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Unhealthy Weight Gain in Pediatric Post-Heart Transplant Patients: Incidence and Risk Factors
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The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
challenges of rural poverty are different than those of the urban poor. We analyzed the effects of rural versus urban poverty on post-transplant mortality, with an additional emphasis on distance from transplant center as an independent risk factor for poor outcomes. Methods: Retrospective review of all pediatric heart transplants performed at Lucile Packard Children’s Hospital between 1990-2010. The primary outcome was mortality. US census data on median income by zip code was used, consistent with prior studies. Poverty was defined as a zip code median household income < $40,000/year. Poverty, distance from transplant center, type of geographical area (urban, suburban, or rural), and race were analyzed. Results: 219 patients underwent pediatric heart transplant at Lucile Packard Children’s Hospital during the study period. 118 (54%) were male and 73 (33%) had CHD. Overall mortality was 47%. African Americans had a slightly higher post-transplant mortality (p= 0.05). 84 patients (38%) were from rural areas. Median distance from our transplant center was 66 miles (IQR 3.5, 2401 miles) with rural patients living further away than urban patients (median distance 102 vs 66 miles). There was no significant association between distance from center and survival at 5 or 10 years (p= 0.9). The median income for all patients was $63,155 (IQR $29,688, $161,205). Poverty was the only independent SE risk factor for post-transplant mortality (p = 0.0002, Fig 1). Conclusion: Poverty is the strongest SE risk factor for mortality after pediatric heart transplant, independent of race, age, or distance from transplant center. This effect appears to be equivalent for both the urban and rural poor. This finding illustrates an important risk post transplant and may necessitate more aggressive monitoring/resource allocation to patients and families living in poor areas.
1( 132) Unhealthy Weight Gain in Pediatric Post-Heart Transplant Patients: Incidence and Risk Factors H.M. Lim , P. Chau, A.R. Alejos, R.E. Lowery, S. Yu, K.R. Schumacher. C.S. Mott Children’s Hospital, Congenital Heart Center, University of Michigan, Ann Arbor, MI. Purpose: Previous studies examining growth after heart transplant (HTx) in pediatric patients have not focused primarily on progression to an unhealthy weight status, either overweight or obese. This study aimed to determine the rate of progression to an unhealthy weight status after pediatric HTx, assess factors associated with unhealthy weight gain, and examine associations with post-HTx comorbidities. Methods: This is a single-center, retrospective, cohort study in subjects (2-18 years old) undergoing HTx since 2000 with ≥ 1-year follow-up. Body Mass Index (BMI) percentiles at HTx and at outpatient follow-up visits were categorized as underweight (< 5 %), normal (5 to 85 %), overweight (85 to 95 %), or obese (≥ 95 %) based on CDC classifications. Changes in BMI classifications over time were assessed for each subject. The cohort was then dichotomized into subjects who experienced a change in their BMI classification into the overweight or obese category and those who maintained a normal weight status. Associations between the dichotomized groups and pre- and post-HTx characteristics were compared using Chi-square or
Fisher’s exact test for categorical variables and Wilcoxon rank sum test for continuous variables. Results: Of 51 patients analyzed, the incidence of overweight or obesity increased significantly from 11.8 % pre-HTx to 31.4% by 1-year post-HTx (p= 0.03). At 3 years post-HTx, 27.3% of patients remained overweight or obese. Younger age at HTx was significantly associated with becoming overweight or obese (p= 0.03). Gender, socioeconomic factors, diagnosis, listing status, pre-HTx feeding status, and BMI at transplant were not associated with unhealthy weight gain in the post-HTx period. Post-HTx steroid burden, immunosuppressive regimen, and incidence of rejection also had no association with unhealthy weight gain. Patients who progressed into the overweight or obese categories were more likely to have hypertension requiring medication at 1-year post-HTx (100% vs 74.3%, p= 0.04). Conclusion: A high proportion of pediatric patients experience unhealthy weight gain after HTx with younger patients being at increased risk. Becoming overweight or obese increases the risk of hypertension. These findings suggest that interventions directed at preventing unhealthy weight gain should be a component of routine pediatric post-HTx care. 1( 133) Temporary Inactivation from the Waitlist Due to Decline in Health Does Not Affect Mid-Term Outcomes among Pediatric Heart Transplant Recipients A.N. Goel ,1 A. Iyengar,1 K.O. Schowengerdt,2 A. Fiore,2 C. Huddleston.2 1David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, CA; 2Saint Louis University School of Medicine, Saint Louis, MO. Purpose: Candidates on the waitlist for pediatric heart transplantation can be active or temporarily inactive. One reason for inactivation is a temporary decline in health (reason 7). These patients may be higher risk than those never taken off the list because even a temporary illness may have an impact on risk for transplantation. We sought to perform the first large-scale study comparing outcomes of heart transplantation in these patients. Methods: The UNOS database was queried for pediatric patients (age < 18) listed for first, isolated heart transplant between 2006 and 2015. Patients were divided into two groups: those who had never been inactive (Group A) and those with a history of inactivation due to temporary decline in health (Group B). Baseline characteristics between the groups were compared using Chi-squared tests. Kaplan-Meier plots and Cox proportional hazard models were used to estimate the association between temporary inactivation due to reason 7 and death-censored graft failure and patient survival. Results: 2713 heart transplant recipients meeting the inclusion criteria were divided into Group A (n = 2414, 89.0%) and Group B (n = 299, 11.0%). Recipients in Group B were comparatively sicker as evidenced by greater VAD use (p < 0.001) and infection prior to transplant (p < 0.001) than those in Group A. Waitlist time was prolonged in Group B patients (p < 0.001) as compared to Group A patients. Incidence of inotrope use was higher in Group A (p = 0.002). Actuarial survival at 3 months (Group A 95.0%, Group B 92.3%, p = 0.185) and 3 years (Group A 86.1%, Group B 83.5%, p = 0.185) were not significantly different between groups. Patients inactivated for reason 7 did not experience an increased risk of death (HR 1.26, 95% CI 0.94 - 1.70) or graft loss (HR 1.19, 95% CI 0.90 - 1.59) when compared to their active listed cohorts. Conclusion: These data demonstrate that pediatric heart transplant candidates with a history of inactive status for reason 7 are at increased operative risk yet demonstrated graft and patient survival comparable to those who had never been inactivated. This study suggests that patients should not be discouraged from receiving transplantation based on a history of inactivation due to temporary decline in health. 1( 134) Allergies and Autoimmune Disorders in Children after Heart Transplantation N. Avdimiretz ,1 S. Seitz,2 M. Cheveldayoff,2 S. Urschel.3 1Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; 2Division
The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
challenges of rural poverty are different than those of the urban poor. We analyzed the effects of rural versus urban poverty on post-transplant mortality, with an additional emphasis on distance from transplant center as an independent risk factor for poor outcomes. Methods: Retrospective review of all pediatric heart transplants performed at Lucile Packard Children’s Hospital between 1990-2010. The primary outcome was mortality. US census data on median income by zip code was used, consistent with prior studies. Poverty was defined as a zip code median household income < $40,000/year. Poverty, distance from transplant center, type of geographical area (urban, suburban, or rural), and race were analyzed. Results: 219 patients underwent pediatric heart transplant at Lucile Packard Children’s Hospital during the study period. 118 (54%) were male and 73 (33%) had CHD. Overall mortality was 47%. African Americans had a slightly higher post-transplant mortality (p= 0.05). 84 patients (38%) were from rural areas. Median distance from our transplant center was 66 miles (IQR 3.5, 2401 miles) with rural patients living further away than urban patients (median distance 102 vs 66 miles). There was no significant association between distance from center and survival at 5 or 10 years (p= 0.9). The median income for all patients was $63,155 (IQR $29,688, $161,205). Poverty was the only independent SE risk factor for post-transplant mortality (p = 0.0002, Fig 1). Conclusion: Poverty is the strongest SE risk factor for mortality after pediatric heart transplant, independent of race, age, or distance from transplant center. This effect appears to be equivalent for both the urban and rural poor. This finding illustrates an important risk post transplant and may necessitate more aggressive monitoring/resource allocation to patients and families living in poor areas.
1( 132) Unhealthy Weight Gain in Pediatric Post-Heart Transplant Patients: Incidence and Risk Factors H.M. Lim , P. Chau, A.R. Alejos, R.E. Lowery, S. Yu, K.R. Schumacher. C.S. Mott Children’s Hospital, Congenital Heart Center, University of Michigan, Ann Arbor, MI. Purpose: Previous studies examining growth after heart transplant (HTx) in pediatric patients have not focused primarily on progression to an unhealthy weight status, either overweight or obese. This study aimed to determine the rate of progression to an unhealthy weight status after pediatric HTx, assess factors associated with unhealthy weight gain, and examine associations with post-HTx comorbidities. Methods: This is a single-center, retrospective, cohort study in subjects (2-18 years old) undergoing HTx since 2000 with ≥ 1-year follow-up. Body Mass Index (BMI) percentiles at HTx and at outpatient follow-up visits were categorized as underweight (< 5 %), normal (5 to 85 %), overweight (85 to 95 %), or obese (≥ 95 %) based on CDC classifications. Changes in BMI classifications over time were assessed for each subject. The cohort was then dichotomized into subjects who experienced a change in their BMI classification into the overweight or obese category and those who maintained a normal weight status. Associations between the dichotomized groups and pre- and post-HTx characteristics were compared using Chi-square or
Fisher’s exact test for categorical variables and Wilcoxon rank sum test for continuous variables. Results: Of 51 patients analyzed, the incidence of overweight or obesity increased significantly from 11.8 % pre-HTx to 31.4% by 1-year post-HTx (p= 0.03). At 3 years post-HTx, 27.3% of patients remained overweight or obese. Younger age at HTx was significantly associated with becoming overweight or obese (p= 0.03). Gender, socioeconomic factors, diagnosis, listing status, pre-HTx feeding status, and BMI at transplant were not associated with unhealthy weight gain in the post-HTx period. Post-HTx steroid burden, immunosuppressive regimen, and incidence of rejection also had no association with unhealthy weight gain. Patients who progressed into the overweight or obese categories were more likely to have hypertension requiring medication at 1-year post-HTx (100% vs 74.3%, p= 0.04). Conclusion: A high proportion of pediatric patients experience unhealthy weight gain after HTx with younger patients being at increased risk. Becoming overweight or obese increases the risk of hypertension. These findings suggest that interventions directed at preventing unhealthy weight gain should be a component of routine pediatric post-HTx care. 1( 133) Temporary Inactivation from the Waitlist Due to Decline in Health Does Not Affect Mid-Term Outcomes among Pediatric Heart Transplant Recipients A.N. Goel ,1 A. Iyengar,1 K.O. Schowengerdt,2 A. Fiore,2 C. Huddleston.2 1David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, CA; 2Saint Louis University School of Medicine, Saint Louis, MO. Purpose: Candidates on the waitlist for pediatric heart transplantation can be active or temporarily inactive. One reason for inactivation is a temporary decline in health (reason 7). These patients may be higher risk than those never taken off the list because even a temporary illness may have an impact on risk for transplantation. We sought to perform the first large-scale study comparing outcomes of heart transplantation in these patients. Methods: The UNOS database was queried for pediatric patients (age < 18) listed for first, isolated heart transplant between 2006 and 2015. Patients were divided into two groups: those who had never been inactive (Group A) and those with a history of inactivation due to temporary decline in health (Group B). Baseline characteristics between the groups were compared using Chi-squared tests. Kaplan-Meier plots and Cox proportional hazard models were used to estimate the association between temporary inactivation due to reason 7 and death-censored graft failure and patient survival. Results: 2713 heart transplant recipients meeting the inclusion criteria were divided into Group A (n = 2414, 89.0%) and Group B (n = 299, 11.0%). Recipients in Group B were comparatively sicker as evidenced by greater VAD use (p < 0.001) and infection prior to transplant (p < 0.001) than those in Group A. Waitlist time was prolonged in Group B patients (p < 0.001) as compared to Group A patients. Incidence of inotrope use was higher in Group A (p = 0.002). Actuarial survival at 3 months (Group A 95.0%, Group B 92.3%, p = 0.185) and 3 years (Group A 86.1%, Group B 83.5%, p = 0.185) were not significantly different between groups. Patients inactivated for reason 7 did not experience an increased risk of death (HR 1.26, 95% CI 0.94 - 1.70) or graft loss (HR 1.19, 95% CI 0.90 - 1.59) when compared to their active listed cohorts. Conclusion: These data demonstrate that pediatric heart transplant candidates with a history of inactive status for reason 7 are at increased operative risk yet demonstrated graft and patient survival comparable to those who had never been inactivated. This study suggests that patients should not be discouraged from receiving transplantation based on a history of inactivation due to temporary decline in health. 1( 134) Allergies and Autoimmune Disorders in Children after Heart Transplantation N. Avdimiretz ,1 S. Seitz,2 M. Cheveldayoff,2 S. Urschel.3 1Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; 2Division