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Triple-drug immunosuppression for heart transplantation in infants and children
J W Brown1, M W Turrentine, K A Kesler
1Department of Surgery, Riley Hospital for Children, Indiana University Medical Center, Indianapolis 46202-5125.
Insights
Triple-drug immunosuppression using OKT3 induction effectively prevents rejection in pediatric heart transplant recipients. Major concerns like infections and lymphoproliferative disease were not significantly realized in this study.
Area of Science:
- Pediatric Cardiology
- Transplantation Immunology
- Immunosuppression Therapy
Background:
- Pediatric cardiac transplantation is complex, requiring effective immunosuppression to prevent rejection.
- Concerns exist regarding side effects of potent immunosuppression, including infections and lymphoproliferative disorders.
Purpose of the Study:
- To evaluate the efficacy and safety of triple-drug immunosuppression with OKT3 induction for rejection prophylaxis in pediatric cardiac allograft recipients.
- To assess the incidence of adverse events such as lymphoproliferative disease, growth retardation, and opportunistic infections.
Main Methods:
- Retrospective analysis of 34 pediatric patients undergoing orthotopic heart transplantation between June 1986 and the study period.
- Patients received triple-drug immunosuppression with OKT3 induction therapy.
- Follow-up included assessment of rejection episodes, infections, lymphoproliferative disease, and growth parameters.
Main Results:
- A survival rate of 76% was observed after a mean follow-up of 33 months.
- Only two deaths were attributed to allograft rejection in patients not receiving maintenance steroids or routine biopsies.
- The incidence of cytomegalovirus infection was low (4%), and two cases of lymphoproliferative disease occurred, one fatal.
- Survivors showed satisfactory growth, and concerns regarding widespread opportunistic infections were not realized.
Conclusions:
- Triple-drug immunosuppression with OKT3 induction is an effective strategy for rejection prophylaxis in pediatric heart transplant recipients.
- The regimen appears safe, with a low incidence of serious adverse events compared to initial concerns.
- Careful monitoring and appropriate management are crucial, especially in specific patient subgroups.
Abstract:
Triple-drug immunosuppression with OKT3 induction is effective rejection prophylaxis in pediatric cardiac allograft recipients. The concerns regarding prevalent lymphoproliferative disease, growth retardation, cytomegalovirus, and other opportunistic infections have not been realized. Since June 1986, 34 pediatric patients, 23 males and 11 females, (age 4 days to 15 years) have undergone orthotopic heart transplantation at our institution. Fifteen patients were less than 6 months old and 13 had type I or II hypoplastic left heart syndrome. There have been four (12%) operative and four (12%) late deaths and a survival rate of 76% after a mean follow-up of 33 months (range, 1 to 82 months). The only deaths attributed to allograft rejection occurred in two newborn recipients (2 and 10 months after surgery) who neither received maintenance steroids nor underwent routine biopsy. The only death from infection (pneumococcus) occurred 6 months after surgery in a 4-year-old patient who was not known to be asplenic. Of the 27 long-term (> 1 year) survivors, 17 (68%) had an average of two rejection episodes during the follow-up period, 10 patients (32%) have been free of graft rejection, and 26 patients (96%) have not experienced a cytomegalovirus infection despite OKT3 induction therapy. Two patients developed lymphoproliferative disease, one of whom was successfully treated by transient reduction of immunosuppression. The other patient died 13 months after transplantation of a lymphoma of the central nervous system. All survivors have demonstrated satisfactory increases in mean height and weight.(ABSTRACT TRUNCATED AT 250 WORDS)