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Midyat L, Muise ED, Visner GA. Pediatric Lung Transplantation for Pulmonary Vascular Diseases: Recent Advances and Challenges. Clin Chest Med 2024; 45:761-769. [PMID: 39069336 DOI: 10.1016/j.ccm.2024.02.023] [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] [Indexed: 07/30/2024]
Abstract
Pediatric lung transplantation for pulmonary vascular diseases has seen notable advancements and trends. Medical therapies, surgical options, and bridging techniques like extracorporeal membrane oxygenation and different forms of transplants have expanded treatment possibilities. Current challenges include ensuring patient adherence to post-transplant therapies, addressing complications like primary graft dysfunction and rejection, and conducting further research in less common conditions like pulmonary veno-occlusive disease and pulmonary vein stenosis. In this review article, the authors will explore the advancements, emerging trends, and persistent challenges in pediatric lung transplantation for pulmonary vascular diseases.
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Affiliation(s)
- Levent Midyat
- Division of Pulmonary Medicine, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, AOB Suite 3300, Pittsburgh, PA 15224, USA.
| | - Eleanor D Muise
- Division of Pulmonary Medicine, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, 240 East 38th Street, 14th Floor, New York, NY 10016, USA
| | - Gary A Visner
- Division of Pulmonary Medicine, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, BCH 3121, Boston, MA 02115, USA
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2
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Fiorino EK, Fishman MP. Approach to the patient with Childhood Interstitial and Diffuse Lung Disease. Pediatr Pulmonol 2024. [PMID: 39056528 DOI: 10.1002/ppul.27162] [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: 09/26/2023] [Revised: 06/06/2024] [Accepted: 06/25/2024] [Indexed: 07/28/2024]
Abstract
Childhood Interstitial and Diffuse Lung Disease (chILD) encompasses a group of rare, chronic lung disorders in infants and children with overlapping clinical features but diverse etiologies. The clinical presentation of chILD is of chronic or recurring respiratory signs and symptoms, often including increased work of breathing and hypoxia, with diffuse radiographic abnormalities on chest imaging. Recognition can be challenging since some clinical features overlap with those of more common pediatric respiratory diseases including asthma and recurrent viral infections, among others. chILD should be considered as an underlying diagnosis when a patient's respiratory symptoms seem disproportionate to the clinical scenario and/or persist. The diagnostic process involves multiple steps and is tailored to the individual patient. Nearly all children will undergo imaging and pulmonary function testing, many will undergo bronchoscopy with bronchoalveolar lavage, many will receive genetic testing, and some will require lung biopsy. Treatment includes preventive care, evaluation for comorbidities, pharmacotherapy according to diagnosis, and ongoing disease surveillance, including revisiting genetic and histopathologic results as new clinical information becomes available and as our understanding of these rare disorders improves. The purpose of this review is to provide a broad approach to the diagnosis and management of patients with chILD.
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Affiliation(s)
- Elizabeth K Fiorino
- Northwell, New Hyde Park, New York, USA
- Departments of Science Education and Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Martha P Fishman
- Harvard Medical School, Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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3
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Alachraf K, Tumin D, Hayes D, Benden C. xTrends in racial and ethnic disparities in pediatric lung transplantation in the United States. Pediatr Pulmonol 2024. [PMID: 38990104 DOI: 10.1002/ppul.27175] [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: 03/11/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Racial and ethnic disparities in pediatric lung transplantation (LTx) related to the shifting cystic fibrosis (CF) population receiving highly effective modulator therapy (HEMT) has not been well investigated. METHODS The UNOS Registry was queried for patients age 1-25 years undergoing bilateral LTx between 1 January 2012 and 31 December 2021. Race and ethnicity were classified as non-Hispanic White, non-Hispanic Black, Hispanic, or none of the above. The primary outcome was posttransplant mortality. Trends in the association between race/ethnicity and mortality were examined using transplant year as a continuous variable and stratifying year based on introduction of HEMT (triple combination therapy) in November 2019. RESULTS In the study sample (N = 941), 7% of patients were non-Hispanic Black, 15% were Hispanic, and 2% were some other racial or ethnic group. One hundred (11%) received LTx after approval of triple combination therapy, and 407 (43%) died during follow-up. We identified a statistically significant disparity in mortality hazard (hazard ratio: 1.91; 95% confidence interval: 1.31, 2.80) in non-Hispanic Black compared to non-Hispanic White patients in the pre-triple combination therapy era. CONCLUSIONS We found higher mortality hazard among non-Hispanic Black compared to non-Hispanic White children undergoing LTx in the United States. Further monitoring of LTx outcomes to identify and address disparities is needed in the current era of triple combination therapy for CF.
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Affiliation(s)
- Kamel Alachraf
- Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
- Department of Academic Affairs, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Don Hayes
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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4
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Avdimiretz N, Benden C. Pediatric lung transplantation: A new landscape following the height of the COVID-19 pandemic. J Heart Lung Transplant 2024:S1053-2498(24)01728-5. [PMID: 38959989 DOI: 10.1016/j.healun.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 06/06/2024] [Accepted: 06/26/2024] [Indexed: 07/05/2024] Open
Affiliation(s)
- Nicholas Avdimiretz
- Division of Pediatric Pulmonary Medicine, Pediatric Lung Transplantation, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California.
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5
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Paraskeva MA, Snell GI. Advances in lung transplantation: 60 years on. Respirology 2024; 29:458-470. [PMID: 38648859 DOI: 10.1111/resp.14721] [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: 02/11/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024]
Abstract
Lung transplantation is a well-established treatment for advanced lung disease, improving survival and quality of life. Over the last 60 years all aspects of lung transplantation have evolved significantly and exponential growth in transplant volume. This has been particularly evident over the last decade with a substantial increase in lung transplant numbers as a result of innovations in donor utilization procurement, including the use donation after circulatory death and ex-vivo lung perfusion organs. Donor lungs have proved to be surprisingly robust, and therefore the donor pool is actually larger than previously thought. Parallel to this, lung transplant outcomes have continued to improve with improved acute management as well as microbiological and immunological insights and innovations. The management of lung transplant recipients continues to be complex and heavily dependent on a tertiary care multidisciplinary paradigm. Whilst long term outcomes continue to be limited by chronic lung allograft dysfunction improvements in diagnostics, mechanistic understanding and evolutions in treatment paradigms have all contributed to a median survival that in some centres approaches 10 years. As ongoing studies build on developing novel approaches to diagnosis and treatment of transplant complications and improvements in donor utilization more individuals will have the opportunity to benefit from lung transplantation. As has always been the case, early referral for transplant consideration is important to achieve best results.
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Affiliation(s)
- Miranda A Paraskeva
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Gregory I Snell
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
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6
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Wannes Daou A, Wallace C, Barker M, Ambrosino T, Towe C, Morales DLS, Wikenheiser-Brokamp KA, Hayes D, Burg G. Flexible bronchoscopy in pediatric lung transplantation. Pediatr Transplant 2024; 28:e14757. [PMID: 38695266 DOI: 10.1111/petr.14757] [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: 07/31/2023] [Revised: 03/09/2024] [Accepted: 04/01/2024] [Indexed: 05/14/2024]
Abstract
Pediatric lung transplantation represents a treatment option for children with advanced lung disease or pulmonary vascular disorders who are deemed an appropriate candidate. Pediatric flexible bronchoscopy is an important and evolving field that is highly relevant in the pediatric lung transplant population. It is thus important to advance our knowledge to better understand how care for children after lung transplant can be maximally optimized using pediatric bronchoscopy. Our goals are to continually improve procedural skills when performing bronchoscopy and to decrease the complication rate while acquiring adequate samples for diagnostic evaluation. Attainment of these goals is critical since allograft assessment by bronchoscopic biopsy is required for histological diagnosis of acute cellular rejection and is an important contributor to establishing chronic lung allograft dysfunction, a common complication after lung transplant. Flexible bronchoscopy with bronchoalveolar lavage and transbronchial lung biopsy plays a key role in lung transplant graft assessment. In this article, we discuss the application of bronchoscopy in pediatric lung transplant evaluation including historical approaches, our experience, and future directions not only in bronchoscopy but also in the evolving pediatric lung transplantation field. Pediatric flexible bronchoscopy has become a vital modality for diagnosing lung transplant complications in children as well as assessing therapeutic responses. Herein, we review the value of flexible bronchoscopy in the management of children after lung transplant and discuss the application of novel techniques to improve care for this complex pediatric patient population and we provide a brief update about new diagnostic techniques applied in the growing lung transplantation field.
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Affiliation(s)
- Antoinette Wannes Daou
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Carolyn Wallace
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Mitzi Barker
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Transplant Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Teresa Ambrosino
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Transplant Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christopher Towe
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Transplant Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - David L S Morales
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Transplant Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kathryn A Wikenheiser-Brokamp
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Pulmonary Biology, The Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Don Hayes
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Transplant Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Gregory Burg
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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7
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Koh W, Zang H, Ollberding NJ, Hayes D. Lung Transplantation for Children with Refractory Acute Respiratory Distress Syndrome. Ann Am Thorac Soc 2024; 21:672-675. [PMID: 38241015 DOI: 10.1513/annalsats.202308-695rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Affiliation(s)
- Wonshill Koh
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio
- University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Huaiyu Zang
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio
| | - Nicholas J Ollberding
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio
- University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Don Hayes
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio
- University of Cincinnati College of Medicine Cincinnati, Ohio
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8
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Benden C, Wikenheiser-Brokamp KA. Antibody-mediated rejection (AMR) in pediatric lung transplantation-Current state and future directions. Pediatr Transplant 2024; 28:e14739. [PMID: 38436533 DOI: 10.1111/petr.14739] [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: 11/01/2023] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
Lung transplantation is considered as the ultimate therapy for children with advanced pulmonary disease. International data show a median conditional 1-year post-transplantation survival of 9.1 years. Recently, antibody-mediated rejection (AMR) has increasingly been recognized as an important cause of allograft dysfunction although pediatric reports are still scarce. Donor-specific anti-human leukocyte antigen (HLA) antibodies (DSA) are known to play a role in AMR development post-transplant but AMR pathogenesis is still poorly understood. Central to the concept of pulmonary AMR is immune activation with the production of allo-specific B-cells and plasma cells directed against donor lung antigens. The frequency of pulmonary AMR in children is currently unknown. Due to the lack of AMR data in children, the diagnostic approach for pediatric pulmonary AMR is solely based on adult literature. This personal viewpoint article evaluates the rational for the creation of age-based thresholds for different diagnostic categories of pulmonary AMR and data on the management of pulmonary AMR in children. To the authors' knowledge, there have been no randomized controlled trials comparing different management regimes in pulmonary AMR, and thus, management and treatment algorithms for pulmonary AMR in children are only extrapolated from adults. To advance the knowledge of AMR in children, the authors propose that children be included in collaborative, multi-center trials. It is vital that future decisions on internationally agreed upon guidelines for pulmonary AMR take its impact on children into consideration. Research is needed to fill the current knowledge gaps in the field of pulmonary AMR in children focused on optimizing outcomes.
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Affiliation(s)
| | - Kathryn A Wikenheiser-Brokamp
- Division of Pathology and Laboratory Medicine, Perinatal Institute, Division of Pulmonary Biology, and Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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9
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Ahmed HF, Guzman-Gomez A, Desai M, Dani A, Morales DLS, Critser PJ, Zafar F, Hayes D. Lung Transplantation for Pulmonary Vascular Disease in Children: A United Network for Organ Sharing Analysis. Pediatr Cardiol 2024; 45:385-393. [PMID: 38148409 DOI: 10.1007/s00246-023-03356-x] [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: 08/30/2023] [Accepted: 11/13/2023] [Indexed: 12/28/2023]
Abstract
Pulmonary vascular disease (PVD) represents an important clinical indication for lung transplant (LTx) in infants, children, and adolescents. There is limited information on LTx outcomes in these patients. We explored LTx volumes and post-LTx survival in children with PVD compared to other diagnoses. The UNOS Registry was queried from 1989 to 2020 to identify first-time pediatric LTx recipients (< 18 yo). PVD was categorized as idiopathic pulmonary arterial hypertension (IPAH) and non-idiopathic arterial hypertension (non-IPAH) and compared to all other patients as other diagnoses. Univariate and multivariate regression models were performed. 984 pediatric LTx patients (593 before 2010 and 391 during/after 2010) were identified, of which 145 (14.7%) had PVD. There has been no significant change in annual rate of all LTxs over comparative eras. However, there has been a decrease in rate of LTxs for PVD patients. Children with PVD had similar survival to other LTx groups in the early era (p = 0.2) and the latter era (p = 0.9). Univariate Cox models, showed that LTx in patients with PVD was associated with a significantly less risk of mortality for children aged 6-11 years compared to younger and older cohorts (HR = 0.4 [0.17-0.98]; p = 0.045), whereas multivariate analysis showed a trend toward higher mortality in 11-17-year-olds (HR = 1.54 [0.97-2.45]; p = 0.06). For PVD patients, oxygen supplementation and ventilator support at LTx were associated with worse post-transplant survival (p = 0.029 and p = 0.01). There has been a decrease in LTx volume for pediatric patients with PVD in the modern era. Post-LTx outcomes for children with PVD are similar to those of other diagnoses in both eras, with children aged 6-11 years having the best survival. Given these findings, LTx should be considered for this patient population.
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Affiliation(s)
- Hosam F Ahmed
- Division of Congenital Heart Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Amalia Guzman-Gomez
- Division of Congenital Heart Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Malika Desai
- Division of Congenital Heart Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alia Dani
- Division of Congenital Heart Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David L S Morales
- Division of Congenital Heart Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Paul J Critser
- Division of Cardiology, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Farhan Zafar
- Division of Congenital Heart Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Don Hayes
- Division of Pulmonary Medicine, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA.
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10
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Ehrsam JP, Meier Adamenko O, Pannu M, Markus Schöb O, Inci I. Lung transplantation in children. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2024; 32:S119-S133. [PMID: 38584780 PMCID: PMC10995684 DOI: 10.5606/tgkdc.dergisi.2024.25806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/05/2023] [Indexed: 04/09/2024]
Abstract
Lung transplantation is a well-established treatment for children facing advanced lung disease and pulmonary vascular disorders. However, organ shortage remains highest in children. For fitting the small chest of children, transplantation of downsized adult lungs, lobes, or even segments were successfully established. The worldwide median survival after pediatric lung transplantation is currently 5.7 years, while under consideration of age, underlying disease, and peri- and posttransplant center experience, median survival of more than 10 years is reported. Timing of referral for transplantation, ischemia-reperfusion injury, primary graft dysfunction, and acute and chronic rejection after transplantation remain the main challenges.
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Affiliation(s)
- Jonas Peter Ehrsam
- School of Medicine, University of Zurich, Zurich, Switzerland
- Department of Thoracic Surgery, Klinik Hirslanden Zurich, Zurich, Switzerland
- Klinik Hirslanden Zurich, Centre for Surgery, Zurich, Switzerland
| | | | | | - Othmar Markus Schöb
- School of Medicine, University of Zurich, Zurich, Switzerland
- Department of Thoracic Surgery, Klinik Hirslanden Zurich, Zurich, Switzerland
- Klinik Hirslanden Zurich, Centre for Surgery, Zurich, Switzerland
| | - Ilhan Inci
- School of Medicine, University of Zurich, Zurich, Switzerland
- Department of Thoracic Surgery, Klinik Hirslanden Zurich, Zurich, Switzerland
- Klinik Hirslanden Zurich, Centre for Surgery, Zurich, Switzerland
- University of Nicosia Medical School, Nicosia, Cyprus
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11
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Brugha R, Wu D, Spencer H, Marson L. Disparities in lung transplantation in children. Pediatr Pulmonol 2023. [PMID: 38131456 DOI: 10.1002/ppul.26813] [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: 02/17/2023] [Revised: 11/17/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
Lung transplantation is a recognized therapy for end-stage respiratory failure in children and young people. It is only available in selected countries and is limited by access to suitable organs. Data on disparities in access and outcomes for children undergoing lung transplantation are limited. It is clear from data from studies in adults, and from studies in other solid organ transplants in children, that systemic inequities exist in this field. While data relating specifically to pediatric lung transplantation are relatively sparse, professionals should be aware of the risk that healthcare systems may result in disparities in access and outcomes following lung transplantation in children.
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Affiliation(s)
- Rossa Brugha
- Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK
- Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Diana Wu
- General Surgery, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Helen Spencer
- Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK
| | - Lorna Marson
- Transplant Unit, Royal Infirmary Edinburgh, Edinburgh, UK
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12
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Himebauch AS, Yehya N, Schaubel DE, Josephson MB, Berg RA, Kawut SM, Christie JD. Poor functional status at the time of waitlist for pediatric lung transplant is associated with worse pretransplant outcomes. J Heart Lung Transplant 2023; 42:1735-1742. [PMID: 37437825 PMCID: PMC10776805 DOI: 10.1016/j.healun.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 06/14/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Whether functional status is associated with survival to pediatric lung transplant is unknown. We hypothesized that completely dependent functional status at waitlist registration, defined using Lansky Play Performance Scale (LPPS), would be associated with worse outcomes. METHODS Retrospective cohort study of pediatric lung transplant registrants utilizing United Network for Organ Sharing's Standard Transplant Analysis and Research files (2005-2020). Primary exposure was completely dependent functional status, defined as LPPS score of 10-40. Primary outcome was waitlist removal for death/deterioration with cause-specific hazard ratio (CSHR) regression. Subdistribution hazard regression (SHR, Fine and Gray) was used for the secondary outcome of waitlist removal due to transplant/improvement with a competing risk of death/deterioration. Confounders included: sex, age, race, diagnosis, ventilator dependence, extracorporeal membrane oxygenation, year, and listing center volume. RESULTS A total of 964 patients were included (63.5% ≥ 12 years, 50.2% cystic fibrosis [CF]). Median waitlist days were 95; 20.1% were removed for death/deterioration and 68.2% for transplant/improvement. Completely dependent functional status was associated with removal due to death/deterioration (adjusted CSHR 5.30 [95% CI 2.86-9.80]). This association was modified by age (interaction p = 0.0102), with a larger effect for age ≥12 years, and particularly strong for CF. In the Fine and Gray model, completely dependent functional status did not affect the risk of removal due to transplant/improvement with a competing risk of death/deterioration (adjusted SHR 1.08 [95% CI 0.77-1.49]). CONCLUSIONS Pediatric lung transplant registrants with the worst functional status had worse pretransplant outcomes, especially for adolescents and CF patients. Functional status at waitlist registration may be a modifiable risk factor to improve survival to lung transplant.
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Affiliation(s)
- Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maureen B Josephson
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Steven M Kawut
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D Christie
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Ahmed HF, Guzman-Gomez A, Desai M, Dani A, Morales D, Critser PJ, Zafar F, Hayes D. Lung Transplantation for Pulmonary Vascular Disease in Children: A United Network for Organ Sharing Analysis. RESEARCH SQUARE 2023:rs.3.rs-3310701. [PMID: 37720024 PMCID: PMC10503841 DOI: 10.21203/rs.3.rs-3310701/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Background Pulmonary vascular disease (PVD) represents an important clinical indication for lung transplant (LTx) in infants, children, and adolescents. There is limited information on LTx outcomes in these patients. We explored LTx volumes and post-LTx survival in children with PVD compared to other diagnoses. Methods The UNOS Registry was queried from 1989-2020 to identify first-time pediatric LTx recipients (<18 yo). PVD was categorized as idiopathic pulmonary arterial hypertension (IPAH) and non-idiopathic arterial hypertension (non-IPAH) and compared to all other patients as other diagnoses. Univariate and multivariate regression models were performed. Results 984 pediatric LTx patients (593 before 2010 and 391 during/after 2010) were identified, of which 145 (14.7%) had PVD. There has been no significant change in annual rate of all LTxs over comparative eras. However, there has been a decrease in rate of LTxs for PVD patients. Children with PVD had similar survival to other LTx groups in the early era (p=0.2) and the latter era (p=0.9). Univariate Cox models, showed that LTx in patients with PVD was associated with a significantly less risk of mortality for children aged 6-11 years compared to younger and older cohorts (HR=0.4 [0.17-0.98];p=0.045), whereas multivariate analysis showed a trend towards higher mortality in 11-17-year-olds (HR=1.54 [0.97-2.45];p=0.06). For PVD patients, oxygen supplementation and ventilator support at LTx were associated with worse post-transplant survival (p=0.029 and p=0.01). Conclusions There has been a decrease in LTx volume for pediatric patients with PVD in the modern era. Post-LTx outcomes for children with PVD are similar to those of other diagnoses in both eras, with children aged 6-11 years having the best survival. Given these findings, LTx should be considered for this patient population.
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Affiliation(s)
| | | | | | - Alia Dani
- Cincinnati Children's Hospital Medical Center
| | | | | | | | - Don Hayes
- Cincinnati Children's Hospital Medical Center
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Sill J, Baskar S, Zang H, Spar D, Iliopoulos I, Morales DLS, Hayes D, Koh W. Atrial arrhythmias following lung transplant: a single pediatric center experience. Front Pediatr 2023; 11:1161129. [PMID: 37425256 PMCID: PMC10326625 DOI: 10.3389/fped.2023.1161129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/15/2023] [Indexed: 07/11/2023] Open
Abstract
Background Outcomes after lung transplant (LTx) in children have slowly improved. Although atrial arrhythmia (AA) is a common and adverse complication following LTx among adults, there is limited data on pediatric recipients. We detail our pediatric single-center experience while providing further insights on occurrence and management of AA following LTx. Methods A retrospective analysis of LTx recipients at a pediatric LTx program from 2014 to 2022 was performed. We investigated timing of occurrence and management of AA following LTx, and its effect on post-LTx outcome. Results Three out of nineteen (15%) pediatric LTx recipients developed AA. The timing of occurrence was 9-10 days following LTx. Those patients in the older age group (age >12 years old) were the only ones who developed AA. Developing AA did not have a negative effect on hospital stay duration or short-term mortality. All LTx recipients with AA were discharged home on therapy that was discontinued at 6 months for those who was on mono-therapy without recurrence of AA. Conclusions AA is an early post-operative complication in older children and younger adults undergoing LTx at a pediatric center. Early recognition and aggressive management can mitigate any morbidity or mortality. Future investigations should explore factors that place this population at risk for AA in order to prevent this complication post-operatively.
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Affiliation(s)
- Jordan Sill
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Shankar Baskar
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Huaiyu Zang
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - David Spar
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Ilias Iliopoulos
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - David L. S. Morales
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Division of Pediatric Cardiothoracic Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Don Hayes
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Wonshill Koh
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Rudym D, Natalini JG, Trindade AJ. Listing Dilemmas: Age, Frailty, Weight, Preexisting Cancers, and Systemic Diseases. Clin Chest Med 2023; 44:35-46. [PMID: 36774166 DOI: 10.1016/j.ccm.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Selection of lung transplant candidates is an evolving field that pushes the boundaries of what is considered the norm. Given the continually changing demographics of the typical lung transplant recipient as well as the growing list of risk factors that predispose patients to poor posttransplant outcomes, we explore the dilemmas in lung transplant candidate selections pertaining to older age, frailty, low and high body mass index, preexisting cancers, and systemic autoimmune rheumatic diseases.
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Affiliation(s)
- Darya Rudym
- Division of Pulmonary and Critical Care Medicine, New York University, Langone Health, 530 First Avenue, HCC-4A, New York, NY 10016, USA.
| | - Jake G Natalini
- Division of Pulmonary and Critical Care Medicine, New York University, Langone Health, 530 First Avenue, HCC-4A, New York, NY 10016, USA
| | - Anil J Trindade
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Oxford House, Room 539, 1313 21st Avenue South, Nashville, TN 37232, USA
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Hayes D, Dani A, Guzman-Gomez A, Zafar F, Morales DLS, Ziady AG. Changing racial and ethnic differences for lung transplantation in cystic fibrosis. Pediatr Transplant 2023; 27:e14404. [PMID: 36206358 PMCID: PMC9839480 DOI: 10.1111/petr.14404] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 08/05/2022] [Accepted: 09/18/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND CFTR modulators, especially (elexacaftor/tezacaftor/ivacaftor), have positively impacted the CF population and quickly decreased LTx numbers. However, no study has investigated if this reduction is universal across all races/ethnicities. METHODS Using the UNOS Registry, we explored the frequency/proportions of LTx in WNH and NW (Black, non-Hispanic/Hispanic-Latino/Asian-non Hispanic/American Indian-Alaskan Native-non-Hispanic/Native Hawaiian/Other Pacific Islander-non-Hispanic/Multiracial) in children and adults with CF in the US. RESULTS Between 1990 and 2019, the annual mean (±SD) number of LTxs for children with CF was 23.2 (±7.7) compared to 5 in 2020 (p < .001) and in 2021 (p < .001). In adults from 1990 to 2019, the mean (±SD) number of LTxs performed was 144.9 (±73.5), which was significantly higher than 2020 (n = 73; p < .001) and 2021 (n = 45; p < .001). Comparing 1990-2019 to post-2019, the proportion of LTxs performed in both children and adults with CF has decreased from 50.5% (696/1378) to 16.4% (9/55) and from 12.1% (4773/39542) to 2.4% (118/5004), respectively. In WNH pediatric patients, the difference in the percentage of all LTx made up by CF patients between the two eras was 41.2% compared to NW patients where the difference was 11%. Similarly in adults, the difference between the two eras was 10.4% in WNH and 2.4% in NW patients. CONCLUSIONS The recent reduction in LTx for the CF population has had less impact on the NW population in the US, so the continuation of optimal referrals for this group is needed.
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Affiliation(s)
- Don Hayes
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alia Dani
- Department of Cardiothoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Amalia Guzman-Gomez
- Department of Cardiothoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Farhan Zafar
- Department of Cardiothoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David L. S. Morales
- Department of Cardiothoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Assem G. Ziady
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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Avdimiretz N, Radtke T, Benden C. Monitoring practices of chronic lung allograft dysfunction in pediatric lung transplantation. Pediatr Pulmonol 2023; 58:213-221. [PMID: 36200536 DOI: 10.1002/ppul.26187] [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: 08/11/2022] [Revised: 09/10/2022] [Accepted: 10/04/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Chronic lung allograft dysfunction (CLAD) continues to negatively impact the survival of pediatric lung transplant (LTx) recipients. Current consensus guidelines are adult-focused. We sought to examine CLAD detection and monitoring practices at pediatric LTx programs. METHODS We conducted a survey among the International Pediatric Lung Transplant Collaborative. Questions consisted of practitioner's experience, LTx program demographics, and querying tests used for CLAD surveillance and detection. Investigations queried included: chest x-ray (CXR), chest computed tomography (CT), lung magnetic resonance imaging (MRI), ventilation/perfusion scanning, conventional pulmonary function testing (PFT), multiple breath washout (MBW), infant/preschool PFT, bronchoalveolar lavage, transbronchial biopsies (TBBx), or other tissue sampling techniques. Preferences for certain modalities over others were questioned based on a five-point Likert scale. RESULTS Twenty-four of 25 programs responded. Chest CT and CXR are used generally for both CLAD surveillance and detection. No programs use lung MRI clinically, it may have some utility in the future. While all centers use conventional PFT, MBW, and infant/preschool PFT are used in one-fifth and one-third of centers, respectively. While the majority of programs use TBBx, only 41.7% would obtain a diagnosis based on tissue histopathology over noninvasive techniques if CLAD is suspected. Utilization of biomarkers is still limited. CONCLUSIONS Our results indicate continued use of conventional PFT along with chest CT and less so CXR for CLAD detection and monitoring in the large majority of centers. Infant/preschool PFT and novel methods such as MBW are used in a few centers only. Respondents agreed there is a timely need for pediatric consensus guidelines on CLAD detection and monitoring.
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Affiliation(s)
- Nicholas Avdimiretz
- Division of Pediatric Respiratory Medicine, Stollery Children Hospital, University of Alberta, Edmonton, Canada
| | - Thomas Radtke
- Division of Occupational and Environmental Medicine, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich & University Hospital Zurich, Zurich, Switzerland
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Hayes D, Cherikh WS, Harhay MO, Perch M, Hsich E, Potena L, Sadavarte A, Zehner A, Singh TP, Zuckermann A, Stehlik J. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Twenty-fifth Pediatric Lung Transplantation Report — 2022; Focus on Pulmonary Vascular Diseases. J Heart Lung Transplant 2022; 41:1348-1356. [DOI: 10.1016/j.healun.2022.07.020] [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: 07/25/2022] [Indexed: 10/16/2022] Open
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