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Hurst DJ, Padilla L, Merlocco A, Rodger D, Bobier C, Gray WH, Sorabella R, Cooper DKC, Pierson RN. Pediatric Cardiac Xenotransplantation: Recommendations for the Ethical Design of Clinical Trials. Transplantation 2024; 108:e292-e300. [PMID: 38419158 DOI: 10.1097/tp.0000000000004968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
For children with complex congenital heart problems, cardiac allotransplantation is sometimes the best therapeutic option. However, availability of hearts for pediatric patients is limited, resulting in a long and growing waitlist, and a high mortality rate while waiting. Cardiac xenotransplantation has been proposed as one therapeutic alternative for neonates and infants, either in lieu of allotransplantation or as a bridge until an allograft becomes available. Scientific and clinical developments in xenotransplantation appear likely to permit cardiac xenotransplantation clinical trials in adults in the coming years. The ethical issues around xenotransplantation of the heart and other organs and tissues have recently been examined, but to date, only limited literature is available on the ethical issues that are attendant with pediatric heart xenotransplantation. Here, we summarize the ethical issues, focusing on (1) whether cardiac xenotransplantation should proceed in adults or children first, (2) pediatric recipient selection for initial xenotransplantation trials, (3) special problems regarding informed consent in this context, and (4) related psychosocial and public perception considerations. We conclude with specific recommendations regarding ethically informed design of pediatric heart xenotransplantation trials.
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Affiliation(s)
- Daniel J Hurst
- Department of Family Medicine, Rowan-Virtua School of Osteopathic Medicine, Stratford, NJ
| | - Luz Padilla
- Department of Surgery, Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - Anthony Merlocco
- Department of Cardiology, University of Tennessee Health Science Center, Memphis, TN
| | - Daniel Rodger
- Institute of Health and Social Care, School of Allied and Community Health, London South Bank University, London, United Kingdom
- Department of Psychological Sciences, Birkbeck College, University of London, London, United Kingdom
| | - Christopher Bobier
- Department of Theology and Philosophy, Saint Mary's University of Minnesota, Winona, MN
| | - William H Gray
- Department of Surgery, Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - Robert Sorabella
- Department of Surgery, Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MN
| | - Richard N Pierson
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MN
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Costaguta AC, Costaguta GA, Rumbo C, Gondolesi G, D'Agostino D, Pallitto MB, Bottasso O, Álvarez F. Lack of differences in outcomes between 3 immunosuppression protocols in the first year after pediatric liver transplantation: A multicenter study. Liver Transpl 2024:01445473-990000000-00409. [PMID: 38949782 DOI: 10.1097/lvt.0000000000000427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 06/17/2024] [Indexed: 07/02/2024]
Abstract
Advances in immunosuppression have extended patient and graft survival rates after solid organ transplantation; however, this is not free of side effects. Balancing safety and efficacy is of paramount importance, particularly in the pediatric setting. Current literature comparing different protocols is scarce, and decisions are mostly guided by physician preference. We aimed to compare 3 different protocols from 4 different centers to identify differences in outcomes after 1 year of follow-up. A retrospective analysis of the databases of the participating centers was performed. Consecutive patients aged <18 years with a first liver-only transplant and no other underlying congenital or acquired immunodeficiency were included. Patients were classified according to the immunosuppression protocol as follows: group A (prednisone + tacrolimus + basiliximab), group B (prednisone + tacrolimus + basiliximab + antithymocyte globulin), and group C (prednisone + tacrolimus). Differences in survival, frequency of rejection, infections, and other complications were analyzed in the entire group (n = 97) and the group with biliary atresia (n = 48). After 1 year of follow-up, no differences in patient or graft survival were observed when comparing either the entire group (n = 97) or patients with biliary atresia only (n = 48). The frequencies of rejection and episodes of infection were similar. Renal function showed no differences either before or after transplantation or between the groups. Immunosuppression protocols used in this study appeared to be equally safe and effective. This could offer the opportunity to tailor them to the patient's individual characteristics without compromising the outcome.
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Affiliation(s)
- Alejandro C Costaguta
- Liver Transplantation Unit of the Sanatorio de Niños de Rosario, Rosario, Santa Fe, Argentina
| | - Guillermo A Costaguta
- Department of Gastroenterology, Hepatology and Nutrition of CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Carolina Rumbo
- Department Hepatology and Liver Transplantation Unit, University Hospital Fundación Favaloro, CABA, Buenos Aires, Argentina
| | - Gabriel Gondolesi
- Department Hepatology and Liver Transplantation Unit, University Hospital Fundación Favaloro, CABA, Buenos Aires, Argentina
| | - Daniel D'Agostino
- Department of Gastroenterology and Hepatology, Hospital Italiano, CABA, Buenos Aires, Argentina
| | - María Belén Pallitto
- Department of Gastroenterology and Hepatology, Hospital Italiano, CABA, Buenos Aires, Argentina
| | - Oscar Bottasso
- Immunology Department, IDICER-CONICET, Rosario, Argentina
| | - Fernando Álvarez
- Department of Gastroenterology, Hepatology and Nutrition of CHU Sainte-Justine, Montreal, Quebec, Canada
- Department of Pediatrics, Montreal's University, Montreal, Quebec, Canada
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Yeh H. Moving the Goalpost: From "Alive" to "Ideal". Transplantation 2023; 107:1667-1668. [PMID: 36814092 DOI: 10.1097/tp.0000000000004557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Affiliation(s)
- Heidi Yeh
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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Morath C, Schmitt A, Kälble F, Zeier M, Schmitt M, Sandra-Petrescu F, Opelz G, Terness P, Schaier M, Kleist C. Cell therapeutic approaches to immunosuppression after clinical kidney transplantation. Pediatr Nephrol 2018; 33:199-213. [PMID: 28229281 DOI: 10.1007/s00467-017-3599-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 01/06/2017] [Accepted: 01/09/2017] [Indexed: 12/11/2022]
Abstract
Refinement of immunosuppressive strategies has led to further improvement of kidney graft survival in recent years. Currently, the main limitations to long-term graft survival are life-threatening side effects of immunosuppression and chronic allograft injury, emphasizing the need for innovative immunosuppressive regimens that resolve this therapeutic dilemma. Several cell therapeutic approaches to immunosuppression and donor-specific unresponsiveness have been tested in early phase I and phase II clinical trials in kidney transplantation. The aim of this overview is to summarize current cell therapeutic approaches to immunosuppression in clinical kidney transplantation with a focus on myeloid suppressor cell therapy by mitomycin C-induced cells (MICs). MICs show great promise as a therapeutic agent to achieve the rapid and durable establishment of donor-unresponsiveness in living-donor kidney transplantation. Cell-based therapeutic approaches may eventually revolutionize immunosuppression in kidney transplantation in the near future.
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Affiliation(s)
- Christian Morath
- Division of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany.
| | - Anita Schmitt
- Department of Internal Medicine V, GMP Core Facility, University of Heidelberg, Heidelberg, Germany
| | - Florian Kälble
- Division of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | - Martin Zeier
- Division of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | - Michael Schmitt
- Department of Internal Medicine V, GMP Core Facility, University of Heidelberg, Heidelberg, Germany
| | - Flavius Sandra-Petrescu
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany.,Department of Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Gerhard Opelz
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany
| | - Peter Terness
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany
| | - Matthias Schaier
- Division of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | - Christian Kleist
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany.,Department of Radiology, Division of Nuclear Medicine, University of Heidelberg, Heidelberg, Germany
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Kullberg-Lindh C, Saalman R, Olausson M, Herlenius G, Lindh M. Epstein-Barr virus DNA monitoring in serum and whole blood in pediatric liver transplant recipients who do or do not discontinue immunosuppressive therapy. Pediatr Transplant 2017; 21. [PMID: 28039929 DOI: 10.1111/petr.12875] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2016] [Indexed: 12/17/2022]
Abstract
The rate of PTLD can be reduced by weaned IS guided by monitoring of EBV DNA. In this single-center retrospective case series study, we analyzed how reduction in IS influenced EBV DNA levels in whole blood and serum in 30 children during the first year after liver transplantation, and how these levels were related to symptoms putatively due to EBV. Primary and reactivated EBV infection was seen in 18 (60%) and eight patients (27%), respectively. Thirteen patients (42%) developed chronic high load the first year post-transplant. IS was successfully discontinued in six patients the first year post-transplant and in another two patients within 3 years. EBV DNA levels were reduced, but persisted long term in all the eight patients who had IS completely withdrawn. There was no case of PTLD. In summary, EBV DNAemia and chronic high load were very common after pediatric liver transplantation. Liver graft tolerance facilitates radical reduction in IS treatment, which may prevent PTLD, but EBV DNAemia may persist long term after discontinued IS.
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Affiliation(s)
- C Kullberg-Lindh
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - R Saalman
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Olausson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - G Herlenius
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Lindh
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Borst AJ, Wechsler DS. Transplanting One Problem for Another. Pediatrics 2017; 139:peds.2017-0542. [PMID: 28557771 PMCID: PMC5841458 DOI: 10.1542/peds.2017-0542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Alexandra J. Borst
- Pediatric Hematology-Oncology, Duke University Medical Center, Durham, North Carolina
| | - Daniel S. Wechsler
- Address correspondence to Daniel S. Wechsler, MD, PhD, Pediatric Hematology-Oncology, Duke University Medical Center, 397 Hanes House, DUMC Box 102382, Durham, NC 27710. E-mail:
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Pan H, Gazarian A, Dubernard JM, Belot A, Michallet MC, Michallet M. Transplant Tolerance Induction in Newborn Infants: Mechanisms, Advantages, and Potential Strategies. Front Immunol 2016; 7:116. [PMID: 27092138 PMCID: PMC4823304 DOI: 10.3389/fimmu.2016.00116] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 03/14/2016] [Indexed: 12/26/2022] Open
Abstract
Although several tolerance induction protocols have been successfully implemented in adult renal transplantation, no tolerance induction approach has, as yet, been defined for solid organ transplantations in young infants. Pediatric transplant recipients have a pressing demand for the elaboration of tolerance induction regimens. Indeed, since they display a longer survival time, they are exposed to a higher level of risks linked to long-term immunosuppression (IS) and to chronic rejection. Interestingly, central tolerance induction may be of great interest in newborns, because of their immunological immaturity and the important role of the thymus at this early stage in life. The present review aims to clarify mechanisms and strategies of tolerance induction in these immunologically premature recipients. We first introduce the discovery and mechanisms of neonatal tolerance in murine experimental models and subsequently analyze tolerance induction in human newborn infants. Hematopoietic mixed chimerism in neonates is also discussed based on in utero hematopoietic stem cell (HSC) transplant studies. Then, we review the recent advances in tolerance induction approaches in adults, including the infusion of HSCs associated with less toxic conditioning regimens, regulatory T cells/facilitating cells/mesenchymal stem cells transplantation, costimulatory blockade, and thymus manipulation. Finally, IS withdrawal in pediatric solid organ transplant is discussed. In conclusion, the establishment of transplant tolerance induction in infants is promising and deserves further investigations. Future studies could focus on the selection of patients, on less toxic conditioning regimens, and on biomarkers for IS minimization or withdrawal.
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Affiliation(s)
- Hua Pan
- Chair of Transplantation, VetAgro Sup-Campus Vétérinaire de Lyon, Marcy l'Etoile, France; Plastic and Reconstructive Surgery Department, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Aram Gazarian
- Chair of Transplantation, VetAgro Sup-Campus Vétérinaire de Lyon, Marcy l'Etoile, France; Department of Hand Surgery, Clinique du Parc, Lyon, France
| | - Jean-Michel Dubernard
- Chair of Transplantation, VetAgro Sup-Campus Vétérinaire de Lyon, Marcy l'Etoile, France; Department of Transplantation, Hôpital Edouard Herriot, Lyon, France
| | - Alexandre Belot
- International Center for Infectiology Research (CIRI), Université de Lyon , Lyon , France
| | - Marie-Cécile Michallet
- Chair of Transplantation, VetAgro Sup-Campus Vétérinaire de Lyon, Marcy l'Etoile, France; Cancer Research Center Lyon (CRCL), UMR INSERM 1052 CNRS 5286, Centre Leon Berard, Lyon, France
| | - Mauricette Michallet
- Chair of Transplantation, VetAgro Sup-Campus Vétérinaire de Lyon, Marcy l'Etoile, France; Department of Hematology, Centre Hospitalier Lyon-Sud, Pierre Benite, France
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The Changing Landscape for Paediatric Regulation of Pharmaceutical Agents with a Focus on Antifungal Agents. CURRENT FUNGAL INFECTION REPORTS 2016. [DOI: 10.1007/s12281-016-0247-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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