Nutrition in Clinical Practice http://ncp.sagepub.com/
Nutrition Management After Pediatric Solid-Organ Transplantation Meheret Asfaw, Jillian Mingle, Jessica Hendricks, Maegan Pharis and Anita M. Nucci Nutr Clin Pract published online 12 February 2014 DOI: 10.1177/0884533614521242 The online version of this article can be found at: http://ncp.sagepub.com/content/early/2014/02/10/0884533614521242 A more recent version of this article was published on - Mar 13, 2014
Published by: http://www.sagepublications.com
On behalf of:
The American Society for Parenteral & Enteral Nutrition
Additional services and information for Nutrition in Clinical Practice can be found at: Email Alerts: http://ncp.sagepub.com/cgi/alerts Subscriptions: http://ncp.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
Version of Record - Mar 13, 2014 >> OnlineFirst Version of Record - Feb 12, 2014 What is This?
Downloaded from ncp.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 19, 2014
521242
research-article2014 Asfaw et al
NCPXXX10.1177/0884533614521242Nutrition in Clinical PracticeAsfaw et al.
Invited Review
Nutrition Management After Pediatric Solid-Organ Transplantation
Nutrition in Clinical Practice Volume XX Number X Month 201X 1–9 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614521242 ncp.sagepub.com hosted at online.sagepub.com
Meheret Asfaw, MMSc, RD, CSP, CNSC, LD1; Jillian Mingle, MS, RD, CSP, LD1; Jessica Hendricks, MS, RD, CSP, LD1; Maegan Pharis, MS, RD, LD1; and Anita M. Nucci, PhD, MPH, RD, LD2
Abstract Survival rates for pediatric transplant recipients and organ grafts have increased due to improvements in surgical techniques and with immunosuppressant treatment therapies. Interdisciplinary management after pediatric organ transplantation is essential to assist not only with the complex medical issues and complications that can result from immunosuppressant therapy but also with the achievement of normal growth and development. Impaired growth is a complication frequently experienced by pediatric transplant patients. The presence or absence of impaired growth is affected by the length of illness prior to transplant, graft function, the use of corticosteroids, and the development of infectious complications after surgery. A review of posttransplant nutrition assessment, nutrition requirements, and nutrition goals is provided. In addition, a case series of experiences with nutrition management of pediatric solid-organ transplant recipients is described. (Nutr Clin Pract. XXXX;xx:xx-xx)
Keywords pediatrics; nutrition assessment; nutrition therapy; nutritional support; organ transplantation
Transplantation of the liver, kidney, and heart has been successfully performed in the pediatric population for several decades.1 Survival rates of solid-organ transplant recipients have appreciably improved over this period with greater than 80% of patients now surviving into adolescence and young adulthood.2-6 Advancements in surgical techniques and immunosuppressive therapies have contributed greatly to these improved rates. While transplant patients face many complications following surgery, the success of solid-organ transplantation has transformed what once was an end-stage disease into a more manageable clinical situation. The diagnoses that lead to the majority of liver transplants in children include biliary atresia, acute hepatic necrosis, and metabolic disease.1 Children with kidney dysplasia, obstructive uropathy, or glomerular sclerosis may be considered candidates for kidney transplant while congenital disease and cardiomyopathies are the most common indications for heart transplantation.1 A distinct challenge to the pediatric transplant population and their healthcare providers is achieving normal growth following transplantation. The essential immunosuppressive drugs and steroids needed for posttransplant patients and allograft survival are accompanied by growth-inhibiting side effects.7 Oftentimes, the pediatric patient has already experienced a degree of growth delay due to his or her pretransplant disease state.8 Optimal nutrition, both pre- and posttransplant, is imperative for posttransplant recovery and continued growth and development. Medical nutrition therapy is an essential component of postoperative pediatric transplant
patient care to support catch-up growth, neurodevelopment, and quality of life. Children’s Healthcare of Atlanta has performed more than 1000 pediatric transplants since the inception of the transplant services program and is one of the leading pediatric hospitals in the United States for pediatric transplantation.9 Clinical dietitians in the hospital Department of Clinical Nutrition participate in the interdisciplinary care of these children during hospitalization and outpatient clinic visits. The purpose of this study is to review posttransplant nutrition assessment, nutrition requirements, and nutrition management approaches with each of the following solid organs: liver, kidney, and heart. In addition, 3 case studies will highlight nutrition problems commonly encountered in this population.
From the 1Department of Clinical Nutrition, Children’s Healthcare of Atlanta, Atlanta, Georgia, and 2Department of Nutrition, Georgia State University, Atlanta, Georgia. Financial disclosure: None declared. Corresponding Author: Anita M. Nucci, PhD, MPH, RD, LD, Department of Nutrition, Georgia State University, PO Box 3995, Atlanta, GA 30302-3995, USA. Email: [email protected].
Downloaded from ncp.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 19, 2014
2
Nutrition in Clinical Practice XX(X)
Nutrition Assessment A thorough pretransplant nutrition assessment is essential to determine anthropometric status; evaluate signs of nutrient deficiency; assess biochemical tests to determine the need to adjust nutrients and electrolytes in the oral, enteral nutrition (EN), or parenteral nutrition (PN) prescription; and obtain a dietary history for preferences and tolerances. This process will help to maximize a child’s nutrition status and increase the chance of successful outcome after transplantation. Anthropometric measures, including weight, recumbent length (until 2 years of age) or height, weight-for-length or height, and occipital head circumference (if 2 years of age. In addition, z scores should be calculated as they provide a more precise description of anthropometric status than percentiles. The severity of malnutrition can be classified using newly published cutoffs as follows: mild malnutrition or at risk of malnutrition (z score
Nutrition Management After Pediatric Solid-Organ Transplantation Meheret Asfaw, Jillian Mingle, Jessica Hendricks, Maegan Pharis and Anita M. Nucci Nutr Clin Pract published online 12 February 2014 DOI: 10.1177/0884533614521242 The online version of this article can be found at: http://ncp.sagepub.com/content/early/2014/02/10/0884533614521242 A more recent version of this article was published on - Mar 13, 2014
Published by: http://www.sagepublications.com
On behalf of:
The American Society for Parenteral & Enteral Nutrition
Additional services and information for Nutrition in Clinical Practice can be found at: Email Alerts: http://ncp.sagepub.com/cgi/alerts Subscriptions: http://ncp.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
Version of Record - Mar 13, 2014 >> OnlineFirst Version of Record - Feb 12, 2014 What is This?
Downloaded from ncp.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 19, 2014
521242
research-article2014 Asfaw et al
NCPXXX10.1177/0884533614521242Nutrition in Clinical PracticeAsfaw et al.
Invited Review
Nutrition Management After Pediatric Solid-Organ Transplantation
Nutrition in Clinical Practice Volume XX Number X Month 201X 1–9 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614521242 ncp.sagepub.com hosted at online.sagepub.com
Meheret Asfaw, MMSc, RD, CSP, CNSC, LD1; Jillian Mingle, MS, RD, CSP, LD1; Jessica Hendricks, MS, RD, CSP, LD1; Maegan Pharis, MS, RD, LD1; and Anita M. Nucci, PhD, MPH, RD, LD2
Abstract Survival rates for pediatric transplant recipients and organ grafts have increased due to improvements in surgical techniques and with immunosuppressant treatment therapies. Interdisciplinary management after pediatric organ transplantation is essential to assist not only with the complex medical issues and complications that can result from immunosuppressant therapy but also with the achievement of normal growth and development. Impaired growth is a complication frequently experienced by pediatric transplant patients. The presence or absence of impaired growth is affected by the length of illness prior to transplant, graft function, the use of corticosteroids, and the development of infectious complications after surgery. A review of posttransplant nutrition assessment, nutrition requirements, and nutrition goals is provided. In addition, a case series of experiences with nutrition management of pediatric solid-organ transplant recipients is described. (Nutr Clin Pract. XXXX;xx:xx-xx)
Keywords pediatrics; nutrition assessment; nutrition therapy; nutritional support; organ transplantation
Transplantation of the liver, kidney, and heart has been successfully performed in the pediatric population for several decades.1 Survival rates of solid-organ transplant recipients have appreciably improved over this period with greater than 80% of patients now surviving into adolescence and young adulthood.2-6 Advancements in surgical techniques and immunosuppressive therapies have contributed greatly to these improved rates. While transplant patients face many complications following surgery, the success of solid-organ transplantation has transformed what once was an end-stage disease into a more manageable clinical situation. The diagnoses that lead to the majority of liver transplants in children include biliary atresia, acute hepatic necrosis, and metabolic disease.1 Children with kidney dysplasia, obstructive uropathy, or glomerular sclerosis may be considered candidates for kidney transplant while congenital disease and cardiomyopathies are the most common indications for heart transplantation.1 A distinct challenge to the pediatric transplant population and their healthcare providers is achieving normal growth following transplantation. The essential immunosuppressive drugs and steroids needed for posttransplant patients and allograft survival are accompanied by growth-inhibiting side effects.7 Oftentimes, the pediatric patient has already experienced a degree of growth delay due to his or her pretransplant disease state.8 Optimal nutrition, both pre- and posttransplant, is imperative for posttransplant recovery and continued growth and development. Medical nutrition therapy is an essential component of postoperative pediatric transplant
patient care to support catch-up growth, neurodevelopment, and quality of life. Children’s Healthcare of Atlanta has performed more than 1000 pediatric transplants since the inception of the transplant services program and is one of the leading pediatric hospitals in the United States for pediatric transplantation.9 Clinical dietitians in the hospital Department of Clinical Nutrition participate in the interdisciplinary care of these children during hospitalization and outpatient clinic visits. The purpose of this study is to review posttransplant nutrition assessment, nutrition requirements, and nutrition management approaches with each of the following solid organs: liver, kidney, and heart. In addition, 3 case studies will highlight nutrition problems commonly encountered in this population.
From the 1Department of Clinical Nutrition, Children’s Healthcare of Atlanta, Atlanta, Georgia, and 2Department of Nutrition, Georgia State University, Atlanta, Georgia. Financial disclosure: None declared. Corresponding Author: Anita M. Nucci, PhD, MPH, RD, LD, Department of Nutrition, Georgia State University, PO Box 3995, Atlanta, GA 30302-3995, USA. Email: [email protected].
Downloaded from ncp.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 19, 2014
2
Nutrition in Clinical Practice XX(X)
Nutrition Assessment A thorough pretransplant nutrition assessment is essential to determine anthropometric status; evaluate signs of nutrient deficiency; assess biochemical tests to determine the need to adjust nutrients and electrolytes in the oral, enteral nutrition (EN), or parenteral nutrition (PN) prescription; and obtain a dietary history for preferences and tolerances. This process will help to maximize a child’s nutrition status and increase the chance of successful outcome after transplantation. Anthropometric measures, including weight, recumbent length (until 2 years of age) or height, weight-for-length or height, and occipital head circumference (if 2 years of age. In addition, z scores should be calculated as they provide a more precise description of anthropometric status than percentiles. The severity of malnutrition can be classified using newly published cutoffs as follows: mild malnutrition or at risk of malnutrition (z score
