Trading one disease for another: The transplantation dilemma

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Organ transplantation in children has become almost routine in many centers. With many of the technical complexities satisfactorily addressed, attention today is moving toward the complications of immunosuppression. Although modern drug regimens have made transplantation feasible, they also carry substantial morbidity. This is particularly concerning, since our current concept is that such immunosuppression needs to be continued forever.

In this context, a report in this issue of The Journal by Starzl and his group, although preliminary, is of enormous interest. In a series of 17 children undergoing kidney transplantation at Children’s Hospital of Pittsburgh, a strategy of antibody-induced lymphocyte depletion prior to transplantation was combined with a major reduction in the intensity of post-transplantation immunosuppression. Conceptually, the idea was to attenuate the immediate anti-donor lymphocyte response, as well as provide conditions that could permit microchimerism to take place.

Although the follow-up of these children is still short, the results are remarkable. All but one are currently enjoying excellent graft function, on a very low dose immunosuppression protocol and receiving no corticosteroids. If this experience is continued and replicated, the implications for pediatric transplantation are almost revolutionary.

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