Hematopoietic stem-cell transplantation following solid-organ transplantation in children

Abstract

Reports of hematopoietic stem-cell transplantation (HSCT) following solid-organ transplantation have been described in adults mainly as case reports. These reports demonstrate feasibility but likely do not reflect true outcomes due to a positive reporting bias. We report herein the outcomes of all our pediatric recipients of allogeneic HSCT following previous solid-organ transplantation between 2000 and 2009. Four children were identified. Two patients underwent heart transplantation followed by cord-blood allogeneic HSCT for T-cell lymphoma/post transplant lymphoproliferative disease (PTLD) and two patients underwent liver transplantation followed by living-donor allogeneic HSCT for severe aplastic anemia (SAA). The mean time between transplants was 4.2 years (range 1.5-6 years). All patients engrafted; however, all patients died from 37 days to 1 year after HSCT. Causes of death included infections (n ¼ 2), multi-organ failure (n ¼ 1) and solid-organ graft rejection (n ¼ 1). Though three patients survived beyond day þ 100, multiple complications were observed including EBV re-activation followed by EBV-positive PTLD (n ¼ 1) and five episodes of severe infections. The patients transplanted for lymphoma did not have evidence of recurrence at last follow-up. Although feasibilty has been shown with this cohort, we conclude that allogeneic HSCT in immunosuppressed patients following solid-organ transplantation remains a very high risk procedure that results in severe morbidity and mortality in children.

Posttransplant Lymphoproliferative Disease after Pediatric Solid Organ Transplantation

“…Allogeneic hematopoietic stem cell transplantation has been reported as a salvage therapy for PTLD in few case reports [69], but the available results were disappointing. …”

Hemophagocytic lymphohistiocytosis presenting in a pediatric patient with near total colonic and small bowel aganglionosis: a case report

“…Schechter et al . reviewed pediatric transplant data spanning 2000 to 2009 and found that there were limited data on patients receiving HSCT and solid organ transplant [ 13 ]. Many of these patients received a secondary transplant due to either severe aplastic anemia following liver transplantation or post-transplant lymphoproliferative disease following solid organ transplant.…”

Allogeneic Hematopoietic Cell Transplantation for Therapy-Related Myeloid Leukemia following Orthotopic Cardiac Transplantation

“…Finally, although there was the potential for a T-cell mediated immune response by the stem cell donor's lymphocytes against the previously transplanted heart, we saw no sign of this during the peri-transplant period. A literature search found several previous case reports of HCT in recipients of cardiac transplantation [10–13]. All but one patient survived HCT without rejecting their cardiac graft.…”

“…All but one patient survived HCT without rejecting their cardiac graft. However, the peri-transplant mortality and morbidity was high, reflecting the fine balance between risks of serious infections and the need for ongoing immunosuppression [10–13]. …”