Patterns of Growth after Kidney Transplantation among Children with ESRD

Abstract

Background and objectives Poor linear growth is a frequent complication of CKD. This study evaluated the effect of kidney transplantation on age-related growth of linear body segments in pediatric renal transplant recipients who were enrolled from May 1998 until August 2013 in the CKD Growth and Development observational cohort study.Design, setting, participants, & measurements Linear growth (height, sitting height, arm and leg lengths) was prospectively investigated during 1639 annual visits in a cohort of 389 pediatric renal transplant recipients ages 2-18 years with a median follow-up of 3.4 years (interquartile range, 1.9-5.9 years). Linear mixed-effects models were used to assess age-related changes and predictors of linear body segments.Results During early childhood, patients showed lower mean SD scores (SDS) for height (21.7) and a markedly elevated sitting height index (ratio of sitting height to total body height) compared with healthy children (1.6 SDS), indicating disproportionate stunting (each P,0.001). After early childhood a sustained increase in standardized leg length and a constant decrease in standardized sitting height were noted (each P,0.001), resulting in significant catch-up growth and almost complete normalization of sitting height index by adult age (0.4 SDS; P,0.01 versus age 2-4 years). Time after transplantation, congenital renal disease, bone maturation, steroid exposure, degree of metabolic acidosis and anemia, intrauterine growth restriction, and parental height were significant predictors of linear body dimensions and body proportions (each P,0.05). ConclusionsChildren with ESRD present with disproportionate stunting. In pediatric renal transplant recipients, a sustained increase in standardized leg length and total body height is observed from preschool until adult age, resulting in restoration of body proportions in most patients. Reduction of steroid exposure and optimal metabolic control before and after transplantation are promising measures to further improve growth outcome.

A comparison of post‐transplant renal function in pre‐emptive and post‐dialysis pediatric kidney transplant recipients

“…Growth is also significantly impacted in pediatric patients with ESRD, and therefore, catch‐up growth following KT is an important consideration for pediatric KT recipients. Those with poor graft function (eGFR <50 mL/min/1.73 m 2 ) may have limited catch‐up growth following KT . However, in both pre‐emptive and post‐dialysis groups, the majority of the patients were able to maintain a minimum eGFR ≥60 mL/min/1.73 m 2 , suggesting that both pre‐emptive and post‐dialysis KT are effective in maintaining renal function in the first year following KT.…”

“…In both adult and pediatric population, it has been suggested that 1 year post‐transplant eGFR is prognostic of favorable graft survival . Moreover, graft function following pediatric KT has shown to be an important factor for growth in children . Thus, the assessment of renal function following KT in pre‐emptive and post‐dialysis pediatric KT recipients allows understanding of whether there is an added benefit to pre‐emptive KT that may contribute to other outcomes, while also elucidating the potential difference in the natural history of graft function changes in the two groups.…”

Management of bone disease in cystinosis: Statement from an international conference

“…In patients on renal replacement therapy, persistent Fanconi syndrome may impair bone health, and native kidney nephrectomy might be considered. Minimal glucocorticoid exposure should be considered to permit attainment of a normal adult height . Preservation of transplant function and optimizing metabolic control can further improve growth .…”

“…64,65 Preservation of transplant function and optimizing metabolic control can further improve growth. 64 GH may be started in case of persistent short stature (>12 months after transplantation). In addition, early and diligent physical and rehabilitation therapy, including muscle strengthening and targeted exercise, can prevent and/or improve skeletal deformities, and possibly eliminate the need for extensive orthopedic surgeries.…”

Pediatric Malnutrition

“…Corticosteroid exposure has been shown to be negatively associated with post–solid organ transplant linear growth 82 – 85 . Chronic corticosteroid use is not limited to solid organ transplant recipients.…”