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Recurrent Rejection in Pediatric Heart Transplantation
Quick Takes
- While rates of recurrent rejection have declined in the current era, around 1 in 10 children post-heart transplant will experience recurrent rejection.
- Children who experience recurrent rejection are more likely to experience graft loss compared with children experiencing 0 or 1 rejection episode.
- Black children who experience recurrent rejection subsequently have a lower freedom from cardiac allograft vasculopathy and graft loss compared with White Children experiencing recurrent rejection.
Study Questions:
What is the prevalence and impact of recurrent rejection (RR) on cardiac allograft vasculopathy (CAV) and graft loss after pediatric heart transplant?
Methods:
A retrospective review was performed using the Pediatric Heart Transplant Society Database for heart transplant patients between January 1, 2000, and June 30, 2020. Freedom from RR (≥2 rejection episodes) was compared by era. Outcomes for children experiencing RR were compared with those experiencing 0 or 1 rejection episodes and by type of rejection.
Results:
Of 6,342 heart transplant recipients, 1,035 (17%) experienced RR. In the current era (2010-2020), pediatric heart transplant recipients were less likely to experience RR (p < 0.05). Freedom from CAV was similar for those experiencing RR to those with only 0 or 1 rejection episodes. Freedom from graft loss was significantly lower for those experiencing RR to those experiencing 0 or 1 episode (56.3% vs. 72.3% vs. 82.3%) and lower for those experiencing recurrent mixed rejection or recurrent antibody-mediated rejection compared with those experiencing recurrent acute cellular rejection (65.3% vs. 50% vs. 81.8%). Black children experiencing RR subsequently had lower freedom from CAV and graft loss than White children (p < 0.05 for all).
Conclusions:
The authors conclude that although the prevalence of RR has decreased, children experiencing RR are at greatly increased risk for losing their graft, particularly those who have recurrent mixed or antibody-mediated rejection.
Perspective:
This study demonstrated that although recurrent rejection after heart transplant has decreased over the last 20 years, it remains a significant issue. The finding of worse outcomes for Black children with recurrent rejection requires further study to understand its root cause.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Heart Transplant
Keywords: Graft Rejection, Heart Transplantation, Pediatrics
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