Loss of Pediatric Kidney Grafts During the “High-Risk Age Window”: Insights From Pediatric Liver and Simultaneous Liver-Kidney Recipients : Graft Loss in Pediatric Liver and Kidney Recipients

Adolescents and young adults appear to be a particularly high-risk group for problems of non-compliance and associated graft loss. We reviewed the progress of 20 young adults (9 female) who had been transferred to three different adult centres at a mean age of 17.9 years (range 15.7-20.9 years) having been transplanted at a mean age of 14.3 years (range 9.6-18.1 years) in the paediatric unit. Eight transplants failed within 36 months of transfer, and in 7 of 20 (35%) the transplant failure was unexpected (3 < 12 months, 3 12-24 months, 1 31 months post transfer). Although many of the patients had recognised problems in family dynamics, only 1 had had a major rejection episode prior to transfer due to admitted non-compliance. In 3 others low cyclosporin levels had been noted. Two young men had been transplanted preemptively in the paediatric unit at 15.3 and 16.7 years, and 3 patients had been transferred to the adult unit via the recently established transition clinic. The results suggest that close attention needs to be paid to this group of patients who require ongoing education and support. Improved dialogue between staff of the paediatric and adult units about transition issues is also essential.

One-year graft and patient survival are better in adolescent transplant recipients (age 11-19 years) than in younger (age i.e. 5 year post-transplant) in the adolescent age group are significantly worse than in younger transplant recipients. A behavioral factor that could explain an important part of the poorer clinical outcome in adolescent transplant recipients is non-compliance with medication taking. Adolescents, like all organ transplant recipients irrespective of their age, must adhere to a life-long immunosuppressive regimen in addition to other aspects of their therapeutic regimen. Therefore, adolescent transplant recipients, as all transplant patients, should be regarded as a chronically ill patient population in whom behavioral and psychosocial management is equally important as state-of-the-art medical management. This paper provides an overview of the current knowledge on prevalence, clinical consequences, and risk-factors for non-compliance with the immunosuppressive regimen in adolescent transplant recipients and offers some suggestions for adolescent-tailored interventions to improve medication adherence.

Age at transplant and graft failure risk are associated in young kidney transplant recipients. The risk of graft failure may also vary by current age, irrespective of age at transplant. We sought to estimate age-specific graft failure rates in young kidney transplant recipients and to estimate the relative hazards of graft failure at different ages, compared with at the age of 25 to 29 years. We evaluated 90,689 patients recorded in the United States Renal Data System database who received a first transplant when younger than 40 years (1988-2009); 18,310 were younger than 21 years at transplant. Time-dependent Cox models with time-varying covariates were used to estimate the association between age (time-dependent) and death-censored graft failure risk, adjusted for time since transplant and other potential confounders. There were 31,857 graft failures over a median follow-up of 5.9 years (interquartile range, 2.5-10.5 years; maximum, 21.8 years). Crude age-specific graft failure rates were highest in 19 year olds (6.6 per 100 person-years). Compared with individuals with the same time since transplant observed at 25 to 29 years of age, death-censored graft failure rates were highest in 17 to 24 year olds (hazard ratio, 1.20; [95% confidence interval 1.13, 1.27] for 17-20 year olds and 1.20 [1.13, 1.26] for 21-24 year olds; both P<0.0001) and lowest in 5 to 12 year olds (hazard ratio, 0.60; [0.53, 0.68] for 5-9 year olds and 0.56 [0.49, 0.64] for 10-12 year olds; both P<0.0001). Among first kidney transplant recipients younger than 40 years, older adolescents and young adults (17-24 years) have the highest risk of graft failure, irrespective of age at transplant.