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Challenges in Pediatric Thoracic Transplant

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Marc G. Schecter, MD
ISHLT Pediatric Transplantation Council Chair
Cincinnati Children's Hospital Medical Center
Cincinnati, Ohio, USA

The last ten (10) months have been a whirlwind. A new city, a new hospital, starting a new pediatric lung transplant program and a new role within the ISHLT have all occurred during this time. Each of these things has an element of uncertainty associated with them. Will the new program be successful? What is the culture of the new institution? How will my family adjust to a new city? Where are the good restaurants? Though these uncertainties have been ever present on my mind, they pale in comparison to the issues that plague our patients and their families. Will I be accepted for transplant? When will I receive my new heart or my new lungs? When I get my new organs, will they work? Our patients and families ask these questions every day. They trust us to make the right decision for their children.

Before a patient can be considered for a thoracic transplant, they must undergo a thorough evaluation to determine if the patient is an appropriate candidate. Most of the time, the patient's underlying condition is the least complicated factor in determining whether a patient is a good candidate for transplant. The existence of co-morbidities certainly impact the decision of whether or not to approve a patient for transplant, but it is the confounding factors that often make our decisions more difficult, especially in pediatrics where we not only have to assess the patient, but the family as well. While assessing both the patient and their family, the multidisciplinary team of transplant experts determine the "red flags" and how much weight to give each one. If there are too many "red flags", transplant may not be an option. There is always the possibility that a good candidate may be passed up, because of the system utilized. How good are we at identifying what really matters? Do we really know which "red flags" are more important? Did we deny a patient transplant that may have had an ideal outcome?

When we have a less than ideal outcome, it is always important to ask why. One of the first questions we should ask ourselves is whether we properly identified the patient as a good transplant candidate. Did we miss something during the evaluation that could have predicted the outcome? Did the cute faced patient blind us to move forward with transplant even though there was an increased risk of a poor outcome because of co-morbidities, family dynamics, or other issues? Did we succumb to the aggressive "I will do anything for my child" parent? Are we concerned about the medical and/or legal consequences of refusing to offer transplant to a patient? Should transplant be an option for everyone, regardless of the potential for worse outcomes? Is the media influencing us?

This year there have been three (3) highly publicized controversies in the United States regarding pediatric thoracic organ transplantation. They all involved the criteria utilized to select and list children for thoracic transplant. Historically, each individual physician/ transplant center has been in control of their selection criteria, with very few hard and fast rules or guidelines governing the selection of patients for transplant. Some centers accept patients for transplant that other centers have denied. For better or worse, these public cases have brought the difficult decisions that we, as transplant physicians, make every day into the public arena, at times involving the legal system and most recently involving the United States Secretary of Health and Human Services. With the recent surge of cases in the media, it is unclear what the future will hold with respect to patient selection for transplant.

While these three (3) cases made national news in the United States this year, I am sure there are more stories both locally and internationally about who is appropriate for transplant and the method by which organs are allocated to patients. How are we to address these questions publically when there may not be consensus among the pediatric thoracic transplant community? More importantly, do we need better or more stringent guidelines to address these issues? We gather every year at the annual ISHLT meeting and discuss new scientific advances and the medical conditions that affect outcomes. However, we rarely discuss how we account for these grey areas we deal with every day in selecting transplant candidates. Should we be reactive to situations in the media or be proactive to avoid the negative spotlight being placed on pediatric thoracic transplant?

The pediatric council asked the Board of Directors to begin this discussion at this year's annual meeting in San Diego. On Saturday afternoon, there will be a symposium entitled "Controversies in Listing Children for Thoracic Organ Transplant". We have assembled a great group of speakers to stimulate the conversation. We hope this conversation will be the catalyst for a consensus conference that will provide cohesive guidelines for the thoracic transplant community. I encourage everyone to attend this symposium (Saturday, April 12, 2014, 2:00 pm - 3:30 pm, in Gaslamp CD).

See you in San Diego.

Disclosure Statement: The author has no disclosures.

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