Growth and Development After Transplantation Workup: Laboratory Studies, Imaging Studies, Other Test
Growth and Development After Transplantation Workup: Laboratory Studies, Imaging Studies, Other Tests
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 the proteins are produced in the liver. There are also many factors that affect albumin levels in children with CKD; thus, it is important to evaluate each child to assess the degree to which the serum albumin reflects nutritional status.
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/exceed dietary reference intakes for children/adolescents, if blood levels are suboptimal, or if there is clinical evidence of deficiency.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 m-TOR inhibitors.
Bone radiograph 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).
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, it 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, this should not be used to monitor bone mineral density in pediatric patients with CKD.
Computed tomography (CT) scanning is also not useful to assess renal osteodystrophy in pediatric patients.
In patients with ESRD and uncontrollable secondary hyperparathyroidism or renal osteodystrophy, perform a parathyroid scan to rule out parathyroid gland hyperplasia. These patients may need parathyroidectomy before transplantation.
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.
Treatment & Management
Meredith J Aull, BPharm, PharmD Assistant Research Professor of Pharmacology in Surgery, Division of Transplant Surgery, Director of Clinical Research and Quality, Kidney and Pancreas Transplant Program, New York-Presbyterian Hospital, Weill Cornell Medical College
Meredith J Aull, BPharm, PharmD is a member of the following medical societies: American College of Clinical Pharmacy, American Society of Transplantation, NATCO, The Organization for Transplant Professionals
Coauthor(s)
Sandip Kapur, MD, FACS G Tom Shires, MD, Faculty Scholar in Surgery, Associate Professor of Surgery (Transplantation), Department of Surgery, Division of Transplant Surgery, Weill Medical College of Cornell University; Associate Attending Surgeon, Associate Attending Physician, Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center
Sandip Kapur, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, Association for Surgical Education, Society of University Surgeons, Transplantation Society, Cell Transplant Society, International Pancreas and Islet Transplant Association, New York Surgical Society
Specialty Editor Board
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Chief Editor
Mary C Mancini, MD, PhD, MMM Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport
Mary C Mancini, MD, PhD, MMM is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Society of Thoracic Surgeons, Phi Beta Kappa
Richard G Ohye, MD Head, Section of Pediatric Cardiovascular Surgery, Associate Professor of Cardiac Surgery, Program Director, Pediatric Cardiac Surgery Fellowship, University of Michigan Medical Center
Richard G Ohye, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, Congenital Heart Surgeons Society, Society of University Surgeons, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, Association for Academic Surgery, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons
Disclosure: Received consulting fee from Sorin, Inc. for review panel membership; Received none from CryoLife, Inc. for testimony at fda panel.
Acknowledgements
Marcela Del Rio, MD Assistant Professor, Department of Pediatric Nephrology, Department of Pediatrics, Division of Pediatric Nephrology, Albert Einstein College of Medicine; Consulting Staff, The Children's Hospital at Montefiore
Marcela Del Rio, MD is a member of the following medical societies: American Society of Nephrology and American Society of Pediatric Nephrology
Disclosure: Nothing to disclose.
John A Goss, MD, FACS Professor of Surgery, Chief, Division of Abdominal Transplantation, Baylor College of Medicine; Director of Liver Transplantation, Texas Children's Hospital; Director of Liver Transplantation, St Luke's Episcopal Hospital; Director of Liver Transplantation, Michael E DeBakey Veterans Affairs Medical Center
John A Goss, MD, FACS is a member of the following medical societies: American Association for the Study of Liver Diseases, American Medical Association, American Society of Transplant Surgeons, Association for Academic Surgery, Sigma Xi, Southwestern Surgical Congress, and Texas Medical Association
Disclosure: Nothing to disclose.
Stuart M Greenstein, MD Professor of Surgery, Albert Einstein College of Medicine; Consulting Surgeon, Department of Surgery, Division of Transplantation, Montefiore Medical Center
Stuart M Greenstein, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, International College of Surgeons, Medical Society of New Jersey, National Kidney Foundation, New York Academy of Sciences, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.
Shefali Mahesh, MD, MBBS Fellow, Department of Pediatric Nephrology, Albert Einstein College of Medicine, Montefiore Medical Center
Shefali Mahesh, MD, MBBS is a member of the following medical societies: American Academy of Pediatrics, American Society of Nephrology, and American Society of Transplantation
Disclosure: Nothing to disclose.
References
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 the proteins are produced in the liver. There are also many factors that affect albumin levels in children with CKD; thus, it is important to evaluate each child to assess the degree to which the serum albumin reflects nutritional status.
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/exceed dietary reference intakes for children/adolescents, if blood levels are suboptimal, or if there is clinical evidence of deficiency.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 m-TOR inhibitors.
Imaging Studies
Bone radiograph 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).
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, it 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, this should not be used to monitor bone mineral density in pediatric patients with CKD.
Computed tomography (CT) scanning is also not useful to assess renal osteodystrophy in pediatric patients.
In patients with ESRD and uncontrollable secondary hyperparathyroidism or renal osteodystrophy, perform a parathyroid scan to rule out parathyroid gland hyperplasia. These patients may need parathyroidectomy before transplantation.
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.
Treatment & Management
Meredith J Aull, BPharm, PharmD Assistant Research Professor of Pharmacology in Surgery, Division of Transplant Surgery, Director of Clinical Research and Quality, Kidney and Pancreas Transplant Program, New York-Presbyterian Hospital, Weill Cornell Medical College
Meredith J Aull, BPharm, PharmD is a member of the following medical societies: American College of Clinical Pharmacy, American Society of Transplantation, NATCO, The Organization for Transplant Professionals
Coauthor(s)
Sandip Kapur, MD, FACS G Tom Shires, MD, Faculty Scholar in Surgery, Associate Professor of Surgery (Transplantation), Department of Surgery, Division of Transplant Surgery, Weill Medical College of Cornell University; Associate Attending Surgeon, Associate Attending Physician, Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center
Sandip Kapur, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, Association for Surgical Education, Society of University Surgeons, Transplantation Society, Cell Transplant Society, International Pancreas and Islet Transplant Association, New York Surgical Society
Specialty Editor Board
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Chief Editor
Mary C Mancini, MD, PhD, MMM Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport
Mary C Mancini, MD, PhD, MMM is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Society of Thoracic Surgeons, Phi Beta Kappa
Richard G Ohye, MD Head, Section of Pediatric Cardiovascular Surgery, Associate Professor of Cardiac Surgery, Program Director, Pediatric Cardiac Surgery Fellowship, University of Michigan Medical Center
Richard G Ohye, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, Congenital Heart Surgeons Society, Society of University Surgeons, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, Association for Academic Surgery, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons
Disclosure: Received consulting fee from Sorin, Inc. for review panel membership; Received none from CryoLife, Inc. for testimony at fda panel.
Acknowledgements
Marcela Del Rio, MD Assistant Professor, Department of Pediatric Nephrology, Department of Pediatrics, Division of Pediatric Nephrology, Albert Einstein College of Medicine; Consulting Staff, The Children's Hospital at Montefiore
Marcela Del Rio, MD is a member of the following medical societies: American Society of Nephrology and American Society of Pediatric Nephrology
Disclosure: Nothing to disclose.
John A Goss, MD, FACS Professor of Surgery, Chief, Division of Abdominal Transplantation, Baylor College of Medicine; Director of Liver Transplantation, Texas Children's Hospital; Director of Liver Transplantation, St Luke's Episcopal Hospital; Director of Liver Transplantation, Michael E DeBakey Veterans Affairs Medical Center
John A Goss, MD, FACS is a member of the following medical societies: American Association for the Study of Liver Diseases, American Medical Association, American Society of Transplant Surgeons, Association for Academic Surgery, Sigma Xi, Southwestern Surgical Congress, and Texas Medical Association
Disclosure: Nothing to disclose.
Stuart M Greenstein, MD Professor of Surgery, Albert Einstein College of Medicine; Consulting Surgeon, Department of Surgery, Division of Transplantation, Montefiore Medical Center
Stuart M Greenstein, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, International College of Surgeons, Medical Society of New Jersey, National Kidney Foundation, New York Academy of Sciences, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.
Shefali Mahesh, MD, MBBS Fellow, Department of Pediatric Nephrology, Albert Einstein College of Medicine, Montefiore Medical Center
Shefali Mahesh, MD, MBBS is a member of the following medical societies: American Academy of Pediatrics, American Society of Nephrology, and American Society of Transplantation
Disclosure: Nothing to disclose.
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