Pediatr Transplantation 2014: 18: 280–287
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Pediatric Transplantation DOI: 10.1111/petr.12239
Hypoalbuminemia and poor growth predict worse outcomes in pediatric heart transplant recipients Castleberry C, White-Williams C, Naftel D, Tresler MA, Pruitt E, Miyamoto SD, Murphy D, Spicer R, Bannister L, Schowengerdt K, Gilmore L, Kaufman B, Zangwill S. Hypoalbuminemia and poor growth predict worse outcomes in pediatric heart transplant recipients. Abstract: Children with end-stage cardiac failure are at risk of HA and PG. The effects of these factors on post-transplant outcome are not well defined. Using the PHTS database, albumin and growth data from pediatric heart transplant patients from 12/1999 to 12/2009 were analyzed for effect on mortality. Covariables were examined to determine whether HA and PG were risk factors for mortality at listing and transplant. HA patients had higher waitlist mortality (15.81% vs. 10.59%, p = 0.015) with an OR of 1.59 (95% CI 1.09–2.30). Survival was worse for patients with HA at listing and transplant (p ≤ 0.01 and p = 0.026). Infants and patients with congenital heart disease did worse if they were HA at time of transplant (p = 0.020 and p = 0.028). Growth was poor while waiting with PG as risk factor for mortality in multivariate analysis (p = 0.008). HA and PG are risk factors for mortality. Survival was worse in infants and patients with congenital heart disease. PG was a risk factor for mortality in multivariate analysis. These results suggest that an opportunity may exist to improve outcomes for these patients by employing strategies to mitigate these risk factors.
Chesney Castleberry1, Connie WhiteWilliams2, David Naftel2, Margaret A. Tresler2, Elizabeth Pruitt2, Shelley D. Miyamoto3, Debbie Murphy4, Robert Spicer5, Louise Bannister6, Kenneth Schowengerdt7, Lisa Gilmore8, Beth Kaufman9 and Steven Zangwill10 1
Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA, 2University of Alabama at Birmingham, Birmingham, AL, USA, 3Children’s Hospital Colorado, Denver, CO, USA, 4Indiana University, Indianapolis, IN, USA, 5Children’s Hospital of Omaha, Omaha, NE, USA, 6Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada, 7St. Louis University, St. Louis, MI, USA, 8Columbia University, New York, NY, USA, 9 Stanford University, Palo Alto, CA, USA, 10 Children’s Hospital of Wisconsin, Milwaukee, WI, USA Key words: pediatric – heart transplant – hypoalbuminemia – nutrition – weight – outcomes Chesney Castleberry, 3333 Burnet Ave, MLC 2003, Cincinnati, OH 45229-3026, USA Tel.: 513 803 2913 Fax: 513 803 4493 E-mail: [email protected] Accepted for publication 24 January 2014
Albumin is an important plasma protein crucial to maintenance of adequate oncotic pressure, as well as having anti-inflammatory and antioxidant properties (1). Poor nutritional status may lead to impairment in albumin synthesis although hepatic function, insulin levels, and oncotic pressure also influence albumin levels (2– 5). Both HA and poor nutritional status have been studied independently and have been linked to poor prognosis in adult heart failure and transplant patients (2–8). One study in pediatrics found that low body mass index was associated
with poor outcome; however, analysis from larger registries did not see decreased survival after transplant based on ideal body weight and BMI calculations (9–11). No pediatric heart transplant study has been performed to assess the risk of HA either at time of listing or transplant. Our purpose was to determine the effect of PG, specifically poor weight gain, and HA on survival of pediatric patients listed for heart transplantation and whether the relationship of these two covariables further impacted survival. Methods
Abbreviations: ECMO, extracorporal membrane oxygenator; HA, hypoalbuminemia; OR, odds ratio; PG, poor growth; PLE, protein losing enteropathy; VAD, ventricular assist device; WAZ, weight for age z score.
280
The Pediatric Heart Transplant Study database includes comprehensive, validated data from 35 pediatric heart transplant institutions. This prospective, event-driven database collects information on pediatric patients (age
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Pediatric Transplantation DOI: 10.1111/petr.12239
Hypoalbuminemia and poor growth predict worse outcomes in pediatric heart transplant recipients Castleberry C, White-Williams C, Naftel D, Tresler MA, Pruitt E, Miyamoto SD, Murphy D, Spicer R, Bannister L, Schowengerdt K, Gilmore L, Kaufman B, Zangwill S. Hypoalbuminemia and poor growth predict worse outcomes in pediatric heart transplant recipients. Abstract: Children with end-stage cardiac failure are at risk of HA and PG. The effects of these factors on post-transplant outcome are not well defined. Using the PHTS database, albumin and growth data from pediatric heart transplant patients from 12/1999 to 12/2009 were analyzed for effect on mortality. Covariables were examined to determine whether HA and PG were risk factors for mortality at listing and transplant. HA patients had higher waitlist mortality (15.81% vs. 10.59%, p = 0.015) with an OR of 1.59 (95% CI 1.09–2.30). Survival was worse for patients with HA at listing and transplant (p ≤ 0.01 and p = 0.026). Infants and patients with congenital heart disease did worse if they were HA at time of transplant (p = 0.020 and p = 0.028). Growth was poor while waiting with PG as risk factor for mortality in multivariate analysis (p = 0.008). HA and PG are risk factors for mortality. Survival was worse in infants and patients with congenital heart disease. PG was a risk factor for mortality in multivariate analysis. These results suggest that an opportunity may exist to improve outcomes for these patients by employing strategies to mitigate these risk factors.
Chesney Castleberry1, Connie WhiteWilliams2, David Naftel2, Margaret A. Tresler2, Elizabeth Pruitt2, Shelley D. Miyamoto3, Debbie Murphy4, Robert Spicer5, Louise Bannister6, Kenneth Schowengerdt7, Lisa Gilmore8, Beth Kaufman9 and Steven Zangwill10 1
Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA, 2University of Alabama at Birmingham, Birmingham, AL, USA, 3Children’s Hospital Colorado, Denver, CO, USA, 4Indiana University, Indianapolis, IN, USA, 5Children’s Hospital of Omaha, Omaha, NE, USA, 6Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada, 7St. Louis University, St. Louis, MI, USA, 8Columbia University, New York, NY, USA, 9 Stanford University, Palo Alto, CA, USA, 10 Children’s Hospital of Wisconsin, Milwaukee, WI, USA Key words: pediatric – heart transplant – hypoalbuminemia – nutrition – weight – outcomes Chesney Castleberry, 3333 Burnet Ave, MLC 2003, Cincinnati, OH 45229-3026, USA Tel.: 513 803 2913 Fax: 513 803 4493 E-mail: [email protected] Accepted for publication 24 January 2014
Albumin is an important plasma protein crucial to maintenance of adequate oncotic pressure, as well as having anti-inflammatory and antioxidant properties (1). Poor nutritional status may lead to impairment in albumin synthesis although hepatic function, insulin levels, and oncotic pressure also influence albumin levels (2– 5). Both HA and poor nutritional status have been studied independently and have been linked to poor prognosis in adult heart failure and transplant patients (2–8). One study in pediatrics found that low body mass index was associated
with poor outcome; however, analysis from larger registries did not see decreased survival after transplant based on ideal body weight and BMI calculations (9–11). No pediatric heart transplant study has been performed to assess the risk of HA either at time of listing or transplant. Our purpose was to determine the effect of PG, specifically poor weight gain, and HA on survival of pediatric patients listed for heart transplantation and whether the relationship of these two covariables further impacted survival. Methods
Abbreviations: ECMO, extracorporal membrane oxygenator; HA, hypoalbuminemia; OR, odds ratio; PG, poor growth; PLE, protein losing enteropathy; VAD, ventricular assist device; WAZ, weight for age z score.
280
The Pediatric Heart Transplant Study database includes comprehensive, validated data from 35 pediatric heart transplant institutions. This prospective, event-driven database collects information on pediatric patients (age
