Immunosuppressive Agents in Pediatric Heart Transplantation
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All pediatric heart transplantation programs currently use a calcineurin inhibitor (CNI), either cyclosporine or tacrolimus, as a primary immunosuppressant. Although these drugs have much toxicity, there is insufficient data to show that CNI-free immunosuppression is safe or feasible from the time of transplantation. Most centers also use an additional adjunctive agent, either in the form of an antimetabolite (azathioprine [AZA] or mycophenolate mofetil) or, less commonly, a mammalian target of rapamycin (mTOR) inhibitor. The addition of these agents reduces early acute rejection events and may improve long-term graft and patient outcomes. The most controversial issue is whether corticosteroids should be routinely added to form a “triple therapy.” Many pediatric transplant centers have successfully used complete steroid avoidance or early steroid withdrawal. Finally, there is no agreement on whether intravenous antibody induction therapy should be routinely used. If used, there is also no agreement regarding whether it should be in the form of a monoclonal (OKT3) or polyclonal T-cell-depleting antibody (e.g., Thymoglobulin®) or an interleukin (IL)-2 receptor (IL2R) antagonist (e.g., basiliximab or daclizumab). A summary of the options for induction and maintenance therapy is shown in Table 8-1. It should be noted that there have been no large-scale randomized controlled trials of any immunosuppressive therapy in pediatric thoracic transplantation.
KeywordsAcute Rejection Mycophenolate Mofetil Heart Lung Transplant Cytokine Release Syndrome Poisoning Information
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