Total lymphoid irradiation for refractory rejection in pediatric heart transplantation

Background We evaluated the role of total lymphoid irradiation (TLI) in the management of refractory rejection among pediatric heart transplant patients. Methods Eleven of 298 patients underwent TLI at 6 to 195 months of age and were divided into subgroups: those who survived (group A, N = 7) and those who did not survive beyond 1 year after TLI (group D, N = 4). Non–TLI recipient data were considered as the controls. Results Six out of 11 patients died eventually (54%). TLI was initiated 3 to 107 months after transplantation with a dosage of 600 to 840 cGy. The pre-TLI rejection rate (0.62 ± 0.40 per month) was higher (p< 0.0001); however, the post-TLI rejection rate (0.24 ± 0.65 per month) showed no significant difference from the control rejection rate. The Cox proportional hazard model found significance for TLI as a risk factor for development of posttransplant coronary artery disease (relative risk, 4.8; 95% CI, 1.1 to 21.3) and posttransplant lymphoproliferative disease (relative risk, 47.9; 95% CI, 1.6 to 1,475.3), respectively. Although the rejection rate decreased after TLI in both groups (group A pre/post, 0.51 ± 0.31/0.06 ± 0.08 per month; group D pre/post, 0.82 ± 0.49/0.57 ± 1.09 per month), significance was obtained only in group A (p = 0.018). Conclusions TLI was an effective adjunct for reversal of refractory rejection in pediatric heart transplantation by reducing the rejection rate. Great care must be taken for the risk of development of coronary artery disease or lymphoproliferative disease.