Differences in linear growth and cortisol production between liver and renal transplant recipients on similar immunosuppression

Malnutrition in Biliary Atresia: Assessment, Management, and Outcomes

Children with biliary atresia (BA), particularly infants, are at high risk for malnutrition attributed to a multitude of factors, including poor oral intake and intolerance of enteral feeding, fat malabsorption, abnormal nutrient metabolism, and increased caloric demand. Malnutrition and sarcopenia negatively impact outcomes in BA, leading to higher pretransplant and posttransplant morbidity and mortality. This review summarizes factors contributing to nutritional deficiencies in BA and offers an organized approach to the assessment and management of malnutrition in this vulnerable population.

Long-term linear growth and puberty in pediatric liver transplant recipients

OBJECTIVE

To explore linear growth, puberty, and predictors of linear growth impairment among pubertal liver transplant recipients.

STUDY DESIGN

Review of data collected prospectively through the Studies of Pediatric Liver Transplantation registry. Thirty-one variables were tested as risk factors for linear growth impairment, and factors significant at P < .1 were included in a logistic regression model. Risk factor analysis was limited to 512 patients who had complete demographic and medical data.

RESULTS

A total of 892 patients surviving their first liver transplant by >1 year, with ≥ 1 height recorded, who were between 8 and 18 years old between the years 2005 and 2009 were included. Median follow-up was 70.2 ± 38.6 months, mean age was 12.9 ± 3.3 years, and mean height z-score (zH) was -0.5 ± 1.4 SD. Twenty percent had linear growth impairment at last follow-up. Of 353 subjects with Tanner stage data, 39% of girls and 42% of boys ages 16-18 years were not yet Tanner 5. Growth impairment rates were higher among boys than girls (30% vs 7%, P < .05) at Tanner stage 4, and occurred in 8/72 (11%) of Tanner 5 subjects. Among patients with parental height data, zH were lower than calculated mid-parental zH (P < .005). Independent predictors of growth impairment included linear growth impairment at transplant (OR 11.53, P ≤ .0001), re-transplantation (OR 4.37, P = .001), non-white race (P = .0026), and primary diagnosis other than biliary atresia (P = .0105).

CONCLUSIONS

Linear growth impairment and delayed puberty are common in pubertal liver transplant recipients, with pre-transplant growth impairment identified as a potentially modifiable risk factor. Catch-up growth by the end of puberty may be incomplete.

Orthopedic complications related to growth hormone therapy in a pediatric population

Since the introduction of recombinant growth hormone, its use has diversified and multiplied. Growth hormone is now the recommended therapy for a growing indication to all forms of short stature because of its direct and indirect role on bone growth. Hereby, we discuss the orthopedic complications associated with growth hormone treatment in pediatric patients. These complications include carpal tunnel syndrome, Legg-Calve-Perthes' disease, scoliosis, and slipped capital femoral epiphysis. Their incidence rates recorded in several growth hormone therapy-related pharmacovigilance studies will be summarized in this study with focused discussion on their occurrence in the pediatric and adolescent age groups. The pathogenesis of these complications is also reviewed.

Approach to optimizing growth, rehabilitation, and neurodevelopmental outcomes in children after solid-organ transplantation

One of the most critical differences between the posttransplant care of children and adults is the requirement in children to maintain a state of health that supports normal physical and psychological growth and development. Most children with organ failure have some degree of growth failure and developmental delay, which is not quickly reversed after successful transplantation. The challenge for clinicians caring for these children is to use strategies that minimize these deficits before transplantation and provide maximal opportunity for recovery of normal developmental processes during posttransplant rehabilitation. The effect of chronic organ failure, frequently complicated by malnutrition, on growth potential and cognitive development is poorly understood. This review presents a summary of what is known regarding risk factors for suboptimal growth and development following solid-organ transplant and describe possible strategies to improve these outcomes.

Linear growth patterns in prepubertal children following liver transplantation

Factors impacting linear growth following pediatric liver transplantation (LT) are not well understood. This longitudinal analysis examines predictors of linear growth impairment in prepubertal children included in Studies of Pediatric Liver Transplantation. In 1143 children with serial measurements, mean height scores increased from -1.55 at LT to -0.87 and -0.68 at 24 and 36 months post LT with minimal subsequent catch up growth observed until 60 months. Subgroup analysis of height measurements at 24 months (n = 696), 33.8% were below 10th percentile at 24 months post LT. Multivariate analysis revealed linear growth impairment more likely in patients with metabolic disease (OR 4.4, CI: 1.83-10.59) and >18 months of steroids exposure (OR 3.02, CI: 1.39-6.55). Higher percentiles for weight (OR 0.80, CI: 0.65-0.99) and height (OR 0.62, CI: 0.51-0.77) at LT decreased risk. Less linear catch up was observed in patients with metabolic disease, non-Biliary atresia cholestatic diseases and lower weight and higher height percentiles prior to LT. Prolonged steroid exposure and elevated calculated glomerular filtration rate and gamma-Glutamyltransferase following LT were associated with less catch up growth. Linear growth impairment and incomplete linear catch up growth are common following LT and may improve by avoiding advanced growth failure before LT and steroid exposure minimization.

Spine after solid organ transplantation in childhood: a clinical, radiographic, and magnetic resonance imaging analysis of 40 patients

STUDY DESIGN

A cross-sectional study of the spine in 40 young adults after solid organ transplantation in childhood.

OBJECTIVE

To evaluate the impact of organ transplantation and long-term immunosuppressive treatment on growing spine using magnetic resonance imaging (MRI).

SUMMARY OF BACKGROUND DATA

A review of the current literature reveals no systematic evaluation of the spine after transplantation in childhood.

METHODS

A total of 40 adult patients (mean age 22.1 years, range, 16.0-27.0), who received either kidney, liver, or heart transplant as children, were evaluated. Mean follow-up after transplantation was 11.2 years (range 3.0-18.0). All patients filled in a questionnaire, underwent an interview and physical examination, as well as had MRI of the spine. Standing spinal radiographs were taken from patients with a rib hump > or = 6 degrees.

RESULTS

There were 8 (20%) patients who had a history of vertebral fracture. Eleven (28%) patients reported frequent back pain at rest. There were 15 (38%) patients who had scoliosis > 10 degrees (range 10 degrees -69 degrees ). On MRI, narrowed disc spaces were noted in 32 (80%) patients, and irregular endplates were noted in 24 (60%). There were 14 (35%) patients who had at least 1 compressed or wedged vertebra (> 20%). Patients treated for acute rejection had wedged vertebrae, speckled or black disc spaces, and irregular endplates more often than patients without rejections. Males had wedged vertebrae more often than females (P = 0.0067).

CONCLUSIONS

Back pain, scoliosis, wedged vertebrae, and narrowed, degenerated disc spaces are common after solid organ transplantation in childhood.

Surgical correction of spinal deformities after solid organ transplantation in childhood

A review of the current literature reveals no systematic analyses of the results of surgical correction of spinal deformity after pediatric organ transplantation. We therefore evaluated clinical and radiographic outcomes of spinal deformity correction after solid organ transplantation in childhood and adolescence. All 211 cases of heart, liver, and kidney transplantations performed in children in our country were reviewed. Six patients had undergone surgical correction of spinal deformity at a mean age 14.6 (range 12-17) years. Clinical data of the patients were evaluated. Radiographs of the whole spine were taken preoperatively, immediately after, at 2-year, and final follow-up visits. The Scoliosis Research Society (SRS) questionnaire was completed and a physical examination was performed at the final follow-up visit. The mean follow-up after spinal surgery was 4.9 years (range 2-7.6 years). Four patients developed scoliosis after organ transplantation without any evidence of scoliosis prior to organ transplantation. One patient with congenital scoliosis was operated on after kidney transplantation. One boy had osteoporosis and severe local kyphosis due to vertebral compression fractures. Four patients underwent anterior and posterior surgery, two posterior only. The mean preoperative Cobb angle of the thoracic curve was 54 degrees (range 42-69 degrees) in the patients with scoliosis. The postoperative values were 30 degrees (26-38 degrees) immediately after instrumentation and 39 degrees (34-42 degrees) at the final follow-up visit. The patient with vertebral compression fractures and progressive kyphosis had 70 degrees curve before surgery, 23 degrees immediately after the operation, and 60 degrees at the final check up. The mean total score on the SRS questionnaire was 95.5 (range 90-101). There is a relatively high incidence (2.8%) of spinal deformities needing operative treatment after solid organ transplantation. Possible etiologies for spinal deformities are growth disturbance and muscle weakness due to the basic disease. The other important factors are related to immunosuppressive medication, especially glucocorticoids needed after transplantation. Primary correction of these deformities was satisfactory, but during follow-up, a certain amount of recurrence of the curves was evident. Poor bone quality may explain some of the loss of correction.

Growth after organ transplantation

Growth is an important feature of childhood, but it is usually impaired before and after organ transplantation. Modest catch-up growth often occurs after renal transplantation. Nevertheless, patients remain short due to the effects of steroids used for immunosuppression. Children with chronic liver failure are also growth impaired, although not to the same extent. They also frequently have poor catch up growth after transplantation, again due to steroids. There are several randomized controlled clinical trials reporting growth hormone (GH) use after renal transplantation. These consistently show a beneficial effect of GH on linear growth. Patients with histories of frequent acute rejections before GH may have increased risk of acute rejection during treatment. Few data exist on liver transplant patients, although GH also appears effective. GH use may be safe and effective for renal transplant recipients who have been stable without acute rejection episodes. There needs to be long-term study of GH use in liver and renal transplant patients. It is critical to focus efforts on improving growth in renal failure before transplantation through GH use and to improve posttransplant growth in all recipients by minimizing steroid exposure.

Avascular Bone Necrosis of the Hip Joint after Solid Organ Transplantation in Childhood: A Clinical and MRI Analysis

BACKGROUND

Aseptic osteonecrosis is a well-known complication after solid organ transplantation in adults. The occurrence of osteonecrosis in growing age has been studied after kidney transplantation, but no systematic evaluation of the joints has been reported after heart or liver transplantation in childhood.

METHODS

A total of 196 children--93% of patients surviving kidney, liver and heart transplantation in Finland--participated in a cross-sectional survey. All children underwent a detailed clinical examination and filled out a questionnaire on musculoskeletal symptoms. Radiographs were taken in case of joint pain or abnormal clinical findings. In addition, magnetic resonance imaging (MRI) from the hips was taken on a random basis from 34 adult patients transplanted as a child. The mean follow-up time of all patients after transplantation was 9.2 years (range, 2.4 to 20.5 years).

RESULTS

Twenty-eight (14%) patients reported prolonged joint or limb pain without previous trauma. Specific etiology for the limb pain was not found in 10 (5.1%) patients. Osteonecrosis seen in radiographs or MRI was noted in seven (3.6%) patients, of which three had received kidney, three liver, and one heart graft. Femoral head was affected in five patients, as well as talus bilaterally in one patient and lateral femoral condyle in one patient. All patients were older than 12 years at the time of diagnosis of the osteonecrosis. MRI of the hips of 34 randomly selected patients showed only one asymptomatic necrosis of the femoral head.

CONCLUSIONS

Symptomatic osteonecrosis of the hip is uncommon after solid organ transplantation in childhood using the current immunosuppressive medications.

Surgery results in significant improvement in growth in children with Crohn's disease refractory to medical therapy

Inflammatory bowel disease (IBD) in children can cause significant impairment in linear growth, and delay in pubertal onset. The aim of this study was to assess the impact of surgery on linear growth in children with Crohn's disease (CD) who were resistant to medical therapy, and had documented evidence of growth impairment. We performed a retrospective study on eight consecutive patients with refractory disease who had attended the paediatric IBD clinic. All patients underwent surgery as part of their treatment. Height and weight were recorded at least 6 months prior to surgery, at the time of surgery, and 6 months post surgery. Growth velocities and height Z-scores were calculated. All patients had evidence of sustained growth suppression prior to surgery. Three patients had evidence of growth failure. There was a significant increase in height velocity from 0.15 cm/month before surgery to 0.54 cm/month after surgery (P = 0.006). There was also a significant decrease in the modified Harvey-Bradshaw index (HBI) of disease activity from 2.00 before surgery, to 0.84 after surgery (P = 0.003). Improvements in height Z-score and weight velocity after surgery were not significant on statistical analysis. Our study demonstrates that before surgery, children with CD refractory to therapy have sustained growth suppression, and in some cases may even have growth failure. Surgical intervention before puberty appears to result in a significant improvement in height velocity and disease activity. These findings need to be further investigated with carefully designed prospective studies.

Incidence and predictors of fractures in children after solid organ transplantation: a 5-year prospective, population-based study

In this population-based prospective follow-up study, children undergoing solid organ transplantation had a highly elevated risk for fractures: The incidence of all fractures was 6-fold higher (92 versus 14 fractures/1000 persons/year; p < 0.001) and vertebral fractures was 160-fold higher (57 versus 0.35 fractures/1000 persons/year; p < 0.001) in the study group compared with the control population. Thus, screening of vertebral fractures at regular intervals is recommended, and preventive strategies should be studied.

INTRODUCTION

The incidence and predictors of fractures after solid organ transplantation are not well documented in the pediatric age group.

MATERIALS AND METHODS

A total of 196 children, which is 93% of patients surviving kidney, liver, and heart transplantation in our country, participated in a retrospective chart review at enrollment followed by a 5-year prospective follow-up study between January 1999 and December 2004. Hospital and medical records were reviewed. All children underwent clinical examinations and answered questionnaires concerning fracture history at the beginning and at the end of the prospective follow-up. Radiographs of the thoracic and lumbar spine were obtained. The fracture incidence was compared with data obtained from public health registries.

RESULTS

Seventy-five (38%) of the transplant patients suffered from a total of 166 fractures after organ transplantation. The incidence of all fractures was 6-fold higher (92 versus 14 fractures/1000 persons/year; p < 0.001) and vertebral fractures was 160-fold higher (57 versus 0.35 fractures/1000 persons/year; p < 0.001) in the study group compared with the control population. The age- and sex-adjusted hazard ratios (95% CI) were 61.3 (40.7-92.4) for vertebral, 17.9 (8.96-35.8) for symptomatic vertebral, 0.99 (0.65-1.50) for nonvertebral, and 2.90 (2.25-3.73) for all fractures in the patients compared with the control population. In a multivariate analysis, older age (hazard ratio [95% CI]; 2.02 [1.07-3.83]), male sex (2.15 [1.22-3.81]), liver transplantation (1.78 [1.01-3.14]), and fractures before transplantation (2.02 [0.92-4.47]) were the most significant independent risk factors.

CONCLUSIONS

Children undergoing solid organ transplantation have a highly elevated risk for fractures. Screening of vertebral fractures at regular intervals is recommended, and preventive strategies should be studied.

Scoliosis after solid organ transplantation in children and adolescents

The occurrence of scoliosis in children after solid organ transplantation is not known. A total of 196 children, which is 93% of patients surviving kidney, liver and heart transplantation in our country, participated in a cross-sectional survey. All children were screened for rib hump, and those with clinically significant hump (over 6 degrees ) underwent radiographs of the spine. The occurrence of scoliosis was compared to data obtained from a previously published comparison group. Forty-three (21.9%) of the patients had scoliosis greater than 10 degrees , and 21 (10.7%) of them had curves greater than 20 degrees . The RR (95% CI) for scoliosis needing treatment (over 20 degrees ) was 17.0 (6.75-42.7) in the patients as compared with control population. The occurrence of scoliosis was 17.9% of the kidney, 13.6% of the liver and 51.7% of the heart transplant patients (p < 0.001). In a logistic regression model, heart transplantation (OR (95% CI) 7.27 (2.62-20.2)) and growth hormone treatment (3.98 (1.77-8.94)) were most significant risk factors for scoliosis. The risk of scoliosis is increased in patients with solid organ transplantation. Pediatricians treating these patients should be aware of this increased risk to diagnose early curves and to refer these patients to an orthopedic surgeon.

Current status of liver transplantation in children

There are two critical issues on opposite ends of the timeline for patients who are eligible for liver transplantation. On the one hand, the crisis in the cadaveric organ supply makes surviving to transplant ever more risky. On the other hand, patients who receive successful transplants face the consequences of long-term immunosuppression and its potentially life-threatening complications. The donor shortage is forcing difficult decisions that affect all patients who await liver transplantation. It is important to scrutinize carefully the results of all policies that govern allocation and the ethics of the solutions we advocate to ensure that no patient subgroup is being at a disadvantage. Current immunosuppression practices are being challenged by an increasing understanding of the immunologic events triggered by the allograft and the goal to free patients from consequences of a lifetime of immunosuppression. Clinicians can expect, and perhaps require, that new immunosuppressive protocols will address how the planned intervention might be expected to advance the understanding of tolerance mechanisms. As knowledge increases, clinicians can anticipate innovative new immunosuppressive proposals. Calcineurin and steroid-free induction, the use of donor-derived bone marrow infusion, recipient pretreatment, costimulatory blockade, and new antibody induction approaches are all being proposed--often in combination--for clinical trials. Researchers face additional challenges in defining endpoints if the goal is not just the short-term reduction in rejection but the minimization, and eventual discontinuation, of immunosuppressive drugs while maintaining excellent long-term graft function. How much "failure" will be accepted and how will it be defined? How will clinicians interpret liver biopsies if they begin to accept that some lymphocytic infiltrates may be beneficial mediators of the ongoing immune activation necessary for the maintenance of tolerance? How will they adjust immunosuppression practices to the dynamic processes in the immune response that maintain tolerance? Remarkable short-term successes in providing transplants for thousands of children with liver failure have brought these challenges into sharp focus. Clinicians must seek to move the life-giving science of transplantation toward a new goal: providing long lifetimes of excellent graft function with minimal toxicity from immunosuppressive drugs and the hope of freedom from immunosuppression altogether. Pediatric liver recipients, whose grafts have inherent tolerogenic potential and for whom we can anticipate decades of life after transplant, may prove to be an ideal study population to further these goals.

Psychosocial adaptation after solid organ transplantation in children

The possibility of extending life with advanced medical procedures such as organ transplantation in childhood has made it possible to focus on patients' well-being in a wider perspective. They still experience a high prevalence of medical and physical disabilities, which definitively have an impact on a child's psychosocial adjustment after transplantation. Many disabilities originate before transplantation, and much effort should be taken to diminish possible complications and ameliorate growth and neurodevelopment, which have an impact for later adjustment regardless of a successful transplantation. Well-being and QOL are not necessarily always correlated to the degree of physical disability. Different social, financial, and demographic factors also have an impact, as do children's and families' ability to cope with a chronic disorder. Nonadherence and noncompliance are a great problem, particularly in adolescents. They are the result and a possible cause of inferior psychosocial adjustment. Continuous multidisciplinary support, follow-up, and education are needed to cope with this problem. Validated and reliable health status measures in pediatric transplant recipients are scarce in the literature, and few assessments can be completed by the children themselves. A continuing effort must be made to improve psychosocial adjustment and QOL after transplantation to achieve the ultimate goal in medicine: the overall well-being of our patients.

Stimulated cortisol secretion is not correlated with prednisone dose or with steroid side-effects in children after renal transplantation

Impairment of adrenocortical function and other adverse effects have to be considered whenever corticosteroids are applied for a prolonged period of time. We hypothesized that the assessment of adrenal function with adrenocortiocotropin (ACTH) stimulation reflects the sensitivity to corticosteroids and would predict the development of side-effects in pediatric patients on triple immunosuppression after renal transplantation.

Serum C-reactive protein in pediatric kidney and liver transplant patients

The clinical manifestations of different complications after organ transplantation (Tx) are often vague, and simple laboratory tests for early diagnosis would be valuable. In this work we retrospectively analyzed our data on the daily measurements of serum C-reactive protein (CRP) in 132 children after 63 liver and 83 kidney Txs. A total of 3,886 CRP measurements were performed and 353 episodes of elevated CRP were recorded. One-third of these were regarded as a response to surgery. The CRP level normalized within 5-10 days post-operatively in patients who had a favorable outcome, but in patients with a poor outcome CRP tended to remain elevated. Half of the CRP elevations were associated with complications such as acute rejection, infection or thrombotic events. An elevated serum CRP level was found in 68% of the rejection episodes, in 88% of the bacterial infections, and in 73% of the viral infections. The most significant elevations were associated with bacterial infection. In nine of 11 vascular complications, an elevation of CRP was also recorded. Serum CRP responded to rejection therapy in 86% of the episodes. The initial CRP level did not predict steroid-resistant rejection. CRP seemed to be a more sensitive marker than fever or white blood cell (WBC) count in all complications. We conclude that the daily measurement of serum CRP is a simple and fairly sensitive, but non-specific, method for detecting rejection and infectious complications after pediatric liver and kidney Tx.

Fine-needle aspiration biopsy allows early detection of acute rejection in children after renal transplantation

analysis detected rejections often before clinical signs. Half of the patients had increased serum creatinine concentration and 38% had fever at the time of rejection diagnosis. Both signs were present in only 19% of the episodes. A decrease in urine output (>20%) was seen in a third of the episodes. The rejections responded well to oral methylprednisolone (3 mg/kg/day), and lymphoglobulins were needed in only 12% of the episodes. More than 90% of the rejections were completely reversible and no transplant was lost because of acute rejection.

CONCLUSION

The results indicate that FNAB is a safe and sensitive method for the diagnosis and follow-up of acute cellular rejection in pediatric recipients of different ages.

Liver transplantation. The pediatric challenge

Successful liver transplantation in a child is often a hard-won victory, requiring all the combined expertise of a dedicated pediatric transplant team. This article outlines the considerable challenges still facing pediatric liver transplant physicians and surgeons. In looking to the future, where should priorities lie to enhance the success already achieved? First, solutions to the donor shortage must be sought aggressively by increasing the use of from split-liver transplants, judicious application of living-donor programs, and increasing the donation rate, perhaps by innovative means. The major immunologic barriers, to successful xenotransplantation make it unlikely that this option will be tenable in the near future. Second, current immunosuppression is nonspecific, toxic, and unable to be individually adjusted to the patient's immune response. The goal of achieving donor-specific tolerance will require new consideration of induction protocols. Developing a clinically applicable method to measure the recipient's immunoreactivity is of paramount importance, for future studies of new immunosuppressive strategies and to address the immediate concern of long-term over-immunosuppression. The inclusion of pediatric patients in new protocols will require the ongoing insistence of pediatric transplant investigators. Third, the current immunosuppressive drugs have a long-term morbidity and mortality of their own. These long-term effects are particularly important in children who may well have decades of exposure to these therapies. There is now some understanding of their long-term renal toxicity and the risk of malignancy. New drugs may obviate renal toxicity, whereas the risk of malignancy is inherent in any nonspecific immunosuppressive regimen. Although progress is being made in preventing and recognizing PTLD, this entity remains an important ongoing concern. The global effect of long-term immunosuppression on the child's growth, development, and intellectual potential is unknown. Of particular concern is the potential for neurotoxicity from the calcineurin inhibitors. Fourth, recurrent disease and new diseases, perhaps potentiated by immunosuppressive drugs, must be considered. Already the recurrence of autoimmune disease and cryptogenic cirrhosis have been documented in pediatric patients. Now, a new lesion, a nonspecific hepatitis, sometimes with positive autoimmune markers, that may progress to cirrhosis has been recognized. It is not known whether this entity is an unusual form of rejection, an unrecognized viral infection, or a response to immunosuppressive drugs themselves. Finally, pediatric transplant recipients, like any other children, must be protected and nourished physically and mentally if they are to fulfill their potential. After liver transplantation the child's growth, intellectual functioning, and psychologic adaptation may all require special attention from parents, teachers, and physicians alike. There is limited understanding of how the enormous physical intervention of a liver transplantation affects a child's cognitive and psychologic function as the child progresses through life. The persons caring for these children have the difficult responsibility of providing services to evaluate these essential measures of children's health over the long term and to intervene if necessary. Part of the transplant physician's our duty to protect and advocate for children is to fight for equal access to health care. In most of the developing world, economic pressures make it impossible to consider liver transplantation a health care priority. In the United States and in other countries with the medical infrastructure to support liver transplantation, however, health care professionals must strive to be sure that the policies governing candidacy for transplantation and allocation of organs are applied justly and uniformly to all children whose lives are threatened by liver disease. In the current regulatory climate that increasingly takes medical decisions out of the hands of physicians, pediatricians must be even more prepared to protect the unique and often complicated needs of children both before and after transplantation. Only in this way can the challenges of the present and the future be met.

Differences in anthropometric parameters and the IFG-I-IGFBP3 axis between liver and renal transplant children

BACKGROUND

Growth can be differently altered after liver and renal transplantation (Tx) in childhood.

METHODS

We compared graft function, linear growth, immunosuppression and serum IGF-I (RIA) and IGFBP3 (IRMA) concentrations in 15 liver (5.6+/-1.1 years old) and 17 renal (7.4+/-0.1 years old) Tx patients who were followed for 4-6 years.

RESULTS

Graft function was normal post-liver Tx, although in renal recipients creatinine clearance decreased significantly during follow-up. Liver Tx children presented an increase in mean height of 0.92+/-0.2 SDS (P<0.01) beyond the 2nd year post-Tx, although in renal Tx patients height SDS did not improve. Immunosuppressive corticoid dosage could be decreased and discontinued in liver Tx patients, while in renal recipients it was maintained between 0.18+/-0.01 and 0.16+/-0.02 mg/kg/day. At 3.7+/-0.4 years post Tx, liver Tx patients presented higher mean serum IGF-I level, lower mean serum IGFBP3 value, leading to a higher mean IGF-I/IGFBP3 molar ratio, P<0.001.

CONCLUSIONS

We found that while catch up growth coud be achieved after liver Tx, height SDS did not improve after renal Tx. This may be related to a reduced renal graft function and/or to differences in immunosuppressive corticoid dosage. In children with renal transplants a challenge for the future will reside in making it possible to substitute steroid therapy without altering graft function.

Infections in pediatric kidney and liver transplant patients after perioperative hospitalization

BACKGROUND

Infectious complications are a major cause of morbidity and mortality after organ transplantation. There are several reports on infections during the first months after transplantation, but there are very few data regarding infections in long-term survivors of pediatric organ transplantation.

METHODS

The incidence and type of infections were retrospectively analyzed in 56 children who underwent 59 liver or renal transplantations. Follow-up was begun when the patient was sent home after a successful operation. All of the children received triple immunosuppression.

RESULTS

During a mean follow-up of 4.8 years (total, 286 patient years), 1540 episodes of infection were recorded. The median incidence was 4.8 episodes/patient year. The greatest number was seen in the smallest children, 3 to 6 months after transplantation. Viral upper respiratory tract infections were the most common problem, accounting for half of the episodes (2.7 episodes/patient year). Gastroenteritis was the second most common viral infection. Only 45 episodes of infection with herpesviruses were recorded, and seven of those were caused by cytomegalovirus. Otitis media and sinusitis were the most common bacterial infections and complicated upper respiratory infection in 23% of episodes. Thirty-nine episodes of urinary tract infections were diagnosed, thirty-one in children with renal transplants. Other bacterial infections were rare, and only three episodes of verified bacterial sepsis were diagnosed.

CONCLUSION

The frequency and type of infections in children with liver and renal transplants who are on triple immunosuppression are quite similar to those in age-matched healthy children.

Growth of long-term survivors of liver transplantation

OBJECTIVE

To assess growth in survivors of liver transplantation.

STUDY DESIGN

Growth was studied in 105 children up to seven years after liver transplantation.

RESULTS

At transplantation, mean height standard deviation score (zH) was -1.22 but 19% of patients were severely growth retarded (height below 0.4th centile). Growth and pubertal retardation were seen in the first six months after liver transplantation. Significant catch up in growth and puberty continued for more than five years. At five years, mean zH was -0.95 and at seven years -0.84. The mean zH of patients at final height was -0.55. zH at six months was predicted by zH and bilirubin at the time of transplantation and prednisolone dose at six months. At four years, zH was predicted by zH at the time of transplantation and the cumulative prednisolone dose. There was no association between zH and age at transplantation, sex, or diagnosis, although those with biliary atresia and those undergoing transplantation under 2 years of age showed more initial growth delay and subsequent catch up. Average age at menarche was 14.2 years.

CONCLUSIONS

The mean height of the group to have reached final height after liver transplantation was on the 27th centile. Those transplanted earlier in childhood are likely to achieve more normal final heights. High steroid dose, poor liver function, and retransplantation are associated with poorer height outcomes. Persisting severe short stature is largely confined to children with severely retarded growth at the time of transplantation. Transient delay in puberty and menarche occur early after transplantation, although appropriate pubertal progress is resumed after two to three years.