The effect of transfer to adult transplant care on kidney function and immunosuppressant drug level variability in pediatric kidney transplant recipients

Abstract

Adolescent age at time of transplant has been recognized as a risk factor for renal allograft loss. Increased risk for graft failure may persist from adolescence to young adulthood. Transfer of care is hypothesized as a risk factor for non‐adherence and graft loss. We explored whether kidney allograft function declined at an accelerated rate after transfer of care to adult transplant centers and whether coefficient of variation of tacrolimus (CV TAC) trough levels predicted allograft loss. Single‐center, retrospective chart review was performed for pediatric kidney transplant recipients who received transplants between 1999 and 2011. Change in eGFR pre‐ and post‐transfer was performed via a linear mixed‐effects model. CV TAC was calculated in transplant recipients with TAC data pre‐ and post‐transfer. t test was performed to determine the difference between means of CV TAC in subjects with and without allograft loss following transfer of care. Of the 138 subjects who transferred to adult care, 47 subjects with data pre‐ and post‐transfer demonstrated a decrease in the rate of eGFR decline post‐transfer from 8.0 mL/min/1.73 m2 per year to 2.1 mL/min/1.73 m2 per year, an ~80% decrease in eGFR decline post‐transfer (P = 0.01). Twenty‐four subjects had CV TAC data pre‐ and post‐transfer of care. Pretransfer CV TAC for subjects with allograft loss post‐transfer was significantly higher than in subjects without allograft loss (49% vs 26%, P < 0.05). Transfer of care was not independently associated with acceleration in eGFR decline. CV TAC may aid in identifying patients at risk for allograft loss post‐transfer.

Long-Term Care of the Pediatric Kidney Transplant Recipient

“…Viral infections such as cytomegalovirus (CMV), Epstein-Barr virus (EBV), and polyoma virus may have more severe consequences in infection-naïve pediatric recipients (4)(5)(6)(7)(8). Furthermore, not only must pediatric transplant recipients get through the high-risk interval in the early post-transplant period, but they must also traverse a second high-risk period of adolescence and young adulthood, during which immunologic risk may be heightened and medication adherence may be suboptimal (9)(10)(11).…”

Medication adherence in pediatric kidney transplantation: How to build a bridge over troubled water

“…Some studies also attribute the higher risk of graft loss within this age period to transitioning from pediatric to adult care, yet others did not observe a higher nonadherence or graft failure risk within the transition period. 10,[12][13][14] Several papers describe potential risk factors for poor adherence, including patient-related factors (e.g., poor knowledge, forgetfulness, side effects, psychological difficulties) as well as family related characteristics (e.g., socioeconomic status, parental oversight of medication intake, poor social support). 5,6,[15][16][17] In contrast to adult patients, morning doses seem to be more difficult for young patients to remember than evening doses as well as weekends being more difficult than weekdays.…”

“…Indeed, adolescence is characterized by a phase of neurocognitive development between the ages of 10 and late twenties during which impulsivity, risk‐taking behavior, and disproportionate emotional reactions are the reflection of immaturity of certain brain regions. Some studies also attribute the higher risk of graft loss within this age period to transitioning from pediatric to adult care, yet others did not observe a higher nonadherence or graft failure risk within the transition period 10,12–14 . Several papers describe potential risk factors for poor adherence, including patient‐related factors (e.g., poor knowledge, forgetfulness, side effects, psychological difficulties) as well as family related characteristics (e.g., socioeconomic status, parental oversight of medication intake, poor social support) 5,6,15–17 .…”

Psychosocial impact of structured transfer of adolescents with kidney transplants to adult services: An interventional national cohort study

“…Transition, including transfer, coincides with a vulnerable phase of the adolescents' lives, governed by high‐risk behaviors secondary to cognitive and psychosocial development 3 . A structured protocol can improve the patients' adherence to regular medication and their engagement with healthcare providers when judged by reduced acute rejection episodes and improved long‐term graft outcomes 4–8 . It has been well‐recognized that medical and psychosocial problems must be addressed during the transition 9 .…”

“…3 A structured protocol can improve the patients' adherence to regular medication and their engagement with healthcare providers when judged by reduced acute rejection episodes and improved long-term graft outcomes. [4][5][6][7][8] It has been well-recognized that medical and psychosocial problems must be addressed during the transition. 9 Although it has been established that transfer by a single referral letter is inadequate to optimize outcomes, 10 limited research exists addressing the impact of a structured protocol on adolescents' psychological distress during transfer.…”