1
|
Hand BN, Hyer JM, Schenk A, Coyne A, Gilmore D, Wang L, Ejaz A. Comparing Kidney Transplant Rates and Outcomes Among Adults With and Without Intellectual and Developmental Disabilities. JAMA Surg 2023; 158:386-392. [PMID: 36790769 PMCID: PMC9932938 DOI: 10.1001/jamasurg.2022.7753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Importance Improving equity in organ transplant access for people with intellectual and developmental disabilities (IDD) is a topic of social discourse in mainstream media, state legislation, and national legislation. However, few studies have compared evaluation rates, transplant rates, and outcomes among adults with and without IDD. Objective To compare rates of kidney transplant and transplant-specific outcomes between propensity-score matched groups of adults with end-stage kidney disease (ESKD [also referred to as end-stage renal disease (ESRD)]) with and without co-occurring IDD. Design, Setting, and Participants This retrospective cohort study included all Medicare inpatient and outpatient standard analytical files from 2013 through 2020. A total of 1 413 655 adult Medicare beneficiaries with ESKD were identified. Propensity-score matching was used to balance cohorts based on age, sex, race, follow-up duration, and Charlson Comorbidity Index. The matched cohorts consisted of 21 384 adults with ESKD (10 692 of whom had IDD) and 1258 kidney transplant recipients (629 of whom had IDD). Data were analyzed between June 1, 2022, and August 1, 2022. Exposure IDD. Main Outcomes and Measures Evaluation for kidney transplant, receipt of kidney transplant, perioperative complications, readmission, mortality, graft rejection, and graft failure. Results Of the 21 384 propensity-score matched adults with ESKD, the median (IQR) age was 55 (43-65) years, 39.2% were male, 27.4% were Black, 64.1% were White, and 8.5% identified as another race or ethnicity. After propensity score matching within the ESKD cohort, 633 patients with IDD (5.9%) received a kidney transplant compared with 1367 of adults without IDD (12.8%). Adults with IDD were 54% less likely than matched peers without IDD to be evaluated for transplant (odds ratio, 0.46; 95% CI, 0.43-0.50) and 62% less likely to receive a kidney transplant (odds ratio, 0.38; 95% CI, 0.34-0.42). Among matched cohorts of kidney transplant recipients, rates of perioperative complications, readmission, and graft failure were similar for adults with and without IDD. Conclusions and Relevance Using the largest cohort of adult kidney transplant recipients with IDD to date, the study team found that rates of evaluation and transplant were lower despite yielding equivalent outcomes. These data support consideration of adults with IDD for kidney transplant and underscore the urgent need for antidiscrimination initiatives to promote the receipt of equitable care for this population.
Collapse
Affiliation(s)
- Brittany N. Hand
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus
| | - J. Madison Hyer
- Center for Biostatistics, The Ohio State University, Columbus
| | - Austin Schenk
- Department of Surgery, The Ohio State University, Columbus
| | - Alex Coyne
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus
| | - Daniel Gilmore
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus
| | - Lauren Wang
- Timothy Freeman Center for Intellectual and Developmental Disabilities, University of Cincinnati, Cincinnati, Ohio
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University, Columbus
| |
Collapse
|
2
|
Tolliver KM, Parent JJ, Hobson MJ. Solid Organ Transplantation for Children with Neurodevelopmental Disabilities – Ethical Considerations and a Call for Clarity. Semin Pediatr Neurol 2023; 45:101035. [PMID: 37003627 DOI: 10.1016/j.spen.2023.101035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 02/25/2023]
Abstract
Pediatric transplant centers are faced with the difficult task of maximizing the benefit of organs donated for transplantation while also ensuring that all patients undergoing transplant evaluation are fairly considered for this life-saving therapy. Children with neurodevelopmental disabilities are a complex patient population that on occasion may face the need for a solid organ transplant. Several concerns exist regarding transplantation in this population, yet standard transplant inclusion and exclusion criteria do not exist. Here we explore important factors regarding organ transplantation for children with neurodevelopmental disorders, including patient outcomes, quality of life considerations, and the fundamental ethical principles underlying this complex medical decision-making.
Collapse
|
3
|
Thom RL, Dalle-Ave A, Bunnik EM, Krones T, Van Assche K, Ruck Keene A, Cronin AJ. Inequitable Access to Transplants: Adults With Impaired Decision-Making Capacity. Transpl Int 2022; 35:10084. [PMID: 35368648 PMCID: PMC8971203 DOI: 10.3389/ti.2022.10084] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/11/2022] [Indexed: 11/13/2022]
Abstract
Inequitable access to deceased donor organs for transplantation has received considerable scrutiny in recent years. Emerging evidence suggests patients with impaired decision-making capacity (IDC) face inequitable access to transplantation. The "Ethical and Legal Issues" working group of the European Society of Transplantation undertook an expert consensus process. Literature relating to transplantation in patients with IDC was examined and collated to investigate whether IDC is associated with inferior transplant outcomes and the legitimacy of this healthcare inequality was examined. Even though the available evidence of inferior transplant outcomes in these patients is limited, the working group concluded that access to transplantation in patients with IDC may be inequitable. Consequently, we argue that IDC should not in and of itself be considered as a barrier to either registration on the transplant waiting list or allocation of an organ. Strategies for non-discrimination should focus on ensuring eligibility is based upon sound evidence and outcomes without reference to non-medical criteria. Recommendations to support policy makers and healthcare providers to reduce unintended inequity and inadvertent discrimination are set out. We call upon transplant centres and national bodies to include data on decision-making capacity in routine reporting schedules in order to improve the evidence base upon which organ policy decisions are made going forward.
Collapse
Affiliation(s)
| | - Anne Dalle-Ave
- Ethics Unit, Institute of Humanities in Medicine, University Hospital of Lausanne, London, United Kingdom
| | - Eline M Bunnik
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Tanja Krones
- Department of Clinical Ethics, University Hospital Zurich, Zurich, Switzerland.,Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | | | - Alex Ruck Keene
- 39 Essex Chambers, London, United Kingdom.,King's College London, London, United Kingdom
| | - Antonia J Cronin
- Guy's and St. Thomas' NHS Trust and King's College London, London, United Kingdom
| |
Collapse
|
4
|
Stahl D. The continuing need to combat disability discrimination in organ transplantation. Surgery 2021; 171:1123-1125. [PMID: 34399988 DOI: 10.1016/j.surg.2021.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/15/2021] [Indexed: 11/30/2022]
Abstract
New evidence provides additional confirmation that when considering persons with intellectual and developmental disabilities, categorical exclusions as well as denials based on the need for support systems are unethical and discriminatory.
Collapse
Affiliation(s)
- Devan Stahl
- Department of Religion, Baylor University, Waco, TX.
| |
Collapse
|
5
|
Wall A, Lee GH, Maldonado J, Magnus D. Genetic disease and intellectual disability as contraindications to transplant listing in the United States: A survey of heart, kidney, liver, and lung transplant programs. Pediatr Transplant 2020; 24:e13837. [PMID: 32997378 DOI: 10.1111/petr.13837] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/21/2020] [Accepted: 08/13/2020] [Indexed: 01/01/2023]
Abstract
Discrimination based on disability is prohibited in organ transplantation, yet studies suggest it continues in listing practices for intellectual disability and genetic diseases. It is not known if this differs between adult and pediatric programs, or by organ type. We performed an online, forced-choice survey of psychosocial listing criteria for adult and pediatric heart, kidney, liver, and lung transplant programs in the United States. Of 650 programs contacted, 343 (52.8%) submitted complete. A minority of programs had formal listing guidelines for any condition considered (Down Syndrome, Duchenne Muscular Dystrophy, Becker Muscular Dystrophy, DiGeorge Syndrome, and Wolf Hirschhorn Syndrome; and mild [IQ < 70] and severe [IQ < 35] intellectual disability), although a majority had encountered most. Pediatric programs were significantly (P < .02) more lenient in the level of contraindication to listing for all genetic conditions considered except Duchenne Muscular Dystrophy, and for mild and severe intellectual disability. Level of contraindication differed significantly by organ type (heart, lung, liver, and kidney) for Duchenne Muscular dystrophy (P = <.001), Becker Muscular Dystrophy (P < .001), DiGeorge Syndrome (P < .001), Wolf-Hirschhorn syndrome (P = .0012), and severe intellectual disability (P < .001). There is significant variation among transplant programs in availability of guidelines for as well as listing practices regarding genetic diseases and intellectual disability, differing by both adult vs pediatric program, and organ type. Programs with absolute contraindications to listing for specific genetic diseases or intellectual disability should reframe their approach, ensuring individualized assessments and avoiding elimination of patients based on membership in a particular group.
Collapse
Affiliation(s)
- Anji Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Gun Ho Lee
- School of Medicine, Stanford University, Stanford, California, USA
| | - Jose Maldonado
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
| | - David Magnus
- Departments of Pediatrics and Medicine and Center for Biomedical Ethics, Stanford University, Stanford, California, USA
| |
Collapse
|
6
|
Chen A, Ahmad M, Flescher A, Freeman WL, Little S, Martins PN, Veatch RM, Wightman A, Ladin K. Access to transplantation for persons with intellectual disability: Strategies for nondiscrimination. Am J Transplant 2020; 20:2009-2016. [PMID: 31873978 DOI: 10.1111/ajt.15755] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 11/21/2019] [Accepted: 12/14/2019] [Indexed: 01/25/2023]
Abstract
Disqualifying patients with intellectual disabilities (ID) from transplantation has received growing attention from the media, state legislatures, the Office of Civil Rights, and recently the National Council on Disability, as well as internationally. Compared with evidence-based criteria used to determine transplant eligibility, the ID criterion remains controversial because of its potential to be discriminatory, subjective, and because its relationship to outcomes is uncertain. Use of ID in determining transplant candidacy may stem partly from perceived worse adherence and outcomes for patients with ID, fear of penalties to transplant centers for poor outcomes, and stigma surrounding the quality of life for people with ID. However, using ID as a contraindication to solid organ transplantation is not evidence-based and reduces equitable access to transplantation, disadvantaging an already vulnerable population. Variability and lack of transparency in referral and evaluation allows for gatekeeping, threatens patient autonomy, limits access to lifesaving treatment, and may be seen as unfair. We examine the benefits and harms of using ID as a transplant eligibility criterion, review current clinical evidence and ethical considerations, and make recommendations for transplant teams and regulatory agencies to ensure fair access to transplant for individuals with ID.
Collapse
Affiliation(s)
- Ashton Chen
- Department of Pediatrics, Wake Forest University Medical School, Winston-Salem, North Carolina, USA
| | - Mahwish Ahmad
- Center for Bioethics, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Bioethics, Case Western Reserve School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Andrew Flescher
- Program in Public Health, Department of Family, Population, and Preventive Medicine, Stony Brook University, Stony Brook, New York, USA
| | | | | | - Paulo N Martins
- Department of Surgery, Division of Transplantation, University of Massachusetts, Worcester, Massachusetts, USA
| | - Robert M Veatch
- Kennedy Institute of Ethics, Georgetown University, District of Columbia, Washington, USA
| | - Aaron Wightman
- Divisions of Nephrology and Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, Washington, USA
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts, USA
| |
Collapse
|
7
|
Renal Replacement Therapy in children with severe developmental disability: guiding questions for decision-making. Eur J Pediatr 2018; 177:1735-1743. [PMID: 30194525 DOI: 10.1007/s00431-018-3238-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/20/2018] [Accepted: 08/29/2018] [Indexed: 10/28/2022]
Abstract
Whether to initiate or to withhold Renal Replacement Therapy (RRT) in children with severe developmental disability (DD) remains a topic of intense debate. The present study investigated the opinion of professionals on this difficult issue and proposed a checklist with guiding questions for decision-making. Clinicians affiliated to different organizations involved in pediatric nephrology worldwide were invited to respond to a web-based survey. This survey focused on the collection of demographic data of the respondents together with their opinion concerning the decision-making regarding RRT in a particular case and for children with severe DD in general. A total of 286 professionals responded to the survey. Sixty-six percent supported initiating RRT in the child of the case report, with pre-emptive transplantation being the preferred modality. Important arguments pro RRT initiation in children with severe DD in general were parental preference, decrease of suffering, and improvement of survival and quality of life. Important contraindications included low IQ, severe comorbidities, and inability of the patient to take medication or for the family to provide sufficient care.Conclusion: The present study presents an inventory on the opinions of health care professionals involved in RRT in children regarding the treatment of children with DD and assists in the decision-making process by identifying important medical and psychosocial arguments for initiating or withholding RRT in severe DD patients. What is Known: •Renal Replacement Therapy (RRT) in children with severe developmental disability (DD) is a topic of intense debate. •Previous studies on the opinion of professionals mainly focused on the use of IQ as an argument in the decision-making whether or not starting RRT. What is New: •The present study investigated the opinion of professionals with regard to considering initiation or withholding RRT in children with severe DD and identified medical and psychosocial arguments playing a role in the decision-making process. •Based on these arguments, a checklist with guiding questions for decision-making is proposed.
Collapse
|
8
|
Hamasaki Y, Yamaguchi T, Takahashi Y, Hashimoto J, Muramatsu M, Kawamura T, Sakai K, Shishido S, Tazaki M. Change in the quality of life of caregivers of pediatric department patients undergoing kidney transplantation: a single-center prospective study. Clin Exp Nephrol 2018; 22:1198-1204. [DOI: 10.1007/s10157-018-1604-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 06/18/2018] [Indexed: 02/05/2023]
|
9
|
Wightman A, Diekema D, Goldberg A. Consideration of children with intellectual disability as candidates for solid organ transplantation-A practice in evolution. Pediatr Transplant 2018; 22. [PMID: 29218833 DOI: 10.1111/petr.13091] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2017] [Indexed: 11/27/2022]
Abstract
Children with intellectual disability were historically excluded from consideration as recipients of solid organ transplants. In light of an evolution in provider practices, this commentary will define intellectual disability and review the relevant provider attitudes and guidelines and known outcomes of solid organ transplant in this population.
Collapse
Affiliation(s)
- Aaron Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, WA, USA
| | - Douglas Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, WA, USA
| | - Aviva Goldberg
- Department of Pediatrics, University of Manitoba College of Medicine, Winnipeg, MB, Canada
| |
Collapse
|
10
|
Martins PN, Kim I, Bozorgzadeh A. Allocation of organs to cognitively impaired patients. Pediatr Transplant 2017; 21. [PMID: 28574199 DOI: 10.1111/petr.12999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Paulo N Martins
- Transplant Division, Department of Surgery, University of Massachusetts, Worcester, MA, USA
| | - Irene Kim
- Transplant Division, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Adel Bozorgzadeh
- Transplant Division, Department of Surgery, University of Massachusetts, Worcester, MA, USA
| |
Collapse
|
11
|
Chen A, Farney A, Russell GB, Nicolotti L, Stratta R, Rogers J, Lin JJ. Severe intellectual disability is not a contraindication to kidney transplantation in children. Pediatr Transplant 2017; 21. [PMID: 28145624 DOI: 10.1111/petr.12887] [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: 12/22/2016] [Indexed: 11/28/2022]
Abstract
Renal transplantation in children with ID is controversial. Acceptability of these children as candidates varies between programs. Limited outcome data in pediatric renal TXP recipients with cognitive impairment diminish their access to TXP. A retrospective chart review was performed of all children who underwent renal transplantation between January 1, 2002 and June 30, 2012 (N=72). Patients were divided into two groups, those with ID prior to transplantation (n=10) and those without (non-ID; n=62). Graft survival and BPAR episodes were compared between the two groups using Kaplan-Meier estimates. Graft survival rates at 3 years post-TXP were 100% in the ID group and 80% in the non-ID group (P=.13). Rates of BPAR at 3 years post-TXP were 10% in the ID group and 27% in the non-ID group (P=.29). Graft survival and acute rejection-free survival rates are similar between children with ID and those without. Based on midterm outcomes, there is no apparent contraindication to renal transplantation in pediatric patients with ID. Children with ID should be considered as TXP candidates provided that they have an adequate social support network.
Collapse
Affiliation(s)
- Ashton Chen
- Department of Pediatrics, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Alan Farney
- Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Gregory B Russell
- Department of Biostatistical Sciences, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Linda Nicolotti
- Department of Pediatrics, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Robert Stratta
- Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Jeffrey Rogers
- Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Jen-Jar Lin
- Department of Pediatrics, Wake Forest Baptist Health, Winston-Salem, NC, USA
| |
Collapse
|
12
|
Wightman A. Is it permissible for a child with neurodevelopmental disabilities to be a living donor transplant candidate, but not a deceased donor candidate? Should donor source influence transplant center deliberations? Pediatr Transplant 2017; 21. [PMID: 27976486 DOI: 10.1111/petr.12850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2016] [Indexed: 12/19/2022]
Abstract
Limited data from surveys and highly publicized cases suggest that pediatric transplant providers and the public may use different standards when evaluating a potential transplant candidate with severe neurodevelopmental disabilities depending on whether a parent or other living donor has been identified. The purpose of this article is to explore the arguments in favor and against differing standards of candidacy for living and deceased donor transplants in pediatric solid organ transplantation using the example of children with severe neurodevelopmental disabilities. I conclude that donor source should not be a relevant consideration of pediatric transplant teams when considering the candidacy of a potential recipient.
Collapse
Affiliation(s)
- Aaron Wightman
- Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| |
Collapse
|
13
|
Wightman A, Bartlett HL, Zhao Q, Smith JM. Prevalence and outcomes of heart transplantation in children with intellectual disability. Pediatr Transplant 2017; 21. [PMID: 27801533 DOI: 10.1111/petr.12839] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2016] [Indexed: 11/28/2022]
Abstract
Heart transplantation in children with intellectual disability is a controversial issue. We sought to describe the prevalence and outcomes of heart transplantation in children with intellectual disability and hypothesized that recipients with intellectual disability have comparable short-term outcomes compared to recipients without intellectual disability. We performed a retrospective cohort analysis of children receiving a first heart-alone transplant in the UNOS STAR database from 2008 to 2013. Recipients with intellectual disability were compared to those without using chi-square tests. Kaplan-Meier curves were constructed for patient and graft survival. Cox proportional hazard models were used to estimate the association between intellectual disability and graft failure and patient survival. Over the study period, 107 children with intellectual disability underwent initial heart transplantation, accounting for 8.9% of first pediatric heart transplants (total=1204). There was no difference in the incidence of acute rejection between groups in the first year after transplant. Mean functional status scores at follow-up improved in both groups after transplantation, but tended to be lower among children with intellectual disability than children without. Log-rank tests did not suggest significant differences in graft survival between those with and without intellectual disability during the first 4 years following transplantation. Children with intellectual disability constitute a significant portion of total heart transplants with short-term outcomes comparable to children without intellectual disability.
Collapse
Affiliation(s)
- Aaron Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Heather L Bartlett
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Qianqian Zhao
- Department of Biostatistics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jodi M Smith
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| |
Collapse
|
14
|
Goel AN, Iyengar A, Schowengerdt K, Fiore AC, Huddleston CB. Heart transplantation in children with intellectual disability: An analysis of the UNOS database. Pediatr Transplant 2017; 21. [PMID: 27933693 DOI: 10.1111/petr.12858] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2016] [Indexed: 11/29/2022]
Abstract
Heart transplantation in children with intellectual disability (ID) is an issue of debate due to the shortage of available donor organs. We sought to perform the first large-scale retrospective cohort study describing the prevalence and outcomes of heart transplantation in this population. The United Network of Organ Sharing database was queried from 2008 to 2015 for pediatric patients (age <19 years) receiving first, isolated heart transplant. Recipients were divided into three subgroups: definite ID, probable ID, and no ID. The chi-square test was used to compare patients' baseline characteristics. Kaplan-Meier and Cox proportional hazard regression analyses were used to estimate the association between ID and death-censored graft failure and patient survival. Over the study period, 565 pediatric patients with definite (131) or probable (434) ID received first heart transplant, accounting for 22.4% of all first pediatric heart transplants (n=2524). Recipients with definite ID did not significantly differ from those without ID in terms of gender, ethnicity, ischemia time, severity of pretransplant condition (waitlist status, mechanical ventilation, inotrope dependence, ECMO, VAD, PVRI, infection prior to transplant), or incidents of acute rejection within the first year. ID was associated with prolonged waitlist time (P<.001). Graft and patient survival at 3 years was equivalent between children with and without ID (P=.811 and .578, respectively). We conclude that intellectual disability is prevalent in children receiving heart transplants, with 22.4% of recipients over the study period having definite or probable ID. ID does not appear to negatively affect transplantation outcomes. Future studies are needed to assess long-term outcomes of transplantation in this population.
Collapse
Affiliation(s)
- Alexander N Goel
- David Geffen School of Medicine, UCLA Medical Center, Los Angeles, CA, USA
| | - Amit Iyengar
- David Geffen School of Medicine, UCLA Medical Center, Los Angeles, CA, USA
| | - Kenneth Schowengerdt
- Division of Pediatric Cardiology, Cardinal Glennon Children's Hospital, St. Louis University School of Medicine, St. Louis, MO, USA
| | - Andrew C Fiore
- Division of Cardiothoracic Surgery, Cardinal Glennon Children's Hospital, St. Louis University School of Medicine, St. Louis, MO, USA
| | - Charles B Huddleston
- Division of Cardiothoracic Surgery, Cardinal Glennon Children's Hospital, St. Louis University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
15
|
Prendergast C, McKane M, Dodd DA, Godown J. The impact of cognitive delay on pediatric heart transplant outcomes. Pediatr Transplant 2017; 21:10.1111/petr.12896. [PMID: 28191755 PMCID: PMC5330601 DOI: 10.1111/petr.12896] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2017] [Indexed: 12/29/2022]
Abstract
The presence of CD may be viewed as a relative contraindication to transplantation; however, its impact on pediatric HTx outcomes is poorly characterized. The aim of this study was to assess the impact of CD on pediatric HTx outcomes using academic progress as a surrogate measure of cognitive performance. The OPTN database was queried for all pediatric HTx recipients (2004-2014) with reported academic progress. Multivariable analysis assessed the impact of DGL and the need for SE on post-HTx graft survival. A total of 2245 children were included: 1707 (76%) within grade level, 269 (12%) with DGL, and 269 (12%) who required SE. The need for SE was not a risk factor for post-HTx mortality; however, DGL was an independent risk factor for worse post-HTx outcomes (AHR 1.4, 95% CI 1.02, 1.79, P=.03). Patients who require SE have similar outcomes compared to those without CD, likely secondary to significant parental involvement. Children with DGL demonstrate inferior post-HTx survival, which could result from less parental oversight in children perceived to maintain compliance. Ensuring adequate social support for patients with evidence of CD may help to improve outcomes.
Collapse
Affiliation(s)
- Christopher Prendergast
- Monroe Carell Jr. Children’s Hospital at Vanderbilt, Division of Pediatric Cardiology, Nashville, TN
| | - Meghann McKane
- Children’s Healthcare of Atlanta, Division of Pediatric Cardiology, Atlanta, GA
| | - Debra A. Dodd
- Monroe Carell Jr. Children’s Hospital at Vanderbilt, Division of Pediatric Cardiology, Nashville, TN
| | - Justin Godown
- Monroe Carell Jr. Children’s Hospital at Vanderbilt, Division of Pediatric Cardiology, Nashville, TN
| |
Collapse
|
16
|
Wightman AG, Freeman MA. Update on Ethical Issues in Pediatric Dialysis: Has Pediatric Dialysis Become Morally Obligatory? Clin J Am Soc Nephrol 2016; 11:1456-1462. [PMID: 27037272 PMCID: PMC4974893 DOI: 10.2215/cjn.12741215] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Improvements in pediatric dialysis over the past 50 years have made the decision to proceed with dialysis straightforward for the majority of pediatric patients. For certain groups, however, such as children with multiple comorbid conditions, children and families with few social and economic resources, and neonates and infants, the decision of whether to proceed with dialysis remains much more controversial. In this review, we will examine the best available data regarding the outcomes of dialysis in these populations and analyze the important ethical considerations that should guide decisions regarding dialysis for these patients. We conclude that providers must continue to follow a nuanced and individualized approach in decision making for each child and to recognize that, regardless of the decision reached about dialysis, there is a continued duty to care for patients and families to maximize the remaining quality of their lives.
Collapse
Affiliation(s)
- Aaron G Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington; and
| | - Michael A Freeman
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
| |
Collapse
|
17
|
Abstract
OBJECTIVE We sought to describe the prevalence and outcomes of liver transplantation in children with intellectual disability (ID). We hypothesized that recipients with ID have comparable short-term outcomes compared with those without ID. METHODS We performed a retrospective cohort analysis of children receiving a first liver-alone transplant in the United Network for Organ Sharing dataset from 2008 to 2013. Recipients with definite or probable ID were compared to children without ID using χ tests. Kaplan-Meier curves were constructed for patient and graft survival. Cox proportional hazard models were used to estimate the association between ID and graft failure and patient survival. RESULTS During the study period, 254 children with definite (115) or probable (139) ID underwent first liver transplant, accounting for 15% of all first pediatric liver transplants (1721). Recipients with definite ID tended to be male have a metabolic indication for transplant, a lower pediatric end-stage liver disease score at listing than recipients with no ID, and were less likely to receive a living donor transplant. Recipients with ID were more likely to have public insurance and had more treatment-related hospitalizations in the first year than those without ID. Functional status tended to improve in all recipients at follow-up. ID was not significantly associated with patient or graft survival. CONCLUSIONS Children with ID form a significant portion of total liver transplant recipients, and their short-term graft and patient survival are comparable with children without ID. Further research is needed to examine long-term outcomes of transplant in this population.
Collapse
|
18
|
Abstract
Abstract:In 1996, Sandra Jensen became the first person with Down syndrome to receive a heart-lung transplant. Although it took place almost 20 years ago, her experience continues to shed light on contemporary challenges that individuals with neurodevelopmental disorders face in securing access to transplantation. While overt discrimination has decreased, barriers persist in physician referrals, center-specific decisionmaking regarding wait-listing, and the provision of accommodations for optimizing the assessment and medical management of these individuals. These issues arise from the persistent biases and assumptions of individuals as well as those of a healthcare system that is inadequately positioned to optimally serve the medical needs of the growing number of individuals with functional impairments. More data and greater transparency are needed to understand the nature and extent of ongoing access problems; however, long-term solutions will require changes at the healthcare professional, regional transplant center, and national levels.
Collapse
|
19
|
Kamin DS, Freiberger D, Daly KP, Oliva M, Helfand L, Haynes K, Harrison CH, Kim HB. What Is the Role of Developmental Disability in Patient Selection for Pediatric Solid Organ Transplantation? Am J Transplant 2016; 16:767-72. [PMID: 26588043 DOI: 10.1111/ajt.13519] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/17/2015] [Accepted: 09/04/2015] [Indexed: 01/25/2023]
Abstract
The National Organ Transplant Act stipulates that deceased donor organs should be justly and wisely allocated based on sound medical criteria. Allocation schemes are consistent across the country, and specific policies are publicly vetted. Patient selection criteria are largely in the hands of individual organ transplant programs, and consistent standards are less evident. This has been particularly apparent for patients with developmental disabilities (DDs). In response to concerns regarding the fairness of transplant evaluations for patients with DDs, we developed a transplant centerwide policy using a multidisciplinary, community-based approach. This publication details the particular policy of our center. All patients should receive individualized assessments using consistent standards; disability should be neither a relative nor an absolute contraindication to transplantation. External review can increase trust in the selection process. Patients in persistent vegetative states should not be listed for transplantation.
Collapse
Affiliation(s)
- D S Kamin
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| | - D Freiberger
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA
| | - K P Daly
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - M Oliva
- Department of Psychology, Jackson Behavioral Health Hospital, Miami, FL
| | - L Helfand
- Department of Social Work, Boston Children's Hospital, Boston, MA
| | - K Haynes
- Office of the General Counsel, Boston Children's Hospital, Boston, MA
| | - C H Harrison
- Office of Ethics, Boston Children's Hospital, Boston, MA
| | - H B Kim
- Pediatric Transplant Center, Boston Children's Hospital, Boston, MA
| |
Collapse
|
20
|
Goldberg AM, Amaral S, Moudgil A. Developing a framework for evaluating kidney transplantation candidacy in children with multiple comorbidities. Pediatr Nephrol 2015; 30:5-13. [PMID: 24452328 DOI: 10.1007/s00467-013-2704-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 11/06/2013] [Accepted: 11/11/2013] [Indexed: 12/15/2022]
Abstract
Children with multiple comorbidities, including neurodevelopmental delay, can develop end-stage kidney disease (ESKD). When and if these children should be eligible for kidney transplantation is an area of debate within the pediatric nephrology community and the public. Discussions focus on expected survival and quality of life posttransplant, as well as resource allocation decisions, as donor kidneys remain a limited resource. This paper focuses on the evidence available regarding outcomes in this population and the ethical issues that should be considered. The authors offer a framework for transplant teams evaluating children with comorbidities for kidney transplant, focusing on the benefits and burdens that transplantation can be expected to achieve.
Collapse
Affiliation(s)
- Aviva M Goldberg
- Section of Nephrology, Department of Pediatrics and Child Health, Faculty of Medicine, University of Manitoba and Health Sciences Centre Children's Hospital, FE009 840 Sherbrook St., Winnipeg, Manitoba, Canada, R3M 0P1,
| | | | | |
Collapse
|
21
|
Dobbels F. Intellectual disability in pediatric transplantation: pitfalls and opportunities. Pediatr Transplant 2014; 18:658-60. [PMID: 25250967 DOI: 10.1111/petr.12345] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Fabienne Dobbels
- Health Services and Nursing Research, Department of Public Health and Primary Care, University of Leuven (KU Leuven), Kapucijnenvoer 35/4, 3000, Leuven, Belgium.
| |
Collapse
|
22
|
Wightman A, Young B, Bradford M, Dick A, Healey P, McDonald R, Smith J. Prevalence and outcomes of renal transplantation in children with intellectual disability. Pediatr Transplant 2014; 18:714-9. [PMID: 25135680 PMCID: PMC4362668 DOI: 10.1111/petr.12339] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2014] [Indexed: 11/30/2022]
Abstract
To describe the prevalence and outcomes of renal transplantation in children with ID we performed a retrospective cohort analysis of all children receiving a first kidney-alone transplant in the UNOS dataset from 2008 to 2011. Recipients with definite, probable, and without ID were compared using chi-square tests. Kaplan-Meier curves were constructed for patient and graft survival. Cox proportional hazard models were used to estimate the association between ID and graft failure and patient survival. Over the study period, 332 children with definite (117) or probable (215) ID underwent first renal transplant, accounting for 16% of all first pediatric renal transplants (n = 2076). Children with definite ID were not significantly different from children without ID with respect to sex, ethnicity, or prevalence of acute rejection. ID was associated with increased likelihood of deceased donor source. ID was not significantly associated with decreased graft or patient survival. In this first large-scale study, up to 16% of first pediatric renal transplants were performed in children with ID. Short-term graft and patient survival after transplant were equivalent between children with and without ID. Further research is needed to examine long-term outcomes of transplant in this population.
Collapse
Affiliation(s)
- Aaron Wightman
- Division of Nephrology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Mail Code 4108, 600 Highland Ave, Madison, WI 53792-4108, Phone (608) 263-9439, Fax: (608) 265-3397
| | - Bessie Young
- VA Puget Sound Healthcare System, Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington School of Medicine
| | - Miranda Bradford
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA, USA
| | - André Dick
- Department of Surgery, University of Washington School of Medicine
| | - Patrick Healey
- Department of Surgery, University of Washington School of Medicine
| | - Ruth McDonald
- Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine
| | - Jodi Smith
- Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine
| |
Collapse
|
23
|
Squires RH, Ng V, Romero R, Ekong U, Hardikar W, Emre S, Mazariegos GV. Evaluation of the pediatric patient for liver transplantation: 2014 practice guideline by the American Association for the Study of Liver Diseases, American Society of Transplantation and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Hepatology 2014; 60:362-98. [PMID: 24782219 DOI: 10.1002/hep.27191] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 04/22/2014] [Indexed: 12/16/2022]
Affiliation(s)
- Robert H Squires
- Department of Pediatrics, University of Pittsburgh School of Medicine; Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | | | | | | | | | | | | |
Collapse
|
24
|
Affiliation(s)
- Joel E Frader
- Northwestern University’s Feinberg School of Medicine, USA
| |
Collapse
|
25
|
Samelson-Jones E, Mancini DM, Shapiro PA. Cardiac Transplantation in Adult Patients with Mental Retardation: Do Outcomes Support Consensus Guidelines? PSYCHOSOMATICS 2012; 53:133-8. [DOI: 10.1016/j.psym.2011.12.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 06/01/2011] [Accepted: 06/02/2011] [Indexed: 10/28/2022]
|
26
|
Panocchia N, Bossola M, Vivanti G. Transplantation and mental retardation: what is the meaning of a discrimination? Am J Transplant 2010; 10:727-730. [PMID: 20420637 DOI: 10.1111/j.1600-6143.2010.03052.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The issue of transplantation for patients affected by mental retardation (MR) has been and continues to be a matter of discussion. The recent policy of the Veneto region, a highly populated area in northern Italy, indicates that patients with MR are not eligible for any transplant of solid organs, indicating intelligence quotient (IQ) <50 as absolute and IQ <70 as a relative exclusion criteria. In the present study, we review current conceptualizations of MR, along with the current knowledge on transplantation in this population. Finally, we will review the international guidelines on this matter and discuss the social, ethical and political significance of such policy, arguing that it discriminates persons affected by MR.
Collapse
Affiliation(s)
- N Panocchia
- Hemodialysis Service, Department of Surgery, Catholic University, Rome, Italy
| | - M Bossola
- Hemodialysis Service, Department of Surgery, Catholic University, Rome, Italy
| | - G Vivanti
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, CA
| |
Collapse
|
27
|
Galante NZ, Dib GA, Medina-Pestana JO. Severe intellectual disability does not preclude renal transplantation. Nephrol Dial Transplant 2010; 25:2753-7. [DOI: 10.1093/ndt/gfq105] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
28
|
Richards CT, Crawley LM, Magnus D. Use of neurodevelopmental delay in pediatric solid organ transplant listing decisions: inconsistencies in standards across major pediatric transplant centers. Pediatr Transplant 2009; 13:843-50. [PMID: 19067911 DOI: 10.1111/j.1399-3046.2008.01072.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Children with NDD present for organ transplant evaluation, but the role of NDD as a listing criterion itself is poorly described. Therefore, we sought to investigate how major pediatric solid organ transplant programs use NDD as a criterion in their listing decisions. We developed a survey that was sent via post to active pediatric solid organ transplant programs across the United States investigating transplant listing decision-making for neurodevelopmentally delayed children. Respondents were medical/surgical directors and transplant coordinators. Descriptive statistics summarize the findings. Programs inconsistently use NDD in listing decisions. Thirty-nine percent of programs stated that they "rarely" or "never" consider NDD in their decisions, whereas 43% of programs "always" or "usually" do. Sixty-two percent of programs report that informal processes guide their use of NDD, and no programs describe their process as "formal, explicit, and uniform." The degree of delay is an additional source of discordance among programs, with 14% of programs reporting mild or moderate NDD as a relative contraindication to listing and 22% reporting that NDD was "irrelevant" to the listing decision. The use of NDD in pediatric solid organ transplant listing decisions is varied and inconsistent across active programs.
Collapse
|