The Registry of the International Society for Heart and Lung Transplantation: Fourteenth Pediatric Lung and Heart-Lung Transplantation Report—2011

Abstract

This Fourteenth Pediatric Lung and Heart-Lung Transplantation Report covers the pediatric lung transplantation and heart-lung transplantation experience from January 1986 through June 2010. During this period, 1,664 pediatric lung transplant procedures and 653 pediatric heart-lung transplant procedures were reported to the International Society for Heart and Lung Transplantation (ISHLT) Registry. It is important to note that recent figures include pediatric lung and heart-lung transplant procedures dating back to 1987 that were previously not reported to the ISHLT Registry but were retrospectively entered in 2010. In 2009, the last complete year included in this year's ISHLT Registry report, 127 pediatric lung transplant procedures were reported, which is an increase of 43% compared with 2004. These figures, however, include only the pediatric lung transplant procedures that were reported to the ISHLT Registry and do not necessarily reflect the trend in numbers of pediatric lung procedures performed worldwide.This pediatric lung and heart-lung transplantation report includes a summary of the data analyses performed by the Registry this year and is supplemented by further analyses and additional figures that are available on the ISHLT Registry Web site (www.ishlt.org/registries). This report does not include detailed analyses and figures for pediatric heart-lung transplantation because this information has been presented in previous reports1Aurora P. Edwards L.B. Christie J.D. et al.Registry of the International Society for Heart and Lung Transplantation: eleventh official pediatric lung and heart-lung transplantation report—2008.J Heart Lung Transplant. 2008; 27: 978-983Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 2Aurora P. Edwards L.B. Christie J.D. et al.Registry of the International Society for Heart and Lung Transplantation: twelfth official pediatric lung and heart-lung transplantation report—2009.J Heart Lung Transplant. 2009; 28: 1023-1030Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 3Aurora P. Edwards L.B. Kucheryavaya A.Y. et al.Registry of the International Society for Heart and Lung Transplantation: thirteenth official pediatric lung and heart-lung transplantation report—2010.J Heart Lung Transplant. 2010; 29: 1129-1141Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar and the number of pediatric heart-lung transplant procedures continues to decrease (7 procedures in 2009, compared with 10 in 2008). Information on rare indications and rare causes of death after pediatric lung transplantation, as well as on risk factors for death or graft failure after pediatric lung transplantation is also reported elsewhere.1Aurora P. Edwards L.B. Christie J.D. et al.Registry of the International Society for Heart and Lung Transplantation: eleventh official pediatric lung and heart-lung transplantation report—2008.J Heart Lung Transplant. 2008; 27: 978-983Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 2Aurora P. Edwards L.B. Christie J.D. et al.Registry of the International Society for Heart and Lung Transplantation: twelfth official pediatric lung and heart-lung transplantation report—2009.J Heart Lung Transplant. 2009; 28: 1023-1030Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 3Aurora P. Edwards L.B. Kucheryavaya A.Y. et al.Registry of the International Society for Heart and Lung Transplantation: thirteenth official pediatric lung and heart-lung transplantation report—2010.J Heart Lung Transplant. 2010; 29: 1129-1141Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar This year's Registry report presents a more detailed analysis of pediatric lung retransplantation because the number of pediatric retransplant procedures reported to the Registry has increased in recent years.Statistical methodsDescriptive characteristics were used as appropriate, presenting proportions and medians ± standard deviations or 5th–95th percentiles. Survival rates were calculated by the Kaplan-Meier method and compared with the log-rank test. No adjustments were made for multiple comparisons; whenever the remaining recipient number was < 10, survival graphs were truncated. More detailed explanations of the statistical methodology accompany slides, where appropriate; slides are available online (www.ishlt.org/registries).Lung transplantationVolume, indications, and donor characteristicsThe number of transplant centers reporting pediatric lung transplant procedures in 2009 increased to 49, compared with 40 in 2008. During the last 5 years, the number of centers reporting pediatric lung transplant procedures increased by 36%, which is likely a partial result of the retrospective data described above (Figure 1) . As in previous years, most of the centers (84%) performed fewer than 5 transplant procedures annually; however, for the first time, 3 centers reported 10 to 19 pediatric lung transplant procedures in 2009, accounting for 28% of transplants reported (Figure 2) . In 2009, the 3 highest-volume centers performed 28% of procedures reported; then again, 50% of the lung transplant procedures occurred in centers that report fewer than 5 procedures annually (Figure 3) .Figure 2Number of centers reporting pediatric lung transplants by center volume. Analysis includes living-donor transplants.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Number of pediatric lung transplants by center volume. Analysis includes living-donor transplants.View Large Image Figure ViewerDownload Hi-res image Download (PPT)During the last decade, the number of pediatric lung transplant procedures reported to the Registry increased considerably, from 73 in 1999 to 127 in 2009 (the last complete calendar year included in this year's report). Most pediatric lung transplant procedures occurred in recipients aged between 12 and 17 years (93 of 127 in 2009; Figure 4) , which increased from 60% of all lung transplants in the era 1986 through 1995 to 70% in the recent era 1996 through June 2010 (Figure 5) . In 2009, only 3 lung transplant procedures were reported in recipients aged younger than 1 year, which is identical to the figures reported in 2008 (Figure 4).Figure 4Age distribution of pediatric lung recipients by year of transplant. Analysis includes living-donor transplants.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Recipient age distribution for pediatric lung recipients. Analysis includes living-donor transplants.View Large Image Figure ViewerDownload Hi-res image Download (PPT)There are geographic differences in the age distribution of pediatric lung transplant recipients: in Europe, 82% of the procedures between January 2000 and June 2010 were performed in recipients aged ≥ 12 years compared with 65% in North America. In contrast, 4% of the reported lung transplant procedures in this period in Europe were performed in recipients aged ≤ 5 years compared with 15% in North America (Figure 6) .Figure 6Age distribution by location for pediatric lung transplantations from January 2000 through June 2010. Analysis includes living-donor transplants.View Large Image Figure ViewerDownload Hi-res image Download (PPT)In the period from January 1986 to June 2010, 64% of the pediatric lung transplant recipients received pediatric donor organs (aged <18 years). Only 6% received organs from donors aged ≥50 years (Figure 7) . Geographic differences in donor age distribution are noticeable: in Europe, 45% of transplanted organs come from pediatric donors compared with 64% in North America. The proportions in regions outside Europe and North America were similar to those in Europe (Figure 8) . In the last 5 years, only 1 pediatric lung transplant procedure from a living donor was reported to the Registry (Figure 9) .Figure 7Age distribution for donors to pediatric lung recipients for transplantations from January 1986 through June 2010. Note: Transplants with unknown donor age and living-donor transplants were excluded from this tabulation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 8Donor age distribution in pediatric lung transplantation by location between January 2000 and June 2010. Note: Transplants with unknown donor age and living-donor transplants were excluded from this tabulation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 9Donor type distribution by year of transplant for pediatric lung recipients. Analysis includes living-donor transplants.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Similar to previous reports,1Aurora P. Edwards L.B. Christie J.D. et al.Registry of the International Society for Heart and Lung Transplantation: eleventh official pediatric lung and heart-lung transplantation report—2008.J Heart Lung Transplant. 2008; 27: 978-983Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 2Aurora P. Edwards L.B. Christie J.D. et al.Registry of the International Society for Heart and Lung Transplantation: twelfth official pediatric lung and heart-lung transplantation report—2009.J Heart Lung Transplant. 2009; 28: 1023-1030Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 3Aurora P. Edwards L.B. Kucheryavaya A.Y. et al.Registry of the International Society for Heart and Lung Transplantation: thirteenth official pediatric lung and heart-lung transplantation report—2010.J Heart Lung Transplant. 2010; 29: 1129-1141Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar the most common underlying diagnosis for children and adolescents (aged <18 years) who undergo lung transplantation is cystic fibrosis (CF). However, differences in age groups can be observed. In children aged ≥ 6 years, CF was the most common diagnosis from January 1990 to June 2010 (Table 1). In children aged 5 years and younger, the most common indications were idiopathic pulmonary arterial hypertension, idiopathic pulmonary fibrosis, congenital heart disease, and surfactant protein B deficiency (Table 1). The overall distribution of indications has not changed notably compared with previous reports.1Aurora P. Edwards L.B. Christie J.D. et al.Registry of the International Society for Heart and Lung Transplantation: eleventh official pediatric lung and heart-lung transplantation report—2008.J Heart Lung Transplant. 2008; 27: 978-983Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 2Aurora P. Edwards L.B. Christie J.D. et al.Registry of the International Society for Heart and Lung Transplantation: twelfth official pediatric lung and heart-lung transplantation report—2009.J Heart Lung Transplant. 2009; 28: 1023-1030Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 3Aurora P. Edwards L.B. Kucheryavaya A.Y. et al.Registry of the International Society for Heart and Lung Transplantation: thirteenth official pediatric lung and heart-lung transplantation report—2010.J Heart Lung Transplant. 2010; 29: 1129-1141Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar However, regional differences exist in the diagnosis distribution: 55% of transplant procedures in North America were undertaken in pediatric recipients with CF compared with 75% in Europe (Figure 10) . Interestingly, the diagnosis of CF accounted for 70% in Europe in last year's report. The increase in the number of transplant procedures for CF in Europe could partly be explained by the above-mentioned retrospective data entry.Table 1Indications for Pediatric Lung Transplantations Occurring From January 1990 Through June 2010aAnalysis includes living-donor transplants.Age<1 year1–5 years6–11 years12–17 yearsDiagnosisNo. (%)No. (%)No. (%)No. (%)Cystic fibrosis1 (1.2)5 (4.5)167 (56.0)775 (71.7)Idiopathic pulmonary arterial hypertension12 (14.0)25 (22.5)30 (10.1)75 (6.9)Retransplant: obliterative bronchiolitis07 (6.3)9 (3.0)34 (3.1)Congenital heart disease13 (15.1)8 (7.2)4 (1.3)9 (0.8)Idiopathic pulmonary fibrosis9 (10.5)20 (18.0)13 (4.4)38 (3.5)Obliterative bronchiolitis (not retransplant)010 (9.0)19 (6.4)45 (4.2)Retransplant (not obliterative bronchiolitis)3 (3.5)4 (3.6)8 (2.7)27 (2.5)Interstitial pneumonitis1 (1.2)2 (1.8)2 (0.7)0Pulmonary vascular disease8 (9.3)7 (6.3)3 (1.0)0Eisenmenger syndrome1 (1.2)5 (4.5)5 (1.7)7 (0.6)Pulmonary fibrosis, other5 (5.8)5 (4.5)12 (4.0)22 (2.0)Surfactant protein B deficiency15 (17.4)3 (2.7)1 (0.4)1 (0.1)COPD/emphysema4 (4.7)2 (1.8)3 (1.0)9 (0.8)Bronchopulmonary dysplasia2 (2.3)2 (1.8)6 (2.0)1 (0.1)Bronchiectasis1 (1.2)0 (0)5 (1.7)13 (1.2)Other11 (12.8)6 (5.4)12 (4.0)26 (2.4)COPD, chronic obstructive pulmonary disease.a Analysis includes living-donor transplants. Open table in a new tab Figure 10Diagnosis distribution by location for pediatric lung transplants from January 2000 through June 2010. IPAH, idiopathic pulmonary artery hypertension; IPF, idiopathic pulmonary fibrosis; OB, obliterative bronchiolitis. Note: Unknown diagnoses were excluded from this tabulation. Analysis includes living-donor transplants.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Immunosuppressive therapyThe use of induction therapy increased further compared with previous reports.1Aurora P. Edwards L.B. Christie J.D. et al.Registry of the International Society for Heart and Lung Transplantation: eleventh official pediatric lung and heart-lung transplantation report—2008.J Heart Lung Transplant. 2008; 27: 978-983Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 2Aurora P. Edwards L.B. Christie J.D. et al.Registry of the International Society for Heart and Lung Transplantation: twelfth official pediatric lung and heart-lung transplantation report—2009.J Heart Lung Transplant. 2009; 28: 1023-1030Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 3Aurora P. Edwards L.B. Kucheryavaya A.Y. et al.Registry of the International Society for Heart and Lung Transplantation: thirteenth official pediatric lung and heart-lung transplantation report—2010.J Heart Lung Transplant. 2010; 29: 1129-1141Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar Between January 2001 and June 2010, induction therapy, consisting of anti-lymphocyte globulin, anti-thymocyte globulin, and interleukin-2 receptor antagonist therapy, was used in 60% of the procedures (Figure 11) ; a decade ago, this was less than 50%.1Aurora P. Edwards L.B. Christie J.D. et al.Registry of the International Society for Heart and Lung Transplantation: eleventh official pediatric lung and heart-lung transplantation report—2008.J Heart Lung Transplant. 2008; 27: 978-983Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 2Aurora P. Edwards L.B. Christie J.D. et al.Registry of the International Society for Heart and Lung Transplantation: twelfth official pediatric lung and heart-lung transplantation report—2009.J Heart Lung Transplant. 2009; 28: 1023-1030Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 3Aurora P. Edwards L.B. Kucheryavaya A.Y. et al.Registry of the International Society for Heart and Lung Transplantation: thirteenth official pediatric lung and heart-lung transplantation report—2010.J Heart Lung Transplant. 2010; 29: 1129-1141Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar No significant 5-year post-transplant survival difference was noted between recipients who did and did not receive induction therapy (Figure 12) .Figure 11Induction immunosuppression for pediatric recipients who underwent lung transplantation between January 2001 and June 2010. MMF, mycophenolate mofetil. Analysis is limited to patients who were alive at the time of the follow-up.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 12Kaplan-Meier survival stratified by induction use for recipients who underwent pediatric lung transplantation from January 2001 through June 2009.View Large Image Figure ViewerDownload Hi-res image Download (PPT)The use of maintenance immunosuppression is displayed in Figure 13. Tacrolimus use increased further compared with cyclosporine. At the 1-year follow-up, 78% of pediatric recipients received tacrolimus compared with 22% who received cyclosporine. As previously reported, mycophenolate mofetil (MMF) is replacing azathioprine as the cell-cycle inhibitor of choice.3Aurora P. Edwards L.B. Kucheryavaya A.Y. et al.Registry of the International Society for Heart and Lung Transplantation: thirteenth official pediatric lung and heart-lung transplantation report—2010.J Heart Lung Transplant. 2010; 29: 1129-1141Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar This trend is even more evident in this year's report: at the 1-year follow-up, 65% of recipients were treated with MMF compared with 30% who received azathioprine. Almost all pediatric recipients continued to receive prednisone as part of their maintenance immunosuppression, even 5 years after lung transplantation. The most common maintenance immunosuppression drug combination was tacrolimus, MMF, and prednisone, which was used in 55% of recipients at the 1-year follow-up and in 47% at the 5-year follow-up, (Figure 14) .Figure 13Maintenance immunosuppression for pediatric lung recipients at follow-up between January 2001 and June 2010. MMF, mycophenolate mofetil. Note: Different patients are analyzed in Year 1 and Year 5. Analysis is limited to patients who were alive at the time of the follow-up.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 14Maintenance immunosuppression drug combinations for pediatric lung recipients for follow-up occurring between January 2001 and June 2010. AZA, azathioprine; MMF, mycophenolate mofetil. Note: Different patients are analyzed in Year 1 and Year 5. Analysis is limited to patients who were alive at the time of the follow-up.View Large Image Figure ViewerDownload Hi-res image Download (PPT)OutcomesSurvival after pediatric lung transplantation continues to be comparable with that reported in adult lung transplant recipients. We define the transplant half-life as the estimated time at which 50% of all recipients have died. In the period from January 1990 to June 2009, the half-life of adult recipients was 5.4 years compared with 5.5 years in pediatric recipients (Figure 15) , although there seems to be better longer-term survival in pediatric patients. The 5-year survival of pediatric lung transplant recipients between January 1990 and June 2009 was 51%. For pediatric recipients who received allografts in the new era between 2002 and June 2009, 5-year survival was 53% and 7-year survival was 45% (Figure 16) . In contrast to the previous year's report, the difference is not statistically significant when survival is analyzed by era; this may be because survival for older cohorts is revised upward compared with previous reports after the retrospective data entry, as described above.Figure 15Kaplan-Meier survival by recipient age group for transplants between January 1990 and June 2009.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 16Kaplan-Meier survival by era for pediatric lung transplantation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Kaplan-Meier survival analysis by recipient age group shows a significantly better survival of recipients aged 1 to 11 years compared with recipients aged 12 to 17 years (Figure 17) . Recipients younger than 1 year have the worst early post-transplant survival within the 3 age groups (<1 year vs 1–11 years vs 12–17 years). Nevertheless, in younger patients surviving at least 1 year after transplant, long-term outcome is comparable with that of other pediatric age groups (Figure 18) . Survival analyzed by procedure type is significantly worse for single-lung transplant procedures compared with bilateral lung transplant procedures; however, the number of pediatric single-lung transplant procedures is relatively small (Figure 19) .Figure 17Kaplan-Meier survival by recipient age group for pediatric lung transplantation from January 1990 through June 2009.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 18Conditional Kaplan-Meier survival by recipient age group for pediatric lung transplantation between January 1990 and June 2009.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 19Kaplan-Meier survival by procedure type for pediatric lung transplantation between January 1990 and June 2009.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Causes of deathIn the first year after lung transplantation, infection (non-cytomegalovirus [CMV]) and graft failure remained the 2 leading causes of death (Figure 20) . Beyond the first year after transplantation, bronchiolitis obliterans syndrome (BOS), graft failure, and non-CMV infection were the leading causes of death. Further details regarding causes of death and relative incidences of leading causes of death are displayed in Figure 20 and Table 2. Details about causes of death labeled as “other” were published in the 2008 ISHLT Registry Report and are not presented again this year because the data have not changed considerably.1Aurora P. Edwards L.B. Christie J.D. et al.Registry of the International Society for Heart and Lung Transplantation: eleventh official pediatric lung and heart-lung transplantation report—2008.J Heart Lung Transplant. 2008; 27: 978-983Abstract Full Text Full Text PDF PubMed Scopus (63) Google ScholarFigure 20Relative incidence of leading causes of death from January 1992 through June 2010 for pediatric lung transplant recipients. CMV, cytomegalovirus.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Table 2Causes of Death in Pediatric Lung Transplant Recipients From January 1992 through June 20100–30 days31 days–1 year>1–3 years>3–5 years>5 years(n = 97)(n = 135)(n = 176)(n = 83)(n = 82)Cause of deathNo. (%)No. (%)No. (%)No. (%)No. (%)Bronchiolitis013 (9.6)70 (39.8)34 (41.0)34 (41.5)Acute rejection3 (3.1)3 (2.2)1 (0.6)2 (2.4)3 (3.7)Malignancy Lymphoma07 (5.2)5 (2.8)4 (4.8)5 (6.1) Non-lymphoma01 (0.7)1 (0.6)2 (2.4)3 (3.7)Infection Cytomegalovirus05 (3.7)000 Non-cytomegalovirus13 (13.4)46 (34.1)26 (14.8)17 (20.5)11 (13.4)Graft failure30 (30.9)27 (20.0)45 (25.6)11 (13.3)14 (17.1)Cardiovascular15 (15.5)6 (4.4)4 (2.3)1 (1.2)1 (1.2)Technical11 (11.3)3 (2.2)1 (0.6)1 (1.2)1 (1.2)Multiple organ failure8 (8.2)13 (9.6)9 (5.1)3 (3.6)7 (8.5)Other17 (17.5)11 (8.1)14 (8.0)8 (9.6)6 (7.3) Open table in a new tab Complications and morbiditiesHypertension, renal impairment, diabetes mellitus, and BOS remain the most common comorbidities after pediatric lung transplantation, and all of these increase in prevalence with time after transplantation. Detailed figures of cumulative prevalence of morbidities within 1 and 5 years after transplantation are reported in Table 3, Table 4, respectively, and are similar to the figures presented in last year's report.3Aurora P. Edwards L.B. Kucheryavaya A.Y. et al.Registry of the International Society for Heart and Lung Transplantation: thirteenth official pediatric lung and heart-lung transplantation report—2010.J Heart Lung Transplant. 2010; 29: 1129-1141Abstract Full Text Full Text PDF PubMed Scopus (87) Google ScholarTable 3Cumulative Prevalence of Morbidity Within 1 Year After Lung Transplant for Pediatric Patients From April 1994 Through June 2010Within 1 YearTotal with known responseOutcome(%)(No.)Hypertension42.2604Renal dysfunction10.2618 Creatinine Abnormal < 2.5 mg/dl7.3 >2.5 mg/dl1.9 Chronic dialysis0.6 Renal transplant0.3Hyperlipidemia4.8622Diabetes24.7619Bronchiolitis obliterans syndrome13.7577 Open table in a new tab Table 4Cumulative Prevalence of Morbidity Within 5 Years After Lung Transplant in Pediatric Recipients for Follow-up From April 1994 Through June 2010Within 5 yearsTotal with known responseOutcome(%)(No.)Hypertension68.8160Renal dysfunction20.1169 Creatinine Abnormal < 2.5 mg/dl13.6 >2.5 mg/dl3.0 Chronic dialysis2.4 Renal transplant1.2Hyperlipidemia14.5165Diabetes34.3166Bronchiolitis obliterans syndrome36.4129 Open table in a new tab Severe renal impairment, defined as creatinine > 2.5 mg/dl (221 μmol/liter), dialysis, or renal transplant, develops in 11% of pediatric lung transplant recipients by 5 years after transplantation and in 17% by 7 years (Figure 21) ; once again, figures were identical with last year's report.3Aurora P. Edwards L.B. Kucheryavaya A.Y. et al.Registry of the International Society for Heart and Lung Transplantation: thirteenth official pediatric lung and heart-lung transplantation report—2010.J Heart Lung Transplant. 2010; 29: 1129-1141Abstract Full Text Full Text PDF PubMed Scopus (87) Google ScholarFigure 21Freedom from severe renal dysfunction for pediatric lung recipients for follow-up from April 1994 through June 2010.View Large Image Figure ViewerDownload Hi-res image Download (PPT)By 5 years after transplantation, malignancies have developed in 14% of pediatric recipients, virtually all of which are lymphoproliferative diseases. By 9 years, the cumulative incidence of malignancies increases to 23%, comprising mostly lymphoproliferative disorders but also 2% skin cancer (Figure 22) .Figure 22Freedom from malignancy for pediatric lung recipients for follow-up from April 1994 through June 2010.View Large Image Figure ViewerDownload Hi-res image Download (PPT)BOS, the second most common morbidity within 5 years after transplantation, was reported in 56% of pediatric lung transplant recipients.3Aurora P. Edwards L.B. Kucheryavaya A.Y. et al.Registry of the International Society for Heart and Lung Transplantation: thirteenth official pediatric lung and heart-lung transplantation report—2010.J Heart Lung Transplant. 2010; 29: 1129-1141Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar For the first time, we analyzed freedom from BOS for pediatric lung recipients, stratified by age group and diagnosis. BOS was reported less frequently in younger surviving lung recipients; that is, in 31% of the recipients aged < 1 year compared with 44% in recipients aged 1 to 11 years and 54% of recipients aged ≥ 12 year