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Published on: October 31, 2012
Pediatric cardiac transplantation in children with high panel reactive antibody
Jeffrey P Jacobs1, James A Quintessenza, Robert J Boucek
1The Congenital Heart Institute of Florida, All Children's Hospital, University of South Florida, St. Petersburg, Florida, USA. jeffjacobs@msn.com
Insights
Pediatric heart transplantation for children with high panel reactive antibodies (PRA) is possible but carries significant risks. Aggressive immunosuppression strategies are necessary, yet overall mortality remains elevated in this high-risk group.
Area of Science:
- Pediatric Cardiology
- Transplantation Immunology
- Congenital Heart Disease
Background:
- Elevated panel reactive antibody (PRA) is a significant risk factor for pediatric heart transplantation.
- This study retrospectively analyzes management and outcomes for children with high PRA (>10%) undergoing heart transplantation.
Purpose of the Study:
- To evaluate the efficacy of modified immunosuppression strategies in pediatric heart transplantation recipients with elevated PRA.
- To compare outcomes between pediatric heart transplant recipients with and without elevated PRA.
Main Methods:
- Retrospective review of 60 pediatric heart transplant recipients, categorized by elevated (Group P, n=8) and non-elevated (Group N, n=52) PRA.
- Modified immunosuppression in Group P included preoperative IVIG, cyclophosphamide/mycophenolate mofetil, and exchange transfusions/plasmapheresis.
- Standard immunosuppression involved pulse steroids, gamma globulin, and polyclonal rabbit antithymocyte globulin, with a calcineurin inhibitor and antiproliferative agent.
Main Results:
- Group P patients were older and heavier; diagnoses included HLHS and CCHD.
- Thirty-day mortality was 25% in Group P versus 7.9% in Group N (p=0.178).
- Overall mortality was significantly higher in Group P (50%) compared to Group N (15.4%) (p=0.043).
Conclusions:
- Heart transplantation offers a survival chance for children with end-stage heart failure and elevated PRA.
- Despite aggressive immunosuppression, pediatric heart transplant recipients with elevated PRA remain at high risk for mortality.
Background:
Elevated panel reactive antibody (PRA) may be considered a risk factor precluding pediatric orthotopic heart transplantation. We retrospectively reviewed our management strategy and outcome data for children undergoing heart transplantation with high PRA (> 10%).
Methods:
Sixty consecutive children (median age = 130.5 days) underwent heart transplantation. Diagnoses included hypoplastic left heart syndrome (HLHS) (30 patients), cardiomyopathy (18 patients), and postoperative complex congenital heart disease (CCHD) (12 patients). Standard induction immunosuppressive therapy included pulse steroids, gamma globulin, and polyclonal rabbit antithymocyte globulin. Initial immunosuppression is a calcinurin inhibitor and an antiproliferative agent. Eight children exhibited elevated PRA (group P). Fifty-two exhibited nonelevated PRA (group N). Immunosuppression was modified in group P as follows: preoperative intravenous immunoglobulin G (IVIG) and/or cyclophosphamide or mycophenolate mofetil and preoperative and postoperative exchange transfusions or plasmapheresis. In group P, cyclophosphamide was the initial antiproliferative agent.
Results:
Group P = 4 HLHS patients (all status post [s/p] prior cardiac surgery) and 4 postoperative CCHD patients. Group N = 26 HLHS patients (4 patients s/p prior cardiac surgery), 18 cardiomyopathy patients, and 8 postoperative CCHD patients. Group P patients were older and weighed more than group N patients. Waiting time for donor heart, cardiac ischemic time, and length of hospital stay were similar in both groups. Thirty-day mortality for group P was 25% and for group N it was 7.9% (p = 0.178). Overall mortality for group P was 50% and for group N it was 15.4% (p = 0.043).
Conclusions:
Although heart transplantation can offer children with end-stage heart failure and elevated PRA their only chance of survival, these patients remain high risk despite aggressive immunosuppression.
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