Rejection with hemodynamic compromise in the current era of pediatric heart transplantation: A multi-institutional study

Biopsy-diagnosed antibody-mediated rejection based on the proposed International Society for Heart and Lung Transplantation working formulation is associated with adverse cardiovascular outcomes after pediatric heart transplant

“…This is consistent with previously published age-related differences after HT in childhood, which include an increased risk of rejection within the first year, increased risk of rejection with severe hemodynamic compromise, greater prevalence of CAV, and shorter transplant half-life in older vs younger HT recipients. [23][24][25][26][27] Likewise, other investigators have found a trend toward younger transplant age and the presence of donor-specific antibodies (DSA) in pediatric HT recipients with a significant association between older donor age and the prevalence of DSA. 28 Future studies on the immunologic changes that occur with age may be important to understanding the pathophysiology of AMR.…”

Antibody-Mediated Rejection in Cardiac Transplantation: Emerging Knowledge in Diagnosis and Management

“…78,258,259 In a large series (n=1217) reported by the Pediatric Heart Transplant Study Group, 15% of patients (<18 years of age) presented with severe acute ventricular dysfunction within 5 years of transplantation, and 30% of these had no or only mild evidence of cellular rejection (ISHLT grade 0 or 1R). 254 Survival was only 50% at 2 years, and 26% of the deaths were attributed to graft vasculopathy, graft failure, or lethal arrhythmias. Pathological evaluation for AMR was not systemically performed in the study group; however, a positive crossmatch or the pretransplantation detection of circulating anti-HLA antibodies was not associated with these events.…”

“…[253][254][255][256][257] The recognition of AMR as a cause of graft dysfunction and graft vasculopathy in the pediatric heart transplant population is also increasing as the criteria for the diagnosis of AMR have been refined and surveillance for AMR has been more widely adopted. 78,258,259 In a large series (n=1217) reported by the Pediatric Heart Transplant Study Group, 15% of patients (<18 years of age) presented with severe acute ventricular dysfunction within 5 years of transplantation, and 30% of these had no or only mild evidence of cellular rejection (ISHLT grade 0 or 1R).…”

Current state of pediatric cardiac transplantation

“…The risk of rejection is highest in the first-year post-transplant, but data from both the PHTS and ISHLT have shown an overall decline in rejection even in the first-year post-transplant (1,38,39) (Figure 19). This decrease significantly impacts the ability to use rejection as an endpoint in any study design or analysis.…”

“…Risk factors include early rejection, anti-HLA antibodies, older age, AfricanAmerican race, and non-adherence (39). Observations regarding rejection with hemodynamic compromise requiring inotropic support have not revealed the same era effect as with the other types of rejection, and worse survival of 49% at 5 years persists (39). Hemodynamic supports appropriate for the clinical presentation and aggressive intensification of immunosuppression is required to manage any rejection with hemodynamic compromise.…”