Transplant Flashcards
is it better to get a transplant or dialysis?
Patients who get a kidney transplant before dialysis live an average of 10 to 15 years longer than if they stayed on dialysis.
Renal Transplant
• Advantages and limitations
Advantages:
• Increased survival rate
• Preferred method of treatment
Limitations:
• Lengthy waiting list
• Long-term immunosuppressive therapy
Pretransplantation period goal:
to optimize nutritional status to decrease:
1- surgical risk
2- post surgical complications
3- length of hospital stay
Concerns with presurgical malnutrition
Presurgical malnutrition can involve under or over nutrition and is associated with increased risk of postsurgical complications
effects of overnutrition on renal health
Over nutrition - Obese patients have
• Higher mortality rate
• Lower graft function
• Increased incidence of wound complications
• More frequent ICU admissions
• More frequent re-intubations
• Increased incidence of post transplant diabetes
acute post-transplant period foal
To manage the increased metabolic demands of surgery
What med is used in Acute post transplant period to increase transplant survival? How? Side effects?
• Pharmacologic immunosuppression used to halt body’s response to the kidney enhances graft survival
• Cyclosporin has several unwanted side-effects:
Gingival hyperplasia
GI disturbances
Hyperglycemia
Gynecomastia
Hepatotoxicity, decreased glycogen synthesis
Nephrotoxicity
Use of corticosteroids in renal transplant and side effects
Corticosteroids used to inhibit the production of lymphokines; side-effects include: Ø Impaired wound healing Ø Avascular necrosis of long bones Ø Upper GI ulceration Ø Protein catabolism Ø Hypertension Ø Steroid induced diabetes Ø Cataract formation Ø Stimulation of appetite, weight gain
Posttransplant Patient -Protein and energy needs
• Generally increase up to 6-8 weeks post op due to stress and excessive dose of corticosteroids
fat reccs in post-transplant
• 25-35% of total Energy. SFA max 7% and remaining are MUFA and PUFA
Sodium reccs
• Hypertension common; restrict sodium
Carbohydrate reccs
- Glucose intolerance common (hyperglycemia frequent with corticosteroids, cyclosporine, …)
- Emphasize on complex carbohydrate, dietary fiber to minimize risk of developing diabetes
what is hyperGL associated with in pot-transplant pts
** Hyperglycemia associated with higher risk for infection, rejection, and decreased survival rate
potassium in post-transplant pts
• Potassium restriction in acute period if hyperkalemia.
• Hyperkalemia caused by poor graft function, impaired potassium excretion with
cyclosporine and potassium-sparing diuretics.
• No restriction in chronic phase (unless hyperkalemia)
immunosuppressants in post-transplant pts
- Used to prevent acute rejection
- Used to maintain long-term survival
- Avoid grapefruit and grapefruit juice if taking tacrolimus and cyclosporine
Nutrition Guidelines for Adult Kidney Transplant Patients: protein
Acute phase (up to 8 weeks post transplant and during acute rejection): 1.3-2.0 g/kg; based on standard or adjusted body weight Chronic phase (after 8 weeks): 0.8-1.0 g/kg with functionning transplant
Nutrition Guidelines for Adult Kidney Transplant Patients: calories
Acute phase (up to 8 weeks post transplant and during acute rejection): 30-35 kcal/kg Chronic phase (after 8 weeks): 25-35 kcal/kg to maintain desirable weight
Nutrition Guidelines for Adult Kidney Transplant Patients: carbs
Acute phase (up to 8 weeks post transplant and during acute rejection): 50-70% non-protein calories; CHO controlled as needed Chronic phase (after 8 weeks): 45--50% totoal kcal; ++ complex CHO fiber 25g/d (female) to 30g/d (male)
Nutrition Guidelines for Adult Kidney Transplant Patients: fats
Acute phase (up to 8 weeks post transplant and during acute rejection): 30-50% non-protein calories Chronic phase (after 8 weeks): 25-35% ot total kcal with SFA <7% of total kcal
Nutrition Guidelines for Adult Kidney Transplant Patients: sodium
Acute phase (up to 8 weeks post transplant and during acute rejection): <4g/d; unrestricted unless HTN or edema Chronic phase (after 8 weeks): <2.4 g/d
Nutrition Guidelines for Adult Kidney Transplant Patients: calcium
Acute phase (up to 8 weeks post transplant and during acute rejection): 1000-1500mg Chronic phase (after 8 weeks): 2000mg
Nutrition Guidelines for Adult Kidney Transplant Patients: phosphorus
Acute phase (up to 8 weeks post transplant and during acute rejection): DRI Chronic phase (after 8 weeks): DRI
Nutrition Guidelines for Adult Kidney Transplant Patients: vitamins, minerals, trace elements
Acute phase (up to 8 weeks post transplant and during acute rejection): DRI Chronic phase (after 8 weeks): DRO
Nutrition Guidelines for Adult Kidney Transplant Patients: fluids
Acute phase (up to 8 weeks post transplant and during acute rejection): Ad libidum; 1 ml/kg dry weight; match output unless diuresis is goal Chronic phase (after 8 weeks): Ad libidum with functioning transplant
Nutrition Guidelines for Adult Kidney Transplant Patients: potassium
Acute phase (up to 8 weeks post transplant and during acute rejection): unrestricted; if hyperkalemia exists <2.4 g/d Chronic phase (after 8 weeks): no restriction unless hyperkalemia
Immunosuppressants and Potential Adverse Effects
Common side effects are nausea and vomiting, diarrhea, hyperglycemia, abdominal pain
Name common renal transplant complications
Obesity
Chronic kidney disease bone mineral disorder (CKD-BMD)
CVD
Rejection
CVD in post-transplant patients
• Increased risk of CVD; dyslipidemias common (70% of patients) • Lipid-lowering medications may be used
Hypomagnesemia in post-transplant patients
- Common after transplant; associated with cyclosporine (immunosuppressant) and tacrolimus (immunosuppressant) use
- IV replacement may be required
Obesity in post-transplant patients
- Weight gain common; may complicate hyperlipidemia and glucose intolerance
- Emphasize diet, behavior modification, exercise
CKD-BMD in post-transplant patients
Chronic kidney disease bone mineral disorder (CKD-BMD)
• Mechanisms not completely understood but could be side effects of altered vitamin D metabolism, alteration in PTH, impact of immunosuppressive medications.
• Calcium supplementation, vitamin D, and antiresorptive agents may be needed.
• Hypophosphatemia occurs in 50% patients. Phosphorous supplementation needed early post-transplant.
Rejection in post-transplant patients
• Corticosteroids increase
• Need for increased protein and energy
requirements
Considerations for dietitians with post-transplant patients
• Prevent and treat protein-energy malnutrition
• Prevent and treat mineral and electrolyte disorders
• Reducing the impact of other comorbidities (diabetes, obesity, hypertension, lipid metabolism disorders)
-> Improvement in the patient’s quality of life
