Pediatric transplant recipients living longer

Intent-to-treat survival among pediatric patients who have received a heart, liver or kidney transplant steadily improved over the past 3 decades, according to a study of more than 47,000 transplants.

In a video presentation that accompanied the study online, Brian T. Hickner, BS, a student at the Baylor College of Medicine, explained that the waitlist and posttransplant survival metric for pediatric transplantation does not paint a full picture.

“For decades, transplantation has prolonged and improved quality of life for children with heart, liver and kidney failure,” Hickner said. “While progress over the years has been well documented in the context of waitlist and posttransplant survival, these individual metrics fall short of providing a complete perspective for children and families.”

“It’s important to assess progress in the context of intent-to-treat survival, which follows patients from the day of listing until death, regardless of whether a transplant is received,” Hickner said. “As a composite function of transplantation rate, in addition to waitlist and posttransplant survival, intent-to-treat is more congruent with what a patient actually experiences when listed for transplant than individual metrics alone ... We were essentially asking the question, are children who are listed for transplant actually living longer?”

Hickner and colleagues used data on thoracic, liver and kidney-pancreas registries collected by the Organ Procurement and Transplantation Network for 47,202 first-time transplant candidates between 1987 and 2017. They found that intent-to-treat survival steadily improved among children listed for heart, (HR 0.96, 95% CI 0.96–0.97), liver (HR 0.95, 95% CI 0.94–0.97), and kidney (HR 0.97, 95% CI 0.95–0.99) transplants.

“What we found is that intent-to-treat survival has steadily improved over time for all three organs,” Hickner said. “For all three organs this is due in part to improved waitlist and post-transplant survival. Additionally, for heart transplants, we found that the percentage of children receiving transplant within 1 year was significantly greater at the end of the study period, compared to the beginning.”

“These data are encouraging, and this is an excellent analysis,” Maia S. Anderson, MD, a surgery resident at Michigan Medicine, and colleagues wrote in an accompanying editorial. “That said, we should not be proud of these findings. Survival differences related to geography and resources remain for children with end-organ disease.”

They said new policy efforts should focus on the issues of regional variation in organ donation rates among children.

“There is also no robust learning health system to continuously drive improvements in pediatric transplant care in the United States; improvements are mostly related to national secular trends,” they wrote. “Action is needed to improve the lives of children with end-organ disease in the United States.”

Hickner addressed this in his presentation.

“Children listed for heart, liver and kidney transplant are in fact living longer than previous years,” Hickner said. “While improved care of patients on the waitlist, and patients who receive transplant have contributed to the success, ample room for growth remains.”

References:

Anderson M, et al. Pediatr. 2022;doi:10.1542/peds.2021-054099.