Transplantation in the Highly Sensitized Pediatric Patient

Abstract

Numerous antibody detection methods have been available for decades. The initial tests were cell-based techniques. Patel and Terasaki 34 developed the complement-dependent cytotoxicity (CDC) assay in the 1960s. This technique allowed the clinical detection of antibodies that were highly correlated with

Effect of Induction Therapy on Graft Survival in Primary Pediatric Heart Transplantation

“…This may be in part by a rising population of transplants in highly HLA sensitized patients. 10 Despite the rising popularity of induction therapy, there have been very few studies investigating the effects of induction on overall graft survival in pediatric heart transplant. To the authors’ knowledge, this study represents the first study to employ propensity scores, therefore reducing potential biases, to assess the association of induction with graft survival in pediatric heart transplantation.…”

Cardiac transplantation in children

“…The practical goal of identifying clinically important circulating HLA antibodies is to avoid allograft rejection and graft loss. 19 The gold standard to assess the potential risk of acute rejection as a result of HLA antibodies would be to crossmatch the donor and recipient prospectively, but this is not practically possible. This has led to techniques known as 'virtual crossmatch' via a panel-reactive antibody (PRA) test; where a PRA >10% is considered 'sensitised'.…”

Transplanting Hearts in the Highly Sensitized Pediatric Candidate: What’s a Program to Do?

“…Using this strategy is known to result in high waitlist mortality , and, for those with a PRA at or around 100%, may make listing for heart transplantation more of a gesture than a therapeutic reality for the child's end‐stage cardiac disease. Pediatric heart transplantation in the presence of a positive versus negative crossmatch clearly increases the risk of mortality after transplantation , though specific immunosuppressive strategies in the face of a positive crossmatch may improve the odds for a successful transplant .…”

“…This study really cannot answer that question as the “ground rules” of assessing the impact of pre‐formed anti‐HLA antibodies on performing a successful heart transplant have changed. Increasingly sophisticated solid phase assays do not just assess a qualitative percentage of reactions to a large number of HLA antigens but also can specify which recipient antibodies react to which specific HLA antigen, the quantitative strength of that antibody in the candidate, and its functionality measured by its ability to fix complement . The ability to know the specific antigens in the donor for which a recipient has antibodies allows a center to do a “virtual crossmatch” and avoid specific antigens in potential donors.…”

“…That situation makes heart transplantation a futile therapy and can lead to “wasting” a donor that could benefit another compatible heart transplant candidate. Where this middle ground exists is likely different for different centers depending on their willingness to take on the given risks of transplanting across a positive crossmatch and their comfort in using current immunosuppressive strategies proposed for that problem . Investigations such as the pediatric heart CTOT multicenter study exploring transplantation in sensitized pediatric heart transplant candidates will hopefully provide greater clarity on the impact of the newer HLA antibody assessment measure beyond simple PRA for a more precise assessment of when heart transplantation is and is not feasible in the sensitized candidate.…”