Abstract
Routine long-term immunosuppression (IS) after pediatric heart transplantation is based on the combination of tacrolimus (TAC) and mycophenolate mofetil (MMF) or everolimus (EVE). Gastrointestinal side-effects of the MMF and/or recurrent infections related to EVE can indicate the use of TAC monotherapy. The safety of TAC monotherapy was analized. Between 2007-2014 September, 26 pediatric heart transplantations were performed in our institute (age: 3 months-16 years; male/female: 12/14; weight: 4.4-61.5 kg). Tacrolimus monotherapy was indicated in 4 cases due to recurrent side effects (age: 11-23 months; male/female: 3/1; weight: 7.6-11.4 kg). Target level of tacrolimus was determined 2 ng/ml higher than used by combined therapy. Surveillance biopsies and echocardiography were performed to detect rejections. Rejections and incidence of infections were studied retrospectively. In every case the first line therapy was the combination of TAC+MMF. In 3 of them MMF/EVE conversion was indicated due to severe enteral side-effects in spite of MMF dose reduction. TAC target level was reduced on TAC+EVE combination depending on posttransplant time. After the conversion the gastrointesinal symptoms were eliminated, but in all of 3 patients recurrent infections were occured (in 2 patients upper-airway infections, in 1 patient permanent high replication of Ebstein Barr virus developed). In 1 patient on TAC+MMF therapy CMV disease and recurrent CMV activations were detected, indicating the reduction of IS. The main follow-up were 14 months. No side-effects was documented related to higher tacrolimus-level. No rejections were detected on biopsies. Infection rate was significantly reduced in every patients. Reduced immunosuppression could be necessary in small children (<2 yrs of age) due to recurrent side effects of TAC+MMF/EVE therapy. Tacrolimus monotherapy can be a good and safe alternative with higher target level. Long-term follow-up is needed to evaluate chronic rejection.
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