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Katz DT, Torres NS, Chatani B, Gonzalez IA, Chandar J, Miloh T, Rusconi P, Garcia J. Care of Pediatric Solid Organ Transplant Recipients: An Overview for Primary Care Providers. Pediatrics 2020; 146:peds.2020-0696. [PMID: 33208494 DOI: 10.1542/peds.2020-0696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2020] [Indexed: 11/24/2022] Open
Abstract
As the number of living pediatric solid organ transplant (SOT) recipients continues to grow, there is an increased likelihood that primary care providers (PCPs) will encounter pediatric SOT recipients in their practices. In addition, as end-stage organ failure is replaced with chronic medical conditions in transplant recipients, there is a need for a comprehensive approach to their management. PCPs can significantly enhance the care of immunosuppressed hosts by advising parents of safety considerations and avoiding adverse drug interactions. Together with subspecialty providers, PCPs are responsible for ensuring that appropriate vaccinations are given and can play an important role in the diagnosis of infections. Through early recognition of rejection and posttransplant complications, PCPs can minimize morbidity. Growth and development can be optimized through frequent assessments and timely referrals. Adherence to immunosuppressive regimens can be greatly improved through reinforcement at every encounter, particularly among adolescents. PCPs can also improve long-term outcomes by easing the transition of pediatric SOT recipients to adult providers. Although guidelines exist for the primary care management of adult SOT recipients, comprehensive guidance is lacking for pediatric providers. In this evidence-based overview, we outline the main issues affecting pediatric SOT recipients and provide guidance for PCPs regarding their management from the first encounter after the transplant to the main challenges that arise in childhood and adolescence. Overall, PCPs can and should use their expertise and serve as an additional layer of support in conjunction with the transplant center for families that are caring for a pediatric SOT recipient.
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Affiliation(s)
- Daphna T Katz
- Holtz Children's Hospital, Jackson Health System, Miami, Florida.,Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida; and
| | - Nicole S Torres
- Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida; and
| | | | | | - Jayanthi Chandar
- Pediatric Nephrology.,Miami Transplant Institute, Miami, Florida
| | - Tamir Miloh
- Miami Transplant Institute, Miami, Florida.,Pediatric Gastroenterology, and
| | - Paolo Rusconi
- Miami Transplant Institute, Miami, Florida.,Pediatric Cardiology
| | - Jennifer Garcia
- Miami Transplant Institute, Miami, Florida .,Pediatric Gastroenterology, and
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Killian MO, Schuman DL, Mayersohn GS, Triplett KN. Psychosocial predictors of medication non-adherence in pediatric organ transplantation: A systematic review. Pediatr Transplant 2018; 22:e13188. [PMID: 29637674 DOI: 10.1111/petr.13188] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2018] [Indexed: 12/27/2022]
Abstract
Adherence to immunosuppressant medication is critical to health and quality-of-life outcomes for children who have received a solid organ transplant. Research on the psychological and social predictors of medication adherence is essential to the advancement of pretransplant assessments and transplant psychosocial services. Despite the importance of identifying risk factors, the literature remains limited regarding psychosocial predictors of non-adherence. A systematic search was conducted to identify studies of the psychosocial predictors of post-transplant medication non-adherence in pediatric solid organ transplantation. From 1363 studies identified in searches of empirical literature, a final sample consisted of 54 publications representing 49 unique studies. Findings regarding psychosocial predictors were inconsistent with non-adherence associated largely with adolescence, racial/ethnic minority status, and presence of mental health issues. Familial predictors of non-adherence problems included single-parent households, lower socioeconomic status, lower family cohesion, presence of family conflict, and poor family communication. Several studies reported an association between non-adherence and social pressures (eg, peer social interaction, wanting to feel normal) among adolescent transplant recipients. While significant methodological and substantive gaps remain in this body of knowledge, this review synthesizes current evidence for assessment for transplant clinicians and researchers.
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Affiliation(s)
- Michael O Killian
- School of Social Work, University of Texas at Arlington, Arlington, TX, USA.,Children's Health, Children's Medical Center Dallas, Dallas, TX, USA
| | - Donna L Schuman
- College of Social Work, University of Kentucky, Lexington, KY, USA
| | | | - Kelli N Triplett
- Children's Health, Children's Medical Center Dallas, Dallas, TX, USA.,University of Texas - Southwestern Medical Center, Dallas, TX, USA
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3
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Killian MO. Psychosocial predictors of medication adherence in pediatric heart and lung organ transplantation. Pediatr Transplant 2017; 21. [PMID: 28198130 DOI: 10.1111/petr.12899] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/13/2017] [Indexed: 11/30/2022]
Abstract
Few studies have identified the psychosocial characteristics of those children and their families associated with future non-adherence to immunosuppressive medications following a heart or lung transplant. UNOS data and medical records information were used to test the association between patient and family psychosocial characteristics and medication adherence. Medication adherence outcomes were obtained using the physician assessments in the UNOS data and measured through patient-level standard deviation scores of immunosuppressive medication blood levels. Complete data were collected on 105 pediatric heart and lung transplant recipients and their families. Multivariate, stepwise analyses were conducted with each adherence outcome. Physician reports of adherence were associated with age of the child at transplantation, parental education, two-parent families, significant psychosocial problems, and the pretransplant life support status of the child. The resulting model (χ2 =28.146, df=5, P<.001) explained approximately 39.5% of the variance in physician reports of adherence (Nagelkerke r2 =.395). Blood level standard deviation scores were predicted by age at transplant (F=5.624, P=.02, r2 =.05). Results point to the difficulties experienced by children and families when undergoing a heart or lung transplantation. Efforts to develop standardized and evidence-based pretransplant psychosocial assessments in pediatric populations are suggested, especially those surrounding familial risk factors.
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Affiliation(s)
- Michael O Killian
- School of Social Work, University of Texas at Arlington, Arlington, TX, USA
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Mazariegos GV, Salzedas AA, Zavatsky J, Sindhi R, Parizhskaya M, McGhee W, Jain A, Reyes J. Long term management of liver transplant rejection in children. BioDrugs 2010; 14:31-48. [PMID: 18034554 DOI: 10.2165/00063030-200014010-00004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The current management of hepatic allograft rejection after liver transplantation in children requires effective baseline immunosuppression to prevent rejection and rapid diagnosis and treatment to manage acute rejection episodes. The subsequent impact on chronic rejection is dependent on the combination of adequate prevention and the treatment of acute rejection. Tacrolimus is a macrolide lactone that inhibits the signal transduction of interleukin-2 (IL-2) via calcineurin inhibition. Introduced in 1989, tacrolimus was first used in the salvage of refractory acute or chronic rejection under cyclosporin or to rescue patients with significant cyclosporin-related complications. The majority of paediatric transplant centres use a combination of steroids with tacrolimus as a basic immunosuppressant regimen following paediatric liver transplantation. This combination has allowed the acute cellular rejection-free rate to increase to between 30 and 60%, while lowering the rate of refractory rejection to less than 5%. Corticosteroid-resistant rejection is commonly treated with monoclonal (muromonab CD3) or polyclonal preparations. Although most episodes of acute cellular rejection occur during the first 6 weeks after liver transplant, the appearance of late acute liver allograft rejection must raise the question of noncompliance, especially in the adolescent population. Chronic rejection is becoming increasingly rare under tacrolimus-based immunosuppression. Tacrolimus is effective in reversing refractory acute cellular rejection or early chronic rejection in patients initially treated with cyclosporin-based regimens. Patients with a history of noncompliance as well as children with autoimmune liver disease are at risk of chronic rejection. Retransplantation therapy for chronic rejection has, fortunately, become more rare in the tacrolimus era with only 3% of retransplants being performed for this indication. Newer immunosuppressive agents are further modifying the long term management of liver allograft rejection. These include mycophenolate mofetil, rapamycin and IL-2 antibodies such as daclizumab. The development of these agents is allowing patient-specific immunosuppressive management to minimise rejection as well as the complications related to immunosuppression.
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Affiliation(s)
- G V Mazariegos
- University of Pittsburgh Medical Center, Department of Surgery, Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania 15213, USA.
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Abstract
Pediatric organ donation and organ transplantation can have a significant life-extending benefit to the young recipients of these organs and a high emotional impact on donor and recipient families. Pediatricians, pediatric medical specialists, and pediatric transplant surgeons need to be better acquainted with evolving national strategies that involve organ procurement and organ transplantation to help acquaint families with the benefits and risks of organ donation and transplantation. Efforts of pediatric professionals are needed to shape public policies to provide a system in which procurement, distribution, and cost are fair and equitable to children and adults. Major issues of concern are availability of and access to donor organs; oversight and control of the process; pediatric medical and surgical consultation and continued care throughout the organ-donation and transplantation process; ethical, social, financial, and follow-up issues; insurance-coverage issues; and public awareness of the need for organ donors of all ages.
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McGuire BM, Rosenthal P, Brown CC, Busch AMH, Calcatera SM, Claria RS, Hunt NK, Korenblat KM, Mazariegos GV, Moonka D, Orloff SL, Perry DK, Rosen CB, Scott DL, Sudan DL. Long-term management of the liver transplant patient: recommendations for the primary care doctor. Am J Transplant 2009; 9:1988-2003. [PMID: 19563332 DOI: 10.1111/j.1600-6143.2009.02733.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
No official document has been published for primary care physicians regarding the management of liver transplant patients. With no official source of reference, primary care physicians often question their care of these patients. The following guidelines have been approved by the American Society of Transplantation and represent the position of the association. The data presented are based on formal review and analysis of published literature in the field and the clinical experience of the authors. These guidelines address drug interactions and side effects of immunosuppressive agents, allograft dysfunction, renal dysfunction, metabolic disorders, preventive medicine, malignancies, disability and productivity in the workforce, issues specific to pregnancy and sexual function, and pediatric patient concerns. These guidelines are intended to provide a bridge between transplant centers and primary care physicians in the long-term management of the liver transplant patient.
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Affiliation(s)
- B M McGuire
- University of Alabama at Birmingham, Birmingham, AL, USA.
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Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 2002. [PMID: 11841046 DOI: 10.1177/0148607102026001011] [Citation(s) in RCA: 365] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
Children (defined as under 18 yr of age) account for approximately 12.5% of all liver transplants in the United States. Even though the annual number of liver transplantation procedures remains relatively constant, the population of long-term survivors of liver transplantation has grown. Presently, the population of long-term survivors of liver transplantation is 10-fold greater then the number of transplantations carried out each year. For long-term survivors of liver transplantation, the goal is to maintain graft function and wellness while decreasing the morbidity associated with long-term immunosuppression. The primary diagnosis leading to liver transplantation in children do not recur in the allograft. Consequently, many of the complications of liver transplantation, both early and long term, relate to the need for immunosuppression. Children may be at increased risk to develop significant end-organ damage as a result of increased serum lipid levels, elevated blood pressure, altered glucose metabolism, decreased renal function, cancer, and diminished bone accretion that occur as a result of immunosuppressive therapy or complications of therapy. As survival rates have increased, health care providers have begun to assess health-related quality of life. We will review our current knowledge of long-term outcome following pediatric liver transplantation in children.
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Affiliation(s)
- John C Bucuvalas
- Pediatric Liver Care Center, Children's Hospital Research Foundation, Cincinnati, Ohio 45229, USA.
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