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Lee JY, Mullis DM, Zawadzki RS, Nilkant R, Kuhan S, Kidambi S, Sharir A, Ma M. Long-Term Outcomes After Lung Transplantation in Children With Intellectual Disabilities. Pediatr Transplant 2024; 28:e14807. [PMID: 38923151 DOI: 10.1111/petr.14807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/20/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The United Network for Organ Sharing (UNOS) started recording data on intellectual disability status in 2008. This study aimed to characterize the long-term outcomes for children with intellectual disabilities (IDs) undergoing lung transplantation. METHODS All pediatric patients (under 18 years old) undergoing bilateral lung transplantation were identified using the UNOS database. The patients were grouped into the following categories: no cognitive delay, possible cognitive delay, and definite cognitive delay. The primary endpoint was graft survival at 3-year posttransplantation. Multivariate Cox proportional hazards modeling was used to estimate the independent effect of cognitive disability on graft survival. RESULTS Five hundred four pediatric patients who underwent lung transplantation between March 2008 and December 2022 were retrospectively analyzed. 59 had a definite cognitive delay (12%), 23 had a possible delay (5%), and 421 had no delay (83%). When comparing these three groups, there was no significant difference in 60-day graft survival (p = 0.4), 3-year graft survival (p = 0.6), 3-year graft survival for patients who survived at least 60-day posttransplantation (p = 0.9), distribution of causes of death (p = 0.24), nor distribution treatment of rejection within 1-year posttransplantation (p = 0.06). CONCLUSIONS Intellectual disability does not impact long-term outcomes after bilateral lung transplantation. Intellectual disability should not be a contraindication to bilateral lung transplantation on the basis of inferior graft survival.
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Affiliation(s)
- James Y Lee
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA
| | - Danielle M Mullis
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA
| | - Roy S Zawadzki
- University of California Irvine, Irvine, California, USA
| | - Riya Nilkant
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA
| | - Sangkavi Kuhan
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA
| | - Sumanth Kidambi
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA
| | - Amit Sharir
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA
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2
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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.
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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
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3
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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.
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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
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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.
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Affiliation(s)
- Devan Stahl
- Department of Religion, Baylor University, Waco, TX.
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5
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Rea KE, McCormick AM, Lim HM, Cousino MK. Psychosocial outcomes in pediatric patients with ventricular assist devices and their families: A systematic review. Pediatr Transplant 2021; 25:e14001. [PMID: 33704884 PMCID: PMC8141009 DOI: 10.1111/petr.14001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 02/17/2021] [Accepted: 02/24/2021] [Indexed: 11/30/2022]
Abstract
Ventricular assist device (VAD) therapy has provided pediatric patients with severe heart failure new therapeutic options. However, pediatric patients and families receiving VAD therapy also experience psychosocial challenges. No synthesis of the literature on psychosocial outcomes within the pediatric VAD population has been conducted; thus, the current review sought to systematically investigate the impact of pediatric VAD on patient, parent, and family psychosocial outcomes and assess variables associated with poorer outcomes. Literature searches were conducted in PsycInfo, PubMed, and Cumulative Index to Nursing and Allied Health Literature databases and full texts were assessed according to pre-established inclusion criteria. Main findings and study quality were reviewed. Sixteen studies were included in the present review. Findings highlighted the likelihood for psychological sequelae among pediatric patients and families receiving VAD therapy, including decreased psychological and emotional well-being, elevated stress, and difficulty coping with changes to family dynamics and responsibilities. Health-related quality of life was reported comparable to that of healthy peers and children with other cardiac conditions. Patients and families on VAD therapy experience significant difficulties in psychological well-being and challenges related to adjustment. The current review underscores the importance of ongoing support for families and continued assessment of psychosocial functioning across VAD support. Three critical periods for increased distress were identified: 1) immediately following VAD implantation, 2) discharge home and the weeks following discharge, and 3) long-term VAD therapy.
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Affiliation(s)
| | | | - Heang M. Lim
- Department of Pediatrics, Michigan Medicine, University of Michigan
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Delany DR, Gaydos SS, Romeo DA, Henderson HT, Fogg KL, McKeta AS, Kavarana MN, Costello JM. Down syndrome and congenital heart disease: perioperative planning and management. JOURNAL OF CONGENITAL CARDIOLOGY 2021. [PMCID: PMC8056195 DOI: 10.1186/s40949-021-00061-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Approximately 50% of newborns with Down syndrome have congenital heart disease. Non-cardiac comorbidities may also be present. Many of the principles and strategies of perioperative evaluation and management for patients with congenital heart disease apply to those with Down syndrome. Nevertheless, careful planning for cardiac surgery is required, evaluating for both cardiac and noncardiac disease, with careful consideration of the risk for pulmonary hypertension. In this manuscript, for children with Down syndrome and hemodynamically significant congenital heart disease, we will summarize the epidemiology of heart defects that warrant intervention. We will review perioperative planning for this unique population, including anesthetic considerations, common postoperative issues, nutritional strategies, and discharge planning. Special considerations for single ventricle palliation and heart transplantation evaluation will also be discussed. Overall, the risk of mortality with cardiac surgery in pediatric patients with Down syndrome is no more than the general population, except for those with functional single ventricle heart defects. Underlying comorbidities may contribute to postoperative complications and increased length of stay. A strong understanding of cardiac and non-cardiac considerations in children with Down syndrome will help clinicians optimize perioperative care and long-term outcomes.
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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.
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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
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Wilkens SJ, Priest J, Kaufman BD, Barkoff L, Rosenthal DN, Hollander SA. Pediatric waitlist and heart transplant outcomes in patients with syndromic anomalies. Pediatr Transplant 2020; 24:e13643. [PMID: 31891211 DOI: 10.1111/petr.13643] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/11/2019] [Accepted: 11/04/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE We sought to determine whether the presence of a systemic SA with potential complicating factors affects waitlist and post-HT outcomes in pediatric patients. METHODS This is a single-center retrospective review of pediatric patients listed for HT between January 1, 2009, and July 1, 2018. Patients were selected based on the presence of any underlying syndromes, which included chromosomal anomalies, skeletal myopathies, connective tissue disorders, mitochondrial disease,and other systemic disorders. Waitlist and post-HT outcomes were compared to those without SA. RESULTS A total of 243 patients were listed for HT, of which 21 (9%) patients had associated SA. Of those, 16 (76%) survived to transplant, 3 (14%) died while on the waitlist, 1 (5%) improved and was removed from the waitlist, and 1 (5%) patient is currently listed. Waitlist survival was not different between those with/without an associated syndrome (P = 1.0). Among those who survived to HT, there was no difference in listing days (70 vs 90, P = .8), survival to hospital discharge [14 (93%) vs 150 (95%), P = .6], post-HT intubation days (2 vs 2 days, P = .6), or post-HT hospital length of stay (18 vs 18 days, P = .8). Overall survival during the study period post-HT was not different between groups (P = .8). CONCLUSION A SA was present in 9% of pediatric patients wait-listed for HT, but was not associated with an increased waitlist mortality or post-HT hospital morbidity or long-term survival. For several anomalies, HT is safe and feasible.
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Affiliation(s)
- Sarah J Wilkens
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - James Priest
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Beth D Kaufman
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Lynsey Barkoff
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - David N Rosenthal
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Seth A Hollander
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
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9
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[Extracorporeal life support and heart-lung transplant in children]. Presse Med 2018; 47:611-619. [PMID: 29580908 DOI: 10.1016/j.lpm.2018.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 01/17/2018] [Indexed: 11/22/2022] Open
Abstract
Extracorporeal life support and heart and/or lung transplant are the last resort in children with end-stage cardiac and/or pulmonary failure and short-term life threaten. Currently, circulatory support is used as a bridge to recovery or as a bridge to transplant but not as a destination therapy. The Excor Berlin Heart is the long-lasting external pneumatic ventricular assist system that is currently available from infancy to adulthood. Long-term prognosis after pediatric cardiac and/or pulmonary transplant is conditioned by the occurrence of graft failure, coronary disease of the cardiac graft, viral infections and bronchiolitis obliterans of the pulmonary graft, the incidence of which increase with time. The scarcity of grafts and the risk of acute rejection due to lack of compliance with immunosuppressive treatment require the transplant specialized teams to choose the best candidates according to psychosocial and biological criteria. The next expected developments concern mainly long-term ventricular assistance with systems that allow for greater autonomy and a return to the child's home.
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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.
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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
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12
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Hollander SA. Heart transplantation in children with intellectual disability. Pediatr Transplant 2017; 21. [PMID: 28191754 DOI: 10.1111/petr.12864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2016] [Indexed: 11/27/2022]
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