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Growth Pre- and Postimplementation of a Steroid-free Induction Protocol in a Large Pediatric Intestinal Transplant Population

Nucci, Anita M*; Strohm, Sharon; Squires, Robert H; Mazariegos, George V§; Sun, Qing||; Sindhi, Rakesh

Journal of Pediatric Gastroenterology and Nutrition: May 2011 - Volume 52 - Issue 5 - p 601–606
doi: 10.1097/MPG.0b013e31821247da
Original Articles: Hepatology and Nutrition

Objectives: Beginning in March 2002, we initiated steroid-free lymphocyte depleting immunosuppression with rabbit anti-human thymocyte globulin (rATG) for all children who received an intestinal transplant (ITx). The purpose of the present study was to determine whether this treatment regimen supported growth. Because steroids were used for rejection episodes only, we hypothesized that improved growth would be observed in steroid-free rATG-treated children.

Patients and Methods: Nutrition outcomes in patients who received an ITx between December 1996 and February 2007 were retrospectively reviewed. Nutritional analysis included evaluation of differences in weight and height z scores between transplantation and 2 years post-ITx by the type of immunosuppressant therapy received.

Results: A total of 109 children received an ITx during the evaluation period. Of these, 29 received a transplant before March 2002 and received an induction regimen that included anti–T-cell immunosuppressant, tacrolimus (TAC), with prednisone (steroid). The remaining 80 children received an induction regimen of rATG and TAC without steroids (steroid-free). Steroid-free children met their full nutritional requirements enterally or orally in a median of 2 months, whereas children treated with the steroid regimen reached nutritional autonomy 7 months after transplant (P < 0.001). A positive trend in z score values over time for height was observed in 48% of steroid-free patients versus 44% in the steroid regimen. The change in mean z score for linear growth over time was most positive (0.55) in the steroid-free group and <120 days of steroids during the follow-up period with 62% of patients in this group observed to have positive growth over time.

Conclusions: Nutritional autonomy was achieved rapidly, and positive growth was observed in the majority of patients with ITx who received steroid-free immunosuppression with rATG.

*Division of Nutrition, Georgia State University, Atlanta, USA

Clinical Nutrition Department, Children's Hospital of Pittsburgh, USA

Division of Pediatric Gastroenterology, USA

§Hillman Center for Pediatric Transplantation, USA

||Department of Surgery, USA

Division of Transplantation, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

Received 17 September, 2010

Accepted 25 January, 2011

Address correspondence and reprint requests to Anita M. Nucci, PhD, RD, LD, Division of Nutrition, Georgia State University, Urban Life Building, 140 Decatur St, Suite 870, Atlanta, GA 30303 (e-mail:

The authors report no conflicts of interest.

Copyright 2011 by ESPGHAN and NASPGHAN