TY - JOUR
T1 - Cardiac allograft vasculopathy and graft failure in pediatric heart transplant recipients after rejection with severe hemodynamic compromise
AU - Kleinmahon, Jake A.
AU - Gralla, Jane
AU - Kirk, Richard
AU - Auerbach, Scott R.
AU - Henderson, Heather T.
AU - Wallis, Gonzalo A.
AU - Ramakrishnan, Karthik
AU - Singh, Rakesh K.
AU - Caldwell, Randall L.
AU - Savage, Andrew J.
AU - Everitt, Melanie D.
N1 - Publisher Copyright:
© 2019 Elsevier Ltd
Copyright:
Copyright 2019 Elsevier B.V., All rights reserved.
PY - 2019/3
Y1 - 2019/3
N2 - BACKGROUND: Rejection with severe hemodynamic compromise (RSHC) carries a mortality risk approaching 50%. We aimed to identify current risk factors for RSHC and predictors of graft failure after RSHC. METHODS: Data from 3,259 heart transplant (HT) recipients between January 2005 and December 2015 in the Pediatric Heart Transplant Study (PHTS) were analyzed. Predictors for RSHC and outcome after RSHC were sought. Time to RSHC was analyzed using the Cox proportional hazards regression model. Cardiac allograft vasculopathy (CAV) after HT and CAV after RSHC were analyzed as time-dependent covariates. Timing of RSHC was analyzed as occurring before and after 4 years after RSHC. RESULTS: There were 309 patients (9.5%) with ≥ 1 RSHC episodes. In 143 patients with RSHC, the first episode was within 1 year after HT. Independent risk factors for RSHC were age 1 to 5 years at HT (hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.04–2.18), age > 10 years at HT (HR, 1.83; 95% CI, 1.29–2.60), black race (HR, 1.64; 95% CI, 1.25–2.15), prior cardiac surgery (HR, 1.55; 95% CI, 1.03–2.31), ventricular assist device support at HT (HR, 1.65; 95% CI, 1.18–2.29), maintenance steroids (HR, 1.39; 95% CI, 1.06–1.82), and recipient on inotropes, pressors, or thyroid hormones (HR, 1.45; 95% CI, 1.09–1.94). Graft survival at 5 years after RSHC was 45.7%. RSHC was a greater risk factor for earlier CAV (HR, 7.78; 95% CI, 5.82–10.40) than other rejection types (HR, 2.31; 95% CI, 1.79–3.00). Patients with late RSHC, after 1 year after RSHC had increased risk of graft loss 4 years after RSHC (HR, 7.12; 95% CI, 2.18–23.22). The 5-year graft survival after RSHC was 50.5% for early RSHC and 39.0% for late RSHC. CONCLUSIONS: Mortality after RSHC is high in the current treatment era. Many patient risk factors for RSHC cannot be modified, including age, race, prior cardiac surgery, and ventricular assist device support. After RSHC, CAV is the only predictor of graft failure. Patients who have late RSHC fare worse than those who have RSHC within the first year after HT.
AB - BACKGROUND: Rejection with severe hemodynamic compromise (RSHC) carries a mortality risk approaching 50%. We aimed to identify current risk factors for RSHC and predictors of graft failure after RSHC. METHODS: Data from 3,259 heart transplant (HT) recipients between January 2005 and December 2015 in the Pediatric Heart Transplant Study (PHTS) were analyzed. Predictors for RSHC and outcome after RSHC were sought. Time to RSHC was analyzed using the Cox proportional hazards regression model. Cardiac allograft vasculopathy (CAV) after HT and CAV after RSHC were analyzed as time-dependent covariates. Timing of RSHC was analyzed as occurring before and after 4 years after RSHC. RESULTS: There were 309 patients (9.5%) with ≥ 1 RSHC episodes. In 143 patients with RSHC, the first episode was within 1 year after HT. Independent risk factors for RSHC were age 1 to 5 years at HT (hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.04–2.18), age > 10 years at HT (HR, 1.83; 95% CI, 1.29–2.60), black race (HR, 1.64; 95% CI, 1.25–2.15), prior cardiac surgery (HR, 1.55; 95% CI, 1.03–2.31), ventricular assist device support at HT (HR, 1.65; 95% CI, 1.18–2.29), maintenance steroids (HR, 1.39; 95% CI, 1.06–1.82), and recipient on inotropes, pressors, or thyroid hormones (HR, 1.45; 95% CI, 1.09–1.94). Graft survival at 5 years after RSHC was 45.7%. RSHC was a greater risk factor for earlier CAV (HR, 7.78; 95% CI, 5.82–10.40) than other rejection types (HR, 2.31; 95% CI, 1.79–3.00). Patients with late RSHC, after 1 year after RSHC had increased risk of graft loss 4 years after RSHC (HR, 7.12; 95% CI, 2.18–23.22). The 5-year graft survival after RSHC was 50.5% for early RSHC and 39.0% for late RSHC. CONCLUSIONS: Mortality after RSHC is high in the current treatment era. Many patient risk factors for RSHC cannot be modified, including age, race, prior cardiac surgery, and ventricular assist device support. After RSHC, CAV is the only predictor of graft failure. Patients who have late RSHC fare worse than those who have RSHC within the first year after HT.
KW - cardiac allograft vasculopathy
KW - graft failure
KW - heart transplant
KW - pediatric
KW - rejection with severe hemodynamic compromise
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U2 - 10.1016/j.healun.2018.12.011
DO - 10.1016/j.healun.2018.12.011
M3 - Article
C2 - 30638837
AN - SCOPUS:85059684544
SN - 1053-2498
VL - 38
SP - 277
EP - 284
JO - Journal of Heart and Lung Transplantation
JF - Journal of Heart and Lung Transplantation
IS - 3
ER -