Elsevier

Transplant Immunology

Volume 68, October 2021, 101443
Transplant Immunology

Research Article
Use of induction therapy in pediatric heart transplant recipients in Switzerland – Analysis of the Swiss national database

https://doi.org/10.1016/j.trim.2021.101443Get rights and content

Highlights

  • Induction therapy is highly common in pediatric heart transplant recipients in Switzerland.

  • Polyclonal antibodies are more frequently used compared to interleukin-2 receptor antagonist.

  • One year after heart transplantation less than 20% of the children were still on steroids.

Abstract

Background

Data on individualized immunosuppressive protocols for the pediatric heart recipients are missing in Europe. To contribute to this very small but specialized field, we describe the use of induction therapy (IT) in pediatric heart transplant patients in Switzerland and the retrospective outcomes.

Method

This is a retrospective national database analysis of children <19 years of age at time of heart transplantation (HT) from 05/2008–01/2018. Use of IT or no IT, use of steroids, calculated panel reactive antibodies (cPRA) and outcomes (Mortality, post-transplant lymphoproliferative disease (PTLD), rejection rates) were studied within a mean follow-up period of 2.9 years (0.2–8.1 years).

Results

All 32 patients (12♂, 20♀), median age at HT of 6.4 years (24 days - 18 years) received IT using either polyclonal antibodies (ATG; 72%) or interleukin-2 receptor antagonist (anti-IL-2R mAb; 28%). Length of treatment was median of 4 (1–63) days. At time of HT all patients received steroids, while at discharge 32% and one year after HT 19%. Kaplan-Meier analysis of survival revealed a one-year survival of 86%. Three out of 7 patients with elevated cPRA (43%) died. Median time to first treated rejection was 19.4 months (±60.5 SD) without significant difference if treated with anti-IL-2R mAb or ATG (p:0.5). No development of PTLD, chronic renal failure needing ongoing renal replacement therapy or diabetes mellitus were recorded.

Discussion

This is the first report of the national practice use of IT within Switzerland. It reveals a high use of IT, no development of PTLD and a low use of steroids at one-year post HT.

Introduction

Nowadays, immunosuppressant drug treatment should be individualized, based on a clinical assessment of the risk of rejection and toxicity. Substantial differences are known to exist between adults and children [[1], [2], [3], [4]]. Still, within the pediatric cohort, there are differences in the effect of individualization of immunosuppression, depending on diagnosis, prior surgery, and age, while geographical differences, which also seem to exist, are best documented with regard to North America and Europe [5]. As the number of children undergoing heart transplantation (HT) in Europe is low, data on individualized immunosuppressive protocols, especially for the use and impact of induction therapy with steroid-free or early steroid withdrawal strategies, are limited. This is aggravated by the fact that there is no European pediatric HT (pHT) database. So far, no data on the use of induction therapy in Switzerland has been analyzed.

The aim of this study is to evaluate the practice of induction therapy (IT) in pediatric heart transplant patients (children <19 years of age) in Switzerland. Of special interest is the use of either polyclonal antibodies (ATG) or interleukin-2 receptor antagonist (anti-IL-2R mAb) as well as the use of steroids and their withdrawal and short- and medium-term outcomes.

Section snippets

Material and methods

This is a retrospective national database analysis of the Swiss Transplant Cohort Study (STCS). In Switzerland, since May 2008, after the enforcement of the new transplantation law, follow-up data of all organ-transplant patients are comprehensively and mandatorily collected in a structured nationwide databank called the Swiss Transplant Cohort Study (STCS). This means that all cardiac transplants performed in Switzerland since 2008 are registered in this database. At the national level, six

Study population

Out of the 347 HT patients registered within the observed time period, 32 patients (12♂, 20♀) were < 19 years of age at the time of transplant and formed the study cohort (Fig. 1). There were 31 primary heart transplants and one re-transplantation in a female recipient. The demographic data, including the underlying disease necessitating transplantation, can be seen in Table 1. In one child, a toxic cardiomyopathy due to anthracycline therapy was diagnosed. Almost half of the patients were in

Discussion

This is the first description of a pHT population from Switzerland. It reveals that 9% of all annual cardiac transplantations were performed in patients <19 years of age. This corresponds well with previous publications on the Swiss national allocation system [6] and also with the international published data that report children account for approximately 14% of all HT [5,7]. Even if the number of transplants in Switzerland is low, international quality standards in terms of survival can be

Limitations

There are several limitations to this study. The most obvious remains the small number of patients. Still, it is the first report on a complete Swiss pediatric transplant cohort. Given the low global number of annually performed pHT (~600 [5]), we think it is crucial to share data among the community to learn from each other. While there are well established databases in North America, they are missing for Europe (note: the European centers participate in ISHLT or PHTS). Database analysis like

Conclusions

Induction therapy is widely accepted in Switzerland with 100% treatment in the pediatric cohort. Polyclonal antibodies represent the most used agent as induction therapy. No PTLD or other negative consequences were registered during the follow-up period.

Funding

The study supported by a research grant of the Swiss Transplant Cohort Study for statistical analysis.

Acknowledgment

The Swiss Transplant Cohort Study is supported by the Swiss National Science Foundation, Unimedsuisse and the Transplant Centers.

References (18)

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Cited by (0)

1

Head of the data center.

2

Chairman Scientific Committee.

3

Executive office.

4

Head, Excecutive office.

5

Executive office.

6

STCS coordinator.

7

The first two autrhors contributed equally to the manuscript.

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