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Pediatric cardiac retransplant: differing patterns of primary graft failure by age at first transplant
John M Karamichalis1, Shelley D Miyamoto, David N Campbell
1The Children's Hospital Heart Institute, Aurora, Colo 80045, USA.
Insights
Infants receiving heart transplants have better initial graft survival than older children, but face more cardiac allograft vasculopathy. Older children experience more rejection, leading to earlier graft failure.
Area of Science:
- Pediatric Cardiology
- Transplant Immunology
- Immunosuppression
Background:
- Pediatric heart transplantation is a life-saving procedure for end-stage heart failure.
- Graft failure necessitates retransplantation, impacting long-term outcomes.
- Age at initial heart transplant may influence graft survival and failure modes.
Purpose of the Study:
- To compare graft failure and retransplant outcomes in infants versus older children after initial heart transplant.
- To identify differences in rejection episodes and graft survival between infant and pediatric heart transplant recipients.
Main Methods:
- Retrospective comparison of 26 retransplant recipients.
- Stratification into infant (<1 year) and pediatric (≥1 year) groups at initial transplant.
- Analysis of graft survival, rejection episodes, and retransplant indications.
Main Results:
- Infants had longer median first graft survival (10.7 vs 3.9 years) and fewer rejection episodes.
- Pediatric recipients showed higher rates of first graft rejection (4.8 vs 3.1 episodes).
- Cardiac allograft vasculopathy was more prevalent in infants (73% vs 20%), while rejection was the primary retransplant indication in older children (91% vs 40%).
Conclusions:
- Infant heart transplant recipients exhibit superior primary graft survival due to immune system advantages.
- Longer graft survival in infants is ultimately limited by a higher incidence of cardiac allograft vasculopathy.
- Graft failure in older pediatric recipients is predominantly rejection-related, potentially limiting cardiac allograft vasculopathy development.
Objective:
This study compared graft failure leading to retransplant in infants versus older children at initial heart transplant.
Methods:
Twenty-six retransplant recipients were compared by age at first transplant: infant group (<1 year) and pediatric group (≥1 year).
Results:
Early retransplant survival was 92%. Retransplant survivals at 1, 3, and 5 years were 83%, 74%, and 67%. There were 15 infant and 11 pediatric patients. First transplant ages were 0.4 ± 0.3 vs. 8.5 ± 5.7 years in infant and pediatric groups, respectively (P < .01). First graft rejection episodes were more common in pediatric group (4.8 ± 2.5 vs 3.1 ± 2.1, P = .032), and rejection rate was higher (1.5 ± 1.1 vs 0.4 ± 0.4, P = .0024). Median first graft survival was longer in infant group (10.7 years vs 3.9 years, P < .001). Recurrent cellular rejection was retransplant indication in 40% of infant group versus 91% of pediatric group (P < .05). Cardiac allograft vasculopathy was more prevalent in infant group (73% vs 20% in pediatric group, P = .032).
Conclusions:
Infant heart transplant recipients had longer primary graft survival, fewer cellular rejection episodes, and higher incidence of cardiac allograft vasculopathy relative to older graft recipients requiring retransplant. Advantages in adaptive immunity in infant heart recipients confer improved primary graft survival, but longer graft life in these patients is limited by cardiac allograft vasculopathy. Older recipient first graft failure was rejection related, and shorter graft life probably limited development of cardiac allograft vasculopathy.
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