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From the Transition Trenches: Working with an At-Risk Transplant Population

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Melissa K. Cousino, PhD
University of Michigan Transplant Center
C.S. Mott Children's Hospital
Ann Arbor, MI, USA

As a pediatric psychologist working in solid organ transplantation, I was thrilled to see the Journal of Heart and Lung Transplantation recently highlight the important topic of transitioning from pediatric to adult transplant care with thoughtful recommendations for practice as described by Putschoegl and colleagues [1]. Across other solid organ transplant populations, transition to adult care has been found to be associated with adverse health outcomes, including increased graft loss and mortality [2,3]. This underscores the value of transition-focused clinical programs with concurrent study of their efficacy [1].

However, it is important to highlight that it may not simply be the physical transfer to adult care that poses the greatest risk. Transplant recipients within the transitioning age range represent a high-risk population. Non-adherence to the treatment regimen is strikingly high among this group [4]. Rates of mental health problems, such as anxiety and depression, also increase in adolescence/young adulthood and can significantly complicate care during this vulnerable time period. Among our own sample of adolescent/young adult pediatric heart transplant recipients, parents endorsed clinically significant patient emotional/behavioral problems in 23% of the sample during routine psychosocial screening. Young people commonly struggle with identity formation, body image/self-esteem issues, peer relations and separation from parents - all of which may impact treatment adherence. Risk-taking behaviors such as substance use are also greater during this developmental period [5].

Thus, in some cases, health education/knowledge and a coordinated hand-off to an adult transplant provider is inadequate for a successful transition. I have been helping to expand our transition-focused transplant clinics and intervention services --- readiness assessments, checklists, and transfer documentation have been helpful to our work, but not sufficient for our higher-risk patients. I regularly encounter cases such as these:

A medically stable young adult presents for routine post-transplant, transition-focused care. Her medication and health-related knowledge are deemed to be excellent. She effortlessly rattles off all medications, their dosing and functions. She uses a pillbox for organizing medications (which she brought to clinic) and phone alarms to assist with medication timing. She has demonstrated ability to independently manage appointment scheduling, communication with medical team, transportation and insurance. She informs us that she has a full-time job with plans to enroll in college courses this year. At the last clinic visit, she met with a member of the adult transplant team. By various 'transition-readiness' metrics, she is a great candidate for transfer of care. However, she also has a history of major depressive disorder with suicidal ideation with plan (i.e., stop taking medications) and emerging personality disorder traits. At times, she engages in high-risk behaviors, including self-injurious cutting and unprotected sex (despite awareness of possible teratogenic risks). Eager to please, yet slow to trust providers, these notable risks to her treatment adherence, long-term graft survival and overall health are likely to go undetected during routine medical visits or on readiness-assessment screeners. Prior to transitioning this patient, established cognitive behavioral therapy and psychopharmacologic treatment targeting mood and adherence will be imperative to her overall health and post-transplant care.

As this case demonstrates, psychosocial functioning must be routinely assessed as part of transition-focused care. Collaborative care provided in partnership with pediatric and adult mental health care clinicians with expertise in the evidence-based treatment of non-adherence to medical regimes and comorbid mental illness should be strongly considered when designing and implementing transition-focused programs. ■

Disclosure Statement: Dr. Cousino does not have a financial relationship with a commercial entity that has an interest in the subject of the submitted article or other conflicts of interest to disclose.


  1. Putschoegl A, Dipchand AI, Ross H, Chaparro C, Johnson JN. Transitioning from pediatric to adult care after thoracic transplantation. Journal of Heart and Lung Transplantation. 2017;36:823-829.
  2. Annunziato RA, Emre S, Shneider B, Barton C, Dugan CA, Shemesh E. Adherence and medical outcomes in pediatric liver transplant recipients who transition to adult services. Pediatric Transplantation. 2007;11(6):608-14.
  3. Watson AR. Non-compliance and transfer from paediatric to adult transplant unit. Pediatric Nephrology. 2000;14(6):469-72.
  4. Dobbels F, Damme?Lombaert RV, Vanhaecke J, Geest SD. Growing pains: Non?adherence with the immunosuppressive regimen in adolescent transplant recipients. Pediatric Transplantation. 2005;9(3):381-90.
  5. Stilley CS, Lawrence K, Bender A, Olshansky E, Webber SA, Dew MA. Maturity and adherence in adolescent and young adult heart recipients. Pediatric Transplantation. 2006;10(3):323-30.

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