title: Long-term follow-up after total lymphoid irradiation in pediatric heart transplant recipients.
abstract: BACKGROUND
  Total lymphoid irradiation (TLI) is used to treat recurrent allograft rejection. Short-term success and complication rates have been reported in pediatric and adult cardiac transplant populations. We report the long-term efficacy and safety of TLI in treating intractable rejection in pediatric patients.
  
  
  METHODS
  Eight pediatric patients were treated with TLI (7 for recurrent rejection, 1 for risk of medication non-compliance). Therapy consisted of a mid-plane dose of 8 Gy administered with a 6-MeV linear accelerator using an anterior-posterior opposed technique. We reviewed outcomes for a total of 40 patient-years of follow-up.
  
  
  RESULTS
  We encountered rejection (>Grade 2 by International Society for Heart and Lung Transplantation criteria) in 56.7% +/- 34.7% of biopsies performed within 90 days before TLI. Rejection rates dropped to 3.1% +/- 8.8% within the first 90 days (p < 0.005) after therapy and remained low at 5.6% +/- 1.3% (p < 0.05) during the first year after completion of TLI. Median time from TLI to the first subsequent rejection episode was 305 days (range, 77-1,920 days). Long-term follow-up (>3 years) of 5 patients demonstrated a continuing low incidence of rejection. Non-Hodgkin's lymphoma was diagnosed in 1 of 8 patients, graft coronary artery disease in 4 of 8 patients, and restrictive cardiomyopathy in 1 of 8 patients after TLI.
  
  
  CONCLUSIONS
  Total lymphoid irradiation is an effective treatment for recurrent rejection and has short- and long-term efficacy. Morbid events may include cancer, graft coronary artery disease, and restrictive cardiomyopathy.
authors.affiliation: Department of Pediatrics, Stanford University, Stanford, California, USA. clifford@leland.stanford.edu
authors.forename: Clifford
authors.initials: C
authors.lastname: Chin
authors.forename: Sharon
authors.initials: S
authors.lastname: Hunt
authors.forename: Robert
authors.initials: R
authors.lastname: Robbins
authors.forename: Richard
authors.initials: R
authors.lastname: Hoppe
authors.forename: Bruce
authors.initials: B
authors.lastname: Reitz
authors.forename: Daniel
authors.initials: D
authors.lastname: Bernstein
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000401:mortality / Q000517:prevention & control*; D016027:Heart Transplantation; D006801:Humans; D007223:Infant; D015182:Lymphatic Irradiation; D008297:Male