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Lung retransplantation in children
C B Huddleston1, E N Mendeloff, A H Cohen
1Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis Children's Hospital, USA. huddleston_c@a1.kids.wustl.edu
Insights
Lung retransplantation in children is a viable option for severe graft dysfunction, offering a chance for survival. Living donor transplants in older children may improve outcomes despite higher risks.
Area of Science:
- Pediatric surgery
- Thoracic surgery
- Transplantation immunology
Background:
- Lung transplantation in children can fail early due to reperfusion injury or late from bronchiolitis obliterans.
- Graft failure can lead to worsening pulmonary dysfunction and recipient death, often necessitating retransplantation.
- While adult lung retransplantation outcomes are established, pediatric data is less defined.
Purpose of the Study:
- To review the outcomes of lung retransplantation in pediatric patients.
- To compare retransplantation procedures with primary lung transplants in children.
- To evaluate the impact of donor type (living related vs. cadaveric) on retransplantation success.
Main Methods:
- Retrospective review of 136 pediatric lung transplant procedures.
- Analysis of 14 pediatric lung retransplantations, including 6 for early graft failure and 8 for bronchiolitis obliterans.
- Comparison of operative data (bypass time, blood transfusion) and survival rates between primary and retransplant procedures.
Main Results:
- Actuarial survival at 2 years post-retransplantation was 58%, with 3 early and 3 late deaths.
- Retransplantation involved longer cardiopulmonary bypass times and greater blood transfusion volumes compared to primary transplants.
- Living related donor lung retransplants demonstrated significantly shorter ischemic times than cadaveric donor transplants.
Conclusions:
- Lung retransplantation is a reasonable therapeutic option for children with severe graft dysfunction.
- Living donor lung transplantation in older children may offer advantages for retransplantation.
- Further research is needed to optimize outcomes and mitigate risks associated with pediatric lung retransplantation.
Background:
Early primary graft failure due to reperfusion injury may occur in up to 10% of all patients undergoing lung transplantation. Late graft failure in the form of bronchiolitis obliterans progressively increases in frequency as posttransplantation follow-up increases. In both situations, the degree of pulmonary dysfunction may worsen and result in the death of the recipient. The only treatment in many instances is retransplantation. The results in adults are reasonably well established.
Methods:
We reviewed our experience in children. Of the 136 transplant procedures performed to date in children, 14 have been retransplantations. Six patients required retransplantation for early primary graft failure and 8 underwent retransplantation for bronchiolitis obliterans.
Results:
There were three early and three late deaths. The actuarial survival at 2 years is 58%. The retransplant procedures were more complex than the primary transplant operations as evidenced by the longer time on cardiopulmonary bypass (199 +/- 71 versus 150 +/- 41 minutes; p < 0.01) and the greater volume of blood transfused (1,303 +/- 936 versus 570 +/- 300 mL; p < 0.01). Two of the long-term survivors who received transplants for bronchiolitis obliterans have subsequently had development of this same condition and 1 died secondary to this. In four instances living related donors were used for the retransplant procedure. The most striking difference in these procedures compared with those transplantations performed with cadaveric donors was the shorter donor lung ischemic times (99.5 and 123.3 minutes for the two lungs for living related donors and 251 and 293 minutes for the first and second lung for the cadaveric donors; p < 0.01).
Conclusions:
We believe that lung retransplantation in children is a reasonable therapy to offer in the circumstance of severe graft dysfunction. In the older child, the option of living donor transplantation offers advantages that might offset of the overall higher risk of this procedure.