Therapy for acute rejection in pediatric organ transplant recipients

Characterization of emergency department visits in pediatric patients within first year of liver transplantation: ten years experience in tertiary care center

BACKGROUND

Liver transplantation is a complex procedure associated with significant post-operative challenges. Monitoring the frequency and timing of Emergency Department (ED) visits post-transplant in a vulnerable population like pediatrics can provide critical insights into patient outcomes and the effectiveness of post-operative care.

OBJECTIVE

This study aims to evaluate the indications, frequency, reasons and length of stay for ED visits among liver transplant recipients within the first year following discharge post-transplantation.

METHODS

A retrospective observational study was conducted on 361 liver transplant recipients, analyzing the frequency, timing, indications, reasons and length of stay for their ED visits post-discharge over 10 years.

RESULTS

361 patients were analyzed in this study with a total of 1300 emergency department visits. (52%) of the patients were males and (48%) were females. Most transplants were from living donors (93%, N = 338). Patients with at least one comorbidity accounted for 35% of total patients with hypertension 6% (20), congenital heart disease 5% (n = 18), and seizure disorder 4% (n = 15) representing the most common comorbidities. Most common indications for liver transplant were biliary atresia (21%) and progressive familiar intrahepatic cholestasis (20%). The most common reasons for ED visits were gastrointestinal symptoms (32%), pulmonary symptoms (22%), and infectious symptoms (16%). Patients' average length of stay in the hospital was 4 ± 10.7 days. Visits within the first 6 months accounted for 58% of total visits in the first year with first and second visits accounting for 47% of total emergency department visits.

CONCLUSION

The study highlights the high frequency of emergency department visits in pediatric subgroup as well the first 6 months as a critical period for follow-up. The study also demonstrated the continuous representation to the emergency department which calls for a closer follow-up and interventions to prevent those revisits.

CLINICAL TRIAL NUMBER

Not applicable.

Long-Term Social Outcomes of Pediatric Liver Transplant Recipients: Transition From Childhood to Adulthood

OBJECTIVES

Chronic disorders may negatively affect people's learning status, marital status, occupational life, and social life. Liver transplant is the only curative treatment for chronic liver diseases. This study was undertaken to evaluate the psychosocial effects of liver transplant in adult patients who had undergone liver transplant during the pediatric period compared with psychosocial facts in the general population.

MATERIALS AND METHODS

We retrospectively reviewed adult patients (>18 years of age) who had received liver transplant as children. We compared sex, age at the time of transplant, current age, type of donor, graft survival status, marital status, age at first delivery, number of children, educational status, and occupational status in the study population versus the general (normal) population. To compare the liver transplant patients included in the study with the general population correctly, we used data from the Turkish Statistical Institute.

RESULTS

Among 77 liver transplant patients included in our study, the mean age at transplant was 10.9 years (range, 0.5-16 y) and the mean age at the time of the study was 25.2 years (range, 18-42 y). Of the patients, 61 (79.2%) were single and 16 (20.8%) were married. Patients in the study population married at a younger age than the general population (25.5 vs 28.1 y for men, 24.3 vs 25.4 y for women). Of 16 married patients, 9 (56.2%) had a healthy child or children. The percentage of patients who graduated from higher education or were continuing their higher education process was higher in our study population than in the general population (36.3% vs 22.8%). Among our study population, 37 patients (48%) were workers.

CONCLUSIONS

Liver transplant had no negative effects on the social, educational, and professional lives among adults in our study who received transplants in the pediatric period.

Vaccinations, response, and controls before and after intestinal transplantation in children

Vaccination is an effective strategy to decrease infections in transplant recipients. Children after intestinal transplantation carry a high risk of infection due to increased immunosuppression. In a series of 22 children after intestinal transplantation, we studied the vaccination schedules and the antibodies against vaccine-preventable diseases before transplantation, and at one and five yr after transplantation. We reviewed whether the vaccination schedules were complete, and we analysed the factors that may influence serological immunity and the incidence of disease in patients with deficient immunity. All patients completed the recommended vaccination schedules for DTaP-IPV and HBV. After transplantation, the negative antibodies against vaccine-preventable diseases were mostly related to an antirejection therapy: for DTaP-IPV: four of four patients with no antibody had been treated for rejection, for HBV: two of five, HAV: three of four, MMR: three of seven, and VZV: three of four. A post-transplantation varicella infection was followed by acute rejection, with probability for a relationship between both events. We observed 50% of varicella cases in unvaccinated children, highlighting the importance of pretransplant vaccination. Waning immunogenicity mediated by antibodies against vaccine-preventable disease after transplantation indicated a need for boosters. The recommendations should be regularly enforced, as the reliance on routine immunizations schedules is not adequate in immunocompromised patients.

Liver transplantation in an African setting

Liver disease in children in the developing world is a frequent occurrence, which is generally inadequately managed because of lack of resources. However, increasingly, there has been a demand for liver transplantation, where primary medical or surgical therapies have failed. The expertise and infrastructure required for a successful outcome are no different from those in more developed countries; if anything, the challenges are greater. Lack of deceased donors because of cultural and religious factors has driven the use of living donors. Short-term survival has generally been good, but long-term outcomes have rarely been reported. In this article, we review the experience of 2 centers at opposite ends of the continent and share our experience of slightly different settings and show that success can be achieved even in resource-reduced environments.

Intestinal transplantation in children: a review of immunotherapy regimens

This review summarizes the outcomes and known adverse effects of current immunosuppression strategies in use in pediatric intestinal transplantation. Intestinal transplantation has evolved from an experimental therapy to a highly successful treatment for children with intestinal failure who have complications with total parenteral nutrition. Because of continued success with intestinal transplantation over the past decade, the focus of clinicians and researchers is shifting from short-term patient survival to optimizing long-term outcomes. Current 5-year patient and graft survival rates after intestinal transplantation are 58% and 40%, respectively, in the US; single centers have reported nearly 80% patient and 60% graft survival rates at 5 years. The immunosuppression strategy in intestinal transplantation includes a tacrolimus-based regimen, usually in conjunction with an antibody induction therapy such as rabbit-antithymocyte globulin, interleukin-2 receptor antagonists, or alemtuzumab. The use of these immunosuppressive regimens, along with improved medical and surgical care, has contributed significantly toward improved outcomes. Optimization of post-transplant immunosuppression strategies to reduce adverse effects while minimizing acute and chronic graft rejection is a strong clinical and research focus.

Childhood pemphigus vulgaris: five cases in 16 years

Pemphigus vulgaris (PV) usually occurs in adults. There are only a few reports of large PV series concerning childhood cases. We report here five cases of PV in patients younger than 16 years. They were analyzed among 169 PV cases out of a total of 192 pemphigus patients diagnosed between 1988-2004. The ratio of childhood cases was 2.9% in our large PV series. This relatively high ratio of childhood patients suggests that PV should not be neglected in the differential diagnosis of bullous lesions in childhood. Four of the five cases were followed up between 2-4 years and all of these four cases showed at least one relapse. PV also seems to show a relapsing course in the pediatric age group like in adults.

Infectious risk in pediatric organ transplant recipients: is it increased with the new immunosuppressive agents?

The risk of infection in pediatric organ transplant recipients is determined by several factors, including age, the types of organ transplanted and the immunosuppressive treatment which has dramatically changed over the past 10 yr. Little information has been reported regarding the infectious complications related to the current immunosuppressive protocols used in these children. This paper reviews (i) the immunosuppressive agents, focusing on their mechanisms of action and on the new regimens, (ii) the infections related to excessive immunosuppression and also anti-infectious properties or infectious adverse reactions associated with specific immunosuppressive agents. With the new immunosuppressive protocols, the advances in immunologic monitoring, microbiological diagnosis, anti-infectious prophylactic and preemptive treatments, strategies to minimize the risk of infection related to the immunosuppressive therapy are proposed.

Tacrolimus: a further update of its use in the management of organ transplantation

Extensive clinical use has confirmed that tacrolimus (Prograf) is a key option for immunosuppression after transplantation. In large, prospective, randomised, multicentre trials in adults and children receiving solid organ transplants, tacrolimus was at least as effective or provided better efficacy than cyclosporin microemulsion in terms of patient and graft survival, treatment failure rates and the incidence of biopsy-proven acute and corticosteroid-resistant rejection episodes. Notably, the lower incidence of rejection episodes after renal transplantation in tacrolimus recipients was reflected in improved cost effectiveness. In bone marrow transplant (BMT) recipients, the incidence of tacrolimus grade II-IV graft-versus-host disease was significantly lower with tacrolimus than cyclosporin treatment. Efficacy was maintained in renal and liver transplant recipients after total withdrawal of corticosteroid therapy from tacrolimus-based immunosuppression, with the incidence of acute rejection episodes at up to 2 years' follow-up being similar with or without corticosteroids. Tacrolimus provided effective rescue therapy in transplant recipients with persistent acute or chronic allograft rejection or drug-related toxicity associated with cyclosporin treatment. Typically, conversion to tacrolimus reversed rejection episodes and/or improved the tolerability profile, particularly in terms of reduced hyperlipidaemia. In lung transplant recipients with obliterative bronchiolitis, conversion to tacrolimus reduced the decline in and/or improved lung function in terms of forced expiratory volume in 1 second. Tolerability issues may be a factor when choosing a calcineurin inhibitor. Cyclosporin tends to be associated with a higher incidence of significant hypertension, hyperlipidaemia, hirsutism, gingivitis and gum hyperplasia, whereas the incidence of some types of neurotoxicity, disturbances in glucose metabolism, diarrhoea, pruritus and alopecia may be higher with tacrolimus treatment. Renal function, as assessed by serum creatinine levels and glomerular filtration rates, was better in tacrolimus than cyclosporin recipients at up to 5 years' follow-up.

CONCLUSION

Recent well designed trials have consolidated the place of tacrolimus as an important choice for primary immunosuppression in solid organ transplantation and in BMT. Notably, in adults and children receiving transplants, tacrolimus-based primary immunosuppression was at least as effective or provided better efficacy than cyclosporin microemulsion treatment in terms of patient and graft survival, treatment failure and the incidence of acute and corticosteroid-resistant rejection episodes. The reduced incidence of rejection episodes in renal transplant recipients receiving tacrolimus translated into a better cost effectiveness relative to cyclosporin microemulsion treatment. The optimal immunosuppression regimen is ultimately dependent on balancing such factors as the efficacy of the individual drugs, their tolerability, potential for drug interactions and pharmacoeconomic issues.