Medical adherence in pediatric organ transplantation

Shellmer, Diana A.; Dabbs, Annette DeVito; Dew, Mary Amanda

doi:10.1097/mot.0b013e32834a8c89

Cited by 61 publications

(62 citation statements)

References 46 publications

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“…The increased risk of graft loss during late adolescence and early adulthood may be due to adolescents' lack of adherence to immunosuppression (11)(12)(13)(14)(15)(16)(17). Given the extension of the high-risk age window into early adulthood, the effect of this nonadherence on graft survival is probably delayed, or, alternatively, the lack of adherence may also extend into early adulthood.…”

Section: Discussionmentioning

confidence: 99%

Age at Graft Loss after Pediatric Kidney Transplantation

Arendonk

James

Boyarsky

et al. 2013

Clinical Journal of the American Society of Nephrology

109

101

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SummaryBackground and objective The risk of graft loss after pediatric kidney transplantation increases during late adolescence and early adulthood, but the extent to which this phenomenon affects all recipients is unknown. This study explored interactions between recipient factors and this high-risk age window, searching for a recipient phenotype that may be less susceptible during this detrimental age interval.Design, setting, participants, & measurements With use of Scientific Registry of Transplant Recipients data from 1987 to 2010, risk of graft loss across recipient age was quantified using a multivariable piecewise-constant hazard rate model with time-varying coefficients for recipient risk factors.Results Among 16,266 recipients, graft loss during ages $17 and ,24 years was greater than that for both 3-17 years (adjusted hazard ratio [aHR], 1.61; P,0.001) and $24 years (aHR, 1.28; P,0.001). This finding was consistent across age at transplantation, sex, race, cause of renal disease, insurance type, pretransplant dialysis history, previous transplant, peak panel-reactive antibody (PRA), and type of induction immunosuppression. The high-risk window was seen in both living-donor and deceased-donor transplant recipients, at all levels of HLA mismatch, regardless of centers' pediatric transplant volume, and consistently over time. The relationship between graft loss risk and donor type, PRA, transplant history, insurance type, and cause of renal disease was diminished upon entry into the high-risk window.Conclusions No recipient subgroups are exempt from the dramatic increase in graft loss during late adolescence and early adulthood, a high-risk window that modifies the relationship between typical recipient risk factors and graft loss.

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Section: Discussionmentioning

confidence: 99%

Age at Graft Loss after Pediatric Kidney Transplantation

Arendonk

James

Boyarsky

et al. 2013

Clinical Journal of the American Society of Nephrology

109

101

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“…33,34 This high-risk period, which is typically attributed to poor adherence to immunosuppression, [35][36][37][38][39][40][41][42] alterations in health insurance coverage, [43][44][45] or difficulties with transition between pediatric and adult posttransplant care, 39,46-51 may explain the dampened improvements that were seen in long-term graft survival despite more impressive short-term improvements.…”

Section: Discussionmentioning

confidence: 99%

National Trends Over 25 Years in Pediatric Kidney Transplant Outcomes

et al. 2014

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WHAT'S KNOWN ON THIS SUBJECT: Kidney transplantation is the optimal treatment of children with end-stage renal disease. The field of pediatric kidney transplantation has changed over time with regard to immunosuppression, surgical technique, organ allocation policy, and rates of living donor transplantation. WHAT THIS STUDY ADDS:Outcomes after pediatric kidney transplantation in the United States have improved over time, independent of changes in recipient, donor, and transplant characteristics. These improvements were most dramatic within the first posttransplant year and among the most highly sensitized patients. abstract OBJECTIVE: To investigate changes in pediatric kidney transplant outcomes over time and potential variations in these changes between the early and late posttransplant periods and across subgroups based on recipient, donor, and transplant characteristics. METHODS:Using multiple logistic regression and multivariable Cox models, graft and patient outcomes were analyzed in 17 446 pediatric kidneyonly transplants performed in the United States between 1987 and 2012.RESULTS: Ten-year patient and graft survival rates were 90.5% and 60.2%, respectively, after transplantation in 2001, compared with 77.6% and 46.8% after transplantation in 1987. Primary nonfunction and delayed graft function occurred in 3.3% and 5.3%, respectively, of transplants performed in 2011, compared with 15.4% and 19.7% of those performed in 1987. Adjusted for recipient, donor, and transplant characteristics, these improvements corresponded to a 5% decreased hazard of graft loss, 5% decreased hazard of death, 10% decreased odds of primary nonfunction, and 5% decreased odds of delayed graft function with each more recent year of transplantation. Graft survival improvements were lower in adolescent and female recipients, those receiving pretransplant dialysis, and those with focal segmental glomerulosclerosis. Patient survival improvements were higher in those with elevated peak panel reactive antibody. Both patient and graft survival improvements were most pronounced in the first posttransplant year. CONCLUSIONS:Outcomes after pediatric kidney transplantation have improved dramatically over time for all recipient subgroups, especially for highly sensitized recipients. Most improvement in graft and patient survival has come in the first year after transplantation, highlighting the need for continued progress in long-term outcomes. The field of pediatric KT has evolved over the past 25 years, including changes in immunosuppression, surgical technique, organ allocation policy, and rates of living donor transplantation. 4 However, the relationship between these changes and post-KT outcomes remains unclear, both in terms of which patient phenotypes have been affected and when any changes in outcomes have occurred (ie, early versus late post-KT).The objective of this study was to examine changes in pediatric KToutcomes over the last 25 years. In particular, our work sought to assess trends in graft survival, rates of primary nonfunct...

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“…The adolescent age range itself is independently associated with worse survival (1), with non-adherence being linked to late rejection and to high rates of death in adolescents (68). The ability and willingness to follow medical recommendations, biological factors, and the normal developmental challenges of adolescence that affect the ability to self-monitor and self-care all play a role in non-adherence (68)(69)(70). Identification and confirmation is challenging and can strain the relationships between the medical team, the adolescent and the family.…”

Section: Non-adherencementioning

confidence: 99%

Current state of pediatric cardiac transplantation

Dipchand

2018

Ann. Cardiothorac. Surg.

110

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Pediatric heart transplantation is standard of care for children with end-stage heart failure. The diverse age range, diagnoses, and practice variations continue to challenge the development of evidence-based practices and new technologies. Outcomes in the most recent era are excellent, especially with the more widespread use of ventricular assist devices (VADs). Waitlist mortality remains high and knowledge of risk factors for death while waiting and following transplantation contributes to decision-making around transplant candidacy and timing of listing. The biggest gap impacting both waitlist and overall survival remains mechanical support options for infants and patients with single ventricle physiology. Though acute rejection has decreased progressively, both diagnosis and management of antibody-mediated rejection has become increasingly challenging and complex, as has the ability to understand the implication of anti-HLA antibodies detected both pre-and post-transplantation-including when and how to intervene. Trends in immunosuppression protocols include more use of induction therapy and steroid avoidance or withdrawal protocols. Common long-term morbidities include renal insufficiency, which can be mitigated with surveillance and renal-sparing strategies, and infections. Functional outcomes are excellent, but significant psychosocial challenges exist in relation to neurodevelopment, non-adherence, and transition from childcentered to adult-centered care. Cardiac allograft vasculopathy (CAV) remains a barrier to long-term survival, though it is more apparent that objective evidence of an impact on the allograft is important with regards to impact on outcomes. Retransplantation is rare in pediatric heart transplant recipients. Pediatric heart transplantation continues to evolve in order to address the challenges of the diverse group of patients that reach end-stage heart failure during childhood.

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Medical adherence in pediatric organ transplantation

Cited by 61 publications

References 46 publications

Age at Graft Loss after Pediatric Kidney Transplantation

Age at Graft Loss after Pediatric Kidney Transplantation

National Trends Over 25 Years in Pediatric Kidney Transplant Outcomes

Current state of pediatric cardiac transplantation

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