*Purpose: Coronary artery vasculopathy (CAV) is one of the leading causes of mortality beyond 3y post-transplant (OHT). Multiple risk factors are associated with development of CAV. As there is contribution of innate immune system and systemic inflammation in development of CAV, we hypothesize that C-reactive protein levels as an indirect marker of systemic inflammation will predict future CAV development.

*Methods: We identified all pediatric patients who underwent OHT from 2004-2018 at our institution and collected pre-, intra-, and post-transplant variables hypothesized to have effects on development of CAV. We also collected CRP levels at 1-year post transplant +/- 1 months performed on routine clinical visits and prior to routine catheterizations. Cardiac catheterization data was also collected to determine the development of CAV. Data was analyzed using Mann-Whitney tests, chi-square with fisher exact, and Cox regression analysis.

*Results: We identified 111 patients with available CRP and catheterization data. Of these, 29.7% (n=33) had CAV, 8.1% (n=9) were re-transplants, and 49.5% (n=55) experienced acute cellular/humoral rejection by 1-year post-OHT. Median age of transplant was 11.7y (9.5, 16.5) in the CAV group and 7.1y (0.5, 13.3) in non-CAV group (p=0.010). Median age at CAV diagnosis was 17.1 y (12.8, 19.8) and median time to CAV development after OHT was 4 y (2.2, 8.5). Median CRP at 1 year was 1.1 mg/L (0.4, 2.7). Median CRP at 1 year in CAV group was 2.4 (1.5, 9) and 0.6 (0.2, 1.5) in non-CAV group (p=0.002). Median CRP in our no rejection group was 0.5 (0.2, 0.4) compared to 1.5 (1.5, 5.0) in group with history of rejection (p=0.014). Using a cut-off of 3 per previous adult studies, CAV-free time was significantly less in the patients with CRP >3 (log rank p=0.027; Figure). CAV was seen more commonly in re-transplants compared to primary OHT (66.7% v/s. 26.5%, p=0.019). In the CAV group, 90.9% had an episode of rejection compared to 59% in the non-CAV group (p<0.001). At the time of analysis CAV group had a higher mortality compared to non-CAV group (33% v/s. 11%, p=0.014; Odds Ratio: 3.83 [CI: 1.41-10.5]). Cox regression including variables associated with death indicated that CAV was independently associated with mortality (p=0.010).

*Conclusions: Median CRP at 1 year was associated with increased risk of CAV development and may serve as a predictive marker of CAV. Further research is required to assess the benefit of CRP levels early after transplantation on risk of development of CAV.

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