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Paediatric cardiac transplantation with steroid-sparing maintenance immunosuppression
J Au1, J W Gregory, I W Colquhoun
1Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle upon Tyne.
Insights
Steroid-sparing immunosuppression in pediatric heart transplant patients successfully reduced steroid use and rejection episodes. This approach also led to significant catch-up growth, improving long-term outcomes.
Area of Science:
- Pediatric Cardiology
- Immunosuppression Therapy
- Organ Transplantation
Background:
- Orthotopic heart transplantation (OHT) is a life-saving procedure for children with end-stage heart failure.
- Long-term immunosuppression is crucial but can lead to significant side effects, including growth impairment.
- Steroid-based regimens are common but associated with adverse outcomes in pediatric OHT recipients.
Purpose of the Study:
- To evaluate the efficacy and safety of a steroid-sparing maintenance immunosuppression protocol in pediatric patients after OHT.
- To assess the impact of this regimen on rejection rates, long-term complications, and growth.
- To determine the feasibility of reducing steroid exposure in this vulnerable population.
Main Methods:
- Retrospective study of 12 children and five infants undergoing OHT.
- Induction immunosuppression included cyclosporine, azathioprine, methylprednisolone, and antihuman lymphocyte immune globulin.
- Maintenance immunosuppression focused on cyclosporine and azathioprine, with minimal or no steroid use.
Main Results:
- Five patients were completely weaned off steroids post-induction; others required minimal steroid pulses for rejection (0.51 episodes/patient year).
- Long-term complications included hypertension (6 patients) and renal impairment (3 patients).
- Actuarial survival was 94% at one year, with no infection-related deaths. All patients followed for >1 year showed improved height SD scores.
Conclusions:
- A steroid-sparing maintenance immunosuppression regimen is effective and safe in pediatric OHT.
- This approach can significantly reduce steroid-related complications and promote catch-up growth.
- Steroid minimization should be considered in pediatric heart transplant protocols to improve long-term patient outcomes.
Abstract:
In order to determine the results of steroid-sparing maintenance immunosuppression in paediatric patients who have undergone orthotopic heart transplantation (OHT), a retrospective study was undertaken in 12 children and five infants (median age 3.5 years). Preoperative diagnoses were cardiomyopathy in seven and congenital heart disease in 10 patients. Immunosuppression was induced by cyclosporin, azathioprine, methylprednisolone, and antihuman lymphocyte immune globulin. It was maintained with cyclosporin and azathioprine. After induction, five patients received no further steroids. The remainder, except one, required only pulses for rejection (13 episodes or 0.51 episodes/patient year). Long term complications included hypertension in six, and renal impairment in three children. There were no early or late deaths from infection. Actuarial survival was 94% at one year. Of the children followed up for more than one year, all demonstrated an increase in height SD scores (mean (SD) -2.15 (1.35) to -1.15 (1.16)). We conclude that a steroid-sparing maintenance immunosuppression regimen can be successfully employed in paediatric OHT, and that significant catch-up growth can be achieved postoperatively.