Milligan Caitlin, Daly Kevin P
Primary Children's Hospital, University of Utah, Salt Lake City, Utah.
Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
JHLT Open. 2025 Jul 30;10:100359. doi: 10.1016/j.jhlto.2025.100359. eCollection 2025 Nov.
Acute cellular rejection (ACR) remains a leading cause of allograft injury after pediatric heart transplantation and contributes to chronic graft dysfunction, cardiac allograft vasculopathy, antibody mediated rejection, and mortality post-transplant. Understanding the risks for developing ACR, with a focus on immunosuppression adherence, and applying appropriate screening methods is important to limit the impact of this complication. While endomyocardial biopsy remains the gold standard for diagnosis and classification of ACR, additional non-invasive screening methods can be used to stratify rejection risk and limit biopsies. These screening methods include the use of gene expression profiling, donor-derived cell-free DNA, echocardiography, and cardiac magnetic resonance imaging. Management of ACR depends on the severity of allograft injury; In cases of severe rejection, treatment includes corticosteroids, anti-thymocyte globulin, and hemodynamic support. This review highlights the impact of ACR on transplant outcomes and risk factors for ACR with a particular emphasis on screening, diagnosis, and management. Ultimately, continued improvement in prevention, earlier detection, and prompt treatment of ACR are important to enhance outcomes for pediatric heart transplant recipients.
急性细胞排斥反应（ACR）仍然是小儿心脏移植后同种异体移植物损伤的主要原因，并导致慢性移植物功能障碍、心脏同种异体血管病变、抗体介导的排斥反应以及移植后死亡。了解发生ACR的风险，重点关注免疫抑制的依从性，并应用适当的筛查方法对于限制这种并发症的影响至关重要。虽然心内膜心肌活检仍然是ACR诊断和分类的金标准，但可以使用其他非侵入性筛查方法来分层排斥反应风险并减少活检次数。这些筛查方法包括基因表达谱分析、供体来源的游离DNA、超声心动图和心脏磁共振成像。ACR的管理取决于同种异体移植物损伤的严重程度；在严重排斥反应的情况下，治疗包括使用皮质类固醇、抗胸腺细胞球蛋白和血流动力学支持。本综述强调了ACR对移植结果的影响以及ACR的危险因素，特别强调了筛查、诊断和管理。最终，持续改善ACR的预防、早期检测和及时治疗对于提高小儿心脏移植受者的结局非常重要。
