Why Do Young Transplant Patients Have Poor Outcomes after Transfer to Adult Care?

The increased rate of adverse outcomes in adolescent and young adult patients transferred from pediatric to adult care appears to reflect factors other than the transfer itself, suggests a report in BMC Nephrology.

The researchers analyzed graft survival in three Canadian cohorts of young patients undergoing kidney transplantation at affiliated pediatric and adult hospitals from 1990 through 2009. Transplantation was performed by the same surgeons even though the two sites were geographically separate. Children are transferred from the pediatric to the adult medical team at about age 18.

Outcomes for 49 pediatric patients undergoing transplantation at the pediatric hospital were compared with outcomes for two cohorts undergoing transplantation at the adult hospital: 48 young adults 18 to less than 25; and 124 adults 25 to 35. Death-censored graft survival was assessed by a multivariate Cox model.

There was no significant difference in graft survival between the pediatric and young adult cohorts. However, survival was significantly better in the adult cohort. The three cohorts had similar rates of admitted nonadherence.

Transfer from the pediatric to the adult center occurred within a relatively narrow age window of 16.6 to 20.9 years. However, the time since transplantation varied substantially: range 0.9 to 11.0 years. Graft function at the time of transfer was also variable. Six of 18 pediatric patients had a serum creatinine greater than 180 µmol/L at transfer; all of these grafts eventually failed.

Addressing the concern that pediatric transplant patients transferred to adult centers are at increased risk for graft loss, the study’s findings suggest that these poor outcomes may reflect advanced graft dysfunction rather than the transfer itself. Young transplant recipients between age 11 to 14 and age 25 are a “unique and vulnerable cohort” in need of effective and consistent management strategies, the researchers write. [Kiberd JA, et al. Kidney transplant survival in pediatric and young adults. BMC Nephrol 2011; 12:54.]

December 2011 (Vol. 3, Number 12)