Ideally, immunizations should be completed before transplantation. Although the response may be attenuated in the immune-suppressed transplant recipient, most transplantation centers recommend the usual schedule of age-appropriate immunizations after stabilization, with some important modifications. In general, live-virus vaccines (e.g., measles-mumps-rubella) are withheld, although some transplant physicians are using the varicella vaccine in susceptible children. Annual influenza immunization should be provided.

The two-edged sword of immunosuppressive therapy renders organ transplantation possible but subjects recipients to an increased risk of acquiring serious infection. In the first months after operation, the management of febrile illness in transplant
recipients is complex and, therefore, always within the province of the transplantation center. Gradually, however, the intensity of immunosuppression is decreased, and the likelihood of overwhelming opportunistic infection is diminished.

In the assessment of an acute febrile illness in children who received a solid-organ transplant more than 3 years previously, the differential diagnosis is weighted heavily toward the common diseases of childhood. The primary-care physician must be aware, however, of concerns specific to individual patients. Urosepsis, for example, is a consideration in a kidney transplant recipient who had undergone lower urinary tract reconstruction. Children with a surgical or functional splenectomy are at risk for infection with encapsulated organisms. Some heart recipients may be susceptible to bacterial endocarditis, and liver recipients are at risk for biliary tract infection. These infections are often a reflection of underlying problems, such as graft rejection or anatomic issues. In the absence of such established risk factors or evidence of bacterial infection, empiric antibiotic therapy rarely is recommended.

As with any children with chronic disease, transplant recipients may be at risk for significant growth delay. Early on, this deficiency may be a consequence of the disorder that necessitated the transplant. After transplantation, growth failure may represent the residue of original disease, graft dysfunction, malnutrition, the complications of drug therapy (e.g., corticosteroids), or behavioral issues.

Primary physicians should monitor statural and ponderal growth very carefully. An alteration in growth velocity, if confirmed, should prompt careful dietary analysis and contact with the transplantation center.

Some children may display excessive weight gain after transplantation. Although this response probably is multifactorial, corticosteroid therapy, increased caloric intake, and low physical activity variously are likely to be operative. Although dietary counseling is provided in the transplantation center, involved primary physicians may wish to identify local resources for dealing with this troublesome issue.

Especially when end-stage kidney, heart, or liver disease has its onset in the first year of life, developmental delay and subsequent school difficulties are very common. Local resources, such as early intervention programs, should be identified, and early referral should be effected. Local physicians can be very helpful in facilitating the school entry (or reentry) of children with organ transplants.

Today, most children with organ transplants will receive two or three different immunosuppressive drugs as maintenance therapy. Many of these agents have the potential for serious interactions with commonly prescribed agents. A review of prescribing decisions with the affected child’s transplantation center always is prudent.

Immunosuppressive agents also have the potential of inducing a variety of side effects. Some (hirsutism, acne, gum hypertrophy, weight gain) are largely cosmetic but may be troubling enough to compromise medication compliance. Other complications are potentially life-threatening and include hypertension, renal or hepatic dysfunction, glucose intolerance, cytopenias, and neurologic complaints. The possibility of drug effect must be entertained whenever a new complaint or finding occurs in children with an organ transplant.

Finally, noncompliance with immunosuppressive agents can result in accelerated graft loss, even years after transplantation. The primary-care physician should assess and reinforce medication compliance at every visit. For this to be effective, of course, communication between the transplant center and primary physician must be current with respect to medication regimens.

With well-functioning allografts, pituitary–ovarian function usually is normal, and pregnancy is possible. Sizable numbers of solid-organ transplant recipients have completed uneventful pregnancies. Thus, counseling with regard to issues of sexuality and contraception is as appropriate for the transplant recipient as for any similarly aged adolescent. Specific transplantation centers vary in their contraception recommendations, so contact with the transplant physician is critical.

Pregnancies do present very complex management issues. They are high-risk and should be supervised from the outset by a perinatal center with a close relationship to the transplant program.

Although the introduction of more potent immunosuppressive drugs definitely has improved the success of solid-organ transplantation, another problem has emerged. Transplanted patients have a life-long increased risk of a variety of malignancies. In some situations, these cancers are biologically indistinguishable from those occurring in patients without transplants. In others, the tumors are unique to those with immunosuppression. Of the latter, a lymphoproliferative syndrome associated with Epstein-Barr virus infection is the most important; the features of the syndrome are summarized in Box 459.1. The possibility of occult malignancy must be kept in mind when investigating any enigmatic new complaint in a child with a solid-organ transplant.

Skin cancer, ranging from squamous or basal cell carcinomas to melanomas, are actually the most common tumors occurring in transplant recipients. As for any child, careful prevention of sun exposure through the use of clothing and sunscreen is a vital component of care.