Pediatric Transplant Rating Instrument – A scale for the pretransplant psychiatric evaluation of pediatric organ transplant recipients

Abstract:  Although the majority of pediatric solid organ transplant centers in the United States employ psychosocial criteria to assess the suitability of potential transplant candidates, there are no standardized pretransplant psychosocial assessment measures. Assessment scales that have been developed were designed for adult transplant recipients and are not suitable for use in the pediatric population. The P-TRI was developed to address this gap in the pediatric pretransplant psychosocial evaluation. It is intended to identify areas of psychosocial vulnerability that may be associated with poor treatment adherence and to facilitate the development of informed and focused psychosocial interventions for pediatric patients before and after transplant surgery. Items on the rating instrument were generated based on a review of the major correlates of treatment adherence in the pediatric population. Data are currently being collected for further reliability and validity analyses.     

Pediatric Transplant Rating Instrument - a scale for the pretransplant psychiatric evaluation of pediatric organ transplant recipients.

Although the majority of pediatric solid organ transplant centers in the United States employ psychosocial criteria to assess the suitability of potential transplant candidates, there are no standardized pretransplant psychosocial assessment measures. Assessment scales that have been developed were designed for adult transplant recipients and are not suitable for use in the pediatric population. The P-TRI was developed to address this gap in the pediatric pretransplant psychosocial evaluation. It is intended to identify areas of psychosocial vulnerability that may be associated with poor treatment adherence and to facilitate the development of informed and focused psychosocial interventions for pediatric patients before and after transplant surgery. Items on the rating instrument were generated based on a review of the major correlates of treatment adherence in the pediatric population. Data are currently being collected for further reliability and validity analyses.     

Determinants of graft survival in pediatric and adolescent live donor kidney transplant recipients: a single center experience

To study the independent determinants of graft survival among pediatric and adolescent live donor kidney transplant recipients. Between March 1976 and March 2004, 1600 live donor kidney transplants were carried out in our center. Of them 284 were 20 yr old or younger (mean age 13.1 yr, ranging from 5 to 20 yr). Evaluation of the possible variables that may affect graft survival were carried out using univariate and multivariate analyses. Studied factors included age, gender, relation between donor and recipient, original kidney disease, ABO blood group, pretransplant blood transfusion, human leukocyte antigen (HLA) matching, pretransplant dialysis, height standard deviation score (SDS), pretransplant hypertension, cold ischemia time, number of renal arteries, ureteral anastomosis, time to diuresis, time of transplantation, occurrence of acute tubular necrosis (ATN), primary and secondary immunosuppression, total dose of steroids in the first 3 months, development of acute rejection and post-transplant hypertension. Using univariate analysis, the significant predictors for graft survival were HLA matching, type of primary urinary recontinuity, time to diuresis, ATN, acute rejection and post-transplant hypertension. The multivariate analysis restricted the significance to acute rejection and post-transplant hypertension. The independent determinants of graft survival in live-donor pediatric and adolescent renal transplant recipients are acute rejection and post-transplant hypertension.     

Evaluation of anthropometric indices for the assessment of nutritional status in girls--III

Total subjects were regrouped into three, based on the growth velocity indicating pre-adolescent, adolescent and post-adolescent stages. Three nutritional indices based on 4 body measurements (weight, height, triceps, midarm circumference) were calculated for each subject. It was found that the energy protein index was the only reliable and suitable index for evaluating the nutritional level of adolescents and post-adolescents while weight/height2 and arm circumference were more suitable for determining the nutritional status of pre-adolescent girls.     

Heart transplantation in children: clinical outcome during the early postoperative period

As improved understanding of transplant-related death should improve survival, we report a single center's experience with pediatric heart transplantation including potential risk factors and causes of death during the early postoperative period. This prospective longitudinal study involved 51 pediatric patients ranging in age from 12 days to 15.1 yr (median: 3 yr). The following pretransplant risk factors were evaluated: diagnosis, age at transplantation, recipient sex, weight and blood type, blood type match, donor/recipient sex match, weight ratio, ischemic time, recipient's status, requirement for mechanical ventilation or circulatory support, dialysis, or inotropic support at transplantation. We also determined the actuarial survival, clinical outcomes, and causes of death in this population. Survival was 86% during the early postoperative period (相似文献   

Perceived barriers to medication adherence in pediatric and adolescent solid organ transplantation

Comparisons of perceived barriers to adherence in pediatric and adolescent SOT have not been systematically conducted despite association between medication non‐adherence and poor outcome. Fifteen centers in CTOT‐C enrolled patients in a cross‐sectional study. Subjects' guardians completed the PMBS and subjects over eight completed the Adolescent Scale (AMBS). Association of three identified PMBS factors and subject age was assessed. Secondary analyses assessed associations between PMBS, AMBS, and patient demographics. Three hundred sixty‐eight subjects or their guardians completed PMBS or AMBS. A total of 107 subjects were 6–11 yr; 261 were ≥12. Unadjusted and propensity‐adjusted analyses indicated higher perceived barriers in guardians of adolescents as compared to guardians of pre‐adolescents medication scheduling and frustration domains regardless of organ (p < 0.05). PMBS and AMBS comparisons revealed that guardians reported fewer ingestion issues than patients (p = 0.018), and differences appeared more pronounced within younger responders for scheduling (p = 0.025) and frustration (p = 0.019). Screening revealed guardians of older patients report increased perceived barriers to adherence independent of socioeconomic status. Guardians of adolescents reported fewer perceived barriers to ingestion/side effects than patients themselves, particularly in pre‐adolescents (8–11 yr). Brief screening measures to assess perceived barriers should be further studied in adherence improvement programs.     

Posterior reversible encephalopathy syndrome after pediatric heart transplantation: Increased risk for children with preexisting Glenn/Fontan physiology

Identification of risk factors for PRES after organ transplant can improve early detection and avoid permanent neurological injury. High calcineurin‐inhibitor levels and hypertension are recognized risk factors for PRES in adult transplant recipients. Limited data exist regarding PRES after pediatric HTx, with studies limited to case reports. We performed a retrospective review of 128 pediatric HTx recipients to identify risk factors for PRES. Seven of 128 (5.5%) recipients developed PRES at a median of 10 days (5–57) after HTx. The median age of recipients with PRES was 10.0 yr (5.7–19.0), compared to 1.4 yr (0.0–19.8) for recipients without PRES (p = 0.010). Fewer than half of recipients with PRES had elevated post‐transplant calcineurin‐inhibitor levels (n = 3) and/or preceding severe hypertension (n = 3). Four of seven who developed PRES (57%) had pretransplant Glenn or Fontan physiology (G/F). G/F was a significant risk factor for PRES (RR 4.99, 95% CI: 1.19–21.0, p = 0.036). Two recipients (29%), both with severe PRES, had residual neurological symptoms. In summary, PRES occurred in 5.5% of pediatric HTx recipients and presented early after HTx. All recipients with PRES were > 5 yr. Patients with pretransplant G/F were at increased risk, a risks factor not previously described.     

Adherence and health-related quality of life in adolescent liver transplant recipients

Abstract:  Adolescence is a particularly high-risk period for non-adherence with post-transplant medical regimens. There remains a lack of research investigating factors related to non-adherence in adolescent LT recipients. The present study empirically assessed the relationship between adherence and HRQOL in adolescent LT recipients. Participants included 25 adolescents (mean = 15.1 yr, range 12–17.9) and their parent/guardian(s). Adherence was assessed using multiple indices including clinician-conducted interviews, rate of clinic attendance, and s.d. of consecutive tacrolimus blood levels. HRQOL was examined using self-report and parent-proxy report on well-validated assessment measures. Results indicated that 76% of participants were non-adherent on at least one measure of adherence, and HRQOL was significantly lower than normative data for healthy children. Tacrolimus s.d. were significant related to poor HRQOL across domains of physical, school, and social functioning. Non-adherent adolescents reported poorer health perceptions, self-esteem, mental health, family cohesion, and more limitations in social and school activities related to physical, emotional, and behavioral problems. These results suggest that empirically based assessment of HRQOL may help identify those at highest risk for behavior, emotional and school difficulties, as well as non-adherence. The examination of tacrolimus s.d. may also help identify patients who may benefit from intervention to promote adherence and HRQOL. Prospective investigations are necessary to further identify the impact of HRQOL on adherence and long-term health outcomes to further guide clinical intervention.     

Group visits in the pediatric heart transplant outpatient clinic

The “GVM” has emerged as an alternative to traditional individualized appointments in the ambulatory care setting. We hypothesized that group visits could successfully be utilized in a PHtx clinic. Seven patients, ages 1–18 yr old, and their families participated in a total of 11 group visits in lieu of individualized appointments. Patients were divided into two groups based on whether they were greater or less than one yr post‐transplant. Patient/provider satisfaction, medication adherence, and content retention were ascertained via questionnaires and free‐response tests. Total clinic throughput time, including per‐patient clinic utilization time, was compared to historical data. Six of seven patients completed the study with one dropout. Overall satisfaction ratings were 3.98 of 4 with all patients reporting that they would “strongly recommend” group visits to others. Health information retention tests demonstrated improvement between pre‐ and post‐tests in eight of nine (89%) of the group visits. Overall clinic utilization decreased by nearly 50% while providing 70 min of face‐to‐face time with the provider. Medication adherence neared 100% for all patients. The GVM can be successfully applied to the PHtx population with high patient and provider satisfaction, more face‐to‐face time, excellent content retention, and greatly improved clinic efficiency.     

Medication adherence in the transition of adolescent kidney transplant recipients to the adult care

Non‐adherence is common in adolescent and young adult kidney transplant recipients, leading to adverse graft outcomes. The aim of this study was to determine whether adherence to immunosuppressant medications changes during transition from a pediatric to an adult program within the same transplant center. Adherence was assessed for a period of two yr before and two yr after the transfer. Subtherapeutic trough levels of serum tacrolimus and level variability were used as measures of adherence. Twenty‐five patients were transitioned between 1996 and 2011 at the median age of 22.3 [IQR 21.6–23.0] yr. Young adults 21–25 yr of age (n = 26) and non‐transitioned adolescents 17–21 yr of age (currently followed in the program, n = 24 and those that lost their grafts prior to the transfer, 22) formed the comparison groups. In the transitioned group, adherence prior to the transfer was not significantly different from the adherence after the transfer (p = 0.53). The rate of non‐adherence in the group of non‐transitioned adolescents who lost their grafts (68%) was significantly higher than in the transitioned group (32%, p = 0.01). In the group of young adults, adherence was not significantly different from the transitioned group (p = 0.27). Thus, transition was not associated with differences in medication adherence in this single‐center study. Large‐scale studies are needed to evaluate the national data on medication adherence after transfer.     

Adolescent attitudes toward psychiatric medication: the utility of the Drug Attitude Inventory

Background: Despite the effectiveness of psychotropic treatment for alleviating symptoms of psychiatric disorders, youth adherence to psychotropic medication regimens is low. Adolescent adherence rates range from 10–80% ( Swanson, 2003 ; Cromer & Tarnowski, 1989 ; Lloyd et al., 1998 ; Brown, Borden, and Clingerman, 1985 ; Sleator, 1985 ) depending on the population and medication studied. Youth with serious mental illness face increased potential for substance abuse, legal problems, suicide attempts, and completed suicide ( Birmaher & Axelson, 2006 ). Nonadherence may increase the potential for negative outcomes. The Drug Attitude Inventory (DAI) was created to measure attitudes toward neuroleptics and to predict adherence in adults (Hogan, Awad, & Eastwood, 1983). No studies have been identified that have used this instrument in adolescent psychiatric populations. The present study was undertaken to evaluate the utility of the DAI for measuring medication attitudes and predicting adherence in adolescents diagnosed with mental health disorders. Method: Structural equation modeling was used to compare the factor structure of the DAI in adults with its factor structure in adolescents. The relationship between adolescent DAI scores and adherence was examined also. Results: The adult factor structure demonstrated only “fair” fit to the adolescent data (RMSEA = .061). Results indicated a low, but significant positive correlation (r = .205, p < .05) between DAI scores and adherence. Conclusions: Lack of optimal model fit suggests that DAI items may require alteration to reflect adolescent experiences with psychiatric medication more accurately. Differences between adolescents and adults in developmental stage, symptom chronicity, diagnosis, and medication class may explain why the adult model demonstrated only “fair fit” to the adolescent data and why the correlation between DAI scores and adherence was low. The DAI may be improved for use with adolescents by creating items reflecting autonomy concerns, diagnostic characteristics, treatment length, and side effect profiles relevant to adolescent experiences.     

Pretransplant peritoneal dialysis and graft thrombosis following pediatric kidney transplantation: a NAPRTCS report

Graft thrombosis is a common cause of graft failure in pediatric renal transplantation. Several previous studies, including a North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) review of pretransplant dialysis status and graft outcomes, have described a potential correlation of peritoneal dialysis (PD) and graft thrombosis. This issue is of particular concern for pediatric transplant programs as more than 65% of children with end stage renal disease are treated with PD. We reviewed 7247 pediatric renal transplants performed between 1987 and 2001. Thrombosis was the cause of graft loss in 2.7% (199) of all the transplants performed. Among failed transplants, thrombosis was the third most common cause of graft loss in both index (11.6%) and subsequent transplants (14.5%). Thrombosis becomes the most common cause of graft failure (21%, 61/294) if one looks at transplants in the later cohort, from 1996 to 2001. This change is primarily because of a decrease in the incidence of acute rejection. In the PD group, 3.4% of all grafts were lost as a result of thrombosis. This compares with 1.9% in the hemodialysis group, 2.4% in the pre-emptive transplant group, and 4.1% among patients who received both dialysis modalities. There was a statistically significant difference in thrombosis failure risk in the different dialysis groups (p = 0.005) with those who received only peritoneal dialysis having the highest risk. Additional significant risk factors for graft thrombosis included; cadaver donor source (p < 0.001), cold ischemia time >24 h (p < 0.001), history of prior transplant (p < 0.001), donor age <6 yr (p < 0.001), and >5 pretransplant blood transfusions (p = 0.02). Using stepwise proportional hazards modeling, only pretransplant peritoneal dialysis, >24 h cold ischemia time, prior transplant, and donor age <6 yr were simultaneously associated with an increased risk of thrombosis. We conclude that pretransplant PD is associated with an increased risk of graft thrombosis. Special precautions should be undertaken in pediatric renal transplant patients who have received PD, especially infants and young children.     

Risk Score for Predicting Adolescent Mental Health Problems Among Children Using Parental Report Only: The TRAILS Study

ObjectiveTo construct a risk score for adolescent mental health problems among children, using parental data only and without potentially stigmatizing mental health items.MethodsWe prospectively derived a prediction model for mental health problems at age 16 using data from parent report on 1676 children aged 11 from the general population. Mental health problems were considered present in the top 15% scores on the combined Achenbach ratings. The model was validated in a separate cohort (n = 336) children. A risk score was constructed for practical application.ResultsIn the derivation cohort, 248 (14.8%) had mental health problems at follow-up. Predictors in the final model were gender, maternal educational level, family history of psychopathology, math achievement at school, frequently moving house, severe disease or death in the family, parental divorce, and child frustration level. The model was well calibrated, showed good discriminatory power (area under the curve 0.75; 95% confidence interval 0.72–0.78), and validated well. The risk score stratified children in classes of risk ranging from 6.6% to 52.2%.ConclusionsA risk score based on parent-reported data only and without mental health items accurately estimated the 5-year risk of adolescent mental health problems among children from the general population. Children with high risk may benefit from further monitoring or intervention. The risk score may be particularly suitable when parents want to circumvent an explicit discussion on possible mental health problems of their child.     

Psychosocial predictors of medication adherence in pediatric heart and lung organ transplantation

Few studies have identified the psychosocial characteristics of those children and their families associated with future non‐adherence to immunosuppressive medications following a heart or lung transplant. UNOS data and medical records information were used to test the association between patient and family psychosocial characteristics and medication adherence. Medication adherence outcomes were obtained using the physician assessments in the UNOS data and measured through patient‐level standard deviation scores of immunosuppressive medication blood levels. Complete data were collected on 105 pediatric heart and lung transplant recipients and their families. Multivariate, stepwise analyses were conducted with each adherence outcome. Physician reports of adherence were associated with age of the child at transplantation, parental education, two‐parent families, significant psychosocial problems, and the pretransplant life support status of the child. The resulting model (χ²=28.146, df=5, P<.001) explained approximately 39.5% of the variance in physician reports of adherence (Nagelkerke r²=.395). Blood level standard deviation scores were predicted by age at transplant (F=5.624, P=.02, r²=.05). Results point to the difficulties experienced by children and families when undergoing a heart or lung transplantation. Efforts to develop standardized and evidence‐based pretransplant psychosocial assessments in pediatric populations are suggested, especially those surrounding familial risk factors.     

Psychosocial predictors of medication non‐adherence in pediatric organ transplantation: A systematic review

Adherence to immunosuppressant medication is critical to health and quality‐of‐life outcomes for children who have received a solid organ transplant. Research on the psychological and social predictors of medication adherence is essential to the advancement of pretransplant assessments and transplant psychosocial services. Despite the importance of identifying risk factors, the literature remains limited regarding psychosocial predictors of non‐adherence. A systematic search was conducted to identify studies of the psychosocial predictors of post‐transplant medication non‐adherence in pediatric solid organ transplantation. From 1363 studies identified in searches of empirical literature, a final sample consisted of 54 publications representing 49 unique studies. Findings regarding psychosocial predictors were inconsistent with non‐adherence associated largely with adolescence, racial/ethnic minority status, and presence of mental health issues. Familial predictors of non‐adherence problems included single‐parent households, lower socioeconomic status, lower family cohesion, presence of family conflict, and poor family communication. Several studies reported an association between non‐adherence and social pressures (eg, peer social interaction, wanting to feel normal) among adolescent transplant recipients. While significant methodological and substantive gaps remain in this body of knowledge, this review synthesizes current evidence for assessment for transplant clinicians and researchers.     

Lymphocytotoxic crossmatch in pediatric living donor liver transplantation

Abstract:  To investigate the relationship between the pretransplant LCT results and the outcome after pediatric LDLT in a single center. The clinical data of 76 children undergoing 79 LDLTs including three retransplantations from May 2001 to January 2006 were retrospectively analyzed. All of the children had end-stage liver disease, and their median age was 1.4 yr (range, six months to 16.5 yr). Immunosuppressive therapy consisted of cyclosporine- or FK-based regimens with steroids. The children were classified into two groups (positive or negative) according to the pretransplant LCT results. The incidences of post-transplant surgical complications and of rejection episodes were compared. The relationship between the pretransplant LCT results and patient and graft survival rates was also analyzed. Seventy-nine pretransplant crossmatch tests were done; 13 (16.5%) were positive, and 66 (83.5%) were negative. No significant difference was found in the pretransplant clinical factors between two crossmatch groups. There was no significant difference between the groups in the incidence of vascular and biliary tract complications, in the rate of early or steroid-resistant cellular rejections, or in one- and three-yr patient (91.7%, 91.7%, respectively, in the positive group, 93.5%, 93.5%, respectively, in the negative group, p = 0.80) and graft (92.3%, 92.3%, respectively, in the positive group, 88.8%, 86.4%, respectively, in the negative group, p = 0.63) survival. The present study demonstrates that there is no reason to do pretransplant LCT to select the living donor for pediatric LDLT.     

Best practices in the pediatric pretransplant psychosocial evaluation

Assessment of psychosocial functioning is an often‐included component of the pretransplant evaluation process. This study reviews several domains of assessment that have been related to post‐transplant outcomes across solid organ transplant populations. These include evaluation of patient and family past adherence, knowledge about the transplantation process, and their neurocognitive, psychological, and family functioning. To date, few comprehensive pretransplant evaluation measures have been standardized for use with children; however, several assessment measures used to evaluate the aforementioned domains are reviewed throughout the study. Additionally, this article discusses some developmental, illness‐specific, and cultural considerations in conducting the psychosocial evaluation. We also discuss ethical issues specific to the pediatric psychosocial evaluation. Recommendations are advanced to promote a comprehensive evaluation that identifies family strengths and risk factors as they begin the transplant journey.     

Health‐related quality of life,treatment adherence,symptom experience and depression in adolescent renal transplant patients

Dobbels F, Decorte A, Roskams A, Van Damme‐Lombaerts R. Health‐related quality of life, treatment adherence, symptom experience and depression in adolescent renal transplant patients.
Pediatr Transplantation 2010:14:216–223. © 2009 John Wiley & Sons A/S. Abstract: Few studies comprehensively assessed psychological and behavioral functioning in adolescent kidney transplant patients. The purpose of this cross‐sectional study was to evaluate depression, QOL, treatment adherence and presence of side effects from the perspective of the patient and his parents, and to compare scores with norm data. All patients (age 10–18 yr) and their parents completed the following instruments: KIDSCREEN‐27 (QOL), a treatment adherence interview, the MTSOSD‐59R (side effects) and the Beck Depression Inventory (depression). Twenty‐three of 26 patients and 22 parents agreed to participate (70% male; median age 15 yr). Adolescents rated their QOL as satisfactory, but parents reported significant problems on several QOL dimensions. Depressive symptoms occurred in 17.4%, and 75% were non‐adherent with their immunosuppressive drugs (confirmed by their parents) and show other problematic health behavior, including smoking, illicit drug use, dietary non‐adherence, and suboptimal exercise levels. The most frequently occurring side effects were increased appetite, fatigue and headache; the most distressing ones were hair loss or thinning of hair, warts on hands or feet, and sores in the mouth or on the lips. Our results underscore the need for regular screening and adequate treatment of the above‐mentioned aspects.     

A Qualitative Exploration Into Parental Recognition of Overweight and Obesity in Pre-Adolescents: A Process of Discovery

IntroductionThe purpose of this study is to describe influential factors as parents become aware that their pre-adolescent is overweight/obese.MethodsA grounded theory approach was used, and 17 parents of obese pre-adolescents were interviewed.ResultsWithin the concept of discovery (“How did you come to realize your pre-adolescent was overweight or obese?”), five central themes emerged. The theme of predisposition emerged as most parents believed there was some type of predisposition for their pre-adolescent to be overweight/obese. Parents avoided using the words overweight, obese, or fat to describe their pre-adolescent’s body habitus, thus leading to the theme “husky build.” “Compared to others” was identified as a theme since most parents described how they compared their overweight pre-adolescent with other pre-adolescents. The health care provider emerged as a theme because the role of the health care provider played a pivotal role in the discovery process for parents. Finally, parental buy-in involved acceptance that their pre-adolescent was overweight and recognition that this status signaled a problem and a potential health threat for their pre-adolescent.DiscussionParents do not rely solely on visual cues. Several factors are involved in the awareness process of parents whose pre-adolescents are clinically obese. The input from the health care provider played a significant role.     

Psychosocial predictors of adolescent sexual behavior

Objective  To find out the psychosocial factors associated with adolescent sexual behavior. Methods  A cross sectional study was carried out in Chandigarh Union Territory of India by enrolling 11^th class students from six randomly selected schools. A pre-tested questionnaire containing 83 items was administered after ensuring privacy and confidentiality. Socio-economic status, residence, gender, grade in the class, religion, acculturation level, self esteem, social support and coping behavior were considered as independent explanatory variables and physical sexual contact (which included kissing, hugging and sexual intercourse) was taken as dependent variable. Results  Two hundred and fifty seven students enrolled for the study had mean age of 17 yr. The prevalence of sexual activity was 20% (95% CI: 13.6%–28.1%) among males and 6% (95% CI: 1.3%–18.8%) among females. Four percent of males and 1% of females reported sexual intercourse. The main reason for not having sexual physical contact was societal norms. After adjusting for confounders in multivariate analysis, male gender (OR: 3.5; 95%CI: 1.5–8.1) and modern attitudes (OR: 0.77; 95%CI: 0.6–0.98) were found to be the risk factors for initiation of sexual activity in adolescence. Conclusion  Cultural norms rather than the individual/psychological factors tend to govern adolescent sexual behavior in Indian society.