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Factors Associated With Neurobehavioral Complications in Pediatric Abdominal Organ Transplant Recipients Identified
Alicia M Alcamo1, Robert S B Clark1,2,3,4,5,6,7, Alicia K Au1,2,3,4,5,6,7
1Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.
Insights
Neurobehavioral complications are common in pediatric abdominal transplant recipients, increasing mortality and hospital stays. Higher tacrolimus levels are linked to these complications, necessitating further research for optimal dosing.
Area of Science:
- Pediatric Medicine
- Transplant Surgery
- Neuroscience
Background:
- Neurologic complications affect up to 40% of adult solid organ transplant recipients, increasing mortality.
- Data on similar complications in pediatric populations are limited.
- This study focuses on neurobehavioral complications in pediatric abdominal solid organ transplant recipients.
Purpose of the Study:
- To describe the occurrence of neurobehavioral complications in pediatric abdominal solid organ transplant recipients.
- To examine the association of these complications with length of stay, mortality, and tacrolimus levels.
Main Methods:
- Utilized electronic health records from 2009-2017 for pediatric abdominal solid organ transplant recipients.
- Developed a computable composite definition for neurobehavioral complications using structured electronic data.
- Analyzed 1,542 readmissions among 318 patients.
Main Results:
- 20.4% of patients experienced at least one admission with a neurobehavioral complication.
- Neurobehavioral complications were associated with increased ICU admission (OR 3.9), longer ICU (10.3 vs 2.2 days) and hospital stays (8.9 vs 4.3 days).
- Higher maximum tacrolimus levels (12.3 vs 9.8 ng/mL) and increased mortality (OR 5.04) were observed in patients with neurobehavioral complications.
Conclusions:
- Electronic health record data can accurately identify neurobehavioral complications in pediatric transplant patients.
- Late neurobehavioral complications are linked to higher resource utilization, mortality, and tacrolimus exposure.
- Further research is needed to clarify the tacrolimus level-complication relationship for improved therapeutic drug monitoring.
Objectives:
Neurologic complications occur in up to 40% of adult abdominal solid organ transplant recipients and are associated with increased mortality. Comparable pediatric data are sparse. This study describes the occurrence of neurologic and behavioral complications (neurobehavioral complications) in pediatric abdominal solid organ transplant recipients. We examine the association of these complications with length of stay, mortality, and tacrolimus levels.
Design:
The electronic health record was interrogated for inpatient readmissions of pediatric abdominal solid organ transplant recipients from 2009 to 2017. A computable composite definition of neurobehavioral complication, defined using structured electronic data for neurologic and/or behavioral phenotypes, was created.
Setting:
Quaternary children's hospital with an active transplant program.
Patients:
Pediatric abdominal solid organ transplant recipients.
Interventions:
None.
Measurements And Main Results:
Computable phenotypes demonstrated a specificity 98.7% and sensitivity of 63.0% for identifying neurobehavioral complications. There were 1,542 readmissions among 318 patients, with 65 (20.4%) having at least one admission with a neurobehavioral complication (total 109 admissions). Median time from transplant to admission with neurobehavioral complication was 1.2 years (interquartile range, 0.52-2.28 yr). Compared to encounters without an identified neurobehavioral complication, encounters with a neurobehavioral complication were more likely to experience ICU admission (odds ratio, 3.9; 2.41-6.64; p < 0.001), have longer ICU length of stay (median 10.3 vs 2.2 d; p < 0.001) and hospital length of stay (8.9 vs 4.3 d; p < 0.001), and demonstrate higher maximum tacrolimus level (12.3 vs 9.8 ng/mL; p = 0.001). Patients with a neurobehavioral complication admission were more likely to die (odds ratio, 5.04; 1.49-17.09; p = 0.009). In a multivariable analysis, type of transplant, ICU admission, and tacrolimus levels were independently associated with the presence of a neurobehavioral complication.
Conclusions:
Common electronic health record variables can be used to accurately identify neurobehavioral complications in the pediatric abdominal solid organ transplant population. Late neurobehavioral complications are associated with increased hospital resource utilization, mortality, and tacrolimus exposure. Additional studies are required to delineate the relationship between maximum tacrolimus level and neurobehavioral complications to guide therapeutic drug monitoring and dosing.
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