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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.