Pediatric transplantation
Lung and Heart–Lung Transplantation in Children and Adolescents: A Long-term Single-center Experience

https://doi.org/10.1016/j.healun.2008.12.012Get rights and content

Background

Pediatric lung transplantation (LTx) remains a challenge for a highly selected group of patients. The requirements for immunosuppressive therapy and the associated risks must be weighed against the long-term prognosis of this operation. Therefore, we retrospectively analyzed our experience after 53 lung and heart–lung transplantations (HLTx) in children.

Methods

All pediatric patients <18 years of age who underwent LTx (n = 37) and HLTx (n = 16) at our institution were included in this study. We analyzed indications for transplantation, survival rates and causes of death. Herein we assess pediatric-specific challenges in comparison to adults.

Results

Thirty-day mortality was 13.2%. Kaplan–Meier survival rates at 1, 3, 5 and 10 years were 69%, 64%, 44% and 39%, respectively. Main indications for transplantation were cystic fibrosis and congenital heart disease with Eisenmenger syndrome. Other diagnoses were retransplantation, primary pulmonary hypertension and pulmonary fibrosis. The main causes of death were infection and chronic graft failure. Reduced-size transplantation was performed in 42% of double-lung transplantation (DLTx) patients without negatively impacting survival. Six patients received pulmonary retransplantation, 1 of whom died early.

Conclusions

Pediatric transplantation is a feasible therapeutic option when undertaken by an experienced team. It should be offered to the small patient population suffering from end-stage pulmonary disease. The limited number of pediatric donor organs can be overcome by using reduced-size organs. However, the management of pediatric-specific complications and therapeutic requirements is essential for positive long-term results after LTx in these patients.

Section snippets

Patients

Between December 1987 and December 2007, a total of 1,002 LTx and HLTx were performed at Hannover Medical School, among them 53 procedures in 47 patients <18 years of age. Six patients received pulmonary retransplantation. Pediatric heart transplantations were excluded from this analysis.

Immunosuppression and Post-operative Management

Post-operative immunosuppression consisted of a triple maintenance therapy based on tacrolimus in combination with mycophenolate mofetil and steroids. Induction therapy was not administered. All patients were

Patient Population

Between December 1987 and December 2007, a total of 53 pediatric LTx and HLTx were performed at our institution. Of these, 31 (58.5%) were double-lung transplantations (DLTx), 6 (11.3%) were single-lung transplantations (SLTx) and 16 (30.2%) were HLTx. Twenty-nine (54.7%) patients were male and 24 (45.3%) female with a mean age of 14 ± 3.8 years (range 1 to 17 years). As shown in Figure 2, the majority of patients were adolescents rather than children. Mean height was 149 ± 22.8 cm and mean

General Considerations

In this study we have described our experience with LTx and HLTx in children and adolescents. As we have noted, the worldwide numbers of pediatric LTx and HLTx performed are low.1, 2 Indeed, a potential reason is that there is low prevalence of presenting indications for LTx in children. This, in addition to a general skepticism toward this therapeutic approach, has resulted in limited cases. According to a recently published analysis by Liou and colleagues,3 the outcome of LTx in children with

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    According to the Italian protocol for urgent lung transplantation, one quarter of our cases were operated in an emergency setting; greater rates of emergency transplantation (66%) were reported only by Gorler and colleagues.5 However, if we focus on subjects at greater perioperative risk such as those in ECMO and/or mechanical ventilation (all the emergency patients in our series), the Hannover rate drops to a comparable value of 28.3%; in addition, in our population the subjects requiring preoperative cardiocirculatory assistance were more than other experiences (21% compared with 17% in Zurich,6 11% in Vienna,8 and 8% in Hannover5) and in most cases (78%) were supported with mechanical ventilation at the same time, twice as much as the number reported by Waseda and colleagues8 (16% vs 8%). In our series of patients, preoperative ECMO and/or MV is related to a prolonged and more difficult postoperative course.

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