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Boucek R, Chinnock R, Scheel J, Deshpande SR, Urschel S, Kirklin J. Paediatric heart transplantation: life-saving but not yet a cure. Cardiol Young 2024; 34:233-237. [PMID: 38258454 DOI: 10.1017/s1047951123004146] [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] [Indexed: 01/24/2024]
Abstract
In the 1980s, heart transplantation was the first successful treatment for infants born with hypoplastic left heart syndrome. Infants who have required heart transplantation benefit from immunologic "advantages," including long-term survival free from cardiac allograft vasculopathy. Currently ∼ 90% of children undergoing a heart transplant are reaching their first-year anniversary and the clinical practices of paediatric heart transplantation have dramatically improved. These successes are largely attributed to research sponsored by the Pediatric Heart Transplant Study Group, the International Society of Heart and Lung Transplantation and, more recently, the Non-profits Enduring Hearts and Additional Ventures. Despite these successes, the field is challenged to increase progress to achieve long-term survival into adulthood. The wait-list mortality, especially among infants, is unacceptably high often leading to palliative measures that can increase post-transplant mortality. Cardiac allograft vasculopathy remains a major cause for progressive graft loss of function and sudden death. The relative tolerance seen in immature recipients has not been translated to modifying older recipients' post-transplant outcomes. The modifiable cause(s) for the increased risks of transplantation in children of different ethnicities and races require definition. Addressing these challenges faces the reality that for-profit research favours funding adult recipients, with ∼ 10-fold greater numbers, and their more modest longevity goals. Advocacy for funding "incentives" such as the Orphan Drug rules in the United States and upholding principles of equity and inclusion are critical to addressing the challenges of paediatric heart transplant recipients worldwide.
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Affiliation(s)
- Robert Boucek
- Enduring Hearts, Scientific Advisory Committee, Atlanta, GA, USA
| | | | - Janet Scheel
- Division of Cardiology, Saint Louis Children's Hospital, Saint Louis, MI, USA
| | - Shriprasad R Deshpande
- Pediatric Cardiology, Children's National Hospital Sheikh Zayed Campus for Advanced Children's Medicine, Washington, CO, USA
| | - Simon Urschel
- Stollery Children's Hospital, Walter McKenzie Center, University of Alberta, Edmonton, AB, Canada
| | - James Kirklin
- University of Alabama at Birmingham Center for Health Promotion, Birmingham, AL, USA
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Watelle L, Touré M, Lamour JM, Kemna MS, Spinner JA, Hoffman TM, Carlo WF, Ballweg JA, Greenway SC, Dallaire F. Single-drug immunosuppression is associated with noninferior medium-term survival in pediatric heart transplant recipients. J Heart Lung Transplant 2023; 42:1074-1081. [PMID: 36997361 DOI: 10.1016/j.healun.2023.02.1705] [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: 07/04/2022] [Revised: 02/08/2023] [Accepted: 02/25/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Patients are usually maintained on at least 2 immunosuppressive drugs (ISDs) after the first year post heart transplant. Anecdotally, some children are switched to single-drug monotherapy (a single ISD) for various reasons and varying durations. Outcomes associated with differences in immunosuppression after heart transplantation are unknown for children. OBJECTIVES A priori we defined a noninferiority hypothesis for monotherapy compared to ≥2 ISDs. The primary outcome was graft failure, a composite of death and retransplantation. Secondary outcomes included rejection, infection, malignancy, cardiac allograft vasculopathy and dialysis. METHODS This international, multicenter, retrospective, observational cohort study used data from the Pediatric Heart Transplant Society. We included patients who underwent first-time heart transplant <18 years of age between 1999 and 2020 with ≥1 year of follow-up data available. RESULTS Our analysis included 3493 patients with a median time post-transplant of 6.7 years. There were 893 patients (25.6%) switched to monotherapy at least once with the remaining 2600 patients always on ≥2 ISDs. The median time on monotherapy after the first year post-transplant was 2.8 years (range 1.1-5.9 years). We found an adjusted hazard ratio (HR) of 0.65 (95%CI: 0.47-0.88) favoring monotherapy compared to ≥2 ISDs (p = 0.002). There were no meaningful differences in the incidence of secondary outcomes between groups, except for a lower rate of cardiac allograft vasculopathy in patients on monotherapy (HR 0.58, 95%CI: 0.45-0.74). CONCLUSIONS For pediatric heart transplant recipients placed on monotherapy, immunosuppression with a single ISD after the first year post-transplant was noninferior to standard therapy with ≥2 ISDs in the medium term. CONDENSED ABSTRACT Some children are switched to a single immunosuppressive drug (ISD) for various reasons after heart transplant, but outcomes associated with differences in immunosuppression are unknown for children. We assessed graft failure in children on a single ISD (monotherapy) compared to ≥2 ISDs in a cohort of 3493 children with a first heart transplant. We found an adjusted hazard ratio of 0.65 (95%CI: 0.47-0.88) favoring monotherapy. We concluded that for pediatric heart transplant recipients placed on monotherapy, immunosuppression with a single ISD after the first year post-transplant was non-inferior to standard therapy with ≥2 ISDs in the medium term.
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Affiliation(s)
- Laurence Watelle
- Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Canada; Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Moustapha Touré
- Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Canada; Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Jacqueline M Lamour
- Division of Pediatric Cardiology, Children's Hospital at Montefiore/Albert Einstein College of Medicine, New York, New York
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Joseph A Spinner
- Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Timothy M Hoffman
- Division of Cardiology, Department of Pediatrics, University of North Carolina School of Medicine, University of North Carolina Children's Hospital, Chapel Hill, North Carolina
| | - Waldemar F Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jean A Ballweg
- The Cardiac Center at the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Steven C Greenway
- Department of Pediatrics and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cardiac Sciences and Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Frederic Dallaire
- Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Canada; Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada.
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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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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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Rosenthal LM, Nordmeyer J, Kramer P, Danne F, Pfitzer C, Berger F, Schmitt KRL, Schubert S. Long-term experience using CNI-free immunosuppression in selected paediatric heart transplant recipients. Pediatr Transplant 2021; 25:e14111. [PMID: 34405495 DOI: 10.1111/petr.14111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 06/19/2021] [Accepted: 07/29/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND CNI-free immunosuppression with conversion to mTORi-based immunosuppression has been demonstrated to reduce CNI-toxicity and to exhibit anti-proliferative properties. However, the experience of CNI-free immunosuppression in paediatric heart transplantation is limited. METHODS A retrospective analysis was conducted of 129 paediatric heart transplants performed between 1997 and 2015. Fifteen patients with clinically indicated conversion from CNI-based to CNI-free immunosuppression were identified. Survival data, rejection episodes, renal function, post-transplantation lymphoproliferative disorder and CAV, including examination with OCT were analysed. RESULTS Immunosuppression conversion was successful in all patients. Fourteen of 15 patients (93%) are currently living with good graft function. Median post-transplant survival was 15 years (range, 5-23 years), and median follow-up since conversion was 6 years (range, 1-11 years). Mild (grade 1R) ACR was present in three patients after discontinuation of CNIs. The recovery of renal function with a significant increase in eGFR was observed at 1 and 3 years after conversion. No patient had angiographic signs of macroscopic CAV according to the current ISHLT classification; however, OCT showed the signs of angiographically silent CAV in all patients. CAV did not progress in any patient, implying CAV was stabilised by mTORi-based CNI-free immunosuppression. CONCLUSIONS CNI-free immunosuppression based on mTORis is a safe and appropriate strategy for maintenance therapy in selected paediatric patients, significantly improves renal function and stabilises CAV. OCT revealed early development of angiographically silent CAV.
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Affiliation(s)
- Lisa-Maria Rosenthal
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany.,Department for Pediatric Cardiology, Charité Universitätsmedizin, Berlin, Germany
| | - Johannes Nordmeyer
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany
| | - Peter Kramer
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany
| | - Friederike Danne
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany
| | - Constanze Pfitzer
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany
| | - Felix Berger
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany.,Department for Pediatric Cardiology, Charité Universitätsmedizin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Katharina Rose Luise Schmitt
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany.,Department for Pediatric Cardiology, Charité Universitätsmedizin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Stephan Schubert
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Berlin, Germany.,Center of Congenital Heart Disease, Heart and Diabetes Center North Rhine-Westfalia (HDZ-NRW), Ruhr-University of Bochum, Bad Oeynhausen, Germany
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