Intestinal and multivisceral transplantation in children.
OBJECTIVE
To describe a single-center experience of pediatric intestinal transplantation (Itx) and to provide an overview of the children who underwent this procedure along with their outcomes.


BACKGROUND
Pediatric Itx presents multiple challenges because of the very young ages at which patients require transplantation and their higher susceptibility to infectious complications.


METHODS
We have performed 141 Itx in 123 children with a median age of 1.37 years. Primary grafts included isolated intestine (n = 28), liver and intestine (n = 27), multivisceral (n = 61), and multivisceral without the liver (n = 7). Two protocol modifications were introduced in 1998: daclizumab induction and frequent rejection surveillance. In 2001, indications for multivisceral transplantation were expanded, and induction with Campath-1H was introduced.


RESULTS
Actuarial patient survival at 1 and 3 years for group 1 (January 1994 to December 1997, n = 25), group 2 (January 1998 to March 2001, n = 29), group 3a (April 2001 to present, daclizumab, n = 51), and group 3b (April 2001 to present, Campath-1H, n = 18) was 44%/32%, 52%/38%, 83%/60%, and 44%/44%, respectively (P = 0.0003 in favor of group 3a). Severe rejection implied a dismal prognosis (65% mortality at 6 months). Observed incidence of severe rejection in groups 1, 2, 3a, and 3b was 32%, 24%, 14%, and 11%, respectively. In multivariable analysis, use of a multivisceral (with or without liver) transplant (P = 0.002), induction with daclizumab (P = 0.005), patient at home prior to transplant (P = 0.007), and age at transplant > or =1 year (P = 0.02) favorably influenced patient survival. Multivisceral transplant was protective with respect to the mortality rate due to rejection, while an older age at transplant was associated with both a lower incidence rate of developing respiratory infection and lower risk of mortality following the respiratory infection. Survivors are off parenteral nutrition and have demonstrated significant growth catch-up.


CONCLUSIONS
Itx in children still is a high-risk procedure but has now become a viable option for children who otherwise have no hope for survival. Control of respiratory infection is of particular importance in the younger children.
Kato
Tomoaki
T
Department of Surgery, University of Miami School of Medicine, 1801 NW 9th Avenue, Miami, FL 33136, USA. tkato@med.miami.edu
Tzakis
Andreas G
AG
Selvaggi
Gennaro
G
Gaynor
Jeffrey J
JJ
David
Andre I
AI
Bussotti
Alessandro
A
Moon
Jang I
JI
Ueno
Takehisa
T
DeFaria
Werviston
W
Santiago
Sergio
S
Levi
David M
DM
Nishida
Seigo
S
Velasco
Monica L
ML
McLaughlin
Gwen
G
Hernandez
Erick
E
Thompson
John F
JF
Cantwell
Patricia
P
Holliday
Norman
N
Livingstone
Alan S
AS
Ruiz
Phillip
P
D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000453:epidemiology / Q000517:prevention & control; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007223:Infant; D007231:Infant, Newborn; D007410:Intestinal Diseases / Q000150:complications / Q000601:surgery*; D007422:Intestines / Q000637:transplantation*; D017093:Liver Failure / Q000150:complications / Q000601:surgery*; D008875:Middle Aged; D051437:Renal Insufficiency / Q000150:complications / Q000601:surgery*; D012189:Retrospective Studies; D013997:Time Factors; D014019:Tissue Donors / Q000706:statistics & numerical data; D016896:Treatment Outcome; D014781:Viscera / Q000637:transplantation*; D014850:Waiting Lists
D007166:Immunosuppressive Agents