Growth and Development After Transplantation Workup

Updated: Oct 16, 2018
  • Author: Meredith J Aull, BPharm, PharmD; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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Workup

Laboratory Studies

Albumin, prealbumin, and retinol-binding protein levels are classic nutritional markers. However, assessment of malnutrition in patients with liver cirrhosis before transplantation cannot rely completely on these tests because those proteins are produced in the liver. There are also many factors that affect albumin levels in children with chronic kidney disease (CKD); thus, it is important to evaluate each child to assess the degree to which the serum albumin reflects nutritional status.

Consider the following:

  • Obtain levels of fat-soluble vitamins (eg, vitamins A, D, and E) and eventually correct deficiencies. Patients on maintenance dialysis may have hypervitaminosis A due to loss of clearance of metabolites that normally occurs in a functional kidney.
  • Obtain prothrombin time (PT) and activated partial thromboplastin time (aPTT).
  • Obtain cholesterol and triglyceride levels.
  • Important mineral elements that can be deficient in these patients include zinc, calcium, and iron.
  • Total lymphocyte count is also a nutritional marker.

In patients with CKD, assess for anemia caused by iron, folate, and erythropoietin deficiency. Patients may be deficient in water-soluble vitamins and minerals; therefore, supplementation should be considered if dietary intake does not meet or exceed dietary reference intakes for children/adolescents, if blood levels are suboptimal, or if the patient shows clinical evidence of deficiency. [31] Monitor calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone for secondary hyperparathyroidism or renal osteodystrophy. These patients may need vitamin D replacement in the pretransplantation and posttransplantation periods.

Lipid profile may be affected by immunosuppressants such as corticosteroids, cyclosporine, or mammalian target of rapamycin (mTOR) inhibitors.

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Imaging Studies

Radiography to assess for renal osteodystrophy is considered inadequate for assessing pediatric patients; however, it may be used to assess skeletal maturation and vascular calcification due to high calcium-phosphate product (CaXP). [31]

Although it is important to obtain bone densitometry (dual-energy x-ray absorptiometry [DEXA] scanning) before transplantation to assess the presence of metabolic bone disease in adults, DEXA is of limited usefulness in children. This is due to lack of adequate pediatric reference data and difficult interpretation in patients with impaired growth, altered body composition, or delayed maturation. Therefore, DEXA should not be used to monitor bone mineral density in pediatric patients with CKD. [31]

Computed tomography (CT) scanning is also not useful to assess renal osteodystrophy in pediatric patients. [31]

In patients with end-stage renal disease (ESRD) and uncontrollable secondary hyperparathyroidism or renal osteodystrophy, perform a parathyroid scan. If the scan shows parathyroid gland hyperplasia, the patient may need parathyroidectomy before transplantation.

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Other Tests

Body composition measurements have been used to assess nutritional status in pediatric patients before and after liver transplantation. These include total body potassium measurement, neutron activation, total body electrical conductivity, and dual-energy x-ray absorptiometry (DEXA) scanning. Unfortunately, only a few centers have these methodologies available. Delayed skin hypersensitivity has been used to assess nutritional status. However, the test is not very accurate in patients with liver transplants.

The criterion standard for assessing bone disease in pediatric patients with CKD is bone biopsy (quantitative bone histomorphometry with double-tetracycline labeling), although it is rarely performed in clinical practice. [31]

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