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Pediatric transplantation
1Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania, USA. reyesj@chplink.chp.edu
Insights
Pediatric liver transplantation has advanced significantly, improving outcomes for children with chronic liver disease. Future strategies focus on enhancing allograft acceptance through leukocyte migration and bone marrow cell infusion.
Area of Science:
- Pediatric Surgery
- Immunology
- Transplantation Medicine
Background:
- Pediatric liver transplantation has evolved due to improvements in organ preservation, surgical techniques, and postoperative care.
- The procedure now addresses not only life-threatening conditions but also quality-of-life issues in children.
- Reduced-size grafts and living donors have decreased mortality for children awaiting liver transplants.
Purpose of the Study:
- To review the advancements in pediatric liver transplantation.
- To discuss the role of immunosuppression and allograft acceptance mechanisms.
- To explore future directions in transplantation, including intestinal transplantation.
Main Methods:
- Review of advancements in organ preservation, surgical techniques, and postoperative care.
- Discussion of the impact of reduced/split grafts and living donors.
- Analysis of the role of tacrolimus and passenger leukocytes in allograft acceptance.
Main Results:
- Pediatric liver transplantation has expanded its applicability beyond end-stage liver disease.
- Tacrolimus is a potent immunosuppressive drug enhancing transplant success.
- Understanding leukocyte migration is key to allograft acceptance.
Conclusions:
- Future liver transplantation will involve manipulating leukocyte traffic and bone marrow cell infusion for enhanced allograft acceptance.
- Intestinal transplantation is a developing frontier.
- Combined immunosuppression with tacrolimus and prednisone shows promise for future strategies.
Abstract:
Advances in organ preservation, surgical technique, and postoperative care have permitted the rapid development of liver transplantation in children. Consequently, the applicability of this procedure has gone beyond the treatment of life-threatening complications of chronic liver disease and now includes disabling morbidities and quality-of-life issues. The use of hepatic segments for transplantation with reduced or split cadaveric grafts and living-related donors has decreased the mortality of children awaiting liver transplantation. We are presently armed with a new potent immunosuppressive drug, tacrolimus, and an understanding that the migration and grafting of passenger leukocytes of bone marrow origin is the seminal explanation for allograft acceptance. The next forefront will involve manipulation of the process not only for the transplantation of already successful whole organs--such as the liver, kidney, pancreas, and heart--but also in the development of the intestinal transplantation program. Thus, augmentation of leukocyte traffic in unconditioned recipients of cadaver allografts with concomitant intravenous infusion of donor bone marrow cells under the same immunosuppressive management of tacrolimus-prednisone treatment will be the path into the future.