obesity in the pediatric transplant patient a growing problem – despite the best of intentions...

Obesity in the Pediatric Transplant Patient

a growing problem – despite the best of intentions

Elizabeth Gerndt-Spaith, RN, BSN, CCTC

10/8/2011

Childhood Obesity

• Obesity is a growing problem in the United States

• It is affecting all age groups• Obesity causes long term health issues for all

age groups, these are presenting at earlier ages. • Definition of Obesity : BMI >95%tile for children

Pediatric Obesity Trends

Patient Profile

5 year old female, mixed race (African American/Caucasian) with ESRD unknown etiology

PMH negative except for obesity, wt 27 kg (97%), ht 113cm (67%), BMI 20.8 (>95% ) prior to transplant

Living related renal transplant, haplotype, PRA 0%Risk Factors- African American ethnicity, obesityImmunosuppression- alemtuzumab, methylprednisolone x

2 doses; tacrolimus and cell cept maintenance

Growth Charts at transplantWeight Height BMI

Clinical Course

• 3 month protocol biopsy- no clinical concerns, findings are suspicious for rejection treated with 3 doses methylprednisolone

• Biopsy at 4 months- no rejection• 5 month biopsy for cause –elevated creatinine- acute

rejection treated with methylprednisolone and maintenance steroids with tacrolimus, cell cept

• subsequent biopsies have shown varying degrees of acute and antibody mediated rejection

• no evidence of non-adherence to medication regimen

Growth Chart 5 years later Weight Height BMI

Clinical Course

• During the 5 years since transplant this child has had continuous excessive weight gain with current age - 10 ½ years old with weight - 91 kg (>99% and rising), ht -155 cm (95%) BMI- 37.9 (>99% and rising).

• Child is an insulin dependent diabetic, has cardiovascular disease as evidenced on echocardiogram with early left ventricular dysfunction and hypertension, has obstructive sleep disorder, hyperlipidemia and is at risk for other obesity related complications.

Interventions

• Multiple sessions with dietician to address weight gain through the years as well as transplant team that began prior to transplant and throughout course

• Referral to Pediatrician• Referral to Fitness Clinic with enrollment ; parent, patient

instruction• Referral to Diabetes Clinic with insulin treatment• Referral to Psychology for Family Counseling to address

psychosocial issues contributing to eating disorder. • Family membership at local YMCA

Summary

• Child was initiated with an immunosuppressive protocol with steroid avoidance, which if it had been successful may have helped with obesity issue

• Prednisone was limited as possible throughout clinical course, however this has not impacted excessive weight gain.

• Multiple interventions have been attempted over the 5 years since transplant without positive impact.

• This child has had an increase in BMI from 20.8 to current BMI of 37.9

Complications of Obesity in Childhood

• psychosocial

• respiratory

• cardiovascular

• endocrine

• orthopedic

• hepatic

• neurological

depression, low self esteem

obstructive sleep pattern

hypertension, left ventricular dysfunction

diabetes, hyperlipidemia

hip, knee deformities

NASH

pseudo tumor cerebri

Treatment Strategies• Psychosocial/ Behavioral interventions• Nutrition Counseling• Weight management clinics• Pharmacotherapy

– appetite suppressants, metabolism booster, absorption blocking agents

• Surgical Interventions - limited timing to occur after sexual and skeletal maturation – Roux en Y– Bilio-pancreatic diversion– Duodenal Switch– gastric banding

Conclusion

• Attempts to minimize steroids may help with weight gain post transplant, but may also affect the need for post transplant steroids due to recurring rejection.

• Children do gain weight in the initial period post transplant on steroid based immunosuppressive protocols, and do not return to baseline BMI in many instances. Pediatric Transplant 2005 Aug;9(4):445-9

• Obesity impairs renal function in children. Kidney Int. 2007 August; 72(3): 279-289

• Childhood obesity is worsening across the country.

• Options for children are limited due to effects on skeletal maturation and sexual development.