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Chen JK, Salerno DM, Corbo H, Mantell BS, Richmond M, Rothkopf A, Lytrivi ID. Immune cell function assay and T lymphocyte counts lack association with rejection or infection in pediatric heart transplant recipients. Clin Transplant 2023; 37:e14858. [PMID: 36372938 DOI: 10.1111/ctr.14858] [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: 09/11/2022] [Revised: 10/31/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Immune cell function assay (ICFA) and CD3 lymphocyte counts have been considered to be useful in discerning the overall intensity of immunosuppression in pediatric orthotopic heart transplant (OHT) recipients. METHODS The aim of this retrospective analysis was to evaluate trends of ICFA and CD3 lymphocyte counts and their association with adverse outcomes post-OHT. RESULTS A total of 381 ICFA and 493 CD3 laboratory values obtained in 78 patients within six months post-OHT were analyzed. There were 14 patients treated for biopsy-proven acute rejection, four of whom had ISHLT grade 2R/3A rejection. In patients with rejection versus those without, CD3 and ICFA values were 122 (IQR 74.5-308) cells/mm2 and 224.5 (IQR 132-343.5) ng/ml compared to 231.8 (IQR 68-421) cells/m2 and 191 (IQR 81.5-333) ng/mL (p = NS for both). Twenty-six patients had at least one detectable cytomegalovirus or Epstein-Barr virus DNAemia within the study timeframe. In patients with viremia versus those without, CD3 and ICFA values were 278.5 (IQR 68-552) cells/mm2 and 130 (IQR 48-284) ng/ml compared to 195 (IQR 74.5-402.5) cells/mm2 and 212 (IQR 89-342) ng/ml (p = NS for both). CONCLUSIONS No association was found between these immune markers and adverse outcomes. In the absence of larger pediatric studies justifying the role of these tests in identifying elevated risk profiles post OHT, we do not recommend their routine use.
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Affiliation(s)
- Justin K Chen
- Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - David M Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, USA
| | - Heather Corbo
- Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Benjamin S Mantell
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| | - Marc Richmond
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| | - Amy Rothkopf
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| | - Irene D Lytrivi
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
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Bansal N, Everitt MD, Nandi D, Spinner J, Conway J, Magnetta DA, Profita EL, Townsend M, Alejos JC, Deshpande SR. Clinical approach to acute cellular rejection from the pediatric heart transplant society. Pediatr Transplant 2022; 26:e14393. [PMID: 36377327 DOI: 10.1111/petr.14393] [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: 04/21/2022] [Revised: 08/04/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early detection of cardiac allograft rejection is crucial for post-transplant graft survival. Despite the progress made in immunosuppression strategies, acute cellular rejection remains a serious complication during and after the first post-transplant year, and there is a continued lack of consensus regarding its treatment, especially in pediatric transplant patients. METHODS An open request was placed via the listserv to the membership of the Pediatric Heart Transplant Society (PHTS). Along with a broad literature search, numerous institutional protocols were pooled, analyzed and consolidated. A clinical approach document was generated highlighting areas of consensus and practice variation. RESULTS The clinical approach document divides cellular rejection by International Society for Heart and Lung Transplantation grades and provides management strategies for each, including persistent cellular rejection. CONCLUSIONS Cellular rejection treatment can be tailored to the clinical status, graft function, and the grade of cellular rejection. A case of mild and asymptomatic rejection may not require treatment, whereas a higher-grade rejection or rejection with graft dysfunction or hemodynamic compromise may require aggressive intravenous therapies, changes to maintenance immunosuppression therapy and augmented surveillance.
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Affiliation(s)
- Neha Bansal
- Children's Hospital at Montefiore, Bronx, New York, USA
| | | | - Deipanjan Nandi
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Joseph Spinner
- Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Jennifer Conway
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Defne A Magnetta
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Weisert M, Harake D, Hede S, Russell M, Alejos J, Menteer J. A multicenter survey on post-transplant lymphoproliferative disorders in pediatric heart transplant recipients: A case for development of consensus guidelines for screening, surveillance, and treatment? Pediatr Transplant 2020; 24:e13730. [PMID: 32416037 DOI: 10.1111/petr.13730] [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: 11/27/2019] [Revised: 03/23/2020] [Accepted: 04/13/2020] [Indexed: 01/29/2023]
Abstract
Post-transplant lymphoproliferative disorders (PTLD) are the main malignancy seen after pediatric heart transplant and are a significant cause of morbidity and mortality. Prior to the development of detailed guidelines, we sought to identify trends in screening, diagnosis, and treatment of pediatric PTLD. All Pediatric Heart Transplant Society (PHTS) institutions were surveyed. No identifiable patient information was shared. From 56 PHTS centers, 22 responses were received (39.3%). 100% agree PTLD cannot be diagnosed solely based on elevated Epstein-Barr virus (EBV) load. All respondents routinely screen for EBV by blood PCR, but frequency of screening varies. There was intermediate consensus regarding the use of computed tomography (CT) and/or positron emission tomography (PET) in surveillance management for PTLD. Most centers require a diagnostic biopsy before initiating new treatment for PTLD (14 of 18, 77.8%), but many reduce immune suppression based on elevated EBV without pathologic PTLD (16 of 22, 72.7%). Beyond immune modulation, rituximab is most commonly used (9 of 13, 69.2%). Consultation with oncology is common (17 of 17, 100%), but timing varies widely. Our survey highlights significant elements of agreement and significant practice variation among PHTS institutions regarding pediatric PTLD. Reduction of immune suppression prior to pathologic diagnosis of PTLD is a common management strategy. When this fails, rituximab is used, but is most often reserved until after confirmation of the diagnosis. Oncology subspecialists are commonly involved in these cases. Our findings highlight the need to develop improved guidelines for evaluation and treatment of pediatric PTLD.
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Affiliation(s)
- Molly Weisert
- Division of Pediatric Cardiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Danielle Harake
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Sannya Hede
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Matthew Russell
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Juan Alejos
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - JonDavid Menteer
- Division of Pediatric Cardiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
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Schweiger M, Zuckermann A, Beiras-Fernandez A, Berchtolld-Herz M, Boeken U, Garbade J, Hirt S, Richter M, Ruhpawar A, Schmitto JD, Schönrath F, Schramm R, Schulz U, Wilhelm MJ, Barten MJ. A Review of Induction with Rabbit Antithymocyte Globulin in Pediatric Heart Transplant Recipients. Ann Transplant 2018; 23:322-333. [PMID: 29760372 PMCID: PMC6248300 DOI: 10.12659/aot.908243] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Pediatric heart transplantation (pHTx) represents only a small proportion of cardiac transplants. Due to these low numbers, clinical data relating to induction therapy in this special population are far less extensive than for adults. Induction is used more widely in pHTx than in adults, mainly because of early steroid withdrawal or complete steroid avoidance. Antithymocyte globulin (ATG) is the most frequent choice for induction in pHTx, and rabbit antithymocyte globulin (rATG, Thymoglobulin®) (Sanofi Genzyme) is the most widely-used ATG preparation. In the absence of large, prospective, blinded trials, we aimed to review the current literature and databases for evidence regarding the use, complications, and dosages of rATG. Analyses from registry databases suggest that, overall, ATG preparations are associated with improved graft survival compared to interleukin-2 receptor antagonists. Advantages for the use of rATG have been shown in low-risk patients given tacrolimus and mycophenolate mofetil in a steroid-free regimen, in sensitized patients with pre-formed alloantibodies and/or a positive donor-specific crossmatch, and in ABO-incompatible pHTx. Registry and clinical data have indicated no increased risk of infection or post-transplant lymphoproliferative disorder in children given rATG after pHTx. A total rATG dose in the range 3.5–7.5 mg/kg is advisable.
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Affiliation(s)
- Martin Schweiger
- Department of Cardiac Surgery, Children's Hospital, Zürich, Switzerland
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | | | - Udo Boeken
- Department of Cardiovascular Surgery, Heinrich Heine University, Düsseldorf, Germany
| | - Jens Garbade
- Department of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Stephan Hirt
- Department of Cardiac and Thoracic Surgery, University of Regensburg, Regensburg, Germany
| | | | - Arjang Ruhpawar
- Cardiac Surgery Clinic, University of Heidelberg, Heidelberg, Germany
| | - Jan Dieter Schmitto
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Felix Schönrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, and DZHK (German Center for Cardiovascular Research), Berlin, Germany
| | - Rene Schramm
- Clinic of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| | - Uwe Schulz
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Markus J Wilhelm
- Clinic for Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Markus J Barten
- University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Immune Therapy. Pediatr Crit Care Med 2016; 17:S69-76. [PMID: 26945331 DOI: 10.1097/pcc.0000000000000626] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In this Consensus Statement, we review the etiology and pathophysiology of inflammatory processes seen in critically ill children with cardiac disease. Immunomodulatory therapies aimed at improving outcomes in patients with myocarditis, heart failure, and transplantation are extensively reviewed. DATA SOURCES The author team experience and along with an extensive review of the medical literature were used as data sources. DATA SYNTHESIS The authors synthesized the data in the literature to present current immumodulatory therapies. For each drug, the physiologic rationale, mechanism of action, and pharmacokinetics are synthesized, and the evidence in the literature to support the therapy is discussed. CONCLUSIONS Immunomodulation has a crucial role in the treatment of certain pediatric cardiac diseases. Immunomodulatory treatments that have been used to treat myocarditis include corticosteroids, IV immunoglobulin, cyclosporine, and azathioprine. Contemporary outcomes of pediatric transplant recipients have improved over the past few decades, partly related to improvements in immunomodulatory therapy to prevent rejection of the donor heart. Immunosuppression therapy is commonly divided into induction, maintenance, and acute rejection therapy. Common induction medications include antithymocyte globulin, muromonab-CD3, and basiliximab. Maintenance therapy includes chronic medications that are used daily to prevent rejection episodes. Examples of maintenance medications are corticosteroids, cyclosporine, tacrolimus, sirolimus, everolimus, azathioprine, and mycophenolate mofetil. Rejection of the donor heart is diagnosed either by clinically or by biopsy and is treated with intensification of immunosuppression.
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