Transplant

Question 1

What is considered a normal weight gain for a transplant patient?

Answer 1

20-40 lbs int eh first 6 months due to no more cachectic effects of dialysis, diet liberalization, lack of physical activity, increased appetite from steroid medications

Question 2

which medications cause hyperlipidemia?

Answer 2

Cyclosporine, Crticosteriods, tacrolimus

Question 3

Which medications are nephrotoxic?

Answer 3

calcineuin inhibitors, cyclosporine, and tactrolimus
sirolimus is not nephrotoxic

Question 4

Which medications interact with grapefruit?

Answer 4

Grapefruit and grapefruit juice impacts absorption of medications, including immunosuppressants (cyclosporine, tacrolimus), calcium channel blockers, and antilipideimcs via the inhibition of CYP3A4 in the gut wall.

Question 5

Food safety in transplant

Answer 5

Regarding dairy –

Higher Risk: unpasteurized (raw) milk and soft cheeses made from unpasteurized (raw) milk such as feta, brie, camembert, blue-veined, queso fresco are higher risk foods
Lower Risk: hard cheeses, processed cheese, cream cheese, mozzarella, soft cheeses labeled “made from pasteurized milk”
Mayonnaise uses raw egg in the recipe so must be avoided unless pasteurized eggs are used.

Correct because raw sprouts are a higher risk food.

Sashimi is raw fish and must be cooked to 145F to lower risk.

Question 6

Side effects of Cyclosporine A?

Answer 6

hyperkalemia, oral candida, weight gain, hyperlipidemia, hypomagnesia, HTN, hyperglycemia, GI distress including abdominal pain, decreased appetite, N/V/D;
Gingival hyperplasia, oral candida

Question 7

side effects of Tacrolimus

Answer 7

• Insulin resistance / hyperglycemia
• Hyperkalemia or hypokalemia
• Hypophosphatemia
• Hypomagnesemia
• GI distress: abdominal pain, anorexia, N/V/D/C
• Mouth / throat sores
• Peripheral edema

Question 8

Recommended intervention for a pt on Azathioprine?

Answer 8

Increase folate intake

Question 9

What is the protein recommendation during acute post-transplantation phase?

Answer 9

1.2-2.0 gm/kg

Question 10

How long is the acute post-transplantation phase?

Answer 10

up to 8 weeks post transplant

Question 11

which mineral might be low with corticosteroid use?

Answer 11

zinc

Question 12

which herbal supplement can increase risk of rejection due to its ability to enhance the immune system?

Answer 12

Echinacea

Question 13

Describe the 2 types of immunosuppressive
therapy commonly used in transplantation

Answer 13

1. Induction therapy: use antilymphocyte antibody medications for a short period of time immediately post-transplant to prevent early
   rejection episodes; minimal side effects
2. Antirejection therapy: used in immediate post- transplant phase, but continued indefinitely

Question 14

What are the 4 classes of immunosuppressive
medications commonly used for antirejection tx?

Answer 14

1. Corticosteroids
2. Calcineurin inhibitors
3. Antimetabolites
4. Target-of-rapamycin inhibitors

Question 15

Why would a multidrug therapy be prescribed
instead of using just one class of medication?

Answer 15

• Each class of drug mediates the immunocompetence cascade at a different point
• To lower doses of individual agents to minimize associated adverse effects associated with each medication

Question 16

What is Neoral and what are some of its benefits?

Answer 16

• Microemulsion preparation of cyclosporine A and has better absorption because it is not dependent on bile
• Preferred over cyclosporine in pts with gastroparesis, diarrhea, biliary diversion, cholestasis, and malabsorption
• Fewer adverse effects

Question 17

What are some recommended interventions for a
pt on Tacrolimus?

Answer 17

• Monitor blood glucose level; address CHO load & distribution
• If hyperlipidemia, limit fat intake to <30% kcal in maintenance phase
• Restrict potassium intake
• Magnesium supplement as needed
• High phosphorus foods and/or phos supplements as needed
• Nutrient dense foods & adequate protein & fluids

Question 18

What are some adverse effects of Sirolimus?

Answer 18

• Dyslipidemia (hypertriglyceridemia and hypercholesterolemia) d/t inhibition of lipoprotein lipase or reduced catabolism of apoB100-containing lipoproteins
• Increased liver enzymes
• Delayed wound healing
• Anemia
• HTN
• Hypokalemia
• Mouth ulcers
• Peripheral edemas
• GI: N/V/D/C, feeling of fullness

Question 19

What are some recommended interventions for a
pt on Sirolimus?

Answer 19

• Monitor blood glucose, manage CHO load/distribution
• Increased protein intake & vitamin supplementation to help with wound healing
• Potassium supplements
• Diet texture/modifications for mouth ulcers

Question 20

What are some adverse effects of Azathioprine?

Answer 20

• Thrombocytopenia & leucopenia
• GI: stomach pain, N/D, fullness, loss of appetite
• Cholestasis
• Wt loss
• Mouth ulcers
• Infection
• Folate deficiency

Question 21

What are some recommended interventions for a
pt on Azathioprine?

Answer 21

• Address increased nutrient demands to prevent infection
• Diet texture/modifications for mouth ulcers
• Folate supplements as needed
• Nutrient dense foods & adequate protein & fluids for GI distress

Question 22

What are some adverse effects of Corticosteroids?

Answer 22

Side effects are dose dependent!
- Impaired wound healing
- Avascular necrosis of long bones, osteopenia
- GI: upper GI ulceration, GI hemorrhage, abdominal distension
- Protein catabolism
- HTN
- Cushingoid appearance
- Sodium / fluid retention
- Hyperkalemia
- Steroid-induced DM
- Cataract formation
- Increased appetite & wt gain
- Retard growth in pediatric transplant population

Question 23

What are some recommended interventions for a
pt on corticosteroids?

Answer 23

• Monitor blood glucose; address CHO load / distribution
• Restrict sodium intake
• Rec. low-calorie snacks & eating behavior modification
• Increase protein needs
• Limit or restrict caffeine if sensitive r/t GI ulcers
• Adequate calcium & vitamin D; consider need for bisphosphonates, calcitriol, and estrogen/testosterone for maintenance of bone health

Question 24

What is the kcal recommendation during the
acute post-transplantation phase?

Answer 24

30-35 kcal/kg/d or 130-150% calculated BEE
- Increased kcal needs r/t high dose corticosteroids & post-operative stress
- Pts on dialysis prior to transplant may display protein-energy malnutrition
and negative nitrogen balance with loss of LBM
- Increased needs with fever and infection

Question 25

What is the CHO recommendation during the acute post-transplantation phase?

Answer 25

**50-70% of nonprotein calories** - Glucose intolerance d/t immunosuppression, surgical stress, genetic, obesity, increased age, infection - High fiber (25-30 g/d)

Question 26

What is the fat recommendation during the acute post-transplantation phase?

Answer 26

**30-50% of nonprotein calories** - Follow the National Heart, Lung, and Blood Institute Adult Treatment Panel III Guidelines, although temporary liberalization may be needed to meet increased energy needs - High fiber (25-30 g/d) for cholesterol management

Question 27

What is the sodium recommendation during the acute post-transplantation phase?

Answer 27

- Unrestricted if BP and fluid balance WNL - Restriction only in the acute phase in the presence of poor allograft function, posttransplant HTN - Restriction to 2-4 g/d (or <2.3 g per KDOQI 2020 Rec 6.5.1) may be needed with medications that cause HTN and fluid restriction

Question 28

How is potassium affected in the acute post-transplantation pt?

Answer 28

- Hyperkalemia associated with poor graft function, immunosuppressive medications (calcineurin inhibitor), and/or catabolic cell lysis r/t surgery or corticosteroids - Interventions: K restriction, adequate calories & protein to minimize catabolism, binding resin (sodium polystyrene) may be used if it persists

Question 29

What are the calcium/vitamin D recommendations during the acute post-transplantation phase?

Answer 29

- Calcium supplementation 1200-1500 mg/d or total <2000 mg/d - Cholecalciferol supplementation to correct vitamin D deficiency, which may occur even with stable graft function - Goal: treat bone loss d/t pretransplant renal osteodystrophy & corticosteroid tx, correct vitD deficiency, reduce hyperparathyroidism

Question 30

What is the zinc recommendation for the acute post-transplantation pt?

Answer 30

- Zinc deficiency associated with corticosteroid tx - Evaluate zinc status if wound complications present - Supplement if dietary intake is insufficient

Question 31

What is the magnesium recommendation for the acute post-transplantation pt?

Answer 31

- Hypomagnesemia associated with use of calcineurin inhibitors, cyclosporine and tacrolimus - Dietary sources often inadequate, may need supplement (oral or IV) if serum levels are low - Supplements should be taken apart from MMF

Question 32

What is the recommendation for using herbals & botanicals in the acute post-transplantation pt?

Answer 32

- Dietary supplements require no proof of efficacy, safety, or QC standards - Herbals that enhance the immune system may increase risk of organ rejection (ginseng, echinacea, astragalus, noni juice) - St. John’s wort may cause drug-drug interactions - Green tea, dong quai, ginseng, milk thistle, ginger have varying effects on in-vitro immune assays → avoid or use w/ extreme caution

Question 33

Why is hyperglycemia a common post-surgical problem in the acute phase?

Answer 33

- Prednisone → insulin resistance - Calcineurin inhibitors → impair insulin secretion - Increased risk with personal / family hx of DM, age, obesity - New-onset diabetes after transplant (NODAT) increases risk of graft loss, infection, CVD, reduced pt survival after transplant

Question 34

Why are GI issues common in the acute post-transplant phase?

Answer 34

- GI issues associated with use of immunosuppressive agents - GI complications may be secondary infection, mucosal injury, ulceration at any point in the GI tract (mouth to anus)

Question 35

What foods can cause drug-nutrient interactions in the acute post-transplant pt?

Answer 35

- Grapefruit and grapefruit juice impacts absorption of medications, including immunosuppressants (cyclosporine, tacrolimus), calcium channel blockers, and antilipideimcs - Mechanism: inhibits CYP3A4 in the gut wall - Pomegranates & Seville (sour) oranges may have similar drug interactions

Question 36

What is the goal for pt care during the chronic post-transplantation phase?

Answer 36

- Nutrition needs mostly stabilized at week 4-6 posttransplant - With functioning graft, diet similar as healthy populations, with monitoring of healthy wt, serum glucose & lipids, bone health - Nutrition management of long-term complications r/t long-term immunosuppressive tx, esp. those with higher risk for diabetes & CVD

Question 37

What is the general nutrition recommendations for a pt in the chronic post-transplant phase?

Answer 37

- Heart healthy, moderate sodium & fat - Kcal: 23-35 kcal/kg or 1.1-1.3 * BEE to achieve/maintain healthy wt - Protein: 0.8-1 g/kg - Per NKF Pocket Guide: 0.6-0.8 g/kg without DM or 0.8-0.9 g/kg with DM

Question 38

How do you manage steroid-induced hyperglycemia in the chronic post-transplant pts?

Answer 38

- Increased BG → higher risk for infection, decreased graft survival, increased mortality - Causes: calcineurin inhibitors & steroids (mainly), obesity, ethnicity, family hx - Oral hypoglycemic agents or insulin - May normalize as steroid doses are tapered down

Question 39

How prevalent is dyslipidemia in the chronic post-transplant pts?

Answer 39

- Occurrence in post-transplant pts as high as 60-79%, may cause CVD & increased mortality - Causes: immunosuppressive tx, obesity, age, gender, hx of diabetes, sedentary lifestyle

Question 40

How prevalent is hyperhomocysteinemia in the chronic post-transplant pts and what is the recommendation for it?

Answer 40

- Hyperhomocysteinemia in post-transplant pts have been reported and may be a risk factor for CVD, although unclear evidence - KDOQI 2020 5.1.1 - In adults with CKD 3-5D or posttransplantation who have hyperhomocysteinemia associated with kidney disease, we recommend not to routinely supplement folate with or without B-complex since there is no evidence demonstrating reduction in adverse cardiovascular outcomes (1A).

Question 41

Would you recommend routine vitamin supplementation for the chronic post-transplant pts?

Answer 41

- Lack of evidence showing benefits, especially for long-term use; usually not needed with return to normal food intake - Iron supplement may be needed in some pts - Per NKF Pocket Guide: DRI daily MVI is reasonable (pg 11-43)