Immunosuppression

When infant heart transplants were first being performed there was some hope that there would be "neonatal tolerance" of the graft. This theory held that because the heart was implanted at such an early age it would come to be recognized as "self." This hypothesis has not proved true, and even babies transplanted as newborns must be kept on lifetime immunosuppression. Most centers use standard "triple therapy"—cyclosporine, azathioprine (or Cellcept), and prednisone. Approximately 40% of centers now use some form of induction therapy (OKT3, Simulect, ATG, etc.). Some centers are now using Tacrolimus (FK-506) instead of cyclosporine (CSA) and most centers attempt to wean infants off of prednisone by 6 months posttransplant to allow for patient growth. Table 13A.4 shows the current ISHLT Pediatric Registry data for postoperative immunosuppression.

At Children's Memorial Hospital patients are given 5 mg/kg of cyclosporine (CSA) and 20 mg/kg of Cellcept p.o. preoperatively. Solu-Medrol is given at a dose of 10 mg/kg IV before cardiopulmonary bypass and a second dose of Solu-Medrol is given just before reperfusion of the donor heart. Simulect (Basiliximab-10 mg I.V. if < 35 kg, 20 I.V. mg if > 35 kg) has been used at our center as induction therapy since 2000, the first dose is given in the operating room after the bypass run, the second dose is given on day 4. Postoperatively, cyclosporine (CSA) is started

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