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Peters AL, Perito ER. Freedom isn't free: Assessing the risks and benefits of steroid-free immunosuppression regimens in pediatric liver transplantation in a real-world setting. Liver Transpl 2024; 30:242-243. [PMID: 38009913 DOI: 10.1097/lvt.0000000000000307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 11/29/2023]
Affiliation(s)
- Anna L Peters
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Emily R Perito
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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Raghu VK, Zhang X, Squires JE, Eisenberg E, Feldman AG, Halma J, Peters AL, Gonzalez-Peralta RP, Ng VL, Horslen SP, Lobritto SJ, Bucuvalas J, Mazariegos GV, Perito ER. Impact of early immunosuppression on pediatric liver transplant outcomes within 1 year. J Pediatr Gastroenterol Nutr 2024; 78:328-338. [PMID: 38374561 PMCID: PMC11017216 DOI: 10.1002/jpn3.12112] [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: 04/27/2023] [Revised: 08/15/2023] [Accepted: 09/26/2023] [Indexed: 02/21/2024]
Abstract
OBJECTIVES The Starzl Network for Excellence in Pediatric Transplantation identified optimizing immunosuppression (IS) as a priority practice improvement area for patients, families, and providers. We aimed to evaluate associations between clinical characteristics, early IS, and outcomes. METHODS We analyzed pediatric liver transplant (LT) data from 2013 to 2018 in the United Network for Organ Sharing (UNOS) and the Society of Pediatric Liver Transplantation (SPLIT) registries. RESULTS We included 2542 LT recipients in UNOS and 1590 in SPLIT. IS choice varied between centers with steroid induction and mycophenolate mofetil (MMF) use each ranging from 0% to 100% across centers. Clinical characteristics associated with early IS choice were inconsistent between the two data sets. T-cell depleting antibody use was associated with improved 1-year graft (hazard ratio [HR] 0.50, 95% confidence interval [CI] 0.34-0.76) and patient (HR 0.40, 95% CI 0.20-0.79) survival in UNOS but decreased 1-year patient survival (HR 4.12, 95% CI 1.31-12.93) and increased acute rejection (HR 1.58, 95% CI 1.07-2.34) in SPLIT. Non-T-cell depleting antibody use was not associated with differential risk of survival nor rejection. MMF use was associated with improved 1-year graft survival (HR 0.73, 95% CI 0.54-0.99) in UNOS only. CONCLUSIONS Variation exists in center choice of early IS regimen. UNOS and SPLIT data provide conflicting associations between IS and outcomes in multivariable analysis. These results highlight the need for future multicenter collaborative work to identify evidence-based IS best practices.
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Affiliation(s)
- Vikram K Raghu
- Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Xingyu Zhang
- Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania, USA
| | - James E Squires
- Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elizabeth Eisenberg
- Patient and Family Voice, Starzl Network for Excellence in Pediatric Transplantation, Pittsburgh, Pennsylvania, USA
| | - Amy G Feldman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jennifer Halma
- Division of Gastroenterology, Hepatology, and Nutrition, Stanford Medicine Children's Health, Palo Alto, California, USA
| | - Anna L Peters
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Vicky L Ng
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Simon P Horslen
- Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steven J Lobritto
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital, New York, New York, USA
| | - John Bucuvalas
- Mount Sinai Kravis Children's Hospital and Recanati/Miller Transplantation Institute, Mount Sinai Health System, New York, New York, USA
| | | | - Emily R Perito
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of California San Francisco, San Francisco, California, USA
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Ewing CB, Farnan S, Squires JE, Raghu VK. Association Between Perioperative Costs and Induction Immunosuppression in Pediatric Liver Transplant Recipients. J Pediatr Gastroenterol Nutr 2023; 76:634-639. [PMID: 36735593 PMCID: PMC10415975 DOI: 10.1097/mpg.0000000000003728] [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] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The objectives of this study was to describe variation in induction regimen, identify predictors of induction immunosuppression (IS) choice, and examine the impact of induction IS regimen on length of stay (LOS) and total perioperative costs in pediatric liver transplant recipients. METHODS We analyzed liver transplant utilization data in the Pediatric Health Information System database. Patients were divided into 3 induction IS groups: (1) steroids only, (2) T-cell depleting antibody (TDA), and (3) non-TDA. We identified predictors of induction IS regimen and examined associations between each outcome and choice of induction IS. RESULTS We analyzed 4905 liver transplant recipients (50% female, 80% under age 13 years, 42% non-Hispanic White). Most patients (3162, 64%) received steroids only induction, and about twice as many patients received a non-TDA regimen (1093, 22%) versus a TDA regimen (650, 13%). Median total perioperative costs were highest for the TDA group [$146,438 (interquartile range $113,461-$195,575)] versus the non-TDA group [$129,307 ($102,632-$173,953)] and the steroids only group ($127,049 ($98,814-$181,053)]. Compared to steroids only induction, TDA was associated with increased LOS (+2 days, P = 0.017) with no difference in cost. Non-TDA induction was associated with a decreased LOS (-3 days, P < 0.001) and increased cost (+$42,542; P < 0.001) independent of LOS. CONCLUSIONS Compared to a steroids only induction IS regimen, non-TDA induction was associated with increased total perioperative costs, even after adjustments for LOS. Future work will combine cost and outcome data to provide decision-making support in pediatric liver transplant recipients.
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Affiliation(s)
- Caroline B. Ewing
- Department of Medicine, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Sheila Farnan
- Division of Pediatric Research, Mayo Clinic, Rochester, MN
| | - James E. Squires
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Vikram K. Raghu
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
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