Submitted by Dr. Jun Oh, IPTA Education Community Co-Chair

Dear IPTA Members,

The past 12 months have been marked by many successful activities to promote educational initiatives in paediatric nephrology. The IPTA Education Committee collaborated on a paper entitled "Paediatric to Adult Transition in Solid Organ Transplant Recipients: A Systematic Review of Existing Transition Programs" in Pediatric Transplantation. Yerigeri and colleagues identify different transition models and their impact on adherence and graft rejection, which correlate with morbidity and mortality and influence transplant outcomes. The heterogeneity of data in the current literature requires further research to establish causality and develop a standardized transition program to improve patient outcomes (Yerigeri S et al, Pediatr Transplantation 2024 Dec; 28(8):e14896).

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Another success was the submission of a white paper as part of the IPTA training survey. The title of the white paper is: "Educational Gaps and Suggestions for Change for Paediatric Transplant Fellowship Training Based on Fellow Survey Responses". This publication gathers fellows' insights on educational needs. We believe that it is essential to hear the original voice of the fellows to significantly improve their education and training. Highlights of this manuscript were accepted as a 3 -Minutes poster for the IPTA Congress in Berlin.

On the 14^th and 15^th of November 2024, the successful IPTA Educational Symposium took place again with more than 200 participants. We were very pleased with the many positive comments and feedback we received. This has encouraged us to plan this symposium again soon. The excellent attendance also showed us that there is a great need for such an event.

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The Education Committee has planned the following projects for 2025: IPTA Fellow Symposium during IPTA Congress 2025 in Berlin. Topics: "Basic Immunology of Rejection" and "Management of AKI in Solid Organ Transplantation". The aim of this event is to provide doctors in training to become transplant physicians not only with the basics of the complex immunological challenges after organ transplantation, but also to give them insights into related subspecialties to gain a broad knowledge. Well-known and established colleagues will speak on various topics and provide ample time for discussion and interaction.

Warm regards,

Dr. Jun Oh
Co-Chair, IPTA Education Committee

The Pediatric Intestine-Inclusive Multiorgan Transplant
Pediatric transplantation of the intestine either alone or in combination with other solid organs is both a technically and immunologically challenging endeavor. From a surgical standpoint, conditions such as a “hostile” abdomen, portal hypertension, chronic infections and vascular access compromise are commonplace to these patients and pose challenges to even the most experienced surgical team. From a medical/immunological standpoint, the large lymphoid load inherent of any intestine-inclusive allograft is an immense immunological hurdle which necessitates an augmented immunosuppression regimen, further increasing post-transplant complications.

Despite all the challenges, pediatric multiorgan transplantation (MOTX) in various combinations such as the liver-intestine, liver-pancreas-intestine, stomach-liver-pancreas-intestine (multivisceral), or stomach-pancreas-intestine (modified multivisceral) has proven to be a lifesaving transplant for these patients who have suffered from the ravages of long-term parenteral nutrition (PN) and have no alternative for survival.

Over two decades ago, chronic long-term PN in children was managed very differently from that of today’s standards. The significant mortality of infants and children with intestinal failure (IF) in the late 1990’s prompted the development of specialized centers, collectively known as the Pediatric Intestinal Failure Consortium (PIFcon, est. June 2006), in which institutions approached the problem in a structured, multidisciplinary manner.

Teams included pediatric gastroenterologist, nutritionist, surgeons, interventional radiologist, intensivists, and specialized nursing units with the sole focus on establishing enteral independence and mitigating the complications of IF. Refinements in the application of intestinal rehabilitative surgery along with the introduction of novel lipid formulations and hormonal therapy served as additional tools in the care of these patients, further increasing the success rates over the ensuing years.

The effect of these developments on the transplant volume of pediatric intestine-inclusive MOTX has been dramatic. Concomitant PN-associated liver failure decreased, eliminating the need for many MOTX. In analyzing the past 2 decades from 2005-2024, there was a significant drop in the mean number of yearly pediatric intestine-inclusive MOTX from the first to the second decade (46.6 vs 25.4, p=0.003) with the peak of 90 cases in 2007 to the low of 13 cases in 2022. A corresponding significant decrease in yearly pediatric isolated intestine transplants (21.5 vs 12.9, p= 0.002) has also been observed, further amplifying the significant decrease in overall intestine transplant activity in the US (Fig 1).

see fig 1

Figure 1: Blue line represents US pediatric intestine transplants that include other multi-organs (liver-intestine, liver-pancreas-intestine, stomach-liver-pancreas-intestine, stomach-pancreas-intestine, liver-intestine-pancreas-kidney, and liver-intestine-pancreas-heart). Orange line represents intestine-only pediatric transplants. (https://optn.transplant.hrsa.gov accessed 2/27/2025)

This has also translated to the observed declining activity of intestinal transplant centers performing this complex procedure. Like the decrease in overall pediatric intestine activity from the first to the second decade, the number of intestine transplant centers performing at least 4 pediatric transplants per year has decreased 50%, from six centers down to three. This has left large swaths of the US without pediatric intestine transplant centers with a sustainable experience of cases (fig 2). Currently, only two centers in the US in the last decade have performed an average of over 7 pediatric intestinal transplants per year.

see fig 2

Figure 2: Areas in the US depicting pediatric intestinal transplant activity. Circumference of concentric ring around each location is representative of pediatric intestinal transplant activity in the last decade from the period 2015-2024. (https://optn.transplant.hrsa.gov accessed 2/27/2025)

These trends will also inevitably lead to a dearth of experienced surgical and medical teams to care for these complex infants and children. If patients are referred late to transplant and present with formidable anti-HLA antibodies, loss of venous access, colonization with resistant microbes, and liver failure - the lack of familiarity with these complex surgical patients may pose challenges to less experienced centers. Chronic IF patients suffering from these insidious complications of PN may even render themselves untransplantable or be deemed too high-risk for a center with less experience.

Summary:
With laudable outcomes of IF centers maintaining patients on PN longer, extreme vigilance must be exercised to prevent the progression of PN complications which would increase the morbidities for an intestine-only recipient and, possibly, transform a potential intestine-only recipient into an intestine-inclusive MOTX recipient. Declining numbers of centers that routinely perform both the pediatric isolated intestine and the more complex intestine-inclusive MOTX have led to large regions of the US without proximity access to experienced centers, potentially further complicating their care and outcome.