Pediatric intensivists: A crucial team member in pediatric transplantation in the 2020s

As a pediatric oncology and critical care fellow in the 1990s, critically ill hematopoietic cell transplant (HCT) patients were considered a lost cause by all but the most optimistic among us. Intensive care unit (ICU) teams felt that a successful outcome for critically ill HCT patients was obtaining a “do not resuscitate” order quickly and avoiding ICU interventions. Understandably, oncology teams avoided sending their HCT patients to the ICU because they knew the ICU would avoid providing ICU interventions. In the 1990s, graft-versus-host disease had few good therapeutic options once it developed. Steroids and cyclosporine were the mainstays of treatment and prevention. Patients were often kept profoundly immunosuppressed to prevent graft-versus-host disease, putting them at high risk for infections, especially the difficult-to-treat viral and fungal infections. While both steroids and cyclosporine remain important medications for graft-versus-host disease prevention and treatment, there are several other medications now available that control the immune system using more targeted mechanisms. Researchers have gained a much more detailed understanding of the intricacies of the immune system and the safest ways to manipulate it to prevent and treat graft-versus-host disease while minimizing unnecessary levels of immunosuppression. While there is still room for improvement, outcomes for pediatric transplant patients in 2026 are considerably better than they were in 1990.1 Pediatric solid-organ transplant patients share similarities with these HCT recipients. Rather than the graft-versus-host disease seen in HCT, solid-organ transplant patients are at risk for graft rejection due to their own immune system rejecting the newly transplanted organ. Strategies used to prevent and treat graft rejection are similar to the management of graft-versus-host disease. Each population has benefited from research done in the other, given these similarities. Like pediatric HCT patients, outcomes for pediatric solid-organ transplant patients have improved considerably over the past 3 decades. Current 1-year survival rates for pediatric heart, kidney and liver transplant patients now exceed 90%.2-4 Like HCT patients, solid-organ transplant patients have a high risk for infection from immunosuppression. Fortunately, the fields of transplant surgery, pediatric critical care, immunology, and infectious diseases have come a long way since the 1990s. Surgical techniques, organ preservation, and postoperative care have much improved. More elegant manipulation of the immune system to manage and prevent immunologic complications is now possible. We have better surveillance testing and medications to manage the inevitable infectious disease complications. There is still much to be learned and more advances to come, but we have made considerable progress in the past 3 decades. A previous issue of the Journal of Pediatric Critical Care focused on complications in pediatric oncology and HCT. This edition will highlight care for pediatric solid-organ transplant recipients as well as infectious complications in solid-organ transplantation and in children undergoing high-dose chemotherapy. These are essential topics for pediatric critical care physicians to understand. Pediatric solid-organ transplant is being performed more frequently across the globe and is not limited to centers in high-income countries. In the 1990s, immunosuppressed children with infectious complications had such poor outcomes that it did not matter whether intensivists understood transplant immunology or not. High risk pediatric transplant patients who received state-of-the-art care had similar abysmal outcomes to those who received mediocre care. However, today it matters. Many of these children can be saved with access to excellent care. Pediatric intensivists are an essential team member in the care of these fragile patients. Fully understanding the pathophysiology of these complex patients will enable us to be the best possible advocates and lead our medical teams confidently to achieve the best possible outcomes. Advances in pediatric transplantation have improved care not only in high-resource settings but also in low- and middle-income countries. Countries, such as India, South Africa, and Brazil, have a wealth of talented medical teams fully capable of providing advanced pediatric transplant care.5 The challenge in these settings is not the ability to perform the transplants themselves but rather how to provide this care to all who could benefit from it – a challenge also faced in high-resource settings. In summary, whether we practice in the Americas, Europe, Africa, or Asia, in a high-resource setting or a resource-limited setting, all pediatric intensivists should be prepared to provide excellent care for pediatric transplant patients. It is our duty to be familiar with their unique challenges and complications, so that we may offer them their best possible chance of survival.