Abstract 13877: Has Late Rejection Decreased in Pediatric Heart Transplantation in the Current Era? A Multi-institutional Study.
Background: Late (occurring > 1yr) rejection (LR) has been shown to increase mortality and morbidity after pediatric heart transplantation (HTx) with an increased risk in older and non-white recipients. Recently the incidence of rejection has been shown to have decreased in the first year after pediatric HTx in the current era. We hypothesized a similar phenomenon has occurred with LR.
Methods: The prospective, multi-center event-driven Pediatric Heart Transplant Study database was used for pts <18yrs at HTx between 1/93-12/07 to analyze the effects of era (‘93-‘98 vs ‘99-‘07) and other factors on the prevalence of LR and its relationship to mortality, moderate-severe coronary vasculopathy (CAV), and retransplantation.
Results: Of 1977 patients (median follow-up 5.2yrs), 663 (33.5%) had LR. Freedom from first (59% vs 69 % 5 yr post-Htx (p< 0.001) and recurrent (P<0.001) LR was significantly lower in the current vs earlier era. LR was significantly (p<0.001) associated with early rejection (rejection <1yr post-HTx) (ER) in both eras, and occurred earlier (mean 0.5yrs earlier, p=0.001) and more frequently (mean 2.1 vs 1.8 rejection events, p=0.02) in recipients with ER. Independent risk factors for LR were earlier era (HR 1.47, p<0.001); non-white race (HR 1.40, p<0.001); older recipient age (HR 1.05, p<0.001); recipient status 2 at transplant (HR 1.21, p=0.036); and male donor (HR 1.17, p=0.055). Late rejectors had a similar higher risk of mortality (OR 4.70, p<0.001) and incidence of moderate-severe CAV or re-transplantation (OR 2.17, p=0.034) in both eras. Rejectors with both ER and LR were at increased risk for developing moderate-severe CAV (OR 4.70, p<0.001).
Conclusions: LR has decreased in the recent era among all subgroups of pediatric HTx recipients. Patients experiencing ER remain at increased risk for LR and subsequent CAV. When LR occurs, its effect on mortality and the development of CAV has not changed over time suggesting an ongoing need for improved primary prevention strategies.
- © 2010 by American Heart Association, Inc.