Long-term follow-up after total lymphoid irradiation in pediatric heart transplant recipients

Abstract

Background Total lymphoid irradiation (TLI) is used to treat recurrent allograft rejection. Short-term success and complication rates have been reported in pediatric and adult cardiac transplant populations. We report the long-term efficacy and safety of TLI in treating intractable rejection in pediatric patients. Methods Eight pediatric patients were treated with TLI (7 for recurrent rejection, 1 for risk of medication non-compliance). Therapy consisted of a mid-plane dose of 8 Gy administered with a 6-MeV linear accelerator using an anterior–posterior opposed technique. We reviewed outcomes for a total of 40 patient-years of follow-up. Results We encountered rejection (>Grade 2 by International Society for Heart and Lung Transplantation criteria) in 56.7% ± 34.7% of biopsies performed within 90 days before TLI. Rejection rates dropped to 3.1% ± 8.8% within the first 90 days ( p < 0.005) after therapy and remained low at 5.6% ± 1.3% ( p < 0.05) during the first year after completion of TLI. Median time from TLI to the first subsequent rejection episode was 305 days (range, 77–1,920 days). Long-term follow-up (>3 years) of 5 patients demonstrated a continuing low incidence of rejection. Non-Hodgkin’s lymphoma was diagnosed in 1 of 8 patients, graft coronary artery disease in 4 of 8 patients, and restrictive cardiomyopathy in 1 of 8 patients after TLI. Conclusions Total lymphoid irradiation is an effective treatment for recurrent rejection and has short- and long-term efficacy. Morbid events may include cancer, graft coronary artery disease, and restrictive cardiomyopathy.