Lung Transplantation in Children. Specific Aspects

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"idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Lung Transplantation in Children. Specific Aspects" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "523" "paginaFinal" => "528" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Antonio Moreno Galdó, Juan Solé Montserrat, Antonio Roman Broto" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Antonio" "apellidos" => "Moreno Galdó" "email" => array:1 [ 0 => "aroman@vhebron.net" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Juan" "apellidos" => "Solé Montserrat" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Antonio" "apellidos" => "Roman Broto" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Unidad de Neumología Pediátrica y Fibrosis Quística, Hospital Universitari Vall d’Hebron, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departament de Pediatria, d’Obstetricia i Ginecologia i de Medicina Preventiva, Universitat Autònoma de Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cirugía Torácica, Hospital Universitari Vall d’Hebron, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitari Vall d’Hebron, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "CIBER Enfermedades Respiratorias (CIBERES), Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trasplante pulmonar en niños. Aspectos específicos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1313 "Ancho" => 2112 "Tamanyo" => 159451 ] ] "descripcion" => array:1 [ "en" => "Evolution of the number of pediatric and adult lung transplants performed in Spain during the years 1990–2012 (National Transplant Organization data 4)." ] ] ] "textoCompleto" => "IntroductionIn recent years, lung transplantation has become established as a therapeutic option for children with severe lung disease in whom other therapeutic options have failed, resulting in good quality of life and prolonged survival, similar to that of transplants performed in adults.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Pediatric transplantation has numerous unique features in relation to transplantation in adults<a class="elsevierStyleCrossRef" href="#bib0010">2</a>: specific characteristics of children at different stages of development (from infants to adolescents), different indications for different age groups, the effects of immunosuppressant treatments, special susceptibility to infections related to an immature immune system, and particular problems in the availability of suitable donors.Although pediatric transplant results have improved considerably in the last two decades<a class="elsevierStyleCrossRef" href="#bib0015">3</a> due to advances in the transplant technique, organ preservation, peri-operative management, immunosuppression, and the prophylaxis and treatment of infectious complications, as in adults, chronic graft dysfunction limits long-term survival.Epidemiology of Pediatric TransplantThe first transplant in an adult in Spain was carried out in 1990. Six transplants were performed that year, with the number of annual transplants increasing gradually to 238 in 2012, to a total of 2940 [Spanish National Transplant Organization (ONT) data].<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a> The ONT considers pediatric transplants as those performed in children under the age of 16. The first pediatric lung transplant was carried out in 1996.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Since then, 114 pediatric transplants have been performed in Spain, accounting for 3.9% of the total.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Unlike adult transplants, the annual number of transplants has remained relatively steady, with a median of 6 per year during this period (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In the Spanish Lung Transplant Registry, 74% of children were aged between 11 and 15 years old.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> These data are comparable with those recorded in the registry of the International Society for Heart & Lung Transplantation (ISHLT),<a class="elsevierStyleCrossRefs" href="#bib0005">1,7</a> in which pediatric transplantation is considered to be a transplant carried out in children aged under 18. According to ISHLT data, 49,673 lung and heart-lung transplants were performed between 1987 and June 2012, 2542 (5.12%) of which were pediatric. The highest percentage of transplants took place in the adolescent group (12–17 years), representing 84% of pediatric transplants in Europe and 68% in North America.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> In this registry, a very modest increase in the number of pediatric transplants was observed from the 73 carried out in 2000 to 107 in 2011, peaking at 125 transplants in 2010.<a class="elsevierStyleCrossRef" href="#bib0005">1</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>The low frequency of transplants in children and absence of an increase similar to that in adult patients is related to 3 factors<a class="elsevierStyleCrossRef" href="#bib0040">8</a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-The low prevalence of severe lung disease in children.</li><li class="elsevierStyleListItem" id="lsti0010">-Advances in the medical care of patients with cystic fibrosis<a class="elsevierStyleCrossRef" href="#bib0045">9</a> (the primary indication in pediatric patients) have considerably improved its course and delayed the age at which lung transplantation may be required.</li><li class="elsevierStyleListItem" id="lsti0015">-The limited availability of young donors.</li></ul>Only a small number of hospitals worldwide carry out pediatric lung transplantation (around 40), and most (88.3%) perform between 1 and 4 transplants per year only, with just 3–4 centers performing between 5 and 9 transplants and 2 centers between 10 and 19 transplants.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> As in Spain, two types of centers can be distinguished among these: centers specifically dedicated to pediatric transplantation, in which transplants are performed in children of all ages (or in some centers in children above preschool age), and adult lung transplant centers in which adolescents or children over 8–10 years of age are also treated.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>IndicationsAs in adults, the general indication for lung transplantation is progressive respiratory failure with a short life expectancy, generally less than 1–2 years, and very poor quality of life.<a class="elsevierStyleCrossRefs" href="#bib0010">2,11</a> It requires that all other therapeutic measures have been exhausted, there is no other serious illness, the ability to comply with a complex therapeutic regimen has been assessed, there is a suitable social environment and the family and/or the child assumes the risks of the transplant.<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> specifies the main diseases in which lung transplantation may be indicated in children. Cystic fibrosis is the most common indication; the other major groups of indications are pulmonary vascular diseases (mainly pulmonary hypertension) and diffuse parenchymal lung diseases.<a class="elsevierStyleCrossRefs" href="#bib0060">12–16</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>In the Spanish Lung Transplant Registry (2006–2010),<a class="elsevierStyleCrossRef" href="#bib0025">5</a> cystic fibrosis accounted for 67.75% of transplants in children aged under 16, post-infectious bronchiolitis obliterans for 12.95%, pulmonary arterial hypertension for 3.2% and interstitial lung diseases, 16.1%. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the number of pediatric transplants carried out in our hospital during the period 1996–2012, with the relative frequency of the different indications.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The proportion of the different indications in relation to age groups has changed in recent years. In the ISHLT registry, cystic fibrosis accounts for 53.8% of transplants in children aged between 6 and 11 years, and 71.5% in those aged between 12 and 17 years.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> It should be taken into consideration, however, that the ISHLT registry includes data from 1990, and that transplant in children under 11 and adolescents with cystic fibrosis is becoming increasingly less common. According to data from the Catalonian lung transplant registry (Spain), cystic fibrosis represents less than 10% of transplants performed in children under 11 years, but 85% of those carried out in adolescents aged between 12 and 17 years.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>When Should a Child Be Referred for Lung Transplantation?The decision to place a child on the waiting list for a lung transplant is not easy, as it is very difficult to predict survival. It is very important to make this decision properly, in order to provide a survival benefit. Some years ago in the USA, the benefit of lung transplantation in children with cystic fibrosis was questioned.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> This was possibly linked to too early inclusion on the waiting list in contrast to the improvement in survival of children with cystic fibrosis due to advances in medical treatment.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> With the adoption of a severity assessment system for prioritizing patients on the waiting list (Lung Allocation Score), a real benefit of transplantation in adults with cystic fibrosis been shown in the USA<a class="elsevierStyleCrossRef" href="#bib0095">19</a>; this scoring system is only applicable in children over 12 years of age. In other countries, a real benefit of lung transplantation has been demonstrated in children with cystic fibrosis and severe lung disease.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>The indications for referring a child with cystic fibrosis for evaluation for lung transplant can be summarized in: frequent hospital admissions for intravenous antibiotic treatment, major limitation for attending school or carrying out normal activities, rapid decline or marked fluctuations in lung function, including an FEV1 <30%, recurrent pneumothorax or hemoptysis, hypoxemia and hypercapnia.<a class="elsevierStyleCrossRefs" href="#bib0080">16,17</a> It is recommended that children be included if their life expectancy is less than 2 years despite receiving full medical therapy and they have poor quality of life that is likely to improve with transplantation.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Using this approach, widely adopted in Europe, most of those who receive a transplant will benefit, although it has the disadvantage that some patients may die on the waiting list or even without being included on it if their prognosis is not properly assessed.<a class="elsevierStyleCrossRef" href="#bib0055">11</a>In children with diffuse parenchymal lung diseases, the most important thing is to assess the presence of moderate or severe functional impairment, need for mechanical ventilation or very high oxygen supplementation, lack of response to treatment, and taking into account the natural course of the disease.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> With some diseases, such as surfactant protein B deficiency, the child cannot survive without a transplant, while others may have a variable response to treatment, as in surfactant protein C deficiency.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>The prognosis in pulmonary hypertension has improved considerably with the new treatments available, so the following criteria are now recommended: children in functional class IV: place on the transplant list and begin medical treatment; if they improve, remove them from the waiting list. Children in functional class III: administer medical treatment; if they do not improve or worsen, place them on the waiting list. Children with bilateral pulmonary vein stenosis or alveolar capillary dysplasia would have to be included on the transplant list at an early stage, as they do not respond to other treatments.<a class="elsevierStyleCrossRefs" href="#bib0065">13,16</a>The nature of these indications means that lung transplantation in mechanically ventilated children is indicated more often than in adults. Infants on mechanical ventilation or children on long-term mechanical ventilation may be considered candidates for lung transplant. It has been shown that mechanically ventilated infants who have received transplants have the same survival post-transplant as non-ventilated older children, and better than ventilated older children.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Invasive mechanical ventilation in children with cystic fibrosis is a risk factor for higher post-transplant morbidity and mortality, unlike non-invasive ventilation.<a class="elsevierStyleCrossRefs" href="#bib0110">22–24</a><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> summarizes the criteria for referring children to lung transplant teams.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>ContraindicationsThere are several situations in which lung transplantation may not be advised, some absolute and others relative,<a class="elsevierStyleCrossRef" href="#bib0085">17</a> while some are specific to each centre (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>In patients with cystic fibrosis, Bulkholderia cepacia genomovar-3, Mycobacterium abscessus and multiresistant fungal infections (Schedosporium prolificans) constitute a contraindication in some centers.Patients with cyanotic heart diseases in whom previous thoracotomies have been performed for palliative purposes have a very high risk of bleeding from chest wall collateral vessels, and should be assessed individually.The Donor OrganOne of the current critical issues in pediatric lung transplantation, and pediatric transplants in general, is the fall in the number of young donors available, with the consequent increase in waiting list times. This is linked to the gradually decreasing number of donors as a result of road traffic accidents in the last 20 years, in parallel with the decrease in road fatalities, particularly after the introduction of new road traffic laws in Spain in 2005. While they represented 43% of donors in 1992, this figure fell to 5.7% of total donations in 2010.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>In our hospital, the median waiting time for children under 2 years old between the periods 1996–2005 and 2006–2011 increased moderately from 84 to 135 days, while for the 3–11 and 12–17 years age groups, it increased significantly, from 107 to 538 days and from 106.5 to 404.5 days, respectively.In order to improve these figures, Pediatric Intensive Care Units must be extremely aware of the need to make the most of potential donors and to optimize their care, and strategies for using lungs from adult donors in children may be employed; it would also be advisable to explore the extension of non-heart-beating donor programs in pediatrics.<a class="elsevierStyleCrossRefs" href="#bib0040">8,25</a>Types of Transplant and Surgical TechniqueSequential double-lung transplant is typically carried out in children; this is compulsory in septic lung disease (cystic fibrosis) and is the procedure of choice in pulmonary hypertension. Single-lung transplantation is less indicated in children than in adults (only 1 out of 31 cases in the Spanish Lung Transplant Registry<a class="elsevierStyleCrossRef" href="#bib0025">5</a>). It can be performed in cases of non-septic parenchymal lung disease (pulmonary fibrosis, bronchiolitis obliterans, retransplantation), if the somatic growth is almost complete and the organ offered is of perfect size and quality. Heart-lung transplant is reserved for pulmonary vascular disease associated with uncorrectable congenital heart disease, and for cases in which there is left ventricular failure.Unlike adults, most pediatric lung transplants are performed with CPB, as most children, due to their size, cannot tolerate single-lung ventilation. However, in adolescents and older children, it is sometimes possible to perform the transplant without CPB.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Although it has been suggested that the use of this technique could be associated with a higher incidence of primary graft failure, in a large series comparing the frequency of primary graft dysfunction between transplants in adults and children, there were no differences in its incidence.<a class="elsevierStyleCrossRef" href="#bib0130">26</a>Due to the difficulty in finding donors of a suitable size for children, there is greater flexibility in accepting size differences between the donor and recipient, and various techniques are performed to accommodate the lungs, including lobectomies (the middle lobe, lingula or lower lobes), non-anatomical resections, or using the lobes only. The upper or lower lobes can be used, but the upper lobes fit better in the thorax.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> Another strategy that has been used is to divide the left lung of an adult donor of suitable size, using the left lower lobe as a left lung and the left upper lobe as a right lung.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> There is experimental evidence in animal models that a “mature” lobe implanted in an immature recipient could grow by pneumocyte division.<a class="elsevierStyleCrossRef" href="#bib0140">28</a>Living donor lobar lung transplantation requires 2 donors, extracting the lower lobe from each of them. This has significant morbidity for the donor and results similar to those of a deceased donor, so it is rarely used at present, except in Japan and Brazil and occasionally in some experienced centers in the USA.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>Special Features in Post-transplant Management and ComplicationsPost-transplant treatment and follow-up is similar to that in adult patients, although there are some major differences.ImmunosuppressionMost pediatric centers use triple immunosuppressant therapy with tacrolimus, mycophenolate and corticosteroids.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Children under 5 years of age have increased clearance of calcineurin inhibitors, which means that higher doses are required in younger recipients; infants may require 2–4 times the adult dose.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> This higher clearance together with more rapid absorption means that there is greater fluctuation in levels, and that more frequent administration (every 8h) may be required in small children. Cystic fibrosis patients require a 40%–50% higher dose of tacrolimus due to poorer absorption and higher clearance. A good alternative may be sublingual tacrolimus, which achieves more stable levels with lower doses.<a class="elsevierStyleCrossRef" href="#bib0150">30</a>MonitoringIt is impossible to apply standard chronic graft dysfunction diagnostic criteria in small children. Spirometry can only be performed after children reach 3–4 years of age, and more reliably from 6 years old upwards. Although there are specific lung function tests in infants, such as forced thoracic compression after prior insufflation, diagnostic criteria using these techniques have not been validated.Biopsy forceps that can be used with 2.8 and 3.6mm pediatric bronchoscopes often do not allow adequate samples to be obtained for the diagnosis of acute rejection or assessment of the airways. The alternative may be to use standard forceps through a rigid bronchoscope, or on rare occasions, to perform an open lung biopsy.Thus, in small children, it is essential to rely on clinical symptoms, SaO2 values and chest computed tomography with inspiratory and expiratory slices.ComplicationsThe same complications can occur in children as in adult patients following lung transplantation, with some that are specific to children.Despite having smaller anatomical structures, vascular anastomotic and airway complications have a frequency in all pediatric age groups similar to that in adults.<a class="elsevierStyleCrossRef" href="#bib0155">31</a>Small children are more prone to viral respiratory infections, most of which are well tolerated. Although an impact on mortality and the development of chronic graft dysfunction has not been reported in any pediatric series,<a class="elsevierStyleCrossRef" href="#bib0160">32</a> community respiratory virus infection, such as respiratory syncytial virus (RSV), adenovirus, metapneumovirus, etc. may lead to graft failure or death of the patient. Most pediatric centers administer prophylaxis against RSV using specific antibodies (palivizumab).<a class="elsevierStyleCrossRef" href="#bib0165">33</a>Children who have undergone transplant have an increased risk of neoplasia, the most common of which is lymphoproliferative syndrome related with Epstein-Barr virus infection, with an incidence ranging from 4% one year post-transplant to 15% after 5 years.<a class="elsevierStyleCrossRef" href="#bib0170">34</a>Prognosis and SurvivalLung transplant recipients experience a major improvement in quality of life, and 88% of children do not have any limitations in their activity 3 years after the transplant.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>According to data from the ISHLT registry, survival 5 years post-transplant is 54% and after 10 years is around 30%, with survival in the 0–1 year and 1–11 year age groups better than that in the 12–17 year age group (mean survival of 6.4 years for infants, 6–6.7 years for small children, and 4.6 years for adolescents).<a class="elsevierStyleCrossRef" href="#bib0005">1</a> One of the causes of the lower survival rate in adolescents is likely poorer treatment compliance in this age group.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> Moreover, infants and preschool children appear to have better immune tolerance to the allograft and a lower incidence of acute rejection and chronic graft dysfunction than older children and adults.<a class="elsevierStyleCrossRef" href="#bib0180">36</a>Survival data in Spain are similar to those of the ISHLT registry. In our centre, survival was 55% at 5 years and 47% at 7 years,<a class="elsevierStyleCrossRef" href="#bib0060">12</a> and in the Spanish transplant registry,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> the one-year survival was 90.3% and 3-year survival was 66.9%.In cases in which the transplant fails, the only alternative is retransplantation, which may be limited by donor availability. In a recent study in the United States, it was observed that the survival after retransplantation was similar to that of the primary transplant if performed after the first year of transplant in unventilated cases, but it was poorer if performed within the first year of transplant or in ventilated patients.<a class="elsevierStyleCrossRef" href="#bib0185">37</a>The advances made in recent years in surgical techniques and immunosuppression mean that lung transplant in children is a reality. Efforts are needed to increase the number of donors available, and to further improve long-term results.Conflict of InterestThe authors declare that they do not have any conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:2 [ "identificador" => "xres296102" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec279776" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres296103" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec279777" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Epidemiology of Pediatric Transplant" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Indications" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "When Should a Child Be Referred for Lung Transplantation?" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Contraindications" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "The Donor Organ" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Types of Transplant and Surgical Technique" ] 11 => array:3 [ "identificador" => "sec0040" "titulo" => "Special Features in Post-transplant Management and Complications" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Immunosuppression" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Monitoring" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Complications" ] 3 => array:2 [ "identificador" => "sec0070" "titulo" => "Prognosis and Survival" ] ] ] 12 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflict of Interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-08-07" "fechaAceptado" => "2013-09-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec279776" "palabras" => array:5 [ 0 => "Lung transplant" 1 => "Children" 2 => "Cystic fibrosis" 3 => "Pulmonary hypertension" 4 => "Pulmonary hypertension" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec279777" "palabras" => array:5 [ 0 => "Trasplante pulmonar" 1 => "Niños" 2 => "Fibrosis quística" 3 => "Hipertensión pulmonar" 4 => "Neumopatías intersticiales" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Lung transplantation has become in recent years a therapeutic option for infants with terminal lung disease with similar results to transplantation in adults. In Spain, since 1996 114 children lung transplants have been performed; this corresponds to 3.9% of the total transplant number. The most common indication in children is cystic fibrosis, which represents between 70-80% of the transplants performed in adolescents. In infants common indications are interstitial lung disease and pulmonary hypertension. In most children a sequential double lung transplant is performed, generally with the help of extracorpo-real circulation. Lung transplantation in children presents special challenges in monitoring and follow-up, especially in infants, given the difficulty in assessing lung function and performing transbronchial biopsies.There are some more specific complications in children like postransplant lymphoproliferative syndrome or a greater severity of respiratory virus infections. After lung transplantation children usually experiment a very important improvement in their quality of life. Eighty eight per cent of children have no limitations in their activity after 3 years of transplantation. According to the registry of the International Society for Heart & Lung Transplantation (ISHLT) survival at 5 years of transplantation is 54% and at 10 years is around 35%." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El trasplante pulmonar se ha consolidado en los últimos años como una opción terapéutica para los niños con una enfermedad pulmonar terminal con unos resultados similares a los del trasplante en adultos.En España, desde 1996 se han realizado en menores de 16 años 114 trasplantes, lo que corresponde a un 3,9% del total de trasplantes.La indicación más frecuente en niños es la fibrosis quística, que representa entre el 70-80% de los trasplantes realizados en adolescentes. En los niños pequeños las indicaciones más frecuentes son las neumopatías intersticiales y la hipertensión pulmonar.En la mayoría de los niños se realiza un trasplante bipulmonar secuencial, en general con la ayuda de circulación extracorpórea.El trasplante pulmonar en niños presenta retos especiales en la monitorización y seguimiento, especialmente en los lactantes, dada la dificultad para valorar la función pulmonar y realizar biopsias transbronquiales.Existen algunas complicaciones más específicas de los niños que de los adultos como el síndrome linfoproliferativo postrasplante o una mayor gravedad de las infecciones por virus respiratorios.Tras el trasplante pulmonar se produce una mejoría muy importante en la calidad de vida de los niños trasplantados. El 88% de los niños no tienen ninguna limitación en su actividad a los 3 años del trasplante. Según los datos del registro de la International Society for Heart & Lung Transplantation (ISHLT) la supervivencia a los 5 años del trasplante es del 54% y a los 10 años del 30-38%." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Moreno Galdó A, Solé Montserrat J, Roman Broto A. Trasplante pulmonar en niños. Aspectos específicos. Arch Bronconeumol. 2013;49:523–528." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1313 "Ancho" => 2112 "Tamanyo" => 159451 ] ] "descripcion" => array:1 [ "en" => "Evolution of the number of pediatric and adult lung transplants performed in Spain during the years 1990–2012 (National Transplant Organization data 4)." ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cystic fibrosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary vascular diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary hypertension \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other pulmonary vascular disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary vein stenosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Alveolar capillary dysplasia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diffuse parenchymal lung diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Interstitial lung diseases specific to children \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surfactant protein deficiency \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic pneumonitis of infancy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Alveolar development disorders \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bronchopulmonary dysplasia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post lymphoma pulmonary fibrosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other interstitial lung diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bronchiolitis obliterans after hematopoietic stem cell transplantation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post-infectious bronchiolitis obliterans \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary graft dysfunction (retransplantation) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab431819.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Indications for Lung Transplantation in Children." ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "No., number of cases. HSCT, hematopoietic stem cell transplantation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No., % \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cystic fibrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 (54.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary vascular diseases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (15.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Idiopathic pulmonary hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other pulmonary vascular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Interstitial disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (17.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Interstitial pneumonitis of infancy<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Idiopathic pulmonary fibrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary fibrosis post-HSCT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post-lymphoma pulmonary fibrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post-infectious bronchiolitis obliterans \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (7.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post-lung transplantation bronchiolitis obliterans syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (3.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab431820.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Surfactant protein C deficiency (1 case), ABCA3 protein deficiency (1 case), chronic pneumonitis of infancy (2 cases)." ] ] ] "descripcion" => array:1 [ "en" => "Indications for Lung Transplant in Children in Hospital Universitari Vall d’Hebron (1996–2012; n=51)." ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Indication for referral to transplant centre \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cystic fibrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frequent hospital admissions for intravenous antibiotic treatment, major limitation for attending school or carrying out normal activities, rapid decline or marked fluctuations in lung function, including an FEV1 <30%, recurrent pneumothorax or hemoptysis, hypoxemia and hypercapnia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Idiopathic pulmonary hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Functional class IV, right heart failure, hypoxia, recurrent syncope, no response to medical treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary vein stenosis, alveolar capillary dysplasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Must be referred at an early stage as they do not respond to treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surfactant protein deficiencies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with protein B deficiency in refractory respiratory failure should be referred at an early stage. Patients with ABCA-3 or protein C deficiency in the case of severe respiratory failure and no response to treatment. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bronchopulmonary dysplasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Given the possibility of progressive improvement of the disease, only patients with severe respiratory failure who do not improve over time should be referred. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post-infectious bronchiolitis obliterans \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with major hypoxemia or requiring invasive mechanical ventilation who do not improve with medical treatment. Take into account the possibility of improvement over the first 2 years. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other diffuse parenchymal lung diseases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with major hypoxemia or requiring invasive mechanical ventilation who do not improve with medical treatment. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab431821.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations for Referring Children With Respiratory Disease to the Lung Transplant Team (Adapted From Sweet<a class="elsevierStyleCrossRef" href="#bib0080">16</a>)." ] ] 4 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absolute contraindications \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Severe organic liver or renal dysfunction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Active extra-pulmonary infection (sepsis, tuberculosis) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Progressive neuromuscular disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Active neoplasm in the previous 2–5 years (depending on the type of tumor) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neurological dysfunction or severe chromosome abnormalities that impede good quality of life \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abnormal transpleural communications between the systemic and bronchial circulation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Relative contraindications \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Burkholderia cepacia genomovar-3 infection \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Severe scoliosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical pleurectomy or chemical pleurodesis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Severe tracheomalacia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lung infection due to multiresistant pathogens \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Difficulty in treatment compliance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Active collagen-vascular disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mechanical ventilation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Renal failure \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab431822.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Contraindications for Lung Transplantation." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:37 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International Society of Heart and Lung Transplantation. The Registry of the International Society for Heart and Lung Transplantation: Sixteenth pediatric lung and heart-lung transplantation report-2013; focus theme: age" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Benden" 1 => "L.B. Edwards" 2 => "A.Y. Kucheryavaya" 3 => "J.D. Christie" 4 => "A.I. Dipchand" 5 => "F. 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Lung Transplantation in Children. Specific Aspects

Trasplante pulmonar en niños. Aspectos específicos

Antonio Moreno Galdóa,b,

Corresponding author

aroman@vhebron.net

Corresponding author.

, Juan Solé Montserratc, Antonio Roman Brotod,e

a Unidad de Neumología Pediátrica y Fibrosis Quística, Hospital Universitari Vall d’Hebron, Barcelona, Spain

b Departament de Pediatria, d’Obstetricia i Ginecologia i de Medicina Preventiva, Universitat Autònoma de Barcelona, Barcelona, Spain

c Servicio de Cirugía Torácica, Hospital Universitari Vall d’Hebron, Barcelona, Spain

d Servicio de Neumología, Hospital Universitari Vall d’Hebron, Barcelona, Spain

e CIBER Enfermedades Respiratorias (CIBERES), Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In recent years&#44; lung transplantation has become established as a therapeutic option for children with severe lung disease in whom other therapeutic options have failed&#44; resulting in good quality of life and prolonged survival&#44; similar to that of transplants performed in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Pediatric transplantation has numerous unique features in relation to transplantation in adults<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#58; specific characteristics of children at different stages of development &#40;from infants to adolescents&#41;&#44; different indications for different age groups&#44; the effects of immunosuppressant treatments&#44; special susceptibility to infections related to an immature immune system&#44; and particular problems in the availability of suitable donors&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Although pediatric transplant results have improved considerably in the last two decades<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> due to advances in the transplant technique&#44; organ preservation&#44; peri-operative management&#44; immunosuppression&#44; and the prophylaxis and treatment of infectious complications&#44; as in adults&#44; chronic graft dysfunction limits long-term survival&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Epidemiology of Pediatric Transplant</span><p id="par0020" class="elsevierStylePara elsevierViewall">The first transplant in an adult in Spain was carried out in 1990&#46; Six transplants were performed that year&#44; with the number of annual transplants increasing gradually to 238 in 2012&#44; to a total of 2940 &#91;Spanish National Transplant Organization &#40;ONT&#41; data&#93;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> The ONT considers pediatric transplants as those performed in children under the age of 16&#46; The first pediatric lung transplant was carried out in 1996&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Since then&#44; 114 pediatric transplants have been performed in Spain&#44; accounting for 3&#46;9&#37; of the total&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Unlike adult transplants&#44; the annual number of transplants has remained relatively steady&#44; with a median of 6 per year during this period &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In the Spanish Lung Transplant Registry&#44; 74&#37; of children were aged between 11 and 15 years old&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> These data are comparable with those recorded in the registry of the <span class="elsevierStyleItalic">International Society for Heart &#38; Lung Transplantation</span> &#40;ISHLT&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;7</span></a> in which pediatric transplantation is considered to be a transplant carried out in children aged under 18&#46; According to ISHLT data&#44; 49&#44;673 lung and heart-lung transplants were performed between 1987 and June 2012&#44; 2542 &#40;5&#46;12&#37;&#41; of which were pediatric&#46; The highest percentage of transplants took place in the adolescent group &#40;12&#8211;17 years&#41;&#44; representing 84&#37; of pediatric transplants in Europe and 68&#37; in North America&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In this registry&#44; a very modest increase in the number of pediatric transplants was observed from the 73 carried out in 2000 to 107 in 2011&#44; peaking at 125 transplants in 2010&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The low frequency of transplants in children and absence of an increase similar to that in adult patients is related to 3 factors<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">The low prevalence of severe lung disease in children&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">Advances in the medical care of patients with cystic fibrosis<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> &#40;the primary indication in pediatric patients&#41; have considerably improved its course and delayed the age at which lung transplantation may be required&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">The limited availability of young donors&#46;</p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">Only a small number of hospitals worldwide carry out pediatric lung transplantation &#40;around 40&#41;&#44; and most &#40;88&#46;3&#37;&#41; perform between 1 and 4 transplants per year only&#44; with just 3&#8211;4 centers performing between 5 and 9 transplants and 2 centers between 10 and 19 transplants&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> As in Spain&#44; two types of centers can be distinguished among these&#58; centers specifically dedicated to pediatric transplantation&#44; in which transplants are performed in children of all ages &#40;or in some centers in children above preschool age&#41;&#44; and adult lung transplant centers in which adolescents or children over 8&#8211;10 years of age are also treated&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Indications</span><p id="par0050" class="elsevierStylePara elsevierViewall">As in adults&#44; the general indication for lung transplantation is progressive respiratory failure with a short life expectancy&#44; generally less than 1&#8211;2 years&#44; and very poor quality of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;11</span></a> It requires that all other therapeutic measures have been exhausted&#44; there is no other serious illness&#44; the ability to comply with a complex therapeutic regimen has been assessed&#44; there is a suitable social environment and the family and&#47;or the child assumes the risks of the transplant&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> specifies the main diseases in which lung transplantation may be indicated in children&#46; Cystic fibrosis is the most common indication&#59; the other major groups of indications are pulmonary vascular diseases &#40;mainly pulmonary hypertension&#41; and diffuse parenchymal lung diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;16</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In the Spanish Lung Transplant Registry &#40;2006&#8211;2010&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> cystic fibrosis accounted for 67&#46;75&#37; of transplants in children aged under 16&#44; post-infectious bronchiolitis obliterans for 12&#46;95&#37;&#44; pulmonary arterial hypertension for 3&#46;2&#37; and interstitial lung diseases&#44; 16&#46;1&#37;&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the number of pediatric transplants carried out in our hospital during the period 1996&#8211;2012&#44; with the relative frequency of the different indications&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The proportion of the different indications in relation to age groups has changed in recent years&#46; In the ISHLT registry&#44; cystic fibrosis accounts for 53&#46;8&#37; of transplants in children aged between 6 and 11 years&#44; and 71&#46;5&#37; in those aged between 12 and 17 years&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It should be taken into consideration&#44; however&#44; that the ISHLT registry includes data from 1990&#44; and that transplant in children under 11 and adolescents with cystic fibrosis is becoming increasingly less common&#46; According to data from the Catalonian lung transplant registry &#40;Spain&#41;&#44; cystic fibrosis represents less than 10&#37; of transplants performed in children under 11 years&#44; but 85&#37; of those carried out in adolescents aged between 12 and 17 years&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">When Should a Child Be Referred for Lung Transplantation&#63;</span><p id="par0070" class="elsevierStylePara elsevierViewall">The decision to place a child on the waiting list for a lung transplant is not easy&#44; as it is very difficult to predict survival&#46; It is very important to make this decision properly&#44; in order to provide a survival benefit&#46; Some years ago in the USA&#44; the benefit of lung transplantation in children with cystic fibrosis was questioned&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> This was possibly linked to too early inclusion on the waiting list in contrast to the improvement in survival of children with cystic fibrosis due to advances in medical treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> With the adoption of a severity assessment system for prioritizing patients on the waiting list &#40;<span class="elsevierStyleItalic">Lung Allocation Score</span>&#41;&#44; a real benefit of transplantation in adults with cystic fibrosis been shown in the USA<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#59; this scoring system is only applicable in children over 12 years of age&#46; In other countries&#44; a real benefit of lung transplantation has been demonstrated in children with cystic fibrosis and severe lung disease&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The indications for referring a child with cystic fibrosis for evaluation for lung transplant can be summarized in&#58; frequent hospital admissions for intravenous antibiotic treatment&#44; major limitation for attending school or carrying out normal activities&#44; rapid decline or marked fluctuations in lung function&#44; including an FEV<span class="elsevierStyleInf">1</span> &#60;30&#37;&#44; recurrent pneumothorax or hemoptysis&#44; hypoxemia and hypercapnia&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> It is recommended that children be included if their life expectancy is less than 2 years despite receiving full medical therapy and they have poor quality of life that is likely to improve with transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Using this approach&#44; widely adopted in Europe&#44; most of those who receive a transplant will benefit&#44; although it has the disadvantage that some patients may die on the waiting list or even without being included on it if their prognosis is not properly assessed&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In children with <span class="elsevierStyleItalic">diffuse parenchymal lung diseases</span>&#44; the most important thing is to assess the presence of moderate or severe functional impairment&#44; need for mechanical ventilation or very high oxygen supplementation&#44; lack of response to treatment&#44; and taking into account the natural course of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> With some diseases&#44; such as surfactant protein B deficiency&#44; the child cannot survive without a transplant&#44; while others may have a variable response to treatment&#44; as in surfactant protein C deficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The prognosis in pulmonary hypertension has improved considerably with the new treatments available&#44; so the following criteria are now recommended&#58; children in functional class IV&#58; place on the transplant list and begin medical treatment&#59; if they improve&#44; remove them from the waiting list&#46; Children in functional class III&#58; administer medical treatment&#59; if they do not improve or worsen&#44; place them on the waiting list&#46; Children with bilateral pulmonary vein stenosis or alveolar capillary dysplasia would have to be included on the transplant list at an early stage&#44; as they do not respond to other treatments&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;16</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The nature of these indications means that lung transplantation in mechanically ventilated children is indicated more often than in adults&#46; Infants on mechanical ventilation or children on long-term mechanical ventilation may be considered candidates for lung transplant&#46; It has been shown that mechanically ventilated infants who have received transplants have the same survival post-transplant as non-ventilated older children&#44; and better than ventilated older children&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Invasive mechanical ventilation in children with cystic fibrosis is a risk factor for higher post-transplant morbidity and mortality&#44; unlike non-invasive ventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;24</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> summarizes the criteria for referring children to lung transplant teams&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Contraindications</span><p id="par0100" class="elsevierStylePara elsevierViewall">There are several situations in which lung transplantation may not be advised&#44; some absolute and others relative&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> while some are specific to each centre &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">In patients with cystic fibrosis&#44; <span class="elsevierStyleItalic">Bulkholderia cepacia</span> genomovar-3&#44; <span class="elsevierStyleItalic">Mycobacterium abscessus</span> and multiresistant fungal infections &#40;<span class="elsevierStyleItalic">Schedosporium prolificans</span>&#41; constitute a contraindication in some centers&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Patients with cyanotic heart diseases in whom previous thoracotomies have been performed for palliative purposes have a very high risk of bleeding from chest wall collateral vessels&#44; and should be assessed individually&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">The Donor Organ</span><p id="par0115" class="elsevierStylePara elsevierViewall">One of the current critical issues in pediatric lung transplantation&#44; and pediatric transplants in general&#44; is the fall in the number of young donors available&#44; with the consequent increase in waiting list times&#46; This is linked to the gradually decreasing number of donors as a result of road traffic accidents in the last 20 years&#44; in parallel with the decrease in road fatalities&#44; particularly after the introduction of new road traffic laws in Spain in 2005&#46; While they represented 43&#37; of donors in 1992&#44; this figure fell to 5&#46;7&#37; of total donations in 2010&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In our hospital&#44; the median waiting time for children under 2 years old between the periods 1996&#8211;2005 and 2006&#8211;2011 increased moderately from 84 to 135 days&#44; while for the 3&#8211;11 and 12&#8211;17 years age groups&#44; it increased significantly&#44; from 107 to 538 days and from 106&#46;5 to 404&#46;5 days&#44; respectively&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In order to improve these figures&#44; Pediatric Intensive Care Units must be extremely aware of the need to make the most of potential donors and to optimize their care&#44; and strategies for using lungs from adult donors in children may be employed&#59; it would also be advisable to explore the extension of non-heart-beating donor programs in pediatrics&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;25</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Types of Transplant and Surgical Technique</span><p id="par0130" class="elsevierStylePara elsevierViewall">Sequential double-lung transplant is typically carried out in children&#59; this is compulsory in septic lung disease &#40;cystic fibrosis&#41; and is the procedure of choice in pulmonary hypertension&#46; Single-lung transplantation is less indicated in children than in adults &#40;only 1 out of 31 cases in the Spanish Lung Transplant Registry<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#41;&#46; It can be performed in cases of non-septic parenchymal lung disease &#40;pulmonary fibrosis&#44; bronchiolitis obliterans&#44; retransplantation&#41;&#44; if the somatic growth is almost complete and the organ offered is of perfect size and quality&#46; Heart-lung transplant is reserved for pulmonary vascular disease associated with uncorrectable congenital heart disease&#44; and for cases in which there is left ventricular failure&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Unlike adults&#44; most pediatric lung transplants are performed with CPB&#44; as most children&#44; due to their size&#44; cannot tolerate single-lung ventilation&#46; However&#44; in adolescents and older children&#44; it is sometimes possible to perform the transplant without CPB&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although it has been suggested that the use of this technique could be associated with a higher incidence of primary graft failure&#44; in a large series comparing the frequency of primary graft dysfunction between transplants in adults and children&#44; there were no differences in its incidence&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Due to the difficulty in finding donors of a suitable size for children&#44; there is greater flexibility in accepting size differences between the donor and recipient&#44; and various techniques are performed to accommodate the lungs&#44; including lobectomies &#40;the middle lobe&#44; lingula or lower lobes&#41;&#44; non-anatomical resections&#44; or using the lobes only&#46; The upper or lower lobes can be used&#44; but the upper lobes fit better in the thorax&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Another strategy that has been used is to divide the left lung of an adult donor of suitable size&#44; using the left lower lobe as a left lung and the left upper lobe as a right lung&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> There is experimental evidence in animal models that a &#8220;mature&#8221; lobe implanted in an immature recipient could grow by pneumocyte division&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Living donor lobar lung transplantation requires 2 donors&#44; extracting the lower lobe from each of them&#46; This has significant morbidity for the donor and results similar to those of a deceased donor&#44; so it is rarely used at present&#44; except in Japan and Brazil and occasionally in some experienced centers in the USA&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Special Features in Post-transplant Management and Complications</span><p id="par0150" class="elsevierStylePara elsevierViewall">Post-transplant treatment and follow-up is similar to that in adult patients&#44; although there are some major differences&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Immunosuppression</span><p id="par0155" class="elsevierStylePara elsevierViewall">Most pediatric centers use triple immunosuppressant therapy with tacrolimus&#44; mycophenolate and corticosteroids&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Children under 5 years of age have increased clearance of calcineurin inhibitors&#44; which means that higher doses are required in younger recipients&#59; infants may require 2&#8211;4 times the adult dose&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> This higher clearance together with more rapid absorption means that there is greater fluctuation in levels&#44; and that more frequent administration &#40;every 8<span class="elsevierStyleHsp" style=""></span>h&#41; may be required in small children&#46; Cystic fibrosis patients require a 40&#37;&#8211;50&#37; higher dose of tacrolimus due to poorer absorption and higher clearance&#46; A good alternative may be sublingual tacrolimus&#44; which achieves more stable levels with lower doses&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Monitoring</span><p id="par0160" class="elsevierStylePara elsevierViewall">It is impossible to apply standard chronic graft dysfunction diagnostic criteria in small children&#46; Spirometry can only be performed after children reach 3&#8211;4 years of age&#44; and more reliably from 6 years old upwards&#46; Although there are specific lung function tests in infants&#44; such as forced thoracic compression after prior insufflation&#44; diagnostic criteria using these techniques have not been validated&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Biopsy forceps that can be used with 2&#46;8 and 3&#46;6<span class="elsevierStyleHsp" style=""></span>mm pediatric bronchoscopes often do not allow adequate samples to be obtained for the diagnosis of acute rejection or assessment of the airways&#46; The alternative may be to use standard forceps through a rigid bronchoscope&#44; or on rare occasions&#44; to perform an open lung biopsy&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Thus&#44; in small children&#44; it is essential to rely on clinical symptoms&#44; SaO<span class="elsevierStyleInf">2</span> values and chest computed tomography with inspiratory and expiratory slices&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Complications</span><p id="par0175" class="elsevierStylePara elsevierViewall">The same complications can occur in children as in adult patients following lung transplantation&#44; with some that are specific to children&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Despite having smaller anatomical structures&#44; vascular anastomotic and airway complications have a frequency in all pediatric age groups similar to that in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Small children are more prone to viral respiratory infections&#44; most of which are well tolerated&#46; Although an impact on mortality and the development of chronic graft dysfunction has not been reported in any pediatric series&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> community respiratory virus infection&#44; such as respiratory syncytial virus &#40;RSV&#41;&#44; adenovirus&#44; metapneumovirus&#44; etc&#46; may lead to graft failure or death of the patient&#46; Most pediatric centers administer prophylaxis against RSV using specific antibodies &#40;palivizumab&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Children who have undergone transplant have an increased risk of neoplasia&#44; the most common of which is lymphoproliferative syndrome related with Epstein-Barr virus infection&#44; with an incidence ranging from 4&#37; one year post-transplant to 15&#37; after 5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Prognosis and Survival</span><p id="par0195" class="elsevierStylePara elsevierViewall">Lung transplant recipients experience a major improvement in quality of life&#44; and 88&#37; of children do not have any limitations in their activity 3 years after the transplant&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">According to data from the ISHLT registry&#44; survival 5 years post-transplant is 54&#37; and after 10 years is around 30&#37;&#44; with survival in the 0&#8211;1 year and 1&#8211;11 year age groups better than that in the 12&#8211;17 year age group &#40;mean survival of 6&#46;4 years for infants&#44; 6&#8211;6&#46;7 years for small children&#44; and 4&#46;6 years for adolescents&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> One of the causes of the lower survival rate in adolescents is likely poorer treatment compliance in this age group&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Moreover&#44; infants and preschool children appear to have better immune tolerance to the allograft and a lower incidence of acute rejection and chronic graft dysfunction than older children and adults&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Survival data in Spain are similar to those of the ISHLT registry&#46; In our centre&#44; survival was 55&#37; at 5 years and 47&#37; at 7 years&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and in the Spanish transplant registry&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> the one-year survival was 90&#46;3&#37; and 3-year survival was 66&#46;9&#37;&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">In cases in which the transplant fails&#44; the only alternative is retransplantation&#44; which may be limited by donor availability&#46; In a recent study in the United States&#44; it was observed that the survival after retransplantation was similar to that of the primary transplant if performed after the first year of transplant in unventilated cases&#44; but it was poorer if performed within the first year of transplant or in ventilated patients&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">The advances made in recent years in surgical techniques and immunosuppression mean that lung transplant in children is a reality&#46; Efforts are needed to increase the number of donors available&#44; and to further improve long-term results&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of Interest</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any conflict of interests&#46;</p></span></span>"
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          "identificador" => "xres296102"
          "titulo" => "Abstract"
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          "identificador" => "xres296103"
          "titulo" => "Resumen"
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        4 => array:2 [
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          "titulo" => "Introduction"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Epidemiology of Pediatric Transplant"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Indications"
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        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "When Should a Child Be Referred for Lung Transplantation&#63;"
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          "titulo" => "Contraindications"
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          "titulo" => "The Donor Organ"
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          "titulo" => "Types of Transplant and Surgical Technique"
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        11 => array:3 [
          "identificador" => "sec0040"
          "titulo" => "Special Features in Post-transplant Management and Complications"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Immunosuppression"
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            1 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Monitoring"
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            2 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Complications"
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            3 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Prognosis and Survival"
            ]
          ]
        ]
        12 => array:2 [
          "identificador" => "sec0065"
          "titulo" => "Conflict of Interest"
        ]
        13 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-08-07"
    "fechaAceptado" => "2013-09-26"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec279776"
          "palabras" => array:5 [
            0 => "Lung transplant"
            1 => "Children"
            2 => "Cystic fibrosis"
            3 => "Pulmonary hypertension"
            4 => "Pulmonary hypertension"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec279777"
          "palabras" => array:5 [
            0 => "Trasplante pulmonar"
            1 => "Ni&#241;os"
            2 => "Fibrosis qu&#237;stica"
            3 => "Hipertensi&#243;n pulmonar"
            4 => "Neumopat&#237;as intersticiales"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Lung transplantation has become in recent years a therapeutic option for infants with terminal lung disease with similar results to transplantation in adults&#46; In Spain&#44; since 1996 114 children lung transplants have been performed&#59; this corresponds to 3&#46;9&#37; of the total transplant number&#46; The most common indication in children is cystic fibrosis&#44; which represents between 70-80&#37; of the transplants performed in adolescents&#46; In infants common indications are interstitial lung disease and pulmonary hypertension&#46; In most children a sequential double lung transplant is performed&#44; generally with the help of extracorpo-real circulation&#46; Lung transplantation in children presents special challenges in monitoring and follow-up&#44; especially in infants&#44; given the difficulty in assessing lung function and performing transbronchial biopsies&#46;There are some more specific complications in children like postransplant lymphoproliferative syndrome or a greater severity of respiratory virus infections&#46; After lung transplantation children usually experiment a very important improvement in their quality of life&#46; Eighty eight per cent of children have no limitations in their activity after 3 years of transplantation&#46; According to the registry of the International Society for Heart &#38; Lung Transplantation &#40;ISHLT&#41; survival at 5 years of transplantation is 54&#37; and at 10 years is around 35&#37;&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">El trasplante pulmonar se ha consolidado en los &#250;ltimos a&#241;os como una opci&#243;n terap&#233;utica para los ni&#241;os con una enfermedad pulmonar terminal con unos resultados similares a los del trasplante en adultos&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En Espa&#241;a&#44; desde 1996 se han realizado en menores de 16 a&#241;os 114 trasplantes&#44; lo que corresponde a un 3&#44;9&#37; del total de trasplantes&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La indicaci&#243;n m&#225;s frecuente en ni&#241;os es la fibrosis qu&#237;stica&#44; que representa entre el 70-80&#37; de los trasplantes realizados en adolescentes&#46; En los ni&#241;os peque&#241;os las indicaciones m&#225;s frecuentes son las neumopat&#237;as intersticiales y la hipertensi&#243;n pulmonar&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En la mayor&#237;a de los ni&#241;os se realiza un trasplante bipulmonar secuencial&#44; en general con la ayuda de circulaci&#243;n extracorp&#243;rea&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El trasplante pulmonar en ni&#241;os presenta retos especiales en la monitorizaci&#243;n y seguimiento&#44; especialmente en los lactantes&#44; dada la dificultad para valorar la funci&#243;n pulmonar y realizar biopsias transbronquiales&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Existen algunas complicaciones m&#225;s espec&#237;ficas de los ni&#241;os que de los adultos como el s&#237;ndrome linfoproliferativo postrasplante o una mayor gravedad de las infecciones por virus respiratorios&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Tras el trasplante pulmonar se produce una mejor&#237;a muy importante en la calidad de vida de los ni&#241;os trasplantados&#46; El 88&#37; de los ni&#241;os no tienen ninguna limitaci&#243;n en su actividad a los 3 a&#241;os del trasplante&#46; Seg&#250;n los datos del registro de la <span class="elsevierStyleItalic">International Society for Heart &#38; Lung Transplantation</span> &#40;ISHLT&#41; la supervivencia a los 5 a&#241;os del trasplante es del 54&#37; y a los 10 a&#241;os del 30-38&#37;&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Moreno Gald&#243; A&#44; Sol&#233; Montserrat J&#44; Roman Broto A&#46; Trasplante pulmonar en ni&#241;os&#46; Aspectos espec&#237;ficos&#46; Arch Bronconeumol&#46; 2013&#59;49&#58;523&#8211;528&#46;</p>"
      ]
    ]
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      0 => array:7 [
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Evolution of the number of pediatric and adult lung transplants performed in Spain during the years 1990&#8211;2012 &#40;National Transplant Organization data 4&#41;&#46;</p>"
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alveolar capillary dysplasia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Diffuse parenchymal lung diseases</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Interstitial lung diseases specific to children&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Surfactant protein deficiency&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bronchiolitis obliterans after hematopoietic stem cell transplantation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Pulmonary graft dysfunction &#40;retransplantation&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;17&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;7&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Post-lung transplantation bronchiolitis obliterans syndrome</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab431820.png"
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            0 => array:3 [
              "identificador" => "tblfn0005"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Surfactant protein C deficiency &#40;1 case&#41;&#44; ABCA3 protein deficiency &#40;1 case&#41;&#44; chronic pneumonitis of infancy &#40;2 cases&#41;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Indications for Lung Transplant in Children in Hospital Universitari Vall d&#8217;Hebron &#40;1996&#8211;2012&#59; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>51&#41;&#46;</p>"
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        "mostrarDisplay" => false
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Indication for referral to transplant centre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cystic fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frequent hospital admissions for intravenous antibiotic treatment&#44; major limitation for attending school or carrying out normal activities&#44; rapid decline or marked fluctuations in lung function&#44; including an FEV<span class="elsevierStyleInf">1</span> &#60;30&#37;&#44; recurrent pneumothorax or hemoptysis&#44; hypoxemia and hypercapnia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Idiopathic pulmonary hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Functional class IV&#44; right heart failure&#44; hypoxia&#44; recurrent syncope&#44; no response to medical treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pulmonary vein stenosis&#44; alveolar capillary dysplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Must be referred at an early stage as they do not respond to treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Surfactant protein deficiencies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with protein B deficiency in refractory respiratory failure should be referred at an early stage&#46; Patients with ABCA-3 or protein C deficiency in the case of severe respiratory failure and no response to treatment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bronchopulmonary dysplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Given the possibility of progressive improvement of the disease&#44; only patients with severe respiratory failure who do not improve over time should be referred&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Post-infectious bronchiolitis obliterans&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with major hypoxemia or requiring invasive mechanical ventilation who do not improve with medical treatment&#46; Take into account the possibility of improvement over the first 2 years&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Other diffuse parenchymal lung diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with major hypoxemia or requiring invasive mechanical ventilation who do not improve with medical treatment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Recommendations for Referring Children With Respiratory Disease to the Lung Transplant Team &#40;Adapted From Sweet<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#41;&#46;</p>"
        ]
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        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:1 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Absolute contraindications</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Severe organic liver or renal dysfunction&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Active extra-pulmonary infection &#40;sepsis&#44; tuberculosis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Progressive neuromuscular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Active neoplasm in the previous 2&#8211;5 years &#40;depending on the type of tumor&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neurological dysfunction or severe chromosome abnormalities that impede good quality of life&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Abnormal transpleural communications between the systemic and bronchial circulation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Relative contraindications</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Burkholderia cepacia</span> genomovar-3 infection&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Severe scoliosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Surgical pleurectomy or chemical pleurodesis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Severe tracheomalacia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lung infection due to multiresistant pathogens&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Difficulty in treatment compliance&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Active collagen-vascular disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mechanical ventilation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Renal failure&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Contraindications for Lung Transplantation&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:37 [
            0 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "International Society of Heart and Lung Transplantation&#46; The Registry of the International Society for Heart and Lung Transplantation&#58; Sixteenth pediatric lung and heart-lung transplantation report-2013&#59; focus theme&#58; age"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Benden"
                            1 => "L&#46;B&#46; Edwards"
                            2 => "A&#46;Y&#46; Kucheryavaya"
                            3 => "J&#46;D&#46; Christie"
                            4 => "A&#46;I&#46; Dipchand"
                            5 => "F&#46; Dobbels"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.healun.2013.08.008"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Heart Lung Transplant"
                        "fecha" => "2013"
                        "volumen" => "32"
                        "paginaInicial" => "989"
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                        "link" => array:1 [
                          0 => array:2 [
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                            "web" => "Medline"
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                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Specific aspects of children and adolescents undergoing lung transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "C&#46; Benden"
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                        ]
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                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1097/MOT.0b013e3283564fba"
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Opin Organ Transplant"
                        "fecha" => "2012"
                        "volumen" => "17"
                        "paginaInicial" => "509"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22941318"
                            "web" => "Medline"
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                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Two decades of pediatric lung transplant in the United States&#58; have we improved&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46; Zafar"
                            1 => "J&#46;S&#46; Heinle"
                            2 => "M&#46;G&#46; Schecter"
                            3 => "J&#46;W&#46; Rossano"
                            4 => "G&#46;B&#46; Mallory Jr&#46;"
                            5 => "O&#46; Elidemir"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Thorac Cardiovasc Surg"
                        "fecha" => "2011"
                        "volumen" => "14"
                        "paginaInicial" => "828"
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                      ]
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              "identificador" => "bib0020"
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                  "referenciaCompleta" => "Datos de Donaci&#243;n y Trasplante&#46; ONT&#46; Available from&#58; <a id="intr0005" class="elsevierStyleInterRef" href="http://www.ont.es/">http&#58;&#47;&#47;www&#46;ont&#46;es</a> &#91;accessed 27&#46;07&#46;13&#93;&#46;"
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            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The Spanish Lung Transplant Registry&#58; first report of results &#40;2006&#8211;2010&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46; Coll"
                            1 => "F&#46; Santos"
                            2 => "P&#46; Ussetti"
                            3 => "M&#46; Canela"
                            4 => "J&#46;M&#46; Borro"
                            5 => "M&#46; de la Torre"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.arbres.2012.06.001"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2013"
                        "volumen" => "49"
                        "paginaInicial" => "70"
                        "paginaFinal" => "78"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22939738"
                            "web" => "Medline"
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              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Primer programa nacional de trasplante pulmonar infantil&#58; experiencia en cuidados intensivos pedi&#225;tricos"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46;M&#46; Fr&#237;as"
                            1 => "S&#46;C&#46; Montero"
                            2 => "I&#46; Ibarra de la Rosa"
                            3 => "S&#46;E&#46; Ulloa"
                            4 => "B&#46;J&#46; Mu&#241;oz"
                            5 => "J&#46;M&#46; Velasco"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "An Esp Pediatr"
                        "fecha" => "1999"
                        "volumen" => "50"
                        "paginaInicial" => "581"
                        "paginaFinal" => "586"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10410421"
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Article information

ISSN: 15792129
Original language: English

DOI:10.1016/j.arbr.2013.10.007

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Year/Month	Html	Pdf	Total

2024 November	5	2	7
2024 October	49	32	81
2024 September	40	19	59
2024 August	66	33	99
2024 July	47	30	77
2024 June	59	25	84
2024 May	105	25	130
2024 April	43	28	71
2024 March	53	24	77
2024 February	31	23	54
2023 March	7	5	12
2023 February	34	24	58
2023 January	38	30	68
2022 December	50	32	82
2022 November	56	22	78
2022 October	48	30	78
2022 September	32	25	57
2022 August	31	41	72
2022 July	43	46	89
2022 June	34	43	77
2022 May	45	41	86
2022 April	35	33	68
2022 March	43	59	102
2022 February	48	43	91
2022 January	65	49	114
2021 December	53	38	91
2021 November	50	56	106
2021 October	57	25	82
2021 September	58	44	102
2021 August	36	43	79
2021 July	50	34	84
2021 June	55	28	83
2021 May	47	45	92
2021 April	153	86	239
2021 March	65	32	97
2021 February	44	31	75
2021 January	49	14	63
2020 December	43	22	65
2020 November	47	24	71
2020 October	41	24	65
2020 September	64	40	104
2020 August	46	19	65
2020 July	34	23	57
2020 June	26	6	32
2020 May	40	21	61
2020 April	43	18	61
2020 March	32	15	47
2020 February	45	15	60
2020 January	46	17	63
2019 December	53	10	63
2019 November	26	16	42
2019 October	24	15	39
2019 September	29	11	40
2019 August	26	11	37
2019 July	39	17	56
2019 June	33	5	38
2019 May	43	10	53
2019 April	26	20	46
2019 March	51	17	68
2019 February	42	13	55
2019 January	38	20	58
2018 December	44	18	62
2018 November	102	21	123
2018 October	159	24	183
2018 September	106	9	115
2018 May	23	1	24
2018 April	26	4	30
2018 March	40	6	46
2018 February	36	5	41
2018 January	38	10	48
2017 December	32	6	38
2017 November	38	4	42
2017 October	43	6	49
2017 September	45	18	63
2017 August	52	11	63
2017 July	46	10	56
2017 June	59	19	78
2017 May	65	13	78
2017 April	59	12	71
2017 March	50	7	57
2017 February	37	9	46
2017 January	23	9	32
2016 December	47	9	56
2016 November	68	9	77
2016 October	55	15	70
2016 September	104	23	127
2016 August	59	15	74
2016 July	46	16	62
2016 March	3	0	3
2016 February	1	0	1
2015 December	3	0	3
2015 October	49	1	50
2015 September	48	10	58
2015 August	55	8	63
2015 July	53	11	64
2015 June	36	8	44
2015 May	42	14	56
2015 April	43	13	56
2015 March	54	13	67
2015 February	38	4	42
2015 January	27	10	37
2014 December	55	19	74
2014 November	44	19	63
2014 October	68	15	83
2014 September	42	15	57
2014 August	46	16	62
2014 July	36	11	47
2014 June	57	17	74
2014 May	52	17	69
2014 April	70	16	86
2014 March	84	28	112
2014 February	0	2	2
2014 January	1	2	3
2013 December	1	2	3

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