1. Obesity in the Pediatric Transplant Patient a growing problem – despite the best of intentions Elizabeth Gerndt-Spaith, RN, BSN, CCTC 10/8/2011

2. 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

3. Pediatric Obesity Trends

4. 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, obesity Immunosuppression- alemtuzumab, methylprednisolone x 2 doses; tacrolimus and cell cept maintenance

5. Growth Charts at transplant WeightHeightBMI

6. 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

7. Growth Chart 5 years later WeightHeight BMI

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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.