Strategies for Optimizing Growth in Children With Kidney Transplants

Tejani, Amir; Butt, Khalid M. H.; Rajpoot, Deepak; González, Rafael; Buyan, Necla; Pomrantz, Andrew; Sharma, Rajesh

doi:10.1097/00007890-198902000-00006

Cited by 77 publications

(21 citation statements)

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“…Although one might predict the significantly higher rate of graft dysfunction or graft loss found in the higher-risk group of patients in this study who never came off steroids, the rate of graft dysfunction or graft loss of 13% in the steroid-free group is considerably lower than the reported rates, which often exceed 50%, in children managed with cyclosporine monotherapy [4,6,10]. Moreover, the overall 5-year actuarial graft survival in our steroid-free group, which comprises 41% living-donor grafts, is 82%.…”

Section: Discussioncontrasting

confidence: 64%

“…Published data clearly indicate that most children who are under the age of 12 years at the time of transplantation and are maintained on cyclosporine-based steroid-free immunosuppression are capable of growth [2][3][4][5][6][7][8][9]. However, such steroid-free regimens are not widely employed because they are associated with a 50%-60% risk for acute cellular rejection (ACR) and a high rate of graft dysfunction or graft loss [4,6,10]. The current study focuses on the clinical course of 52 children who remained off steroids for up to 3 years after transplantation and addresses the key question of whether or not steroid-free tacrolimus-based immunosuppression permits growth without significant compromise to graft function or graft loss.…”

Section: Introductionmentioning

confidence: 99%

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Growth and renal function after steroid-free tacrolimus-based immunosuppression in children with renal transplants

Ellis

2000

Pediatric Nephrology

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Steroid withdrawal after renal transplantation and cyclosporine-based immunosuppression enhances growth in children, but this practice is not widely employed because of a 50%-60% rate of rejection, graft dysfunction, or graft loss. The current study evaluates growth and renal function after withdrawal and discontinuation of steroids within 1 year of transplantation in 52 children receiving tacrolimus (FK-506)-based immunosuppression. Height Z-score, weight-for-height index (WHI), and body mass index (BMI), as well as graft loss and calculated creatinine clearance as a measure of glomerular filtration rate (GFR), were assessed. Children were divided into three groups according to age at transplantation: group I, 16 children aged 0-5 years; group II, 17 children aged 6-12 years; group III, 19 children aged 13-16 years. Significant and sustained improvement in height occurred in groups I and III, with Z-scores increasing by 1.51 and 1.57 standard deviations at 3 years after transplantation compared with the Z-score at transplantation (P<0.02). Mean WHI values remained near 100% in groups I and III, and significantly increased above 100% only in group II at 2 years after transplantation. Although actual BMI scores improved significantly in groups II and III at both 2 and 3 years post transplantation (P<0.05), when BMI scores were adjusted for height age, none of these groups had values >95% denoting obesity. Failure of steroid withdrawal, defined as reinstitution of steroids, graft dysfunction, or graft loss, occurred in 9 of 68 (13%) children who underwent steroid withdrawal at any time after transplantation, and resulted in graft dysfunction or graft loss in 5 (7%). Over a 3-year period, rates of renal dysfunction, as manifested by >50% rise in the serum creatinine level above baseline, or graft loss were lower in these 68 children compared with 8 children who never had steroid withdrawal (P<0.05). Mean GFR at 3 years after transplantation ranged from 96 to 102 ml/min per 1.73 m2 in all three steroid withdrawal groups, and remained stable during the 3 years of follow-up. These data indicate that steroid withdrawal enables normalization of growth without obesity, and without imposing an excessive risk for graft dysfunction or graft loss.

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Section: Discussioncontrasting

confidence: 64%

Section: Introductionmentioning

confidence: 99%

Growth and renal function after steroid-free tacrolimus-based immunosuppression in children with renal transplants

Ellis

2000

Pediatric Nephrology

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“…Steroids result in nearly universal growth retardation in children despite dose minimization [13]. The mean pretransplant height in children has improved with better attention to dialysis, nutrition and increasing growth hormone use.…”

Section: Introductionmentioning

confidence: 99%

Corticosteroid avoidance in pediatric renal transplantation

Vidhun

Sarwal

2005

Pediatr Nephrol

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Corticosteroids have played a central role in the evolution of renal transplant as the modality of choice for renal replacement in end stage kidney disease. Their use is associated with significant, dose related morbidity including osseous, cardiovascular, metabolic complications, body disfigurement and growth retardation in children. The strategies that have been employed to minimize these side effects include reduction in the daily administered dose of steroids, use of alternate day dosing regimens, steroid withdrawal post-transplantation and complete steroid avoidance. Steroid dose minimization has been associated with increased rates of acute rejection, though introduction of newer and more potent immunosuppressives has helped reduce the incidence of this complication. Steroid minimization will benefit patient morbidity due to cataracts, cardiovascular and osseous complications, but may offer little benefit towards improving linear growth. Alternate day steroid therapy may have a greater impact on growth improvement, but may be troubled by regimen non-adherence. Steroid withdrawal post-transplant, the ultimate target, is successful in a cohort of patients, but overall, has been historically associated with unacceptably high rates of clinical acute rejection, and has thus been used sparingly in adults and even less so in children. Complete corticosteroid avoidance, using newer induction and immunosuppressive agents, has been associated with an 8-23% incidence of acute rejection in pediatric renal transplant patients, significant catch-up growth post-transplant, improvements in post-transplant hypertension and hyperlipidemia, and a high safety profile at current follow-up. Newer induction protocols may allow complete steroid-free immunosuppression thus offering significant advantages in preventing the above-mentioned steroid related morbidity, which could also possibly be applicable to other areas of solid organ transplantation in all age groups.

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“…Additionally, corticosteroids have been shown to suppress GH peaks during a 24-h study period (28)(29)(30). Abnormal GH responses to arginine and L-DOPA stimulation were observed in some pediatric renal allograft recipients on corticosteroid treatment (31,32 (36)(37)(38)(39)(40). No significant adverse effect on renal function was noted in these studies.…”

Section: Growth Hormone and Corticosteroidinduced Growth Failurementioning

confidence: 83%