Metabolic Screening to Assess Cardiovascular Risk in Pediatric Kidney Transplant Recipients

Background: Post-transplant immunosuppression, such as steroids and calcineurin inhibitors, have been implicated in the development of new onset diabetes after transplantation (NODAT) and dyslipidemia increasing the risk of cardiovascular events affecting allograft and patient survival. The estimated incidence of NODAT in the pediatric transplant population is around 3-20%. Yet the incidence of metabolic syndrome, defined as a constellation of cardiovascular risk factors such as obesity, dyslipidemia, insulin resistance, and hypertension, has been difficult to establish among pediatric kidney transplant recipients. A contributing factor is a lack of guidelines to effectively screen these patients. We implemented a quality improvement (QI) project to streamline how our patients are screened. Our aim is to identify at-risk patients earlier with the goal of decreasing the morbidity and mortality related to the metabolic syndrome. Methods: Non-fasting lipid panel, random plasma glucose and hemoglobin A1c (HgbA1c) were obtained annually. 162 pediatric kidney transplant patients aged 2 years to 20 years old were screened. Patients were referred to endocrinology if BMI was > 90% percentile, HgbA1c > 6 %, and abnormal fasting lipid profile was present. Primary outcome of interest is the percentage of patients who received metabolic syndrome screening labs pre and post implementation. Secondary outcome is the incidence of metabolic syndrome. Results: Prior to QI initiation, only 18 patients (0.1%) had metabolic syndrome screening labs. After initiation, 91 patients (56%) received screening labs. HgbA1c level > 6% was found in 4 patients and they were referred to endocrinology and 7 patients had HgbA1c in the pre-diabetic range (5.6-6%). 4 patients had abnormal non-fasting lipid panels that will require reassessment on a fasting sample. The prevalence of patients with a component of metabolic syndrome was 18%. Conclusion: Early identification and regular screening for metabolic syndrome in pediatric kidney transplant recipients is critical for the overall health and survival of the patient and their allograft. Without a standardized process to screen these patients, there is a risk of missing a group of patients with early signs of disease. The results of this QI intervention show that standardized screening is feasible and leads to early recognition of abnormal metabolic profile.