimate the effect of DRWR. The primary end point was graft survival at 1 year. RESULTS The median DRWR for each quintile was 0.90 (0.37-1.04), 1.17 (1.04-1.29), 1.43 (1.29-1.57), 1.74 (1.58-1.97), and 2.28 (1.97-5.00). Pairwise comparisons showed improved survival for Q3 and Q4 over each of the bottom 2 quintiles and the top quintile. Regression analyses found that Q3 and Q4 were protective against graft failure compared with the bottom 2 quintiles. There was no difference in hazard among the top 3 quintiles. Significant covariates included primary diagnosis, ischemia time, serum bilirubin level, transplantation year, mechanical ventilation at transplantation, and extracorporeal membrane oxygenation at transplantation. Sex, female-to-male transplantation, and mechanical circulatory support at transplantation were not significant in univariate analyses. CONCLUSIONS Modest oversizing by DRWR (1.29-1.97) is associated with increased survival and lower risk in infant heart transplantation. Additional investigation is needed to establish best practices for size matching in this population.
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Affiliation(s)
- James Y Lee
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Sumanth Kidambi
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Roy S Zawadzki
- Department of Statistics, Donald Bren School of Information and Computer Sciences, University of California, Irvine, California
| | - David N Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - John C Dykes
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Teimour Nasirov
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Michael Ma
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California.
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11
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Hayes EA, Walczak AB, Goodhue Meyer E, Nicol K, Deitemyer M, Duffy V, Moore Padilla M, Gajarski RJ, Nandi D. An in vitro comparison of intra-operative isohemagglutinin and human leukocyte antigen removal techniques in pediatric heart transplantation. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2023; 55:189-193. [PMID: 38099633 PMCID: PMC10723569 DOI: 10.1051/ject/2023034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/21/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Highly sensitized pediatric patients awaiting heart transplantation experience longer wait times and thus higher waitlist mortality. Similarly, children less than 2 years of age have increased waitlist times and mortality when compared to their older peers. To improve the likelihood of successful transplantation in these patients, various strategies have been utilized, including peri-operative plasmapheresis. However, limited data exists comparing plasmapheresis techniques for antibody reduction. This study's aim was to compare the in vitro magnitude of isohemagglutinin titers (IT) and human leukocyte antigen (HLA) antibody removal and the time required between membrane-based plasmapheresis (MP) and centrifuge-based plasmapheresis (CP) incorporated into the extracorporeal (EC) circuit. METHODS Two MP (Prismaflex) and two CP (Spectra Optia, Terumo BCT) circuits were incorporated into four separate EC circuits primed with high titer, highly sensitized type O donor whole blood. Assays were performed to determine baseline IT and anti-HLA antibodies and then at 30-minute increments until completion of the run (two plasma volume exchanges) at two hours. RESULTS There was a decrease in anti-A and anti-B IgM and IgG titers with both MP and CP. Mean anti-A and anti-B titer reduction was by 4.625 titers (93.7% change) and 4.375 titers (93.8% change) using MP and CP, respectively. At 2 h of apheresis, CP reduced 62.5% of all ITs to ≤ 1:4, while MP reduced 50% of ITs to ≤ 1:4. Additionally, reduction of anti-HLA class II antibody to mean fluorescence intensity (MFI) <3000 was achieved with both MP and CP. At 2 h of apheresis, CP reduced MFI by 2-3.5 fold and MP reduced MFI by 1.7-2.5 fold. Both demonstrated similar hemolytic and thrombotic profiles. CONCLUSIONS In this in vitro plasmapheresis model of IT and anti-HLA antibody reduction, both MP and CP incorporated into the EC circuit can be used quickly and effectively to reduce circulating antibodies. While CP may have some greater efficiency, further study is necessary to verify this in vivo.
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Affiliation(s)
- Emily A. Hayes
- The Heart Center, Nationwide Children’s Hospital Columbus OH 43205 USA
| | - Ashley B Walczak
- The Heart Center, Nationwide Children’s Hospital Columbus OH 43205 USA
| | - Erin Goodhue Meyer
- Department of Hematology/Apheresis, Nationwide Children’s Hospital Columbus OH 43205 USA
| | - Kathleen Nicol
- Department of Pathology, Nationwide Children’s Hospital Columbus OH 43205 USA
| | - Matthew Deitemyer
- The Heart Center, Nationwide Children’s Hospital Columbus OH 43205 USA
| | - Vicky Duffy
- The Heart Center, Nationwide Children’s Hospital Columbus OH 43205 USA
| | - Michelle Moore Padilla
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine Atlanta GA 30322 USA
| | | | - Deipanjan Nandi
- The Heart Center, Nationwide Children’s Hospital Columbus OH 43205 USA
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12
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Adam I, Motyka B, Tao K, Jeyakanthan M, Alegre ML, Cowan PJ, West LJ. Sex, T Cells, and the Microbiome in Natural ABO Antibody Production in Mice. Transplantation 2023; 107:2353-2363. [PMID: 37871273 PMCID: PMC10593149 DOI: 10.1097/tp.0000000000004658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/10/2023] [Accepted: 02/21/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND "Natural" ABO antibodies (Abs) are produced without known exposure to A/B carbohydrate antigens, posing significant risks for hyperacute rejection during ABO-incompatible transplantation. We investigated anti-A "natural" ABO antibodies versus intentionally induced Abs with regard to the need for T-cell help, the impact of sex, and stimulation by the microbiome. METHODS Anti-A was measured by hemagglutination assay of sera from untreated C57BL/6 wild-type (WT) or T cell-deficient mice of both sexes. Human ABO-A reagent blood cell membranes were injected intraperitoneally to induce anti-A Abs. The gut microbiome was eliminated by maintenance of mice in germ-free housing. RESULTS Compared with WT mice, CD4 + T-cell knockout (KO), major histocompability complex-II KO, and αβ/γδ T-cell receptor KO mice produced much higher levels of anti-A nAbs; females produced dramatically more anti-A nAbs than males, rising substantially with puberty. Sensitization with human ABO-A reagent blood cell membranes did not induce additional anti-A in KO mice, unlike WT. Sex-matched CD4 + T-cell transfer significantly suppressed anti-A nAbs in KO mice and rendered mice responsive to A-sensitization. Even under germ-free conditions, WT mice of several strains produced anti-A nAbs, with significantly higher anti-A nAbs levels in females than males. CONCLUSIONS Anti-A nAbs were produced without T-cell help, without microbiome stimulation, in a sex- and age-dependent manner, suggestive of a role for sex hormones in regulating anti-A nAbs. Although CD4 + T cells were not required for anti-A nAbs, our findings indicate that T cells regulate anti-A nAb production. In contrast to anti-A nAbs, induced anti-A production was T-cell dependent without a sex bias.
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Affiliation(s)
- Ibrahim Adam
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Institute and Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Bruce Motyka
- Alberta Transplant Institute and Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Kesheng Tao
- Alberta Transplant Institute and Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Mylvaganam Jeyakanthan
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle-Upon-Tyne, United Kingdom
| | | | - Peter J. Cowan
- Department of Medicine, Immunology Research Centre, St. Vincent’s Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Lori J. West
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Institute and Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
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13
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Zorn E. ABO Antibody Development, a New Look at a Very Old Question. Transplantation 2023; 107:2311-2312. [PMID: 37287101 PMCID: PMC10728807 DOI: 10.1097/tp.0000000000004659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Emmanuel Zorn
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, USA
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14
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Goldstone AB, Bacha EA, Sykes M. On cardiac xenotransplantation and the role of xenogeneic tolerance. J Thorac Cardiovasc Surg 2023; 166:968-972. [PMID: 36621453 PMCID: PMC10267285 DOI: 10.1016/j.jtcvs.2022.11.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/23/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Andrew B Goldstone
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiothoracic Surgery, Morgan Stanley Children's Hospital of New York, Columbia University, New York, NY
| | - Emile A Bacha
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiothoracic Surgery, Morgan Stanley Children's Hospital of New York, Columbia University, New York, NY
| | - Megan Sykes
- Departments of Medicine, Microbiology and Immunology, and Surgery, Columbia Center for Translational Immunology, Department of Medicine, Columbia University, New York, NY.
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15
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Konstantinov IE, Cooper DKC, Adachi I, Bacha E, Bleiweis MS, Chinnock R, Cleveland D, Cowan PJ, Fynn-Thompson F, Morales DLS, Mohiuddin MM, Reichart B, Rothblatt M, Roy N, Turek JW, Urschel S, West L, Wolf E. Consensus statement on heart xenotransplantation in children: Toward clinical translation. J Thorac Cardiovasc Surg 2023; 166:960-967. [PMID: 36184321 PMCID: PMC10124772 DOI: 10.1016/j.jtcvs.2022.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Affiliation(s)
- Igor E Konstantinov
- Royal Children's Hospital, University of Melbourne, Murdoch Children's Research Institute, Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, Mass
| | - Iki Adachi
- Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Emile Bacha
- Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, NY
| | | | | | - David Cleveland
- Department of Surgery, University of Alabama, Birmingham, Ala
| | - Peter J Cowan
- Immunology Research Centre, St. Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | | | - David L S Morales
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Muhammad M Mohiuddin
- Program in Cardiac Xenotransplantation, University of Maryland School of Medicine, Baltimore, Md
| | - Bruno Reichart
- Transregional Collaborative Research Center, Walter Brendel Centre of Experimental Medicine, Ludwig Maximilians University, Munich, Germany
| | | | - Nathalie Roy
- Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Joseph W Turek
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Simon Urschel
- Pediatric Cardiac Transplantation Program, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Lori West
- Pediatric Cardiac Transplantation Program, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada; Canadian Donation and Transplantation Research Program, Alberta Transplant Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Eckhard Wolf
- Gene Center and Department of Veterinary Sciences, Ludwig Maximilians University, Munich, Germany
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16
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Kim Y, Kim B, Kang M, Nam H, Ko DH, Park Y. Associations of Perioperative Red Blood Cell Transfusion With Outcomes of Kidney Transplantation in Korea Over a 16-Year Period. J Korean Med Sci 2023; 38:e212. [PMID: 37463685 DOI: 10.3346/jkms.2023.38.e212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/22/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND This study investigated the associations between transfusion of different types of red blood cell (RBC) preparations and kidney allograft outcomes after kidney transplantation (KT) over a 16-year period in Korea using a nationwide population-based cohort. METHODS We investigated the reported use of RBCs during hospitalization for KT surgery, rejection, and graft failure status using nationwide data from the National Health Information Database (2002-2017). The associations between the type of perioperative RBC product and transplant outcomes were evaluated among four predefined groups: no RBC transfusion, filtered RBCs, washed RBCs, and packed RBCs (pRBCs). RESULTS A total of 17,754 KT patients was included, among which 8,530 (48.0%) received some type of RBC transfusion. Of the patients who received RBC transfusion, 74.9%, 19.7%, and 5.4% received filtered RBCs, pRBCs, or washed RBCs, respectively. Regardless of the type of RBC products, the proportions of acute rejection and graft failure was significantly greater in patients receiving transfusion (P < 0.001). Cox proportional hazards regression analyses showed that the filtered RBC and pRBC groups were significantly associated with both rejection and graft failure. The washed RBC group also had hazard ratios greater than 1.0 for rejection and graft failure, but the association was not significant. Rejection-free survival of the pRBC group was significantly lower than that of the other groups (P < 0.001, log-rank test), and graft survival for the no RBC transfusion group was significantly greater than in the other groups (P < 0.001, log-rank test). CONCLUSION Perioperative RBC transfusion was associated with poor graft outcomes. Notably, transfusion of pRBCs significantly increased transplant rejection. Therefore, careful consideration of indications for RBC transfusion and selection of the appropriate type of RBCs is necessary, especially for patients at high risk of rejection or graft failure.
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Affiliation(s)
- Yoonjung Kim
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Banseok Kim
- Department of Laboratory Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Minjin Kang
- Research Institute, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - HyunJun Nam
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dae-Hyun Ko
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Yongjung Park
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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17
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Galili U. Antibody production and tolerance to the α-gal epitope as models for understanding and preventing the immune response to incompatible ABO carbohydrate antigens and for α-gal therapies. Front Mol Biosci 2023; 10:1209974. [PMID: 37449060 PMCID: PMC10338101 DOI: 10.3389/fmolb.2023.1209974] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/09/2023] [Indexed: 07/18/2023] Open
Abstract
This review describes the significance of the α-gal epitope (Galα-3Galβ1-4GlcNAc-R) as the core of human blood-group A and B antigens (A and B antigens), determines in mouse models the principles underlying the immune response to these antigens, and suggests future strategies for the induction of immune tolerance to incompatible A and B antigens in human allografts. Carbohydrate antigens, such as ABO antigens and the α-gal epitope, differ from protein antigens in that they do not interact with T cells, but B cells interacting with them require T-cell help for their activation. The α-gal epitope is the core of both A and B antigens and is the ligand of the natural anti-Gal antibody, which is abundant in all humans. In A and O individuals, anti-Gal clones (called anti-Gal/B) comprise >85% of the so-called anti-B activity and bind to the B antigen in facets that do not include fucose-linked α1-2 to the core α-gal. As many as 1% of B cells are anti-Gal B cells. Activation of quiescent anti-Gal B cells upon exposure to α-gal epitopes on xenografts and some protozoa can increase the titer of anti-Gal by 100-fold. α1,3-Galactosyltransferase knockout (GT-KO) mice lack α-gal epitopes and can produce anti-Gal. These mice simulate human recipients of ABO-incompatible human allografts. Exposure for 2-4 weeks of naïve and memory mouse anti-Gal B cells to α-gal epitopes in the heterotopically grafted wild-type (WT) mouse heart results in the elimination of these cells and immune tolerance to this epitope. Shorter exposures of 7 days of anti-Gal B cells to α-gal epitopes in the WT heart result in the production of accommodating anti-Gal antibodies that bind to α-gal epitopes but do not lyse cells or reject the graft. Tolerance to α-gal epitopes due to the elimination of naïve and memory anti-Gal B cells can be further induced by 2 weeks in vivo exposure to WT lymphocytes or autologous lymphocytes engineered to present α-gal epitopes by transduction of the α1,3-galactosyltransferase gene. These mouse studies suggest that autologous human lymphocytes similarly engineered to present the A or B antigen may induce corresponding tolerance in recipients of ABO-incompatible allografts. The review further summarizes experimental works demonstrating the efficacy of α-gal therapies in amplifying anti-viral and anti-tumor immune-protection and regeneration of injured tissues.
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Affiliation(s)
- Uri Galili
- Department of Medicine, Rush University Medical College, Chicago, IL, United States
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18
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Bleiweis MS, Fricker FJ, Upchurch GR, Peek GJ, Stukov Y, Gupta D, Shih R, Pietra B, Sharaf OM, Jacobs JP. Heart Transplantation in Patients Less Than 18 Years of Age: Comparison of 2 Eras Over 36 Years and 323 Transplants at a Single Institution. J Am Coll Surg 2023; 236:898-909. [PMID: 36794835 DOI: 10.1097/xcs.0000000000000604] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND We reviewed our management strategy and outcome data for all 311 patients less than 18 years of age who underwent 323 heart transplants at our institution (1986 to 2022) in order to assess changes in patterns of practice and outcomes over time and to compare two consecutive eras: era 1 (154 heart transplants [1986 to 2010]) and era 2 (169 heart transplants [2011 to 2022]). STUDY DESIGN Descriptive comparisons between the two eras were performed at the level of the heart transplant for all 323 transplants. Kaplan-Meier survival analyses were performed at the level of the patient for all 311 patients, and log-rank tests were used to compare groups. RESULTS Transplants in era 2 were younger (6.6 ± 6.5 years vs 8.7 ± 6.1 years, p = 0.003). More transplants in era 2 were in infants (37.9% vs 17.5%, p < 0.0001), had congenital heart disease (53.8% vs 39.0%, p < 0.010), had high panel reactive antibody (32.1% vs 11.9%, p < 0.0001), were ABO-incompatible (11.2% vs 0.6%, p < 0.0001), had prior sternotomy (69.2% vs 39.0%, p < 0.0001), had prior Norwood (17.8% vs 0%, p < 0.0001), had prior Fontan (13.6% vs 0%, p < 0.0001), and were in patients supported with a ventricular assist device at the time of heart transplant (33.7% vs 9.1%, p < 0.0001). Survival at 1, 3, 5, and 10 years after transplant was as follows: era 1 = 82.4% (76.5 to 88.8), 76.9% (70.4 to 84.0), 70.7% (63.7 to 78.5), and 58.8% (51.3 to 67.4), respectively; era 2 = 90.3% (85.7 to 95.1), 85.4% (79.7 to 91.5), 83.0% (76.7 to 89.8), and 66.0% (49.0 to 88.8), respectively. Overall Kaplan-Meier survival in era 2 was better (log-rank p = 0.03). CONCLUSIONS Patients undergoing cardiac transplantation in the most recent era are higher risk but have better survival.
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Affiliation(s)
- Mark S Bleiweis
- From the Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, FL
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19
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Blitzer D, Lirette S, Kane L, Copeland JG, Baran DA, Copeland H. Do vasoactive medications impact donor hearts clinical outcomes in pediatric heart transplantation? Pediatr Transplant 2023; 27:e14500. [PMID: 36898843 DOI: 10.1111/petr.14500] [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: 07/13/2022] [Revised: 12/20/2022] [Accepted: 02/22/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVES There is limited data examining donor vasopressor and/or inotrope medications (vasoactives) on pediatric orthotopic heart transplant (OHT) outcomes. We aim to evaluate the effects of vasoactives on pediatric OHT outcomes. METHODS The United Network for Organ Sharing database was retrospectively reviewed from January 2000 to March 2018 for donor hearts. Exclusion criteria included multiorgan transplants and recipient age >18. Donors receiving vasoactives at the time of procurement were compared to donors not on vasoactives, including the number of vasoactives and the type. End-points of interest were survival at 30 days and 1 year as well as post-transplant rejection at 1 year. Logistic and Cox models were used to quantify survival end-points. RESULTS Of 6462 donors, 3187 (49.3%) were receiving at least one vasoactive. Comparing any vasoactive medication versus none, there was no difference in 30-day survival (p = .27), 1 year survival (p = .89), overall survival (p = .68), or post-transplant rejection (p = .98). There was no difference in 30-day survival for donors receiving 2 or more vasoactive infusions (p = .89), 1 year survival (p = .53), overall survival (p = .75), or post-transplant rejection at 1 year (p = .87). Vasopressin was associated with decreased 30-day mortality (OR = 0.22; p = .028), dobutamine with decreased 1-year mortality (OR = 0.37; p = .036), overall survival (HR = 0.51; p = .003), and decreased post-transplant rejection (HR = 0.63; p = .012). CONCLUSIONS There is no difference in pediatric OHT outcomes when the cardiac donor is treated with vasoactive infusions at procurement. Vasopressin and dobutamine were associated with improved outcomes. This information can be used to guide medical management and donor selection.
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Affiliation(s)
- David Blitzer
- Department of Surgery, Division of Cardiovascular Surgery, Columbia University, New York, New York, USA
| | | | - Lauren Kane
- Division of Cardiothoracic Surgery, TransMedics, Inc., Andover, Massachusetts, USA
| | - Jack G Copeland
- Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - David A Baran
- Cleveland Clinic Heart Vascular and Thoracic Institute, Weston, Florida, USA
| | - Hannah Copeland
- Lutheran Hospital, Fort Wayne, Indiana, USA.,Indiana University School of Medicine - Fort Wayne, Fort Wayne, Indiana, USA
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20
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Cooper DKC, Pierson RN. Milestones on the path to clinical pig organ xenotransplantation. Am J Transplant 2023; 23:326-335. [PMID: 36775767 PMCID: PMC10127379 DOI: 10.1016/j.ajt.2022.12.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/20/2022] [Accepted: 12/28/2022] [Indexed: 01/19/2023]
Abstract
Progress in pig organ xenotransplantation has been made largely through (1) genetic engineering of the organ-source pig to protect its tissues from the human innate immune response, and (2) development of an immunosuppressive regimen based on blockade of the CD40/CD154 costimulation pathway to prevent the adaptive immune response. In the 1980s, after transplantation into nonhuman primates (NHPs), wild-type (genetically unmodified) pig organs were rejected within minutes or hours. In the 1990s, organs from pigs expressing a human complement-regulatory protein (CD55) transplanted into NHPs receiving intensive conventional immunosuppressive therapy functioned for days or weeks. When costimulation blockade was introduced in 2000, the adaptive immune response was suppressed more readily. The identification of galactose-α1,3-galactose as the major antigen target for human and NHP anti-pig antibodies in 1991 allowed for deletion of expression of galactose-α1,3-galactose in 2003, extending pig graft survival for up to 6 months. Subsequent gene editing to overcome molecular incompatibilities between the pig and primate coagulation systems proved additionally beneficial. The identification of 2 further pig carbohydrate xenoantigens allowed the production of 'triple-knockout' pigs that are preferred for clinical organ transplantation. These combined advances enabled the first clinical pig heart transplant to be performed and opened the door to formal clinical trials.
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Affiliation(s)
- David K C Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA.
| | - Richard N Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
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21
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Bluhme E, Henckel E, Jorns C. Potential of neonatal organ donation and outcome after transplantation. Pediatr Transplant 2023; 27:e14486. [PMID: 36792069 DOI: 10.1111/petr.14486] [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: 09/03/2021] [Revised: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 02/17/2023]
Abstract
Organ transplantation is limited by access to suitable organs. Infant recipient waitlist mortality is increased due to the scarcity of size-matched organs. Neonatal organ donors have been proposed as an underutilized source of donor organs. However, the literature on the actual prevalence and outcome of neonatal organ donation and transplantation is fragmented and not well analyzed. This literature review aims to summarize the available literature on the potential of neonatal organ donation and to analyze published cases of neonatal organ transplantation. A systematic search of the Medline and Cochrane databases yielded 2964 articles, which were screened for eligibility. In total, 86 articles were considered eligible, of which 34 were included in the literature review: 8 articles describing the potential of neonatal organ donation programs, and 26 articles describing clinical transplantation. Current evidence suggests there is a large pool of potential neonatal organ donors. In contrast, the literature on neonatal organ donor utilization is sparse. However, case series of successful kidney, heart, liver, hepatocyte, and multivisceral transplantation using organs from neonatal donors are summarized. Although good posttransplant organ function was achieved, the use of neonatal organs is associated with increased risk of thrombosis in both kidney and liver transplantation. Neonatal organ donation is a promising alternative for expanding the current donor pool. Experience is limited, but reported patient and graft survival are acceptable and more research on the subject is warranted.
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Affiliation(s)
- Emil Bluhme
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Department of Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Ewa Henckel
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Department of Neonatology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Carl Jorns
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Department of Transplantation, Karolinska University Hospital, Stockholm, Sweden
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22
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Sherard C, Atteya M, Vogel AD, Bisbee C, Kang L, Turek JW, Rajab TK. Partial heart transplantation can ameliorate donor organ utilization. J Card Surg 2022; 37:5307-5312. [PMID: 36259737 DOI: 10.1111/jocs.17050] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/23/2022] [Accepted: 10/05/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The treatment of babies with unrepairable heart valve dysfunction remains an unsolved problem because there are no growing heart valve implants. However, orthotopic heart transplants are known to grow with recipients. AIM Partial heart transplantation is a new approach to delivering growing heart valve implants, which involves transplantation of the part of the heart containing the valves only. In this review, we discuss the benefits of this procedure in children with unrepairable valve dysfunction. CONCLUSION Partial heart transplantation can be performed using donor hearts with poor ventricular function and slow progression to donation after cardiac death. This should ameliorate donor heart utilization and avoid both primary orthotopic heart transplantation in children with unrepairable heart valve dysfunction and progression of these children to end-stage heart failure.
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Affiliation(s)
- Curry Sherard
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Miriam Atteya
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Andrew D Vogel
- Department of Surgery, Alabama College of Osteopathic Medicine, Dothan, Alabama, USA
| | - Cora Bisbee
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lillian Kang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Joseph W Turek
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Taufiek K Rajab
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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23
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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: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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24
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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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25
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Chauhan D, Orlandi V, Rajab TK, Bedeir K, Volfovsky A, Mokashi S. Postoperative Outcomes in Infants Undergoing ABO-incompatible Heart Transplantation in the United States. Ann Thorac Surg 2022; 114:1746-1752. [PMID: 34582759 PMCID: PMC8948097 DOI: 10.1016/j.athoracsur.2021.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 07/23/2021] [Accepted: 08/16/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND ABO-incompatible heart transplant is a method to increase the infant donor pool. However data on long-term survival and rejection after ABO-incompatible heart transplant in recent era are limited. METHODS The United Network for Organ Sharing database was queried for infant heart transplants performed from January 2008 to March 2020. Patient demographics and known risk factors for posttransplant mortality were collected. Statistical analysis using Bayesian additive regression trees was performed to evaluate the association of ABO incompatibility and overall survival, graft survival, acute rejection episodes, and length of stay. RESULTS Of 1368 included infants (age < 1 year), 280 (20.47%) were ABO incompatible. ABO incompatibility was not associated with increased all-cause mortality, acute rejection episodes, or length of stay, whereas extracorporeal membrane oxygenation and intubation status of the recipient at the time of transplantation were associated with increased all-cause mortality and graft failure. Idiopathic cardiomyopathy was associated with a decreased likelihood of posttransplant all-cause mortality. One-, 5-, and 10-year survival rates among compatible vs incompatible transplants were estimated to be 90% vs 88%, 82% vs 79%, and 77% vs 73%, respectively. CONCLUSIONS ABO-incompatible infant heart transplant does not affect posttransplant survival, incidence of rejection, or postoperative length of stay. Therefore it remains a viable and important strategy to increase the infant donor pool.
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Affiliation(s)
- Dhaval Chauhan
- Division of Pediatric Cardiac Surgery, Emory University School of Medicine, Atlanta, Georgia.
| | - Vittorio Orlandi
- Department of Statistical Science, Duke University, Durham, North Carolina
| | - Taufiek Konrad Rajab
- Division of Pediatric Cardiac Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Kareem Bedeir
- IMC Cardio-Thoracic & Vascular Surgical Associates, Mobile, Alabama
| | | | - Suyog Mokashi
- Department of Surgery, Division of Cardiothoracic Surgery, Creighton University School of Medicine, Omaha, Nebraska
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26
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Evaluating the Potential for ABO-incompatible Islet Transplantation: Expression of ABH Antigens on Human Pancreata, Isolated Islets, and Embryonic Stem Cell-derived Islets. Transplantation 2022; 107:e98-e108. [PMID: 36228319 DOI: 10.1097/tp.0000000000004347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND ABO-incompatible transplantation has improved accessibility of kidney, heart, and liver transplantation. Pancreatic islet transplantation continues to be ABO-matched, yet ABH antigen expression within isolated human islets or novel human embryonic stem cell (hESC)-derived islets remain uncharacterized. METHODS We evaluated ABH glycans within human pancreata, isolated islets, hESC-derived pancreatic progenitors, and the ensuing in vivo mature islets following kidney subcapsular transplantation in rats. Analyses include fluorescence immunohistochemistry and single-cell analysis using flow cytometry. RESULTS Within the pancreas, endocrine and ductal cells do not express ABH antigens. Conversely, pancreatic acinar tissues strongly express these antigens. Acinar tissues are present in a substantial portion of cells within islet preparations obtained for clinical transplantation. The hESC-derived pancreatic progenitors and their ensuing in vivo-matured islet-like clusters do not express ABH antigens. CONCLUSIONS Clinical pancreatic islet transplantation should remain ABO-matched because of contaminant acinar tissue within islet preparations that express ABH glycans. Alternatively, hESC-derived pancreatic progenitors and the resulting in vivo-matured hESC-derived islets do not express ABH antigens. These findings introduce the potential for ABO-incompatible cell replacement treatment and offer evidence to support scalability of hESC-derived cell therapies in type 1 diabetes.
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27
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Raza SS, Hara H, Cleveland DC, Cooper DKC. The potential of genetically engineered pig heart transplantation in infants with complex congenital heart disease. Pediatr Transplant 2022; 26:e14260. [PMID: 35233893 PMCID: PMC10124767 DOI: 10.1111/petr.14260] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 12/16/2022]
Abstract
Despite advances in surgical and medical techniques, complex congenital heart disease in neonates and infants continues to be associated with significant mortality and morbidity. More than 500 infants in the USA are placed on the cardiac transplantation wait-list annually. However, there remains a critical shortage of deceased human donor organs for transplantation with a median wait-time of 4 months. Hence, infant mortality on the heart transplant wait-list in the USA is higher than for any other solid organ transplant group. Orthotopic transplantation of a pig heart as a bridge to allotransplantation might offer the best prospect of long-term survival of these patients. In recent years, there have been several advances in genetic engineering of pigs to mitigate the vigorous antibody-mediated rejection of a pig heart transplanted into a nonhuman primate. In this review, we briefly highlight (i) the history of clinical heart xenotransplantation, (ii) current advances and techniques of genetically engineering pigs, (iii) the current status of pig orthotopic cardiac graft survival in nonhuman primates, and (iv) progress toward pursuing clinical trials of cardiac xenotransplantation. Ultimately, we argue that pig heart xenotransplantation should initially be used as a bridge to cardiac allotransplantation in neonates and infants.
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Affiliation(s)
- Syed Sikandar Raza
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David C Cleveland
- Department of Cardiothoracic Surgery, Children's of Alabama, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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28
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Urschel S. Xenotransplantation: Is the future now? Pediatr Transplant 2022; 26:e14271. [PMID: 35304806 DOI: 10.1111/petr.14271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Simon Urschel
- Walter McKenzie Center, University of Alberta/Stollery Children's Hospital, Edmonton, Alberta, Canada
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29
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Singh TP, Cherikh WS, Hsich E, Harhay MO, Hayes D, Perch M, Potena L, Sadavarte A, Zuckermann A, Stehlik J. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Twenty-fifth Pediatric Heart Transplantation Report — 2022; Focus on Infant Heart Transplantation. J Heart Lung Transplant 2022; 41:1357-1365. [DOI: 10.1016/j.healun.2022.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 07/20/2022] [Indexed: 11/24/2022] Open
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30
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Maritati F, Bini C, Cuna V, Tondolo F, Lerario S, Grandinetti V, Busutti M, Corradetti V, La Manna G, Comai G. Current Perspectives in ABO-Incompatible Kidney Transplant. J Inflamm Res 2022; 15:3095-3103. [PMID: 35642217 PMCID: PMC9148605 DOI: 10.2147/jir.s360460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/17/2022] [Indexed: 12/22/2022] Open
Abstract
For a long time, ABO incompatible living donor kidney transplantation has been considered contraindicated, due to the presence of isohemagglutinins, natural antibodies reacting with non-self ABO antigens. However, as the demand for kidney transplantation is constantly growing, methods to expand the donor pool have become increasingly important. Thus, in the last decades, specific desensitization strategies for ABOi transplantation have been developed. Nowadays, these regimens consist of transient removal of preformed anti-A or anti-B antibodies by using plasmapheresis or immunoadsorption and B-cell immunity modulation by CD20+ cells depletion with rituximab, in association with maintenance immunosuppression including corticosteroids, tacrolimus and mycophenolate mofetil. The outcome in ABOi kidney transplantation have markedly improved over the years. In fact, although randomized trials are still lacking, recent meta analysis has revealed that there is no difference in terms of graft and patient's survival between ABOi and ABO compatible kidney transplant, even in the long term. However, many concerns still exist, because ABOi kidney transplantation is associated with an increased risk of bleeding and infectious complications, partly related to the effects of extracorporeal treatments and the strong immunosuppression. Thus, a continuous improvement in desensitization strategies, with the aim of minimize the immunosuppressive burden, on the basis of immune pathogenesis, antibodies titers and/or ABO blood group, is warranted. In this review, we discuss the main immune mechanisms involved in ABOi kidney transplantation, the pathogenesis of tolerance and the desensitization regimens, including immunoadsorption and plasmapheresis and the immunosuppressive protocol. Finally, we provide an overview on outcome and future perspectives in ABOi kidney transplant.
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Affiliation(s)
- Federica Maritati
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Claudia Bini
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Vania Cuna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Tondolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sarah Lerario
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Valeria Grandinetti
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Busutti
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Valeria Corradetti
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giorgia Comai
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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31
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Zhao D, Zhu L, Zhang S, Guo Z, Wang L, Pan T, Sa R, Chen Z, Jiang J, Chen G. Case Report: Successful ABO-Incompatible Deceased Donor Kidney Transplantation in an Infant Without Pre-transplant Immunological Treatment. Front Med (Lausanne) 2022; 9:838738. [PMID: 35308516 PMCID: PMC8924516 DOI: 10.3389/fmed.2022.838738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 01/27/2022] [Indexed: 11/15/2022] Open
Abstract
ABO blood group antibodies have not been generated or are at low titer during early infancy. Therefore, in theory, ABO-incompatible kidney transplantation (ABOi KT) may be successfully achieved in small infants without any pre-transplant treatment. We report here the first ABO-incompatible deceased donor kidney transplantation (ABOi DDKT) in an infant. The recipient infant was ABO blood group O, and the donor group A. The recipient was diagnosed with a Wilms tumor gene 1 (WT1) mutation and had received peritoneal dialysis for 4 months prior to transplant. At 7 months and 27 days of age, the infant underwent bilateral native nephrectomy and single-kidney transplantation from a 3-year-old brain-dead donor. No pre- or post-transplantation antibody removal treatment was performed, since the recipient's anti-iso-hemagglutinin-A Ig-M/G antibody titers were both low (1:2) before transplantation and have remained at low levels or undetectable to date. At 11 months post-transplant, the recipient is at home, thriving, with normal development and graft function. This outcome suggests that ABOi DDKT without antibody removal preparatory treatment is feasible in small infants, providing a new option for kidney transplantation in this age range.
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Affiliation(s)
- Daqiang Zhao
- Institution of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Ministry of Public Health, Chinese Academy of Medical Sciences, Wuhan, China
| | - Lan Zhu
- Institution of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Ministry of Public Health, Chinese Academy of Medical Sciences, Wuhan, China
| | - Shengyuan Zhang
- Institution of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiliang Guo
- Institution of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lu Wang
- Institution of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Ministry of Public Health, Chinese Academy of Medical Sciences, Wuhan, China
| | - Tianhui Pan
- Institution of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rula Sa
- Institution of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhishui Chen
- Institution of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Ministry of Public Health, Chinese Academy of Medical Sciences, Wuhan, China
| | - Jipin Jiang
- Institution of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Ministry of Public Health, Chinese Academy of Medical Sciences, Wuhan, China
| | - Gang Chen
- Institution of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Ministry of Public Health, Chinese Academy of Medical Sciences, Wuhan, China
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32
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Jalali S, Harpur CM, Piers AT, Auladell M, Perriman L, Li S, An K, Anderson J, Berzins SP, Licciardi PV, Ashhurst TM, Konstantinov IE, Pellicci DG. A high-dimensional cytometry atlas of peripheral blood over the human life span. Immunol Cell Biol 2022; 100:805-821. [PMID: 36218032 PMCID: PMC9828744 DOI: 10.1111/imcb.12594] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022]
Abstract
Age can profoundly affect susceptibility to a broad range of human diseases. Children are more susceptible to some infectious diseases such as diphtheria and pertussis, while in others, such as coronavirus disease 2019 and hepatitis A, they are more protected compared with adults. One explanation is that the composition of the immune system is a major contributing factor to disease susceptibility and severity. While most studies of the human immune system have focused on adults, how the immune system changes after birth remains poorly understood. Here, using high-dimensional spectral flow cytometry and computational methods for data integration, we analyzed more than 50 populations of immune cells in the peripheral blood, generating an immune cell atlas that defines the healthy human immune system from birth up to 75 years of age. We focused our efforts on children under 18 years old, revealing major changes in immune cell populations after birth and in children of schooling age. Specifically, CD4+ T effector memory cells, Vδ2+ gamma delta (γδ)T cells, memory B cells, plasmablasts, CD11c+ B cells and CD16+ CD56bright natural killer (NK) cells peaked in children aged 5-9 years old, whereas frequencies of T helper 1, T helper 17, dendritic cells and CD16+ CD57+ CD56dim NK cells were highest in older children (10-18 years old). The frequency of mucosal-associated invariant T cells was low in the first several years of life and highest in adults between 19 and 30 years old. Late adulthood was associated with fewer mucosal-associated invariant T cells and Vδ2+ γδ T cells but with increased frequencies of memory subsets of B cells, CD4+ and CD8+ T cells and CD57+ NK cells. This human immune cell atlas provides a critical resource to understand changes to the immune system during life and provides a reference for investigating the immune system in the context of human disease. This work may also help guide future therapies that target specific populations of immune cells to protect at-risk populations.
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Affiliation(s)
- Sedigheh Jalali
- Murdoch Children's Research InstituteMelbourneVICAustralia,Department of PaediatricsUniversity of MelbourneMelbourneVICAustralia
| | | | - Adam T Piers
- Murdoch Children's Research InstituteMelbourneVICAustralia,Melbourne Centre for Cardiovascular Genomics and Regenerative MedicineMelbourneVICAustralia
| | - Maria Auladell
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and ImmunityUniversity of MelbourneMelbourneVICAustralia,Global Product Development Consulting for Infectious DiseasesPharmaceutical Product Development (PPD), Part of Thermo Fisher ScientificBennekomThe Netherlands
| | - Louis Perriman
- Murdoch Children's Research InstituteMelbourneVICAustralia,The Fiona Elsey Cancer Research InstituteBallaratVICAustralia,Federation UniversityBallaratVICAustralia
| | - Shuo Li
- Murdoch Children's Research InstituteMelbourneVICAustralia
| | - Kim An
- Murdoch Children's Research InstituteMelbourneVICAustralia,Melbourne Centre for Cardiovascular Genomics and Regenerative MedicineMelbourneVICAustralia
| | - Jeremy Anderson
- Murdoch Children's Research InstituteMelbourneVICAustralia,Department of PaediatricsUniversity of MelbourneMelbourneVICAustralia
| | - Stuart P Berzins
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and ImmunityUniversity of MelbourneMelbourneVICAustralia,The Fiona Elsey Cancer Research InstituteBallaratVICAustralia,Federation UniversityBallaratVICAustralia
| | - Paul V Licciardi
- Murdoch Children's Research InstituteMelbourneVICAustralia,Department of PaediatricsUniversity of MelbourneMelbourneVICAustralia
| | - Thomas M Ashhurst
- Sydney Cytometry Core Research FacilityThe University of Sydney and Centenary InstituteSydneyNSWAustralia,School of Medical Sciences, Faculty of Medicine and HealthThe University of SydneySydneyNSWAustralia
| | - Igor E Konstantinov
- Murdoch Children's Research InstituteMelbourneVICAustralia,Melbourne Centre for Cardiovascular Genomics and Regenerative MedicineMelbourneVICAustralia,Cardiothoracic SurgeryRoyal Children's HospitalMelbourneVICAustralia
| | - Daniel G Pellicci
- Murdoch Children's Research InstituteMelbourneVICAustralia,Department of PaediatricsUniversity of MelbourneMelbourneVICAustralia,Melbourne Centre for Cardiovascular Genomics and Regenerative MedicineMelbourneVICAustralia,Department of Microbiology and Immunology, Peter Doherty Institute for Infection and ImmunityUniversity of MelbourneMelbourneVICAustralia
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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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Bentall A, Jeyakanthan M, Braitch M, Cairo CW, Lowary TL, Maier S, Halpin A, Motyka B, Zou L, West LJ, Ball S. Characterization of ABH-subtype donor-specific antibodies in ABO-A-incompatible kidney transplantation. Am J Transplant 2021; 21:3649-3662. [PMID: 34101982 PMCID: PMC8597088 DOI: 10.1111/ajt.16712] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 04/30/2021] [Accepted: 05/15/2021] [Indexed: 01/25/2023]
Abstract
ABO-incompatible (ABOi) transplantation requires preemptive antibody reduction; however, the relationship between antibody-mediated rejection (AMR) and ABO-antibodies, quantified by hemagglutination (HA), is inconsistent, possibly reflecting variable graft resistance to AMR or HA assay limitations. Using an ABH-glycan microarray, we quantified ABO-A antigen-subtype (A-subtype)-specific IgM and IgG in 53 ABO-O recipients of ABO-A kidneys, before and after antibody removal (therapeutic plasma exchange [TPE] or ABO-A-trisaccharide immunoadsorption [IA]) and 1-year posttransplant. IgM binding to all A-subtypes correlated highly (R2 ≥ .90) and A-subtype antibody specificities was reduced equally by IA versus TPE. IgG binding to the A-subtypes (II-IV) expressed in kidney correlated poorly (.27 ≤ R2 ≤ .69). Reduction of IgG specific to A-subtype-II was equivalent for IA and TPE, whereas IgG specific to A-subtypes-III/IV was not as greatly reduced by IA (p < .005). One-year posttransplant, IgG specific to A-II remained the most reduced antibody. Immunostaining revealed only A-II on vascular endothelium but A-subtypes II-III/IV on tubular epithelium. These results show that ABO-A-trisaccharide is sufficient for IgM binding to all A-subtypes; this is true for IgG binding to A-II, but not subtypes-III/IV, which exhibits varying degrees of specificity. We identify A-II as the major, but importantly not the sole, antigen relevant to treatment and immune modulation in adult ABO-A-incompatible kidney transplantation.
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Affiliation(s)
- Andrew Bentall
- Department of NephrologyUniversity HospitalBirminghamUK,Division of Nephrology and HypertensionMayo Clinic College of MedicineRochesterMinnesotaUSA
| | - Mylvaganam Jeyakanthan
- Department of Cardiothoracic SurgeryJames Cook University HospitalMiddlesbroughUK,Department of PediatricsUniversity of AlbertaEdmontonABCanada
| | | | - Christopher W. Cairo
- Alberta Glycomics Centre and Department of ChemistryUniversity of AlbertaEdmontonABCanada
| | - Todd L. Lowary
- Alberta Glycomics Centre and Department of ChemistryUniversity of AlbertaEdmontonABCanada
| | - Stephanie Maier
- Alberta Transplant Institute and Canadian Donation and Transplantation Research ProgramUniversity of AlbertaEdmontonABCanada
| | - Anne Halpin
- Department of PediatricsUniversity of AlbertaEdmontonABCanada,Alberta Transplant Institute and Canadian Donation and Transplantation Research ProgramUniversity of AlbertaEdmontonABCanada,Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonABCanada
| | - Bruce Motyka
- Department of PediatricsUniversity of AlbertaEdmontonABCanada,Alberta Transplant Institute and Canadian Donation and Transplantation Research ProgramUniversity of AlbertaEdmontonABCanada
| | - Lu Zou
- Alberta Glycomics Centre and Department of ChemistryUniversity of AlbertaEdmontonABCanada
| | - Lori J. West
- Department of PediatricsUniversity of AlbertaEdmontonABCanada,Alberta Transplant Institute and Canadian Donation and Transplantation Research ProgramUniversity of AlbertaEdmontonABCanada,Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonABCanada,Department of SurgeryUniversity of AlbertaEdmontonABCanada,Department of Medical Microbiology and ImmunologyUniversity of AlbertaEdmontonABCanada
| | - Simon Ball
- Department of NephrologyUniversity HospitalBirminghamUK,School of Immunity and InfectionUniversity of BirminghamBirminghamUK
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Kazakova ED, Yashunsky DV, Nifantiev NE. The Synthesis of Blood Group Antigenic A Trisaccharide and Its Biotinylated Derivative. Molecules 2021; 26:5887. [PMID: 34641431 PMCID: PMC8512078 DOI: 10.3390/molecules26195887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/24/2021] [Accepted: 09/24/2021] [Indexed: 01/04/2023] Open
Abstract
Blood group antigenic A trisaccharide represents the terminal residue of all A blood group antigens and plays a key role in blood cell recognition and blood group compatibility. Herein, we describe the synthesis of the spacered A trisaccharide by means of an assembly scheme that employs in its most complex step the recently proposed glycosyl donor of the 2-azido-2-deoxy-selenogalactoside type, bearing stereocontrolling 3-O-benzoyl and 4,6-O-(di-tert-butylsilylene)-protecting groups. Its application provided efficient and stereoselective formation of the required α-glycosylation product, which was then deprotected and subjected to spacer biotinylation to give both target products, which are in demand for biochemical studies.
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Affiliation(s)
| | | | - Nikolay E. Nifantiev
- Laboratory of Glycoconjugate Chemistry, N. D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Leninsky pr. 47, 119991 Moscow, Russia; (E.D.K.); (D.V.Y.)
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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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Donné M, De Pauw M, Vandekerckhove K, Bové T, Panzer J. Ethical and practical dilemmas in cardiac transplantation in infants: a literature review. Eur J Pediatr 2021; 180:2359-2365. [PMID: 33959817 DOI: 10.1007/s00431-021-04100-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/29/2021] [Accepted: 05/02/2021] [Indexed: 01/11/2023]
Abstract
The waiting time in infants for a cardiac transplant remains high, due to the scarcity of donors. Consequently, waiting list morbidity and mortality are higher than those in other age groups. Therefore, the decision to list a small infant for cardiac transplantation is seen as an ethical dilemma by most physicians. This review aims to describe outcomes, limitations, and ethical considerations in infant heart transplantation. We used Medline and Embase as data sources. We searched for publications on infant (< 1 year) heart transplantation, bridge-to-transplant and long-term outcomes, and waiting list characteristics from January 2009 to March 2021. Outcome after cardiac transplant in infants is better than that in older children (1-year survival 88%), and complications are less frequent (25% CAV, 10% PTLD). The bridge-to-transplant period in infants is associated with increased mortality (32%) and decreased transplantation rate (43%). This is mainly due to MCS complications or the limited MCS options (with 51% mortality in infancy). Outcomes are worse for infants with CHD or in need of ECMO-support.Conclusion: Infants listed for cardiac transplantation have a high morbidity and mortality, especially in the period between diagnosis and transplantation. For those who receive cardiac transplant, the outlook is encouraging. Unfortunately, despite growing experience in VAD, mortality in children < 10 kg and children with CHD remains high. After transplantation, patients carry a psychological burden and there is a probability of re-transplantation later in life, with decreased outcomes compared to primary transplantation. These considerations are seen as an important ethical dilemma in many centers, when considering cardiac transplantation in infants (< 1 year). What is Known: • For infants, waitlist mortality remains high. In the pediatric population, MCS reduces the waiting list mortality. What is New: • Outcomes after infant cardiac transplantation are better than other age groups; however, MCS options remain limited, with persistently high waiting list mortality. • Future developments in MCS and alternative options to reduce waiting list mortality such as ABO-incompatible transplantation and pulmonary artery banding are encouraging and will improve ethical decision-making when an infant is in need of a cardiac transplant.
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Affiliation(s)
- Marieke Donné
- Department of Pediatrics, University Hospital of Ghent, Ghent, Belgium
| | - Michel De Pauw
- Department of Cardiology, University Hospital of Ghent, Ghent, Belgium
| | | | - Thierry Bové
- Department of Cardiac Surgery, University Hospital of Ghent, Ghent, Belgium
| | - Joseph Panzer
- Department of Pediatric Cardiology, University Hospital of Ghent, Ghent, Belgium.
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Issitt R, Booth J, Crook R, Robertson A, Molyneux V, Richardson R, Cross N, Shaw M, Tsang V, Muthurangu V, Sebire NJ, Burch M, Fenton M. Intraoperative anti-A/B immunoadsorption is associated with significantly reduced blood product utilization with similar outcomes in pediatric ABO-incompatible heart transplantation. J Heart Lung Transplant 2021; 40:1433-1442. [PMID: 34187714 PMCID: PMC8579753 DOI: 10.1016/j.healun.2021.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 11/16/2022] Open
Abstract
Background Intraoperative anti-A/B immunoadsorption (ABO-IA) was recently introduced for ABO-incompatible heart transplantation. Here we report the first case series of patients transplanted with ABO-IA, and compare outcomes with those undergoing plasma exchange facilitated ABO-incompatible heart transplantation (ABO-PE). Methods Data were retrospectively analysed on all ABO-incompatible heart transplants undertaken at a single centre between January 1, 2000 and June 1, 2020. Data included all routine laboratory tests, demographics and pre-operative characteristics, intraoperative details and post-operative outcomes. Primary outcome measures were volume of blood product transfusions, maximum post-transplant isohaemagglutinin titres, occurrence of rejection and graft survival. Secondary outcome measures were length of intensive care and hospital stay. Demographic and survival data were also obtained for ABO-compatible transplants during the same time period for comparison. Results Thirty-seven patients underwent ABO-incompatible heart transplantation, with 27 (73%) using ABO-PE and 10 (27%) using ABO-IA. ABO-IA patients were significantly older than ABO-PE patients (p < 0.001) and the total volume of blood products transfused during the hospital admission was significantly lower (164 [126-212] ml/kg vs 323 [268-379] ml/kg, p < 0.001). No significant differences were noted between methods in either pre or post-transplant maximum isohaemagglutinin titres, incidence of rejection, length of intensive care or total hospital stay. Survival comparison showed no significant difference between antibody reduction methods, or indeed ABO-compatible transplants (p = 0.6). Conclusions This novel technique appears to allow a significantly older population than typical to undergo ABO-incompatible heart transplantation, as well as significantly reducing blood product utilization. Furthermore, intraoperative anti-A/B immunoadsorption does not demonstrate increased early post-transplant isohaemagglutinin accumulation or rates of rejection compared to ABO-PE. Early survival is equivalent between ABO-IA, ABO-PE and ABO-compatible heart transplantation.
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Affiliation(s)
- Richard Issitt
- Perfusion Department, Great Ormond Street Hospital, London, UK; Institute of Cardiovascular Science, University College London, London, UK; Digital Research Informatics and Virtual Environment Unit, NIHR Great Ormond Street Hospital BRC, London, UK.
| | - John Booth
- Digital Research Informatics and Virtual Environment Unit, NIHR Great Ormond Street Hospital BRC, London, UK
| | - Richard Crook
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Alex Robertson
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | | | | | - Nigel Cross
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Michael Shaw
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Victor Tsang
- Institute of Cardiovascular Science, University College London, London, UK; Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - Vivek Muthurangu
- Institute of Cardiovascular Science, University College London, London, UK
| | - Neil J Sebire
- Digital Research Informatics and Virtual Environment Unit, NIHR Great Ormond Street Hospital BRC, London, UK
| | - Michael Burch
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK; Department of Paediatric Cardiology, Institute of Child Health, University College London, London, UK
| | - Matthew Fenton
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK; Department of Paediatric Cardiology, Institute of Child Health, University College London, London, UK
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Abstract
Pediatric heart transplantation has additional and unique aspects from standard pediatric heart surgery and adult heart transplantation. The purpose of this article is to review pediatric heart transplantation and special surgical considerations. The methods used by the authors involved reviewing the literature and surgical techniques surrounding this patient population and procedure. The article presents a general review of the topic including the history, current state, surgical approaches, post-operative management, and outcomes in this patient population.
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Affiliation(s)
- Aliessa Barnes
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, MO, United States
| | - William Gibson
- Department of Surgery, Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, MO, United States.
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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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Fenton M. Blood group-incompatible heart transplantation in children-an idea worth spreading. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 5:313-314. [PMID: 33743200 DOI: 10.1016/s2352-4642(21)00067-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew Fenton
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
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Guariento A, Blitzer D, Vida V. Commentary: Donor selection in heart transplantation: It's a match! J Thorac Cardiovasc Surg 2021; 164:995-996. [PMID: 33593608 DOI: 10.1016/j.jtcvs.2021.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Alvise Guariento
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - David Blitzer
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Vladimiro Vida
- Paediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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Bikhet M, Morsi M, Hara H, Rhodes LA, Carlo WF, Cleveland D, Cooper DK, Iwase H. The immune system in infants: Relevance to xenotransplantation. Pediatr Transplant 2020; 24:e13795. [PMID: 32845539 PMCID: PMC7606572 DOI: 10.1111/petr.13795] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/10/2020] [Accepted: 06/22/2020] [Indexed: 12/17/2022]
Abstract
Despite the improvement in surgical interventions in the treatment of congenital heart disease, many life-threatening lesions (eg, hypoplastic left heart syndrome) ultimately require transplantation. However, there is a great limitation in the availability of deceased human cardiac donors of a suitable size. Hearts from genetically engineered pigs may provide an alternative source. The relatively immature immune system in infants (eg, absence of anti-carbohydrate antibodies, reduced complement activation, reduced innate immune cell activity) should minimize the risk of early antibody-mediated rejection of a pig graft. Additionally, recipient thymectomy, performed almost routinely as a preliminary to orthotopic heart transplantation in this age-group, impairs the T-cell response. Because of the increasing availability of genetically engineered pigs (eg, triple-knockout pigs that do not express any of the three known carbohydrate antigens against which humans have natural antibodies) and the ability to diagnose congenital heart disease during fetal life, cardiac xenotransplantation could be preplanned to be carried out soon after birth. Because of these several advantages, prolonged graft survival and even the induction of tolerance, for example, following donor-specific pig thymus transplantation, are more likely to be achieved in infants than in adults. In this review, we summarize the factors in the infant immune system that would be advantageous in the success of cardiac xenotransplantation in this age-group.
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Affiliation(s)
- Mohamed Bikhet
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Mahmoud Morsi
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Leslie A. Rhodes
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar F. Carlo
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David Cleveland
- Department of Pediatric Cardiovascular Surgery, Children’s Hospital of Alabama, Birmingham, AL, USA
| | - David K.C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Hayato Iwase
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, AL, USA
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Stormon MO, Hardikar W, Evans HM, Hodgkinson P. Paediatric liver transplantation in Australia and New Zealand: 1985-2018. J Paediatr Child Health 2020; 56:1739-1746. [PMID: 32649047 DOI: 10.1111/jpc.14969] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 01/09/2023]
Abstract
Liver transplantation has become the standard of care for children with end-stage liver disease. In Australia and New Zealand, there are four paediatric liver transplant units, in Sydney, Melbourne, Brisbane and Auckland. Over the past 30 years, there have been significant changes to indications for transplant, as well as medical and surgical advances. In this paper, using retrospective data from the Australia and New Zealand Liver Transplant Registry, we review 977 children (less than 16 years of age) who underwent liver transplant from 1985 to 2018. The most common indication was biliary atresia (54%), although there has been an increase in other indications, including inborn errors of metabolism, fulminant hepatic failure and malignant liver tumours. Over the past 3 decades, areas of change and innovation include: the use of 'split grafts' to enable an adult and a child to receive the same donor liver, live donation, improvements in immunosuppressive regimens and infectious prophylaxis protocols and innovative surgical techniques allowing transplantation in smaller infants. The outcomes for children who undergo liver transplant in ANZ are excellent, with current 10-year patient survival rates of 95%, comparable to other larger centres around the world.
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Affiliation(s)
- Michael O Stormon
- Department of Gastroenterology, Children's Hospital Westmead, Sydney, New South Wales, Australia
| | - Winita Hardikar
- Department of Gastroenterology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Helen M Evans
- Department of Gastroenterology, Starship Children's Hospital Auckland, Auckland, New Zealand
| | - Peter Hodgkinson
- Queensland Liver Transplant Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Qureshi SS, M S, Dhareshwar J, Smriti V. Limb sparing surgery with vascular reconstruction for nonrhabdomyosarcoma soft tissue sarcoma in infants: A novel solution using allogenic vein graft from the parent. J Pediatr Surg 2020; 55:1673-1676. [PMID: 32409175 DOI: 10.1016/j.jpedsurg.2020.03.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/12/2020] [Accepted: 03/28/2020] [Indexed: 10/24/2022]
Abstract
Surgery continues to remain an integral component of treatment, especially for nonrhabdomyosarcoma soft tissue sarcoma as compared to rhabdomyosarcoma owing to their general insensitivity to chemotherapy. A key determinant of outcomes, particularly for extremity tumors includes complete tumor resection with negative margins; however, a significant limitation for limb salvage surgery is the adherence of sarcomas to vital vascular structures. Hitherto, vascular involvement constituted an adequate reason for amputation. However, modern reconstructive techniques and availability of prosthetic grafts in addition to autologous venous grafts have rendered limb salvage surgery possible in a substantial majority of patients. Vascular resection and reconstruction for extremity soft tissue sarcoma in children have not been used routinely for reasons like the small-caliber of native vessels, limited options for conduits and rapid somatic growth. The situation is inconceivable in infants owing to the contemporaneous diminutive caliber of the vessels. We report two infants with lower extremity nonrhabdomyosarcoma soft tissue sarcoma who underwent limb salvage surgery with resection of femoral vessels following which vascular reconstruction was successfully performed using the great saphenous vein allograft harvested from the father.
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Affiliation(s)
- Sajid S Qureshi
- Division of Paediatric Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Advanced Centre for Training Research and Education in Cancer (ACTREC), Tata Memorial Centre, Mumbai, India; Homi Bhabha National Institute (HBNI), Mumbai, India.
| | - Suresh M
- Division of Paediatric Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Advanced Centre for Training Research and Education in Cancer (ACTREC), Tata Memorial Centre, Mumbai, India; Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Jayesh Dhareshwar
- Cardiovascular Surgeon, Department of Surgical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - Vasundhara Smriti
- Homi Bhabha National Institute (HBNI), Mumbai, India; Department of Radiology, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
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Cardigan R, New HV, Tinegate H, Thomas S. Washed red cells: theory and practice. Vox Sang 2020; 115:606-616. [DOI: 10.1111/vox.12971] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 05/27/2020] [Accepted: 06/09/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Rebecca Cardigan
- Department of Haematology NHS Blood & Transplant University of Cambridge Cambridge UK
| | - Helen V. New
- Department of Haematology NHS Blood & Transplant Imperial College London London UK
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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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48
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Daly KP. The ABO-incompatible paradigm shifts only as far as allocation policy allows. J Heart Lung Transplant 2020; 39:636-638. [DOI: 10.1016/j.healun.2020.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 04/21/2020] [Indexed: 11/27/2022] Open
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ABO-incompatible heart transplantation in children-a systematic review of current practice. Indian J Thorac Cardiovasc Surg 2020; 36:190-193. [PMID: 33061203 DOI: 10.1007/s12055-020-00971-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/08/2020] [Accepted: 05/13/2020] [Indexed: 02/03/2023] Open
Abstract
Pediatric heart transplantation has significantly improved in the survival of children with cardiomyopathy and/or complex congenital heart defects. With the increasing number of children needing transplantation, there is a growing demand for the organ, making it harder to cope with the increasing number of children on the waiting list. One of the advances that helped reduce the waiting list mortality significantly is the ability to transplant children from donors with ABO incompatibility. Modification of perfusion abilities and management of donor organ improves outcome in this select population, making ABO-incompatible transplantation an attractive option in the wider armamentarium available for pushing boundaries in these children without impacting on outcomes.
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Issitt R, Crook R, Shaw M, Robertson A. The Great Ormond Street Hospital immunoadsorption method for ABO-incompatible heart transplantation: a practical technique. Perfusion 2020; 36:34-37. [PMID: 32493108 PMCID: PMC7770210 DOI: 10.1177/0267659120926895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Traditionally, ABO-incompatible heart transplantation was accomplished using a plasma exchange technique to remove recipient plasma containing donor-incompatible anti-A/B isohaemagglutinins. However, this technique exposed patients to large volumes of allogeneic blood and blood products (up to three times the patient’s circulating volume). In 2018, we published the first reported case of an ABO-incompatible heart transplant using an intraoperative immunoadsorption technique which minimises the exposure to blood products by specifically targeting anti-A/B isohaemagglutinins. We have subsequently used this technique in all children undergoing ABO-incompatible heart transplantation and become convinced of its efficacy in this population while observing no adverse effects. This article outlines the practical details required to perform the technique in order to avoid hyperacute rejection.
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Affiliation(s)
- Richard Issitt
- Perfusion Department, Great Ormond Street Hospital, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | - Richard Crook
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Michael Shaw
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Alex Robertson
- Perfusion Department, Great Ormond Street Hospital, London, UK
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