Andersons pediatric cardiology 1785
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Immunosuppression
Thegoalofimmunosuppressivetherapyistopreventrejectionwhileminimizing
morbiditiesrelatedtochronicimmunesuppression.Therearealargenumberof
center-specificprotocolsforthemaintenanceimmunosuppression,withongoing
controversyregardingtheoptimalregime(Figs.67.17and67.18).Indeed,there
areamyriadofagents,dosages,protocols,andcombinationsthathavebeenused
forboththeinductionandmaintenanceofimmunosuppression,making
definitivecomparisonsandrecommendationsdifficult.2Adetaileddiscussionof
thevariousprotocolsisbeyondthescopeofthischapter.
FIG.67.17 Summaryofmaintenanceimmunosuppressioninchildren
afterhearttransplantatthetimeofhospitaldischargebyera.MMF,
Mycophenolatemofetil;MPA,mycophenolicacid.(Fromtheregistryofthe
InternationalSocietyofHeartandLungTransplantation.JHeartLung
Transplant.2016;35(10):1185–1195.)
FIG.67.18 Summaryofmaintenanceimmunosuppressioninchildrenat1
and5yearsafterhearttransplantation.AZA,Azathioprine;MMF,
mycophenolatemofetil;MPA,mycophenolicacid.(Fromtheregistryofthe
InternationalSocietyofHeartandLungTransplantation.JHeartLung
Transplant.2016;35(10):1185–1195.)
MonitoringandSurveillanceAfter
Transplantation
Thehallmarkofcaresubsequenttotransplantationismeticulousattentionto
detail,withahighindexofsuspicionfortransplant-relatedproblems.Careof
childrenafterhearttransplantationmustaccountforphysicalgrowthand
development;thestageofimmunologicdevelopment;intellectual,emotional,
andsocialmaturation;educationalactivities;andotherparametersofqualityof
life.Eachoneoftheseaspectscansignificantlyaffectmorbidityandmortality
aftertransplantation.
Rejection
Rejectionistheprocessofdestructionofgeneticallyforeignmaterialbythe
immunesystemofthehost.Itvariesinseverityandtimingbetweenindividuals
andmaywaxandwanewithinanindividualpatient.Acuterejectionremainsan
importantcauseofmortalityandmorbidityaftertransplantation(seeTable67.3
andFig.67.14),althoughitsincidencehasdecreasedinthemostrecentera(Fig.
67.19).Therearefewidentifiableriskfactorsforrejectionpriorto
transplantationotherthansensitizationtoHLAantigens(seeearlier).Preformed
donor-specificanti-HLAantibodiescanleadtoantibody-mediatedrejection
(AMR)withinthefirstfewhoursaftertransplantation.Cellularrejectionusually
startsduringthefirstfewweeksandispresenttosomedegreeinmostpatients.
RejectionismostcommonlymediatedbyTcells,althoughhumoralrejection
mediatedbyB-cellactivationisincreasingowingtothelargernumberof
patientssensitizedtoHLAantigens.Thereisincreasingevidencefortheroleof
bothacutecellularrejection(ACR)andAMRinthesurvivalofthetransplanted
organ(Fig.67.20)andthedevelopmentofvasculopathy.2,12,61,62
