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666: Predictors of Obesity in Children after Heart Transplant: An Analysis of the ISHLT Pediatric Heart Transplant Registry
The Journal of Heart and Lung Transplantation Volume 28, Number 2S
levels, HLA DR mismatches, and rejection episodes in the first year following transplantation were studied. Results: The overall incidence of post-transplant diabetes (PTDM) was 9.2% (n⫽25). PTDM incidence was 8.9% (5 of 56) in the sirolimus-only group, 11.8% (6 of 51) in the combined sirolimus and tacrolimus group, 11.6% (5 of 43) in the tacrolimus-only group, and 7.4% (9 of 122) in the cyclosporin-only group. In sirolimus-treated patients, diabetics vs. nondiabetics, there was no significant difference in age at transplantation (mean 2.4y ⫾4.3 and 2.3y⫾4.4, p⫽0.95). There was a significant difference in average and maximum sirolimus levels, means 9⫾4.2 vs. 6.8⫾2.2 ng/mL, p⫽0.03; maximum level means 26.8⫾15 vs. 14.6⫾7.7 ng/mL, p⫽0.003. There was no significant difference in HLA DR mismatches (p⫽0.45) or the number of rejection episodes (p⫽0.2). Conclusions: Post-transplant diabetes can occur in young children receiving heart transplantation and treated with sirolimus. Diabetes is significantly correlated with higher sirolimus levels. The incidence of post-transplant diabetes in sirolimus-treated patients is less than the incidence in patients treated with tacrolimus alone or combined with sirolimus. The mechanism of sirolimus-associated diabetes in children, be it insulin-deficiency or insulin-resistance, remains to be elucidated. 666 Predictors of Obesity in Children after Heart Transplant: An Analysis of the ISHLT Pediatric Heart Transplant Registry B.D. Kaufman1, S. Chuai2, F. Dobbels3, R.E. Shaddy1 1University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, PA; 2University of Pennsylvania, School of Medicine, Philadelphia, PA; 3University of Leuven, Leuven, Belgium Purpose: Obesity has been associated with adverse outcomes in both adult and pediatric heart transplant (HT). Patient-related traits and clinical events post-HT may influence weight gain. Risk factors for obesity in children post-HT have not been well described. Methods and Materials: The ISHLT Pediatric Heart Transplant Registry was queried for HT recipients ⱖ2yrs old between 1996 and 2006 with data for BMI percentile (BMI%) at HT and at 1year follow-up (Fup). BMI% cohorts were defined as: Wasted ⬍5th BMI%, Normal 5-95th BMI%, and Obese ⬎95th BMI% at 1 yr post-HT. Cohorts were compared for pre- and post-HT traits and events that might predict obesity post-HT. Results: Data from 1007 pediatric HT pts were available for BMI%ile analysis at 1 year post-HT. At 1 yr post-HT, 21% of pts were Obese; which had increased from 10% Obese at time of HT(p⬍.001). 63% of Obese pts 1yr post-HT were Normal at HT, while 34% had been Obese at HT and 4% were Wasted at HT (p⬍.001). 67% of Obese pts at HT remained Obese at 1yr Fup. Pre HT diagnoses of the Obese cohort were: Congenital heart disease 27%, Cardiomyopathy 65%, Retransplant 7%, and Other 1%. On univariate analyses, gender, age at HT, diagnosis, medical status at HT, waiting time, and length of stay post-HT did not predict obesity at 1yr Fup. Incidence of hospitalization, rejection, or coronary disease during 1st yr Fup also did not differ between BMI cohorts. Maintenance steroid use at 1yr Fup was Obese 69%, Normal 59% (p.036). There was no difference in steroid use for rejections or previous use. Obese cohort had increased hyperlipidemia (31%) and hypertension (71%) at 1yr post-HT. Overall mortality was increased in pts with Obesity at 1yr post-HT (p.03). Conclusions: The incidence of obesity doubled from time of HT to 1 yr post-HT. Obesity at time of HT and maintenance steroid use at 1yr, were the only risk factors for post-HT obesity identified. As these are potentially modifiable risk factors for poor HT outcomes, attention to weight loss and alternative medication regimens are warranted.
Abstracts
S297
667 The Use of Intravascular Ultrasound in the Diagnosis of Cardiac Allograft Vasculopathy in Pediatric Heart Transplant Recipients: A Ten Year Experience M.A. Kuhn1, R.E. Chinnock2, D.D. Deming2, R.L. Larsen1, A.J. Razzouk3, L.L. Bailey3 1Loma Linda University Medical Center and Children’s Hospital, Loma Linda, CA; 2Loma Linda University Medical Center and Children’s Hospital, Loma Linda, CA; 3Loma Linda University Medical and Children’s Hospital, Loma Linda, CA Purpose: Intravascular ultrasound (IVUS) has been used routinely in the diagnosis of cardiac allograft vasculopathy (CAV) in heart transplant recipients of all ages. This retrospective study evaluates our experience with IVUS in our pediatric population over a 10-year period (7/97 – 6/08). Methods and Materials: Beginning at 7 years of age, IVUS was incorporated into the annual study. Morphometric analysis was performed on ten random vessel segments. The degree of intimal changes was assessed based on the Stanford Classification. Patients were divided into those with minor intimal thickening (Class 1/2) and those with moderate to severe thickening (Class 3/4). Outcome variables included graft loss, retransplantation, death, CAV on autopsy, CAV ⫾ angiographic changes on catheterization(CAV/Angio⫹), and other causes of graft loss. Comparisons were made using chi-square analysis. A p-value ⬍ 0.05 was considered significant. Results: Since 1997, 163 children have undergone 415 IVUS procedures. There were 3 procedural complications, all coronary vasospasm that resolved without sequelae. The table shows the comparison between the two groups. There was a significant association between the development of intimal thickening and CAV. The vast majority of graft loss was due to CAV in the Class 3/4 group (13/15 cases). The majority of graft loss in the Class 1/2 group was not due to CAV and all the cases resulted in death. There was no significant difference between the two groups when comparing death or other causes of death. Conclusions: In conclusion, the presence of significant intimal changes on IVUS correlates strongly with the development of CAV in pediatric heart transplant recipients. IVUS is an excellent tool for the early diagnosis of developing CAV.
CAV
CAV/Angioⴙ Graft Loss Retransplant Death Other
SC 1/2 (n ⫽ 135) 4 4 SC 3/4 (n ⫽ 31) 13 22 p-value ⬍0.0001 ⬍0.0001
13 15 ⬍0.0001
0 8 ⬍0.0001
13 7 ⬍0.06
10 2 NS
668 Does Cytomegalovirus Serology Impact Outcome Following Pediatric Heart Transplantation? W.T. Mahle1, J.C. Alejos2, M. Foushee3, D.C. Naftel3, J. Rao4, R. Caldwell5, K. Uzark6, A.M. Berg1, K.R. Kanter1 1Emory University, Atlanta; 2UCLA, Los Angeles; 3University of Alabama Birmingham, Birmingham; 4Riley Children’s Hospital, Indianapolis; 5Cincinnati Children’s Medical Center, Cincinnati Purpose: Cytomegalovirus (CMV) infection has been implicated in a number of complications following heart transplantation (HT). A recent study suggested that children with positive CMV serology (CMV⫹) before HT are at increased risk of developing coronary allograft vasculopathy (CAV) and death when compared to CMVrecipients. We analyzed data from the Pediatric Heart Transplant Study group to determine the impact of recipient CMV status and
levels, HLA DR mismatches, and rejection episodes in the first year following transplantation were studied. Results: The overall incidence of post-transplant diabetes (PTDM) was 9.2% (n⫽25). PTDM incidence was 8.9% (5 of 56) in the sirolimus-only group, 11.8% (6 of 51) in the combined sirolimus and tacrolimus group, 11.6% (5 of 43) in the tacrolimus-only group, and 7.4% (9 of 122) in the cyclosporin-only group. In sirolimus-treated patients, diabetics vs. nondiabetics, there was no significant difference in age at transplantation (mean 2.4y ⫾4.3 and 2.3y⫾4.4, p⫽0.95). There was a significant difference in average and maximum sirolimus levels, means 9⫾4.2 vs. 6.8⫾2.2 ng/mL, p⫽0.03; maximum level means 26.8⫾15 vs. 14.6⫾7.7 ng/mL, p⫽0.003. There was no significant difference in HLA DR mismatches (p⫽0.45) or the number of rejection episodes (p⫽0.2). Conclusions: Post-transplant diabetes can occur in young children receiving heart transplantation and treated with sirolimus. Diabetes is significantly correlated with higher sirolimus levels. The incidence of post-transplant diabetes in sirolimus-treated patients is less than the incidence in patients treated with tacrolimus alone or combined with sirolimus. The mechanism of sirolimus-associated diabetes in children, be it insulin-deficiency or insulin-resistance, remains to be elucidated. 666 Predictors of Obesity in Children after Heart Transplant: An Analysis of the ISHLT Pediatric Heart Transplant Registry B.D. Kaufman1, S. Chuai2, F. Dobbels3, R.E. Shaddy1 1University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, PA; 2University of Pennsylvania, School of Medicine, Philadelphia, PA; 3University of Leuven, Leuven, Belgium Purpose: Obesity has been associated with adverse outcomes in both adult and pediatric heart transplant (HT). Patient-related traits and clinical events post-HT may influence weight gain. Risk factors for obesity in children post-HT have not been well described. Methods and Materials: The ISHLT Pediatric Heart Transplant Registry was queried for HT recipients ⱖ2yrs old between 1996 and 2006 with data for BMI percentile (BMI%) at HT and at 1year follow-up (Fup). BMI% cohorts were defined as: Wasted ⬍5th BMI%, Normal 5-95th BMI%, and Obese ⬎95th BMI% at 1 yr post-HT. Cohorts were compared for pre- and post-HT traits and events that might predict obesity post-HT. Results: Data from 1007 pediatric HT pts were available for BMI%ile analysis at 1 year post-HT. At 1 yr post-HT, 21% of pts were Obese; which had increased from 10% Obese at time of HT(p⬍.001). 63% of Obese pts 1yr post-HT were Normal at HT, while 34% had been Obese at HT and 4% were Wasted at HT (p⬍.001). 67% of Obese pts at HT remained Obese at 1yr Fup. Pre HT diagnoses of the Obese cohort were: Congenital heart disease 27%, Cardiomyopathy 65%, Retransplant 7%, and Other 1%. On univariate analyses, gender, age at HT, diagnosis, medical status at HT, waiting time, and length of stay post-HT did not predict obesity at 1yr Fup. Incidence of hospitalization, rejection, or coronary disease during 1st yr Fup also did not differ between BMI cohorts. Maintenance steroid use at 1yr Fup was Obese 69%, Normal 59% (p.036). There was no difference in steroid use for rejections or previous use. Obese cohort had increased hyperlipidemia (31%) and hypertension (71%) at 1yr post-HT. Overall mortality was increased in pts with Obesity at 1yr post-HT (p.03). Conclusions: The incidence of obesity doubled from time of HT to 1 yr post-HT. Obesity at time of HT and maintenance steroid use at 1yr, were the only risk factors for post-HT obesity identified. As these are potentially modifiable risk factors for poor HT outcomes, attention to weight loss and alternative medication regimens are warranted.
Abstracts
S297
667 The Use of Intravascular Ultrasound in the Diagnosis of Cardiac Allograft Vasculopathy in Pediatric Heart Transplant Recipients: A Ten Year Experience M.A. Kuhn1, R.E. Chinnock2, D.D. Deming2, R.L. Larsen1, A.J. Razzouk3, L.L. Bailey3 1Loma Linda University Medical Center and Children’s Hospital, Loma Linda, CA; 2Loma Linda University Medical Center and Children’s Hospital, Loma Linda, CA; 3Loma Linda University Medical and Children’s Hospital, Loma Linda, CA Purpose: Intravascular ultrasound (IVUS) has been used routinely in the diagnosis of cardiac allograft vasculopathy (CAV) in heart transplant recipients of all ages. This retrospective study evaluates our experience with IVUS in our pediatric population over a 10-year period (7/97 – 6/08). Methods and Materials: Beginning at 7 years of age, IVUS was incorporated into the annual study. Morphometric analysis was performed on ten random vessel segments. The degree of intimal changes was assessed based on the Stanford Classification. Patients were divided into those with minor intimal thickening (Class 1/2) and those with moderate to severe thickening (Class 3/4). Outcome variables included graft loss, retransplantation, death, CAV on autopsy, CAV ⫾ angiographic changes on catheterization(CAV/Angio⫹), and other causes of graft loss. Comparisons were made using chi-square analysis. A p-value ⬍ 0.05 was considered significant. Results: Since 1997, 163 children have undergone 415 IVUS procedures. There were 3 procedural complications, all coronary vasospasm that resolved without sequelae. The table shows the comparison between the two groups. There was a significant association between the development of intimal thickening and CAV. The vast majority of graft loss was due to CAV in the Class 3/4 group (13/15 cases). The majority of graft loss in the Class 1/2 group was not due to CAV and all the cases resulted in death. There was no significant difference between the two groups when comparing death or other causes of death. Conclusions: In conclusion, the presence of significant intimal changes on IVUS correlates strongly with the development of CAV in pediatric heart transplant recipients. IVUS is an excellent tool for the early diagnosis of developing CAV.
CAV
CAV/Angioⴙ Graft Loss Retransplant Death Other
SC 1/2 (n ⫽ 135) 4 4 SC 3/4 (n ⫽ 31) 13 22 p-value ⬍0.0001 ⬍0.0001
13 15 ⬍0.0001
0 8 ⬍0.0001
13 7 ⬍0.06
10 2 NS
668 Does Cytomegalovirus Serology Impact Outcome Following Pediatric Heart Transplantation? W.T. Mahle1, J.C. Alejos2, M. Foushee3, D.C. Naftel3, J. Rao4, R. Caldwell5, K. Uzark6, A.M. Berg1, K.R. Kanter1 1Emory University, Atlanta; 2UCLA, Los Angeles; 3University of Alabama Birmingham, Birmingham; 4Riley Children’s Hospital, Indianapolis; 5Cincinnati Children’s Medical Center, Cincinnati Purpose: Cytomegalovirus (CMV) infection has been implicated in a number of complications following heart transplantation (HT). A recent study suggested that children with positive CMV serology (CMV⫹) before HT are at increased risk of developing coronary allograft vasculopathy (CAV) and death when compared to CMVrecipients. We analyzed data from the Pediatric Heart Transplant Study group to determine the impact of recipient CMV status and