Andersons pediatric cardiology 1786

FIG 67.19 Percentage of children with transplanted hearts experiencing treated rejection between discharge and 1-year follow-up by era (From the registry of the International Society of Heart and Lung Transplantation J Heart Lung Transplant 2016;35(10):1185–1195.) FIG 67.20 Kaplan-Meier survival in children with transplanted hearts based on the presence of rejection within the first year after transplantation (From the registry of the International Society of Heart and Lung Transplantation J Heart Lung Transplant 2016;35(10):1185–1195.) The gold standard for diagnosis of rejection remains the endomyocardial biopsy There is, however, tremendous variability in the use of routine surveillance biopsies, with some centers continuing them indefinitely and others discontinuing them after a period of time posttransplant.63 Biopsies are graded according to the revised criteria of the ISHLT.64 For acute cellular rejection, grade 0 R indicates no rejection, grade 1 R represents mild rejection, grade 2 R indicates moderate rejection, and grade 3 R represents severe rejection More recently, to aid in the diagnosis and treatment of AMR, the ISHLT has also developed a pathology-based AMR grading system.65 There have been many efforts to identify and validate noninvasive tests for diagnosing rejection, including echocardiography, intramyocardial electrography, and the profiling of gene expression As yet no noninvasive test has been developed to consistently and accurately diagnose and/or predict rejection The incidence of acute rejection peaks in the first month after transplantation and then tapers off by 3 months66 (Fig 67.21) More than 20% of pediatric heart transplant recipients experience rejection in the first year, with 65% of recipients experiencing at least one episode of rejection at any time after heart transplantation.2,67 Data from PHTS have shown an overall decline in the incidence and prevalence of rejection over time in the first year posttransplant.68 These episodes are usually asymptomatic, identified only by biopsy, and are easily treated That said, both the PHTS and the ISHLT registries show that treated rejection in the first year posttransplant decreases long-term survival.2,69 Nevertheless, acute rejection has decreased over time (see Fig 67.19) and is rare in pediatric heart transplant recipients after the first year posttransplant.70 Data from the PHTS have identified antibody-mediated rejection in 11% of patients, accounting for 35% of rejection episodes.69 FIG 67.21 Freedom from first acute episode of rejection shown as a hazard function curve (From Dodd DA, Cabo J, Dipchand AI Acute rejection: natural history, risk factors, surveillance, and treatment In: Canter CE, Kirklin JK, eds Pediatric Heart Transplantation ISHLT Monograph Series, vol Philadelphia: Elsevier; 2007:chap 9, fig 3, p 143.) Late rejection more than 1 year posttransplant has also decreased over time, though with a persistent impact on CAV and mortality.67 Risk factors include early rejection, anti-HLA antibodies, older age, African American race, and nonadherence.13,71 Rejection with hemodynamic compromise requiring inotropic support and the resultant increased mortality has not experienced the same era ... The incidence of acute rejection peaks in the first month after transplantation and then tapers off by 3 months66 (Fig 67.21) More than 20% of pediatric heart transplant recipients experience rejection in the first year, with 65% of recipients... treated rejection in the first year posttransplant decreases long-term survival.2,69 Nevertheless, acute rejection has decreased over time (see Fig 67.19) and is rare in pediatric heart transplant recipients after the first year posttransplant.70 Data from the PHTS have identified antibody-mediated rejection in 11% of patients,... rejection: natural history, risk factors, surveillance, and treatment In: Canter CE, Kirklin JK, eds Pediatric Heart Transplantation ISHLT Monograph Series, vol Philadelphia: Elsevier; 2007:chap 9, fig