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200: Center-Specific Outcomes for Pediatric Heart Transplantation: Do Past Outcomes Predict Future Performance?
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The Journal of Heart and Lung Transplantation, Vol 29, No 2S, February 2010
eras (P⬍0.001 for trend). White children were more likely to be on a ventilator or ECMO at the time of transplant in all 5 eras (P⬍0.01 for all). The proportion of children with congenital heart disease declined with time in all racial groups (P⬍0.001). There was no significant race-era interaction for early (6-mo) post-HT survival (P⫽0.20) which improved with time (hazard ratio, HR 0.80, 95% CI 0.7, 0.9 for successive eras, P⬍0.001) in all three groups adjusted for age, diagnosis, invasive support, renal function, bilirubin, previous surgery and ischemic time. Conditional survival (in 6-mo survivors) was worse in black children in adjusted analysis (HR 2.2, CI 1.9, 2.5, P⬍0.001) and did not improve in any racial group with time (P⫽NS for race-era interaction). Conclusions: The improvement in early post-HT survival appears to have benefited white, black and Hispanic children equally during the last 2 decades. Conditional survival has not improved in any racial group. Targeted efforts in high-risk children may improve conditional and overall survival following heart transplant. 199 Use of Induction Agents and Incidence of Infection and Malignancy Following Pediatric Heart Transplantation R.J. Gajarski,1 E.D. Blume,3 K. Schechtman,6 J. Zheng,6 L.J. West,5 S. Urschel,5 S. Miyamoto,4 L. Altamirano,5 D. Naftel,7 J.K. Kirklin,7 M.C. Zamberlan,1 C. Canter.2 1C.S. Mott Children’s Hospital, University of Michigan Health System, Ann Arbor, MI; 2St. Louis Children’s Hospital, Washington University School of Medicine, St. Louis, MO; 3Boston Children’s Hospital, Harvard Medical School, Boston, MA; 4Denver Children’s Hospital, University of Colorado Health System, Aurora, CO; 5Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada; 6Washington University School of Medicine, St. Louis, MO; 7University of Alabama, Birmingham, AL. Purpose: Previously, induction use in pediatric heart transplant (HTx) recipients was associated with an increased lymphoma risk. This study reviewed the current era incidence and risks for infection and malignancy in pediatric patients (pts) induced with cytolytic agents or IL-2R antagonists. Methods and Materials: Data from a prospective, multi-center eventdriven registry of outcomes after HTx listing in pts ⬍18yrs (Pediatric Heart Transplant Study) was used to analyze infection, malignancy and associated risk factors in pts receiving induction between 1/93-12/08. Results: Of 2374 pts, 1258 (53%) received induction and more frequently from 1999-2008 compared with 1993-1998 (70.8% vs 57.5%, p⬍0.001). At HTx, induced pts were more likely to have congenital heart disease (CHD) (56.9% vs 48.1%, p⬍0.001) but no more likely to be EBV⫹ (50.3% vs 51.4%, p⫽0.67). Post transplant lymphoproliferative disease (PTLD) (n⫽114) was the most common malignancy (93.4%), and 48 PTLD pts became EBV⫹ post-HTx. Patients who received induction and those EBV⫹ at HTx had a lower risk for PTLD (HR 0.5, CI 0.3-0.84; p⫽0.002 and HR 0.43, CI 0.27-0.72; p⫽0.009, respectively).[figure1]
Induced pts had lower total infections/pt (1.05⫾2.1 vs 1.22⫾2.1, p⫽0.04) as well as fungal (0.05⫾0.3 vs 0.08⫾0.3, p⫽0.01) and CMV (0.10⫾0.4 vs 0.14⫾0.5, p⫽0.03) infections. Conclusions: Induction use has increased since 1999, is common in CHD pts and was not associated with pre-HTx EBV status. PTLD accounted for
most malignancies and was frequently observed in EBV naive pts who seroconverted post-HTx. Contrary to prior reports, induction was not associated with an increased risk of malignancy or infection. Future analyses will focus on differential effect of induction type. 200 Center-Specific Outcomes for Pediatric Heart Transplantation: Do Past Outcomes Predict Future Performance? W.T. Mahle, K.R. Kanter, R.N. Vincent. Children’s Healthcare of Atlanta, Atlanta, GA. Purpose: Efforts are currently underway to direct patients toward the highest-quality hospitals. Some healthcare purchasers have implemented standards for evidence-based hospital referral for high-risk procedures, including pediatric heart transplantation. Most purchasers in the United States have employed publicly available data from the Scientific Registry of Transplant Recipients (SRTR) with particular attention to 1 yr and 3 yr patient survival. Given the relatively small number of pediatric heart transplants, we sought to determine if past performance is a reliable predictor of future performance. Methods and Materials: To assess how well previous survival data predicted subsequent patient survival, we created a logistic regression model. Two eras were analyzed. For 1 yr survival transplant dates were: era 1⫽ 1/1/03 to 6/30/05 era 2⫽1/1/06 to 6/30/08. For 3 yr survival transplant dates were: era 1⫽ 1/1/01 to 6/30/03 era 2⫽ 7/1/03 to 12/31/05. Centers with annualized volumes of ⬍ 4 transplants/year were not included. Results: In analysis of 36 pediatric heart transplant centers 1 yr survival in era 1 had no association with 1 yr mortality in era 2, p⫽1.0. In contrast, centers with lower than expected 3 yr mortality in era 1 were much more likely to have lower 3 yr mortality in era 2, OR 6.6, 95% CI 1.5-28.5, p⫽.01. The latter association was also found when one examined only moderate to high volume centers. Theoretically, if one were to adapt an evidence-based strategy referring transplant candidates to centers with superior 3 yr survival one would anticipate an additional 24 children surviving to 3 yrs, assuming 300 annual pediatric heart transplants. Conclusions: Historical transplant center performance is related to subsequent outcomes. However, analysis of 3 yr, rather than 1 yr, survival should be considered the benchmark. Evidence-based hospital referral for pediatric heart transplantation may improve overall survival. 201 Lung Transplantation in Children after Hematopoietic Stem-Cell Transplantation S. Yousef,1 C. Benden,3 T. Frischer,8 G. Westall,1 S. Goldfarb,4 M. Ballman,5 P. Aurora,6 G. Doherty,6 D. Boyer,7 G. Visner,7 M. Woo,12 M.G. Michaels,9 S.C. Sweet,10 M.G. Schecter,2 G.B. Mallory,2 O. Elidemir.2 1University of Miami, Miami, FL; 2Baylor College of Medicine, Houston, TX; 3University Hospital Zurich, Zurich, Switzerland; 4Children’s Hospital of Philadelphia, Philadelphia, PA; 5 Hannover Medical School, Hannover, Germany; 6Great Ormond Street Hospital, London, United Kingdom; 7Harvard University, Boston, MA; 8 University of Vienna, Vienna, Austria; 9Children’s Hospital of Pittsburgh, Pittsburgh, PA; 10Washington University, St. Louis, MO; 11 Alfred Hospital and Monash University, Melbourne, Vic, Australia. Purpose: Hematopoietic stem-cell transplantation (HSCT) is a life saving treatment modality for a variety of disorders. Chronic graft-versus-host disease and associated bronchiolitis obliterans (BO) continues to cause morbidity and mortality in long-term survivors. In selected patients in selected centers, lung transplantation has become a therapeutic option in these patients. Outcomes of lung transplantation after HSCT in children have not been evaluated. We hypothesized that pediatric HSCT recipients with BO would have comparable outcomes compared to other lung transplant recipients. Methods and Materials: Member centers of International Pediatric Lung Transplant Collaborative participated in a multi-center, retrospective, casecontrol study. IRB approval was obtained at each center. Here we report initial results from 4 centers that completed data collection so far. Several outcome parameters were evaluated and compared with randomly chosen
The Journal of Heart and Lung Transplantation, Vol 29, No 2S, February 2010
eras (P⬍0.001 for trend). White children were more likely to be on a ventilator or ECMO at the time of transplant in all 5 eras (P⬍0.01 for all). The proportion of children with congenital heart disease declined with time in all racial groups (P⬍0.001). There was no significant race-era interaction for early (6-mo) post-HT survival (P⫽0.20) which improved with time (hazard ratio, HR 0.80, 95% CI 0.7, 0.9 for successive eras, P⬍0.001) in all three groups adjusted for age, diagnosis, invasive support, renal function, bilirubin, previous surgery and ischemic time. Conditional survival (in 6-mo survivors) was worse in black children in adjusted analysis (HR 2.2, CI 1.9, 2.5, P⬍0.001) and did not improve in any racial group with time (P⫽NS for race-era interaction). Conclusions: The improvement in early post-HT survival appears to have benefited white, black and Hispanic children equally during the last 2 decades. Conditional survival has not improved in any racial group. Targeted efforts in high-risk children may improve conditional and overall survival following heart transplant. 199 Use of Induction Agents and Incidence of Infection and Malignancy Following Pediatric Heart Transplantation R.J. Gajarski,1 E.D. Blume,3 K. Schechtman,6 J. Zheng,6 L.J. West,5 S. Urschel,5 S. Miyamoto,4 L. Altamirano,5 D. Naftel,7 J.K. Kirklin,7 M.C. Zamberlan,1 C. Canter.2 1C.S. Mott Children’s Hospital, University of Michigan Health System, Ann Arbor, MI; 2St. Louis Children’s Hospital, Washington University School of Medicine, St. Louis, MO; 3Boston Children’s Hospital, Harvard Medical School, Boston, MA; 4Denver Children’s Hospital, University of Colorado Health System, Aurora, CO; 5Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada; 6Washington University School of Medicine, St. Louis, MO; 7University of Alabama, Birmingham, AL. Purpose: Previously, induction use in pediatric heart transplant (HTx) recipients was associated with an increased lymphoma risk. This study reviewed the current era incidence and risks for infection and malignancy in pediatric patients (pts) induced with cytolytic agents or IL-2R antagonists. Methods and Materials: Data from a prospective, multi-center eventdriven registry of outcomes after HTx listing in pts ⬍18yrs (Pediatric Heart Transplant Study) was used to analyze infection, malignancy and associated risk factors in pts receiving induction between 1/93-12/08. Results: Of 2374 pts, 1258 (53%) received induction and more frequently from 1999-2008 compared with 1993-1998 (70.8% vs 57.5%, p⬍0.001). At HTx, induced pts were more likely to have congenital heart disease (CHD) (56.9% vs 48.1%, p⬍0.001) but no more likely to be EBV⫹ (50.3% vs 51.4%, p⫽0.67). Post transplant lymphoproliferative disease (PTLD) (n⫽114) was the most common malignancy (93.4%), and 48 PTLD pts became EBV⫹ post-HTx. Patients who received induction and those EBV⫹ at HTx had a lower risk for PTLD (HR 0.5, CI 0.3-0.84; p⫽0.002 and HR 0.43, CI 0.27-0.72; p⫽0.009, respectively).[figure1]
Induced pts had lower total infections/pt (1.05⫾2.1 vs 1.22⫾2.1, p⫽0.04) as well as fungal (0.05⫾0.3 vs 0.08⫾0.3, p⫽0.01) and CMV (0.10⫾0.4 vs 0.14⫾0.5, p⫽0.03) infections. Conclusions: Induction use has increased since 1999, is common in CHD pts and was not associated with pre-HTx EBV status. PTLD accounted for
most malignancies and was frequently observed in EBV naive pts who seroconverted post-HTx. Contrary to prior reports, induction was not associated with an increased risk of malignancy or infection. Future analyses will focus on differential effect of induction type. 200 Center-Specific Outcomes for Pediatric Heart Transplantation: Do Past Outcomes Predict Future Performance? W.T. Mahle, K.R. Kanter, R.N. Vincent. Children’s Healthcare of Atlanta, Atlanta, GA. Purpose: Efforts are currently underway to direct patients toward the highest-quality hospitals. Some healthcare purchasers have implemented standards for evidence-based hospital referral for high-risk procedures, including pediatric heart transplantation. Most purchasers in the United States have employed publicly available data from the Scientific Registry of Transplant Recipients (SRTR) with particular attention to 1 yr and 3 yr patient survival. Given the relatively small number of pediatric heart transplants, we sought to determine if past performance is a reliable predictor of future performance. Methods and Materials: To assess how well previous survival data predicted subsequent patient survival, we created a logistic regression model. Two eras were analyzed. For 1 yr survival transplant dates were: era 1⫽ 1/1/03 to 6/30/05 era 2⫽1/1/06 to 6/30/08. For 3 yr survival transplant dates were: era 1⫽ 1/1/01 to 6/30/03 era 2⫽ 7/1/03 to 12/31/05. Centers with annualized volumes of ⬍ 4 transplants/year were not included. Results: In analysis of 36 pediatric heart transplant centers 1 yr survival in era 1 had no association with 1 yr mortality in era 2, p⫽1.0. In contrast, centers with lower than expected 3 yr mortality in era 1 were much more likely to have lower 3 yr mortality in era 2, OR 6.6, 95% CI 1.5-28.5, p⫽.01. The latter association was also found when one examined only moderate to high volume centers. Theoretically, if one were to adapt an evidence-based strategy referring transplant candidates to centers with superior 3 yr survival one would anticipate an additional 24 children surviving to 3 yrs, assuming 300 annual pediatric heart transplants. Conclusions: Historical transplant center performance is related to subsequent outcomes. However, analysis of 3 yr, rather than 1 yr, survival should be considered the benchmark. Evidence-based hospital referral for pediatric heart transplantation may improve overall survival. 201 Lung Transplantation in Children after Hematopoietic Stem-Cell Transplantation S. Yousef,1 C. Benden,3 T. Frischer,8 G. Westall,1 S. Goldfarb,4 M. Ballman,5 P. Aurora,6 G. Doherty,6 D. Boyer,7 G. Visner,7 M. Woo,12 M.G. Michaels,9 S.C. Sweet,10 M.G. Schecter,2 G.B. Mallory,2 O. Elidemir.2 1University of Miami, Miami, FL; 2Baylor College of Medicine, Houston, TX; 3University Hospital Zurich, Zurich, Switzerland; 4Children’s Hospital of Philadelphia, Philadelphia, PA; 5 Hannover Medical School, Hannover, Germany; 6Great Ormond Street Hospital, London, United Kingdom; 7Harvard University, Boston, MA; 8 University of Vienna, Vienna, Austria; 9Children’s Hospital of Pittsburgh, Pittsburgh, PA; 10Washington University, St. Louis, MO; 11 Alfred Hospital and Monash University, Melbourne, Vic, Australia. Purpose: Hematopoietic stem-cell transplantation (HSCT) is a life saving treatment modality for a variety of disorders. Chronic graft-versus-host disease and associated bronchiolitis obliterans (BO) continues to cause morbidity and mortality in long-term survivors. In selected patients in selected centers, lung transplantation has become a therapeutic option in these patients. Outcomes of lung transplantation after HSCT in children have not been evaluated. We hypothesized that pediatric HSCT recipients with BO would have comparable outcomes compared to other lung transplant recipients. Methods and Materials: Member centers of International Pediatric Lung Transplant Collaborative participated in a multi-center, retrospective, casecontrol study. IRB approval was obtained at each center. Here we report initial results from 4 centers that completed data collection so far. Several outcome parameters were evaluated and compared with randomly chosen