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Nucci AM, Crim K, King E, Ganoza AJ, Remaley L, Rudolph J. Nutrition support considerations in pediatric small bowel transplantation. Nutr Clin Pract 2024; 39:75-85. [PMID: 37925666 DOI: 10.1002/ncp.11091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/06/2023] [Accepted: 10/12/2023] [Indexed: 11/07/2023] Open
Abstract
Enteral autonomy is the primary goal of intestinal failure therapy. Intestinal transplantation (ITx) is an option when enteral autonomy cannot be achieved and management complications become life-threatening. The purpose of this review is to summarize existing medical literature related to nutrition requirements, nutrition status, and nutrition support after pediatric ITx. Achieving or maintaining adequate growth after intestinal transplant in children can be challenging because of episodes of rejection that require the use of corticosteroids, occurrences of infection that require a reduction or discontinuation of enteral or parenteral support, and fat malabsorption caused by impaired lymphatic circulation. Nutrient requirements should be assessed and modified regularly based on nutrition status, growth, ventilatory status, wound healing, and the presence of complications. Parenteral nutrition (PN) should be initiated as a continuous infusion early postoperatively. Enteral support should be initiated after evidence of graft bowel function and in the absence of clinical complications. Foods high in simple carbohydrates should be limited, as consumption may result in osmotic diarrhea. Short-term use of a fat-free diet followed by a low-fat diet may reduce the risk of the development of chylous ascites. Micronutrient deficiencies and food allergies are common occurrences after pediatric ITx. Enteral/oral vitamin and mineral supplementation may be required after PN is weaned. Nutrition management of children after ITx can be challenging for all members of the healthcare team. Anthropometric parameters and micronutrient status should be monitored regularly so that interventions to promote growth and prevent or reverse nutrient deficiencies can be implemented promptly.
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Affiliation(s)
- Anita M Nucci
- Department of Nutrition, Georgia State University, Atlanta, Georgia, USA
| | | | - Elizabeth King
- Department of Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Armando J Ganoza
- Thomas E. Starzl Transplant Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lisa Remaley
- Thomas E. Starzl Transplant Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeffrey Rudolph
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Ruan W, Galvan NTN, Dike P, Koci M, Faraone M, Fuller K, Koomaraie S, Cerminara D, Fishman DS, Deray KV, Munoz F, Schackman J, Leung D, Akcan-Arikan A, Virk M, Lam FW, Chau A, Desai MS, Hernandez JA, Goss JA. The Multidisciplinary Pediatric Liver Transplant. Curr Probl Surg 2023; 60:101377. [PMID: 37993242 DOI: 10.1016/j.cpsurg.2023.101377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/29/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Nhu Thao N Galvan
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Peace Dike
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Melissa Koci
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Marielle Faraone
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kelby Fuller
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | | | - Dana Cerminara
- Department of Pharmacy, Texas Children's Hospital, Houston, TX
| | - Douglas S Fishman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kristen Valencia Deray
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Flor Munoz
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Julie Schackman
- Division of Anesthesiology, Perioperative, & Pain Medicine, Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Daniel Leung
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Ayse Akcan-Arikan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Manpreet Virk
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Fong W Lam
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Alex Chau
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Moreshwar S Desai
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Jose A Hernandez
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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An S, Lee S, Rhu J, Kim JM, Choi GS, Joh JW. Safety and Efficacy of Conversion to Once-Daily Tacrolimus from Twice-Daily Tacrolimus in Pediatric Liver Transplant Recipients. J Pediatr Surg 2023; 58:2054-2058. [PMID: 37277238 DOI: 10.1016/j.jpedsurg.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 04/21/2023] [Accepted: 05/07/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Nonadherence to immunosuppression is the most common cause of late acute rejection in pediatric liver transplant (LT) recipients. A prolonged-release once-daily tacrolimus formulation was developed to improve adherence and long-term allograft survival. METHODS We screened 179 pediatric LT recipients who converted from twice-daily tacrolimus (TD-TAC) to once-daily tacrolimus (OD-TAC) between February 2011 and September 2019. RESULTS One hundred seventy-nine recipients converted to OD-TAC and were followed for 18 months. 152 OD-TAC-converted recipients (84.9%) experienced uneventful follow-up, while 21 recipients showed LFT elevation. Four recipients had biopsy-proven acute rejection within six months of conversion, all of which were successfully treated with steroid pulse. 166 recipients (92.7%) remain on OD-TAC and 13 (7.3%) were switched back to TD-TAC. The mean tacrolimus trough level significantly decreased three months following conversion (3.14 ± 1.9 ng/mL) compared with pre-conversion levels (3.69 ± 1.98 ng/mL). Mean tacrolimus trough levels remained unchanged from 3 months to 12 months following conversion. Percent coefficient of variation of tacrolimus trough levels decreased significantly from 32.5 ± 16.4 ng/mL to 27.5 ± 15.6 ng/mL after conversion to OD-TAC, reflecting a decrease in variation of tacrolimus trough levels following conversion. CONCLUSIONS Conversion to OD-TAC in pediatric LT recipients with stable graft function is safe and effective. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- SungHyo An
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sanghoon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Abstract
Liver transplantation (LT) for children results in excellent short- and long-term patient and graft survival. LT is a lifesaving procedure in children with acute or chronic liver disease, hepatic tumors, and select genetic metabolic diseases in which it can significantly improve quality of life. In this article, the authors discuss the unique aspects of pediatric LT, including the indications, appropriate patient selection and evaluation, allocation of organs, transplant surgery including the use of variant grafts, posttransplant care including immunosuppression management, prognosis, and transition of care.
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Affiliation(s)
- Sara Kathryn Smith
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins School of Medicine, 600 N Wolfe Street, Baltimore, MD 21287, USA.
| | - Tamir Miloh
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Miami, Highland Professional Building, 1801 Northwest 9th Avenue, Miami, FL 33136, USA
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Abstract
PURPOSE OF REVIEW Long-term survival is now the rule rather than the exception for infants and children who undergo liver transplantation for end-stage liver disease, metabolic liver conditions and a variety of other indications. Pediatricians and primary care providers play vital roles in the care and management of this patient population. The purpose of this review is to highlight key aspects important to the care of the pediatric liver transplant recipient. RECENT FINDINGS Significant advances in immunosuppressive therapies and surgical techniques have contributed to improved graft and patient survival rates, shifting the focus beyond immediate survival to strategies to minimize comorbidities related to long-term immunosuppression during growing years, attend to patient and parent-reported outcomes and enhance quality of life. A multidisciplinary approach allows for monitoring and surveillance of both routine (growth, nutritional rehabilitation, cognitive development, mental and psychosocial health, contraception and daily activities) and transplant-related (adverse effects of immunosuppression, susceptible infections, extra-hepatic systems, transition from childhood to adolescence to adulthood) themes. SUMMARY Effective communication between the primary care physician and the transplant team is imperative for optimizing best outcomes. The primary care provider should be aware of the multifacet nature of posttransplant management, which includes medication regimens, common complications and infections.
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Abstract
Liver transplantation (LT) for children has excellent short- and long-term patient and graft survival. LT is a lifesaving procedure in children with acute or chronic liver disease, hepatic tumors, and a few genetic metabolic diseases in which it can significantly improve quality of life. In this article, the authors discuss the unique aspects of pediatric LT, including the indications, patient selection and evaluation, allocation, transplant surgery and organ selection, posttransplant care, prognosis, adherence, and transition of care.
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Affiliation(s)
- Yen H Pham
- Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Texas Children's Hospital, 18200 Katy Freeway, Suite 250, Houston, TX 77094, USA
| | - Tamir Miloh
- Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Houston, TX 77030, USA.
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Mitchell T, Gooding H, Mews C, Adams L, MacQuillan G, Garas G, Ravikumara M, Lopez A, Collins M, Jeffrey G. Transition to adult care for pediatric liver transplant recipients: the Western Australian experience. Pediatr Transplant 2017; 21. [PMID: 27762479 DOI: 10.1111/petr.12820] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2016] [Indexed: 01/25/2023]
Abstract
Transition to adult care is a vulnerable period for pediatric transplant recipients and is associated with reduced medication compliance, graft loss, and increased mortality. Psychosocial outcomes in young adults differ between pediatric transplant recipients and their healthy peers. We conducted a single-center, retrospective cohort study of all pediatric liver transplant recipients who were transitioned through our center. This study aimed to assess the outcomes of transitioned pediatric liver transplant recipients at an Australian center, including mortality, adherence, and psychosocial morbidity. The 1- and 5-year survival rates following transition were 100% and 92%, respectively. There were no episodes of late rejection. In total, 66.7% of patients were compliant with immunosuppression and 61.1% of patients were compliant with clinic attendance. There was a significant relationship between medication compliance and clinic attendance, as well as presence of psychological issues with clinic non-attendance. Psychosocial outcomes were in keeping with age-matched data from the general population. All patients were employed or studying following transition. This is the first study of its kind in the Australian population, and outcomes were superior to published international data. Despite the demonstrated good outcomes, transition programs may improve healthcare engagement in this cohort.
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Affiliation(s)
- Tim Mitchell
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Hannah Gooding
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Cathy Mews
- Department of Gastroenterology, Princess Margaret Hospital for Children, Perth, WA, Australia
| | - Leon Adams
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - Gerry MacQuillan
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - George Garas
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Madhur Ravikumara
- Department of Gastroenterology, Princess Margaret Hospital for Children, Perth, WA, Australia
| | - Ainslie Lopez
- Department of Gastroenterology, Princess Margaret Hospital for Children, Perth, WA, Australia
| | - Megan Collins
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Gary Jeffrey
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
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Miloh T, Barton A, Wheeler J, Pham Y, Hewitt W, Keegan T, Sanchez C, Bulut P, Goss J. Immunosuppression in pediatric liver transplant recipients: Unique aspects. Liver Transpl 2017; 23:244-256. [PMID: 27874250 DOI: 10.1002/lt.24677] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 11/03/2016] [Indexed: 02/07/2023]
Abstract
Pediatric liver transplantation has experienced improved outcomes over the last 50 years. This can be attributed in part to establishing optimal use of immunosuppressive agents to achieve a balance between minimizing the risks of allograft rejection and infection. The management of immunosuppression in children is generally more complex and can be challenging when compared with the use of these agents in adult liver transplant patients. Physiologic differences in children alter the pharmacokinetics of immunosuppressive agents, which affects absorption, distribution, metabolism, and drug excretion. Children also have a longer expected period of exposure to immunosuppression, which can impact growth, risk of infection (bacterial, viral, and fungal), carcinogenesis, and likelihood of nonadherence. This review discusses immunosuppressive options for pediatric liver transplant recipients and the unique issues that must be addressed when managing this population. Further advances in the field of tolerance and accommodation are needed to relieve the acute and cumulative burden of chronic immunosuppression in children. Liver Transplantation 23 244-256 2017 AASLD.
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Affiliation(s)
- Tamir Miloh
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Andrea Barton
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | | | - Yen Pham
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | | | | | | | | | - John Goss
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX
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Calinescu AM, McLin V, Spahni S, Boggini T, Randriambelonoro M, Jaquier-Grant R, Steiner M, Geissbuhler A, Wildhaber BE. [KidsETransplant: a serious game for liver transplanted children]. Med Sci (Paris) 2017; 32:1120-1126. [PMID: 28044976 DOI: 10.1051/medsci/20163212016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Serious games are increasingly used in pediatric care, especially to educate young patients with chronic diseases, to improve their understanding of the disease and develop independence in disease management, as it can ultimately improve clinical results. This is also true for liver transplanted children and adolescents, who are not only challenged by their therapeutic burden, but who need to face transition to adult care, often without remembering their transplantation, which was performed, most of the time, very early in their life. KidsETransplant aims to improve long term outcomes of liver transplanted patients, using the principle of a serious game in 3D.
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Affiliation(s)
- Ana-Maria Calinescu
- Centre universitaire romand de chirurgie pédiatrique, Service de chirurgie pédiatrique, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Valérie McLin
- Unité de gastroentérologie et hépatologie pédiatrique, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Stéphane Spahni
- Service de cyber-santé et télémédecine, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Thomas Boggini
- Service de cyber-santé et télémédecine, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Mirana Randriambelonoro
- Service de cyber-santé et télémédecine, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Roxane Jaquier-Grant
- Centre universitaire romand de chirurgie pédiatrique, Service de chirurgie pédiatrique, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Michèle Steiner
- Unité de gastroentérologie et hépatologie pédiatrique, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Antoine Geissbuhler
- Service de cyber-santé et télémédecine, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Barbara E Wildhaber
- Centre universitaire romand de chirurgie pédiatrique, Service de chirurgie pédiatrique, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
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