Further Outpatient Care
Special-education services, speech therapy, and physical therapy were required in 63% of small bowel recipients. These professional services may assist recipients of other organs. [19]
Psychological services may help the child who receives a transplant, as well as the parents and family and caregivers. It may improve the chance of a rapid nutritional rehabilitation.
Cyclosporine may cause gingival hyperplasia. Dental hygienic therapy 2-4 times a year decreases gingival overgrowth.
Tacrolimus has been associated with an increased incidence of hyperglycemia and new-onset diabetes mellitus after transplantation. Patients with symptomatic hyperglycemia may require insulin therapy or substitution of tacrolimus with another immunosuppressant.
Sirolimus is associated with hyperlipidemia, which should be treated with lipid-lowering agents or a change of medication to mycophenolate mofetil or other alternate immunosuppressant.
Further Inpatient Care
Aggressive nutritional care is indicated in the immediate postoperative period. Total parenteral nutrition may be necessary, but start enteral feeding as soon as possible.
Because of the large fluid requirements after transplantation, infants and children may need supplemental fluid replacement via nasogastric or gastrostomy tubes.
In the immediate postoperative period, correct nausea, vomiting, and diarrhea, which are often the results of medications used during this period.
Inpatient & Outpatient Medications
Use of antihypertensive medication has been shown to be a factor affecting growth after kidney transplantation. Pediatric patients not receiving antihypertensives during the first posttransplant month had better growth through 3 years after transplantation. [25]
Transfer
Transfer the patient to a transplant center as soon as nutritional deficits appear evident and failure to thrive cannot be corrected medically.
Deterrence/Prevention
Optimize the nutritional status of patients before transplantation to avoid severe growth retardation that cannot be corrected later.
Limit the use of steroids after transplantation, when possible (see Medical Care).
Complications
Liver transplantation in children with severe malnutrition is associated with perioperative complications, including infections, wound closure delay, and increased mortality rates.
Complications of transplantation that may influence growth include the following:
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Graft malfunction and retransplantation
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Chronic rejection [39]
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Cholestasis
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Obesity (resulting from steroids)
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Cardiovascular disease (hypertension, hyperlipidemia)
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Infection (eg, cytomegalovirus [CMV]): CMV may precipitate acute allograft rejection. CMV donor-recipient mismatches are an independent risk factor for poor graft survival.
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Posttransplant lymphoproliferative disorder
Prognosis
The mean height of liver transplant recipients 4 years after transplantation is predicted by their height at the time of transplantation and their cumulative steroid dose. Patients who are severely growth retarded at the time of transplantation have a threefold increased chance of growth retardation 4 years after transplantation. Catch-up growth occurs up to the seventh year after transplantation. Recipients of liver transplants usually have further growth retardation during the first 6 months after surgery but demonstrate good catch-up growth 6-24 months after transplantation.
Although nutritional status usually improves after liver transplantation, approximately 20% of patients require long-term enteral nutrition because of feeding problems.
Children with successful liver and renal transplantation usually attain healthy puberty, although it is delayed. Pregnancies have been reported.
Patient Education
Families with small children waiting for liver transplantation should be educated regarding the risks associated with preoperative malnutrition. Approximately 60% of infants with end-stage liver disease have malnutrition, and 60-80% have growth failure before transplantation. If left untreated, these patients have a poor outcome during transplantation. Early transplantation can be the best option to prevent further growth and development failure. An early referral to a transplantation center appears to be critical. [40, 41, 42]
Patients with CKD should be educated about diet modification to prevent hyperkalemia and renal osteodystrophy. After transplantation, phosphaturia and magnesiuria may develop, especially with the use of calcineurin inhibitors, and these losses must be corrected with oral supplementation. Hyperglycemia, hyperlipidemia, and obesity may also develop and should be avoided or corrected.
For patient education resources, see the Growth Hormone Deficiency Center, as well as Growth Failure in Children, Growth Hormone Deficiency in Children, Growth Hormone Deficiency, and Growth Hormone Deficiency FAQs.
