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Published on: November 7, 2020
Impact of early immunosuppression on pediatric liver transplant outcomes within 1 year
Vikram K Raghu1, Xingyu Zhang2, James E Squires1
1Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Insights
Optimizing immunosuppression after pediatric liver transplants is crucial. Early immunosuppression choices varied by center, with conflicting outcomes data between registries, highlighting the need for collaborative research on best practices.
Area of Science:
- Pediatric transplantation
- Immunosuppression therapy
- Graft survival
Background:
- Optimizing immunosuppression (IS) is a priority for pediatric transplantation.
- Early IS regimens vary significantly across transplant centers.
- Understanding IS impact on outcomes is critical for patients and providers.
Purpose of the Study:
- To evaluate associations between clinical characteristics, early IS, and outcomes in pediatric liver transplant (LT) recipients.
- To analyze data from two major pediatric LT registries to identify trends and discrepancies.
Main Methods:
- Analysis of pediatric LT data from 2013-2018 using the United Network for Organ Sharing (UNOS) and Society of Pediatric Liver Transplantation (SPLIT) registries.
- Inclusion of 2542 LT recipients in UNOS and 1590 in SPLIT.
- Multivariable analysis to assess the impact of early IS choices on graft survival, patient survival, and acute rejection.
Main Results:
- Significant variation in IS choices (steroid induction, mycophenolate mofetil [MMF]) observed across centers.
- T-cell depleting antibody use showed conflicting associations: improved survival in UNOS, but decreased survival and increased rejection in SPLIT.
- MMF use was associated with improved 1-year graft survival in UNOS data only.
Conclusions:
- Center-specific variations in early IS regimens are evident.
- Conflicting associations between IS and outcomes were found between UNOS and SPLIT registries.
- Multicenter collaborative efforts are essential to establish evidence-based IS best practices in pediatric transplantation.
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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