Systematic review: Body composition in children with inflammatory bowel disease.

BACKGROUND: Paediatric inflammatory bowel disease (IBD) is associated with weight loss, growth restriction and malnutrition. Bone mass deficits are well described, little is known about other body composition compartments. AIMS: To define the alterations in non-bone tissue compartments in children with IBD, and explore the effects of demographic and disease parameters. METHODS: A systematic search was carried out in the PubMed (www.ncbi.nlm.nih.gov/pubmed) and Web of Science databases in May 2014 (limitations age <17 years, and composition measurements compared with a defined control population). RESULTS: Twenty-one studies were included in this systematic review, reporting on a total of 1479 children with IBD [1123 Crohn's disease, 243 ulcerative colitis], pooled mean age 13.1 ± 3.2 years, and 34.9% female. Data were highly heterogeneous, in terms of methodology and patients. Deficits in protein-related compartments were reported. Lean mass deficits were documented in 93.6% of Crohn's disease and 47.7% of ulcerative colitis patients when compared with healthy control populations. Lower lean mass was common to both sexes in Crohn's disease and ulcerative colitis, deficits in females with persisted for longer. Fat-related compartment findings were inconsistent, some studies report reductions in body fat in new diagnosis/active Crohn's disease. CONCLUSIONS: It is clear that almost all children with Crohn's disease and half with ulcerative colitis have reduced lean mass, however, body fat alterations are not well defined. To understand what impact this may have on health and disease in children with IBD, further studies are needed to identify in which tissues these deficits lie, and to quantify body fat and its distribution.

Management of acute rejection in paediatric liver transplantation.

The success of paediatric liver transplantation is attributed to improved surgical techniques and the advent of calcineurin inhibitor-based immunosuppression. Acute rejection (AR) rarely results in graft loss with calcineurin inhibitor immunosuppressive regimens, and the advent of newer agents like interleukin (IL)-2 receptor antibodies. The latter have the benefit of reducing the incidence of AR further and may be of use in patients who are susceptible to recurrent AR, were retransplanted for graft rejection or are in a steroid-sparing regimen. A total of 60 % of all paediatric liver transplants result in AR; however, there is a 75 % response rate to initial steroid therapy. Steroid therapy remains the mainstay of initial AR management, coupled with an increase in baseline immunosuppression. Steroid-resistant rejection (SRR), previously an immediate indication for potent anti-lymphocyte preparations, is now effectively treated with chimeric or humanised IL-2 receptor monoclonal antibodies. Recurrent AR can be treated by adding adjuvant immunosuppressive agents such as mycophenolate mofetil (MMF) or sirolimus. Studies have also demonstrated the efficacy of MMF as rescue therapy for SRR. Anti-lymphocyte preparations such as anti-thymocyte globulin (ATG) and OKT3 are rarely used in SRR but may be of use as rescue therapy for severe SRR. The challenges of the management of AR remain in the management of recurrent AR and SRR. We discuss the pathogenesis, diagnosis and management of AR, including prevention, and specific management of AR and SRR based on current evidence and our own experience at the King's College Paediatric Liver, Gastroenterology and Nutrition Centre in London.