Medical Care
Nutritional care of the pediatric patient must be viewed as a continuum between the pretransplant and posttransplant periods.
Immunosuppression
Tailor the patient’s immunosuppression regimen to ensure adequate suppression of the immune system while attempting to minimize comorbidities such as growth impairment.
Corticosteroids
An alternate-day schedule can be useful in patients who cannot be completely withdrawn from corticosteroids.
A complete withdrawal from steroids can often be achieved in individuals after liver transplantation.
Early corticosteroid withdrawal has been studied in select pediatric kidney transplant recipients and does have positive effect on growth in certain pediatric patients.
A subgroup analysis of a randomized controlled trial of steroid withdrawal performed by Sarwal and colleagues found that patients younger than 5 years at time of kidney transplantation in the steroid-free arm had improvement in linear growth at 3 years after transplantation. [32] It is important to note that corticosteroid doses in the arm that remained on maintenance corticosteroids was low, which may have affected results.
In the TWIST study, another randomized controlled trial, patients in the steroid-free arm experienced significantly better linear growth compared with patients who remained on maintenance corticosteroids. [33] Subgroup analysis found that steroid-free prepubertal patients experienced the most benefit in terms of growth.
Steroid-free regimens have also been studied in pediatric intestinal transplantation using rabbit antithymocyte globulin induction therapy and tacrolimus. [34] Steroid-free patients experienced a more rapid time to nutritional autonomy and positive growth compared with those patients remaining on steroids.
Recombinant human growth factor
Guidelines exist to direct clinicians considering use of recombinant human growth factor (rhGH) in pediatric patients with chronic kidney disease (CKD). [31] Guidance is also available for use of rhGH in pediatric kidney transplant recipients. [35]
Analysis of the NAPRTCS Transplant Registry compared 513 kidney transplant recipients who received rhGH to 2263 who did not receive rhGH, and found the following results [36] :
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Patients younger than 10 years at the time of rhGH initiation achieved better incremental increases in height.
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rhGH-treated patients had a significantly better final adult height compared with patients who did not receive rhGH.
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Allograft function, acute rejection, and graft failure rates were similar between groups. Only patients who had an acute rejection episode prior to rhGH initiation appear to be at higher risk for a subsequent rejection episode.
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Adverse events—including increased intracranial pressure, avascular necrosis, slipped capital femoral epiphysis, and malignancy—did not differ between the groups.
Small, preliminary trials of rhGH in liver recipients have demonstrated the drug to be effective in children with low height standard-deviation score. [27, 37, 38]
Provide treatment of bacterial overgrowth or other gastrointestinal infections. This is important to prevent further malabsorption. Use a broad-spectrum antibiotic with good gram-negative and anaerobic coverage. Monitor for and promptly correct electrolyte imbalances.
Assess metabolic bone disease. Fractures are a common occurrence in transplant recipients, but can be prevented with supplementation of calcium and vitamin D, physical activity, and avoidance of osteopenic medications. Because the immediate posttransplantation period is characterized by marked bone loss, carefully monitor children at risk for fractures. Children with severe cholestasis before transplantation are at higher risk for bone disease.
Surgical Care
Timing of transplantation appears to be critical in avoiding failure of postoperative growth. [12, 28] Children who receive transplants at younger ages are more likely to reach normal heights.
Postoperative complications, such as infections, surgical complications, and mortality, correlate with the pretransplantation height.
Healthy development may be obtained if transplantation is performed before the occurrence of significant neurologic deficits and retardation.
Patients with CKD and persistent nephrotic syndrome with significant urinary protein losses may benefit from native nephrectomies before transplantation.
Consultations
A dietician should be consulted. The dietitian should record anthropometric measures and determine caloric requirements for each child. Children who are malnourished and require supplemental feedings with nasogastric or gastrostomy feedings frequently have food aversions or delays in accepting oral feedings. Consultation with a feeding therapist can be helpful in such cases. Speech may also be delayed, in which case a speech therapist should be consulted.
Diet
Intensive preoperative nutritional therapy is critical in children undergoing liver transplantation. Diet should be highly caloric and rich in protein and should continue for at least 2-3 years after liver transplantation. Infants with biliary atresia should receive at least 140 kcal/kg/d. Nasogastric feedings may be needed to achieve this goal.
An elemental diet may be useful in the presence of malabsorption. Protein restriction for hepatic encephalopathy is rarely necessary in children, as compared with adults. Medium-chain triglycerides may be added because they are successfully absorbed in patients with cholestasis. However, at least 10% of total energy requirements should be provided by long-chain triglycerides to prevent deficiency of essential fatty acids.
The diet should also prevent specific nutritional deficits. Fat-soluble vitamins and multivitamin preparations are recommended.
Occasional hypercholesterolemia may develop after transplantation. Institute an appropriate diet.
Patients on peritoneal dialysis before transplantation may require protein supplementation. After transplantation, the diet should be appropriate for age, with careful monitoring for side effects of the immunosuppressant medications, including hyperglycemia, hyperlipidemia, and obesity.
