There are only a few reports of successful use of mammalian target of rapamycin (mTORI) as primary immunosuppression in pediatric heart transplantation. Compared to calcineurin inhibitors, mTORI have less side effects, especially nephrotoxicity, infections, and malignancies. A retrospective study was conducted at our institution of all 170 heart transplants from 1995 to 2015. Nineteen patients were switched from tacrolimus (n=15) or cyclosporin (n=4) to everolimus (n=4) or sirolimus (n=15) due to nephrotoxicity (n=5), malignancy (n=8), EBV viremia/reactive plasmacytic changes (n=5), and immune hemolytic anemia (n=1). We monitored for rejection, infection, BUN, creatinine, hyperlipidemia, EBV and CMV copies, CBC, cardiac allograft vasculopathy (CAV), and death. Target trough levels of sirolimus and everolimus were 4-10. Four treatment failures included debilitating rash, bone marrow suppression, recurrent rejection, and renal transplantation. There were no deaths. One patient had recurrent rejection episodes, and tacrolimus was reinitiated. One patient with preexisting CAV underwent heart retransplantation. One patient, who was treated for PTLD, transformed to CD30+ Hodgkins disease, and was treated with brentuximab. There were three acute rejection episodes. Median creatinine preswitch was higher 0.82 than postswitch 0.78 (P=.016). Median eGFR was lower preswitch, 75.6, than postswitch, 91.2 (P=.0004). These results indicate that conversion to mTORI as primary immunosuppression may be safely accomplished in some pediatric heart transplant patients.
What is known and objective Reports of cidofovir dosing with extracorporeal membrane oxygenation (ECMO) support are limited. This case series describes our clinical experience and provides a literature review regarding cidofovir dosing in paediatric patients requiring ECMO support. Case summary Three patients with adenovirus‐associated acute respiratory distress syndrome (ARDS) were treated with cidofovir while requiring ECMO support. A 27‐month‐old patient was treated with cidofovir 1 mg/kg/dose three times weekly, and a 19‐month‐old patient and an 18‐year‐old patient were treated with cidofovir 5 mg/kg/dose weekly. What is new and conclusion This case series describes the dosing and positive clinical response of cidofovir in paediatric patients with adenovirus‐associated ARDS requiring ECMO support.
BackgroundThere is debate whether cytomegalovirus immunoglobulin (CMV‐Ig) is also needed for CMV prevention in heart transplant recipients in the era of good anti‐viral drugs.MethodsWe conducted a cost‐savings quality initiative on CMV‐Ig eventually leading to discontinuation of routine use of CMV‐Ig for CMV prevention. Subsequently, a retrospective cohort study was conducted, comparing patients in cohort I (CMV‐Ig plus anti‐viral drugs, 2013‐2015) to cohort II (anti‐virals alone, 2015‐2017). The medication acquisition costs and outcomes of CMV infection were assessed.ResultsThere were 39 total patients: 22/39(56%) in cohort I, with mean follow‐up of 35.14 ± 17.38 months and 17/39(44%) in cohort II, mean follow‐up of 19.12 ± 7.08 months. In cohort I, 5/22(22.7%) patients died from causes unrelated to CMV and 0/17 in cohort II died. There were 5/22(22.7%) patients in cohort I, and 2/17(9%) patients in cohort II that developed CMV infection (P = .508). Freedom from rejection was 81.8% (18/22) in cohort I, and 71% (12/17) in cohort II (P = .46), and 100% for allograft vasculopathy. There was significant reduction in medication acquisition cost following the protocol change of $260 839 or $15 343 per patient.ConclusionOur study demonstrated an acquisition cost savings with similar clinical outcomes utilizing anti‐viral CMV prophylaxis alone vs anti‐viral prophylaxis plus CMV‐Ig.
IntroductionThe United Network of Organ Sharing (UNOS) bylaws and Centers for Medicare and Medicaid Services (CMS) accreditation standards require that transplant centers have a pharmacist. However, there are no established guidelines and there is a paucity of literature describing pharmacists in the pediatric ambulatory setting.ObjectiveThis project aims to describe the activities of pediatric clinical pharmacists in an ambulatory pediatric cardiac transplant clinic.MethodsThis is a single‐center pilot project describing pediatric clinical pharmacist interventions before (phase I) and after (phase II) implementation of comprehensive and standardized clinical activities. The list of defined key clinical activities was developed using UNOS and CMS accreditation standards, an evaluation of the literature, and cardiac transplant team feedback.ResultsPrior to a defined list of clinical activities, pediatric clinical pharmacists saw 74 unique patients during 174 patient encounters and recorded 240 interventions (phase I). Following implementation of standard activities, pediatric clinical pharmacists saw 81 unique patients during 225 patient encounters and recorded 510 interventions (phase II). The development of defined key activities led to a 129.4% increase in documented interventions per patient encounter. Interventions with the greatest increase included: medication schedule (phase I, 13.2%; phase II, 37.3%; P < .001), medication dose adjustment (phase I, 5.7%; phase II, 22.2%; P < .001), outpatient pharmacy coordination (phase I, 1.1%; phase II, 15.6%; P < .001), medication discontinuation (phase I, 0.6%; phase II, 9.3%; P < .001), and medication adherence education (phase I, 0%; phase II, 6.2%; P < .001).ConclusionThere was a significant increase in the number and variety of medication‐related interventions after the development and implementation of defined key clinical activities for pediatric clinical pharmacists in a pediatric cardiac transplant ambulatory care clinic.
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