Growth following solid organ transplantation in childhood

Abstract

One of the ultimate goals of successful solid organ transplantation in pediatric recipients is attaining an optimal final adult height. This manuscript will discuss growth following transplantation in pediatric recipients of kidney, liver, heart, lung or small bowel transplants. Remarkably similar factors impact growth in all of these recipients. Age is a primary factor, with younger recipients exhibiting the greatest immediate catch-up growth. Graft function is a significant contributing factor, with a reduced glomerular filtration rate correlating with poor growth in kidney recipients and the need for re-transplantation with impaired growth in liver recipients. The known adverse impact of steroids on growth has led to modification of the steroid dose and even steroid withdrawal and avoidance. In kidney and liver recipients, this strategy has been associated with the development of acute rejection. In infant heart transplantation, avoiding maintenance corticosteroid immunosuppression is associated with normal growth velocity in the majority of patients. With marked improvements in patient and graft survival rates in pediatric organ recipients, quality of life issues, such as normal adult height, should now receive paramount attention. In general, normal growth following solid organ transplantation should be an achievable goal that results in normal adult height.

Long-term outcome of liver transplantation in childhood: A study of 20-year survivors

“…Steroid‐free immunosuppressive regimens may contribute to better growth, but this is debated, and arguments have been made to mitigate the role of steroid therapy in growth retardation, even more so when alternate‐day therapy is used . Efforts to mitigate renal damage in children undergoing organ transplantation might be effective, as impaired renal function has a significant effect on growth velocity; this effect was indeed found in the current report. The good combined outcome on growth and on renal function 10 years after transplantation in Korean children suggests that, early on, a low‐dose calcineurin inhibitor combined with mycophenolate mofetil, and later on, a very low‐dose calcineurin inhibitor or the withdrawal of the calcineurin inhibitor could help to improve growth as well as renal function …”

The Renal Transplant Patient—Updates for the Pediatrician

“…As in the general pediatric population, childhood overweight and obesity are significant health challenges in children after kidney transplantation. Optimization of nutritional status is often difficult in growing children awaiting transplant, likely influenced by multiple factors including reduced appetite (uremia), increased catabolic state (acidosis), loss of potential nutrients in dialysate, and chronic inflammation [4,34]. Weight gain after kidney transplantation, indiscriminant of recipient age, may well be an appropriate result of improved appetite and reversal of the uremic milieu.…”

“…Acute rejection rates have fallen to an all-time low, from over 50 % (1987)(1988)(1989)(1990)(1991) to close to 10 % (2007-2013) at 1 year after kidney transplantation [3]. Introduction of human recombinant growth hormone together with reduction of corticosteroid use in immunosuppression protocols has proven to complement the remarkable catch-up growth observed in children (especially those under 6 years of age) after trend toward normalization of filtering function with kidney transplantation [4][5][6]. Malignancy in children after kidney transplantation, previously on the rise through the early 2000s, has shown a more encouraging shift in the recent decade with a healthy reversal of the historical upward trend [3].…”

Pediatric Malnutrition

“…Corticosteroid exposure has been shown to be negatively associated with post–solid organ transplant linear growth 82 – 85 . Chronic corticosteroid use is not limited to solid organ transplant recipients.…”