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14 Preventive Health intheAdult Solid Organ Transplant Recipient
431© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
C. J. Wong (ed.), Primary Care of the Solid Organ Transplant Recipient,
https://doi.org/10.1007/978-3-031-98076-3_15
Chapter 15
Care ofthePediatric Solid Organ
Transplant Recipient
KatelynM.Saarela andEvelynK.Hsu
15.1 Introduction
Solid organ transplantation is the standard of care for end-stage organ failure in
children [1]. Based on Organ Procurement and Transplantation Network (OPTN)
data as of September 2024, there were just over 8700 pediatric solid organ trans-
plants performed between 2020 and 2024in the USA (Fig.15.1). Advancements in
pre-and post-transplant management have resulted in improved patient and graft
survival (Table15.1) with a shift in focus to long-term outcomes and quality of life
for those transplanted in childhood. The primary care provider (PCP) is founda-
tional to the care of children pre-and post-transplant and is integral to patient sur-
vival post-transplant. They provide vital continuity, ensure administration of routine
care including vaccinations, monitor growth and nutrition, and establish long-term
relationships that impact adherence and patient/graft outcomes. Furthermore, the
PCP serves as the link between the patient and transplant team, coordinates care
with other specialists, and provides an added layer of support for the family and
siblings of the transplanted child. Equally important, the PCP is often the rst-line
provider during periods of illness and fever for the transplant patient and must be
able to perform a focused exam and interpret laboratory data appropriately [3–5]. In
this chapter, we will provide an overview of the care of pediatric transplant patients,
the recommended role of the primary care provider, and the need to provide routine
care in the context of organ transplantation.
K. M. Saarela (*) · E. K. Hsu
Division of Gastroenterology and Hepatology, Department of Pediatrics, Seattle Children’s
Hospital, University of Washington School of Medicine, Seattle, WA, USA
e-mail: Katelyn.saarela@seattlechildrens.org
432
0
200
400
600
800
1000
1200
1400
1600
1800
2000
2020 20212022202
32
024
NUMBER OF PEDIATRIC TRANSPLANTS
YEAR
UNITED STATES TRANSPLANTS < 1 TO 17 YEARS
Kidney Liver Heart Lung Intestine
Fig. 15.1 Number of Pediatric Solid Organ Transplants 2020–2024 (Data from United Network
for Organ Sharing)
Table 15.1
Survival rates of pediatric SOT recipients by organ type [2]
Organ type
1-year patient survival
rate
3-year patient survival
rate
5-year patient survival
rate
Heart 93.3% 88.2% 84.4%
Kidney (DDKT) 97.6% 93.6% 86.9%
Liver (DDLT) ~94% ~92% 90.3%
Lung 81% 63.9% 57.5%
Intestine
(isolated)
91.3% ~85% 78.3%
DDKT deceased donor kidney transplant, DDLT deceased donor liver transplant
15.2 The Continuity Care Provider
Most children who receive a solid organ transplant will be exclusively followed by
their transplant team for the rst 3months post-transplant, with some families asked
to relocate to be near the transplant center. However, the PCP’s understanding of the
indication for transplant, donor/recipient serologic data, and transplant course
including early rejection and infectious complications, are essential to resuming
routine care from the rst month to several months post-transplantation.
It is understood that the transition period from hospital to home is one of unease
and uncertainty as caregivers assume full responsibility for medication manage-
ment, symptom monitoring, frequent clinic visits and appointments for monitoring
(e.g., blood draws, imaging, depending on the specic organ transplanted). Lerret
etal. described the patient/parent perspective and demonstrated that the quality of
discharge teaching and care coordination from the rst hospitalization was
K. M. Saarela and E. K. Hsu
433
associated with post-discharge coping and adherence with medication administra-
tion [6, 7].
The PCP can aid in this transition and actively facilitate follow-up. Pediatric
transplant recipients should have routine follow-up with their PCP at a minimum
frequency based on the American Academy of Pediatrics Periodicity Schedule, with
consideration for more frequent follow-up based on comorbidities and transplant
complications [8]. Table15.2 illustrates a proposed follow-up schedule for the rst
year after transplant, involving both the primary care provider (PCP) and the trans-
plant center. Intensity of follow-up varies by transplant center as well as individual
patient characteristics and complications.
15.3 Vaccination
Vaccination offers a vital opportunity to mitigate certain infectious risks in immu-
nocompromised children requiring solid organ transplant and every effort should be
made to provide routine vaccination to transplant candidates and household mem-
bers. Vaccinations provide a safe, simple, and cost-effective opportunity to prevent
serious illness, disability, and death in children and are strongly recommended by
the American Academy of Pediatrics [9]. With the rise of several vaccine- preventable
diseases, vaccinations in the pre-transplant period are of utmost importance and
should be pursued per routine immunization schedules with catch up and acceler-
ated schedules as appropriate [10, 11]. Administration of as many vaccines as pos-
sible in the pre-transplant period is recommended to increase likelihood of
effectiveness prior to anticipated immunosuppression post-transplant. Inactivated
Table 15.2 Typical follow-up schedule 0–12months post-transplantation
a
a
Columns represent weeks
15 Care ofthePediatric Solid Organ Transplant Recipient
434
vaccines can be administered upwards of 2weeks prior to transplant. However,
attention to timing and degree of illness/clinical decline in the pediatric transplant
candidate should be assessed prior to administering live-virus vaccines as there
should be a minimum of 4weeks between vaccination and transplant [3, 11, 12].
15.3.1 Post-Transplant Vaccination
While inactivated vaccines can be safely administered post-transplant, they should
not be administered any sooner than 3months post-transplant given the lack of
effectiveness in the setting of high immunosuppression, with the exception of inac-
tivated inuenza vaccine (IIV) which should be considered ≥1month from trans-
plant prior to and during respiratory viral season [12, 13]. Other vaccine
considerations within the rst 3months of transplant are the COVID-19 vaccine and
respiratory syncytial virus vaccine in pediatric SOT recipients (most centers admin-
ister to those severely immunocompromised and<24months) [14, 15].
Historically, live-virus vaccines have been contraindicated in immunocompro-
mised SOT recipients. However, emerging data have demonstrated safety and posi-
tive immunogenic effects of live-virus vaccinations post-transplant in select patients
based on type of transplant, time from transplant, time from rejection, immunosup-
pression levels, and immunologic evaluation [12, 16, 17]. The PCP may consider
live-virus vaccination (measles-mumps-rubella (MMR), varicella) in selected
patients (Table15.3); however, because of the complexity of live-virus vaccinations
in pediatric SOT recipients, it is recommended to always consult with the transplant
team rst.
Table 15.3 Potential candidates for live-virus vaccination in pediatric solid organ transplant
recipients
a
Serology Not immune to components of MMR or Varicella
Type of transplant Liver or kidney
Time from transplant/
rejection
1-year post-transplant AND 2months post-rejection episode
Clinical status Clinically well
Immunosuppression Corticosteroids <2mg/kg/day or total cumulative <20mg/day
Tacrolimus <8ng/mL for two consecutive readings
Cyclosporine <100ng/mL for two consecutive readings
Immune criteria Absolute lymphocyte count >1500in children <6years and>1000
cells/uL for children >6years
a
Based on Suresh etal 2018 consensus meeting [16]. Transplant team should be consulted prior to
any live-virus vaccine administration
K. M. Saarela and E. K. Hsu
435
There is extensive evidence that patients after transplant have waning immunity
against vaccine-preventable diseases with exact mechanisms not fully elucidated
but postulated to be driven by certain types of immunosuppression (e.g., mycophe-
nolate mofetil), number of vaccine boosters, and inability to maintain immunologic
memory [18, 19]. The PCP has an important role to partner with the transplant
center and transplant infectious disease specialist to ensure all recommended and
catch up vaccines are administered as safely and expeditiously as possible in the
pre-transplant period. Moreover, the PCP can reinforce the importance of household
members being up to date on their own vaccines to reduce risk to the transplant
recipient.
15.4 Fever andInfection inPediatric Solid Organ
Transplant Recipients
The pediatrician or PCP is often the rst outpatient provider to see a pediatric trans-
plant recipient with a fever and they must understand the broad differential diagno-
sis while also performing a focused clinical history and physical exam. Careful
pre-transplant evaluation of the recipient and donor can help both the transplant
providers and PCP understand unique infectious risks prior to transplant.
Furthermore, an advanced understanding of the surgical procedure, and infection
prevention in the perioperative period will help mitigate serious and preventable
infections. Finally, timely recognition of infection post-transplant will allow for
effective and early treatment of infections post-transplant [20].
Similar to adult solid organ transplant recipients (see Chap. 8), the infection risk
is highest in the rst 6months from transplant and can be divided into a timeline
with three distinct periods. (1) In the rst 30 days from transplant, patients are
higher risk of bacterial and fungal infections from surgical complications, contami-
nated allograft, and nosocomial infections. (2) The second phase is 30–180days
which is when the effect of immune suppression is most notable with viral infec-
tions associated with latent or chronic infections (Herpes Simplex Virus, Epstein–
Barr Virus, Cytomegalovirus, Human Herpes Virus-6) opportunistic, and reactivated
viral infections. (3) The third period is >180days which can be divided into two
subgroups: those who have good allograft outcomes and on are on stable, mainte-
nance immunosuppression—this group is primarily affected by common
community- acquired infections; while those in the second group have poor allograft
outcomes resulting in higher immunosuppression and suffer from more opportunis-
tic infections as well as infections related to technical/anatomic factors (i.e., urinary
tract infections in renal transplant, intra-abdominal or biliary infections in liver
transplant, pneumonia and lung abscess in heart transplant recipients, and resistant
organisms in cystic brosis lung transplant recipients due to colonization) [21].
15 Care ofthePediatric Solid Organ Transplant Recipient
436
15.4.1 Cytomegalovirus (CMV)
CMV is a common viral illness that can lead to mild viral symptoms or be asymp-
tomatic in immunocompetent individuals. However, CMV after solid organ trans-
plant can lead to asymptomatic viremia, end-organ dysfunction or present as CMV
syndrome which is dened as detection of CMV plus any 2 of the following: fever
for ≥2days, new or increased malaise, leukopenia or neutropenia, >5% atypical
lymphocytes, thrombocytopenia, or elevated hepatic transaminases [22, 23].
Upwards of a third of pediatric SOT recipients will have reactivation of CMV after
transplant with the greatest risk in those of donor positive, recipient negative serosta-
tus. Primary infection poses the greatest risk and is associated with the highest mor-
bidity and mortality. The presentation of primary CMV infection varies with type of
organ transplantation with glomerular injury and rejection in renal transplant recipi-
ents [24]; hepatitis, liver failure and rejection in liver transplant recipients [25]; and
accelerated coronary artery arthrosclerosis in cardiac transplant recipients [26].
Early recognition and treatment of CMV is vital to preserve graft health and miti-
gate progression to end-organ disease [23]. (For discussion of CMV infection in
adults, see Chap. 8)
15.4.2 Epstein Barr Virus (EBV)
EBV infection in the post-transplant patient can have variable presentations includ-
ing asymptomatic viremia, mild non-specic viral symptoms, and post-transplant
lymphoproliferative disease (PTLD) [27]. It is another infection that carries high
morbidity and mortality in transplant recipients and can be particularly challenging
as there is not a direct anti-viral therapy and often requires immunosuppression
reduction and is dependent on host immune response. Donor and recipient serologic
status prior to transplant are vital to understand for the purposes of risk stratica-
tion. Seronegative SOT recipients are deemed high risk for viremia and PTLD, par-
ticularly in the rst 3years post-transplant, if the donor has a past history of infection
and recipient is negative (D+/R−); moderate risk for community acquisition and
subsequent infection if both donor and recipient are negative (D−/R−) with recom-
mended implementation of prevention strategies [28]. PTLD incidence is also
dependent on organ type which may reect the unique immunosuppression regi-
mens, lymphoid load in the allograft, and chronic antigenic exposure with highest
risk of PTLD in intestinal transplants, followed by moderate risk in liver, pancreas,
heart, and lung, and lowest risk in renal transplants [29, 30]. EBV and PTLD should
be suspected in patients with protracted fever, lymphadenopathy, organomegaly,
diarrhea, or laboratory derangements such as leukopenia, thrombocytopenia, or
K. M. Saarela and E. K. Hsu
437
atypical lymphocytosis. Evaluation includes quantitative EBV polymerase chain
reaction assays to assess degree of viremia, a focused clinical history and physical
exam, and consideration for imaging of the neck, chest, abdomen, and pelvis.
Depending on symptoms and imaging, endoscopic evaluation may also be war-
ranted to assess for intestinal PTLD. Every effort should be made for histologic
conrmation of PTLD and further assessed via Epstein–Barr encoded RNA
(EBER) probe.
15.4.3 Polyomaviruses
BK virus is a human polyomavirus and has emerged as an important cause of renal
allograft dysfunction and risk of infection depends on degree of immunosuppres-
sion [31]. Worsening BK viremia can lead to BK viral-associated nephropathy and
ultimately, graft loss. Hence, judicious management of immunosuppression is war-
ranted with initial elevations in BK viral load in the peripheral blood by polymerase
chain reaction. BK virus is rarely pathogenic in immunocompetent hosts, however,
in renal transplant recipients, it can present with ureteral stenosis, interstitial nephri-
tis and progressive impairment in renal function [32]. Emerging data suggest non-
renal solid organ transplant recipients are also affected by BK viremia with one
study demonstrating upwards of 14% of non-renal solid organ transplant patients
had BK viremia and 7% with viral loads >10,000 copies/mL which is known to cor-
relate with BK viremia nephropathy and is likely a contributing cause of chronic
kidney disease in non-renal solid organ transplant patients [33]. In most cases, the
pediatric transplant nephrologist will monitor for BK virus; primary care pediatri-
cians should involve the nephrology team early in workup of acute kidney injury or
chronically rising serum creatinine.
15.4.4 Non-infectious Etiologies ofFever
Non-infectious etiologies for fever must also be considered including rejection,
post-transplant lymphoproliferative disorder, and malignancy. Pediatric SOT recipi-
ents are at much higher risk for malignancy in the setting of their chronic immuno-
suppression and increased oncogenic infection risk. Lymphomas [including
post-transplant lymphoproliferative disorder (PTLD)] and skin cancer comprise the
majority of the cancer diagnoses in pediatric solid organ transplant recipients but
they are also at high risk for other solid and hematological cancers [34–36].
Education from the PCP should be focused on sun protection and need for routine
skin examinations, similar to adult SOT recipients (see Chaps. 10, and 14) [37].
15 Care ofthePediatric Solid Organ Transplant Recipient
438
15.5 Growth andNutrition inPediatric Solid
Organ Transplantation
One of the biggest distinctions in the post-transplant care of children compared to
that of adults is the vital requirement to maintain health that supports normal physi-
cal growth and development [38]. The primary care provider has an essential role in
monitoring nutritional status and growth in children after SOT as well as ensuring
maximal nutritional support. Childhood growth and development are dependent on
nutrition, and children who do not receive sufcient nutrition are at high risk of
impaired cognitive skills and growth failure [39]. As a result, most children with
end-stage organ failure have some degree of malnutrition, growth failure, and devel-
opmental delay. These deciencies are not quickly reversed with transplant and
require vigilant monitoring. Ng, etal., reviewed 2291 children who had undergone
their rst liver-only transplantation that were enrolled in the Studies of Pediatric
Liver Transplantation database registry and found that 5years after liver transplant,
73% of patients were below the average height of the normal population, 47% below
the lower quartile, and just under 30% below the tenth percentile [40]. Furthermore,
up to 25% of pediatric renal transplant recipients do not reach their predicted adult
height. [38, 41] These numbers are particularly salient as several studies have shown
that short stature in pediatric transplant patients has a negative psychosocial impact
with resultant challenges with behavior, cognition, functional status, and academic
achievement [41–43]. Growth decit and age at transplant, immunosuppression
regimen including duration and frequency of corticosteroids, and allograft dysfunc-
tion are all contributory factors with impacts on growth in pediatric transplant recip-
ients [44]. While “catch-up” growth and development are observed in many children
post-transplant, some do not overcome pre-transplant decits [38, 45].
Clinical transplant dieticians are a vital member of the transplant team and pro-
vide thorough nutritional assessments pre-and post-transplant with the goal to sup-
port growth and physical development. Moreover, the transplant dietician provides
education regarding food safety, immunosuppression-food interactions, aids in the
transition to oral nutrition, and prevents nutrition-related complications [46].
The PCP is uniquely positioned to support the growth and nutrition of children
who have received a transplant given continuity of care, long-standing relationships
with the patient and family, and ties to the community for resources.
15.6 Development
With advancements in post-transplant survival, attention has shifted to health-
related quality of life (HRQOL) and survivorship following pediatric organ trans-
plantation. While organ transplantation addresses the immediate end-organ
dysfunction and associated comorbidities, pediatric SOT patients are known to have
lower functional outcomes, such as school and social functioning, and lower
K. M. Saarela and E. K. Hsu