The purpose of this study is to determine the clinical outcomes of sensitized pediatric heart transplant recipients with a positive donor-specific cytotoxicity crossmatch and to compare this group with outcomes in nonsensitized heart transplant recipients.
There is currently a renewed interest in alloantibodies in transplantation. In 1966, Kissmeyer and colleagues reported that pre-existing antibodies directed against donor cells could cause hyperacute rejection of the renal allograft. Three years later, in a landmark study, Patel and Terasaki showed that a lymphocytotoxic assay to identify donor-specific antibodies was highly predictive of acute graft failure. These observations led to the practice of performing prospective, donor-specific crossmatches by lymphocytotoxicity assay for all kidney transplants and for heart and lung transplants when the candidate has a positive panel reactive antibody (PRA) assay. A concept evolved that transplantations should not be performed across a positive cytotoxicity crossmatch. The purpose of this study is to determine the clinical outcomes of sensitized pediatric heart transplant recipients with a positive donor-specific cytotoxicity crossmatch and to compare this group with outcomes in nonsensitized heart transplant recipients. This study plans to enroll 370 pediatric heart transplant recipients over a period of 3 years. The follow-up period will last up to 3 years. All participants will be enrolled pretransplant. In the pretransplant phase, visits will occur every 6 months. These routine visits will continue until transplant or the end of the study. They will coincide with routine pretransplant status visits. At the time of transplant, the participants will be assigned to one of two groups. Group A will include participants who are allo-antibody negative (less than 10% by AHG CDC-PRA and ELISA in all DTT-treated serum samples). Cohort B will include participants who have the presence of a DTT-treated AHG CDC-PRA of greater than or equal to 10% and/or an ELISA-PRA greater than or equal to 10% in any pretransplant sample. Both cohorts will receive standard transplantation care. This study has no interventions. All participants will undergo regular blood tests, and, those in the sensitized group will have additional blood testing performed after the transplant and lasting until the end of the study. Post-transplant visits will occur while participants are recovering in the hospital; at Months 1, 3, and 6; and annually until the study closes. The information collected for the study include data from a physical exam, routine testing, adverse (AEs) and serious adverse (SAEs) events assessments, and blood collection. Each time a biopsy is done, the study will ask to review the biopsy tissue and to collect a sample. If stored tissue is not available, none will be collected.
Study Type
OBSERVATIONAL
Enrollment
290
Per standard of care guidelines for immunosuppression at each clinical site.
Per standard of care guidelines for immunosuppression at each clinical site.
Per standard of care guidelines for immunosuppression at each clinical site.
Children's Hospital Boston, Harvard Medical School
Boston, Massachusetts, United States
St. Louis Children's Hospital, Washington University
St Louis, Missouri, United States
Children's Hospital of New York, Columbia University Medical Center
New York, New York, United States
Percentage of Participants Positive for Event of Death, Graft Loss or Rejection With Hemodynamic Compromise at 12 Months Post-Transplantation
This is a composite outcome of death, graft loss or rejection with hemodynamic compromise. Rejection was considered to be with hemodynamic compromise if the rejection event had new onset echocardiographically measured from fractional shortening \<26% with ≥5% fall from last echocardiogram or the rejection event had new onset of heart failure.
Time frame: 12 months post-transplantation
Time to Production of Post-Transplant de Novo Donor-specific Alloantibodies
Time (in days) from transplant to development of de novo donor-specific alloantibodies (DSA). This measure is calculated as time from transplant until the earliest time of development of any de novo DSA. The DSA is a newly developed alloantibody that is against the donor organ. Alloantibodies are important mediators of acute and chronic rejection.
Time frame: Transplantation to first year post transplant (up to 12 months post transplant).
Percentage of Participants Positive for de Novo Donor-Specific Alloantibody Production in the First Year Post-Transplantation
A de novo donor-specific alloantibody (DSA) is a newly developed alloantibody that is against the donor organ. This measure includes all de novo DSA (≥1000 MFI) regardless of is persistence or timing within the first year post-transplant. Alloantibodies are important mediators of acute and chronic rejection.
Time frame: Transplantation to first year post transplant (up to 12 months post transplant).
Percentage of Participants- Mortality While on Transplantation Wait-List
Death that occurred while on the transplantation wait-list, and thus before receiving a heart transplant.
Time frame: Pre-transplantation
Time From Participant Listing on Organ Wait-List to Receiving Organ Transplant, Death or De-Listing
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Per standard of care guidelines for immunosuppression at each clinical site.
Per standard of care guidelines for immunosuppression at each clinical site.
Post-transplant course of intravenous immunoglobulin therapy per standard of care guidelines for immunosuppression at each clinical site.
Maintenance corticosteroids per standard of care guidelines for immunosuppression at each clinical site.
Children's Hospital at Montefiore
The Bronx, New York, United States
Children's Hospital of Philadelphia, University of Pennsylvania
Philadelphia, Pennsylvania, United States
Children's Hospital of Pittsburgh of UPMC
Pittsburgh, Pennsylvania, United States
Vanderbilt University
Nashville, Tennessee, United States
Hospital for Sick Children, Labatt Family Heart Centre
Toronto, Ontario, Canada
Time (in days) from listing on the organ wait-list to receiving an organ transplant, death or de-listing. This measure is calculated as time from listing on the organ wait-list until the earliest time among transplantation, death and de-listing.
Time frame: Study enrollment to transplantation
Percentage of Participants With the Presence of Anti-HLA IgG Antibodies by Luminex SA Testing
Luminex SA testing was used to detect the presence of anti-HLA IgG Antibodies for all samples at a central laboratory.
Time frame: Pre-transplantation
Percentage of Participants -Quantification of Anti-HLA IgG Antibodies by Luminex SA Testing
Quantification of anti-HLA IgG antibodies is measured in mean fluorescence intensity (MFI). The maximum MFI for the given subject is provided.
Time frame: Pre-transplantation
Percentage of Participants With the Presence of Anti-MICA Antibodies by Luminex TM Assay
Major histocompatibility complex class I chain-related gene A (MICA) is an antigen that is a potential marker of rejection. Luminex TM assay was used to detect its presence.
Time frame: Pre-Transplantation
Percentage of Participants -Overall Participant and Graft Survival
This measure looks at the participants who did not die and/or did not receive a subsequent heart transplant.
Time frame: Transplantation to the end of study (up to 4 years post transplant).
Presence of C4d on Endomyocardial Biopsy (EMB)
The biopsy of the heart stained positive for the presence of C4d, a potential marker of rejection.
Time frame: Transplantation to the end of study (up to 4 years post transplant).
Percentage of Participants With Occurrence of Re-Hospitalization(s)
Hospitalization is defined as any hospitalization lasting greater than 24 hours.
Time frame: Transplantation to the end of study (up to 4 years post transplant).
Percentage of Participants Positive for Severe Infection(s)
Severe infections are defined as a clinical illness considered likely infectious in origin that leads to hospitalization.
Time frame: Transplantation to the end of study (up to 4 years post transplant).
Time to Diagnosis of Chronic Rejection
Time (in days) to the diagnosis of chronic rejection. Chronic rejection is defined as stenosis, irregularity, or ectasia of the epicardial vessels, or severe peripheral pruning of the distal coronary artery tree. Time to diagnosis is time from transplantation until the first diagnosis of chronic rejection.
Time frame: Transplantation to the end of study (up to 4 years post transplant).
Time to Post-Transplantation Lymphoproliferative Disorder
Time (in days) post-transplant lymphoproliferative disorder (PTLD). PTLD is defined as histopathological evidence of lymphoid proliferation (nodal or extranodal) fulfilling the criteria of the revised classification of the WHO 2008 (Swerdlow 2008). Time to PTLD is time from transplantation until the diagnosis of PTLD.
Time frame: Transplantation to the end of study (up to 4 years post transplant).
Time to New-Onset Diabetes Mellitus
Time (in days) to new-onset diabetes mellitus. New-onset diabetes mellitus is defined as the new onset of insulin dependency or the need for oral hypoglycemic agents lasting more than 30 days post-transplant. Time to new-onset diabetes is time from transplantation until the diagnosis of new-onset diabetes.
Time frame: Transplantation to the end of study (up to 4 years post transplant).
Percentage of Participants Experiencing Acute Rejection
Acute rejection is defined as any one of the following types of rejection: acute cellular rejection (International Society for Heart and Lung Transplant (ISHLT)) system for grading rejection grade 2R or greater), acute refractory cellular rejection (acute cellular rejection unresponsive to two sequential courses of corticosteroids), acute antibody mediated rejection (histological evidence of unequivocal acute capillary injury, with complement deposition and margination of macrophages with or without neutrophils), acute mixed rejection (evidence of acute antibody mediated rejection with ISHLT grade 1R or greater), or acute clinical rejection (clinically-based acute rejection, no matter the ISHLT grade, leading to an acute augmentation of immunosuppression).
Time frame: Transplantation to the end of study.
Time to Acute Rejection
Time (in days) to acute rejection. Acute rejection is defined as any one of the following types of rejection: acute cellular rejection (International Society for Heart and Lung Transplant (ISHLT) system for grading rejection grade 2R or greater), acute refractory cellular rejection (acute cellular rejection unresponsive to two sequential courses of corticosteroids), acute antibody mediated rejection (histological evidence of unequivocal acute capillary injury, with complement deposition and margination of macrophages with or without neutrophils), acute mixed rejection (evidence of acute antibody mediated rejection with ISHLT grade 1R or greater), or acute clinical rejection (clinically-based acute rejection, no matter the ISHLT grade, leading to an acute augmentation of immunosuppression). Time to acute rejection is time from transplantation to first acute rejection date.
Time frame: Transplantation to the end of study.