1 - The surgical and immunosuppressive basis for infections in the pediatric solid organ transplant recipient

Abstract

Pediatric solid organ transplant changes the lives of thousands of patients every year. Balanced immunosuppression is essential in ensuring acceptance of the organ transplant and successful outcomes. The purpose of immunosuppression is to modulate the immune system’s ability to recognize the transplanted organ, otherwise known as rejection. However, an overly suppressed immune system increases the risk of certain infections in pediatric solid organ transplant patients. The goal of balanced immunosuppression is to walk the line between organ rejection and infection. Risk factors other than immunosuppression also contribute to the risk of infection in pediatric solid organ transplants. They are more likely to have chronic disease and malnutrition, which can affect normal immune responses. Many pediatric patients are also dependent on the use of central lines, peritoneal, or hemodialysis catheters, all of which increase the risk of invasive infections. The actual transplant surgery can be complicated by working with smaller vascular and other types of structures, and patients often have poor wound healing after surgery. Frequently, the pediatric solid organ transplant patient is also naïve to many different infections, as there is less lifetime exposure to infectious agents. Many children cannot complete the full immunization schedule before transplant. These factors contribute to underdeveloped protective immunity. As children have not had the chance to acquire immunity to a variety of infections, this can elevate the risk of severe infections after transplant. Sources of infection after transplant include donor-derived infections, infections acquired around the time of surgery, reactivation of latent infections, and other infections acquired through the lifetime of patients after transplant.