Renal Transplant

A Clinical Case StudyBy: Valerie Douglass

Heather Stout

Background:

Common causes of kidney disease include diabetes and hypertension

As kidney disease progresses to a new stage it is irreversible.

Transplant: Kidney is most transplanted organ Over 12,000 per year in US Needed due to ESRD The shorter the length a patient is on dialysis, survival rate

increases following transplant (Meier-Kriesche 2000). Death resulting from transplant increases with age (Meier-

Kriesche 2001).

Background cont’d:

Transplant: 105,742 adult transplants were performed between 1988-

1999 in US (Hariharan 2002). 18,589 were cadaver transplants under the age of 50

(Hariharan 2002). Kidney is most transplanted organ Over 12,000 per year in US Needed due to ESRD The shorter the length a patient is on dialysis, survival rate

increases following transplant (Meier-Kriesche 2000). Death resulting from transplant increases with age (Meier-

Kriesche 2001).

What is CRF?

Slow, gradual loss of kidney function Progressive destruction of nephrons Leads to ESRD Causes:

ARF that does not improve Kidney stones, nephritis, renal artery

obstruction, polycystic kidney disease Diabetic nephropathy HTN, atherosclerosis

Stages of Renal Failure:

Stage 1: Kidney damage w/ normal or ↑ GFR

Stage 2,3,4: Renal insufficiency Labs begin to change Fatigue

Stage 5: ESRD Kidney failure Anemia, uremia, yellow skin, GI problems, HTN Tissue wasting due to PEM

**After transplant, a patient only moves from a stage 5 back to a stage 3. If all goes well, the patient will live the remainder of their lives in stage 3.

Renal Transplant:

Who is eligible? Patients BMI has to be <35 For those with ESRD Must be healthy enough to tolerate surgery Can tolerate immunosuppressive drugs Free of:

Cancer Heart Disease Malnourishment

Rejection:

Affects 50% of patients at least once Symptoms:

Fever Pain Tenderness of transplant site

Acute Drastic ↑ in creatinine Usually during the 1st year

Chronic Creatinine levels stay ↑ Creatinine levels can predict long term renal transplant survival

(Hariharan 2002). Assoc. with proteinuria

Medical Nutrition Therapy:

Medicare Part B Covers MNT 6-36 months

Immunosuppressive drugs Nutrition:

Heart Healthy ↑protein & kcals for wound healing Avoid simple sugars

This is to help control blood sugar levels Sodium restriction

The body is already retaining fluids, sodium restriction is needed so more fluids are not retained.

Monitor potassium Physical activity

Enez Joaquin

Age: 26 Sex: Female Education: High School Occupation: Secretary Ethnicity: Pima Indian Religion: Catholic Family:

Husband, 28, also type 2 diabetic Daughter, 9, in good health

Purchases and prepares food for family

Enez’s History:

Family history: DM (both parents) Diagnosed with type 2 DM at 13 years old Progressively decompensated renal function over

the next 7 years from uncontrolled diabetes Reached stage 5 ESRD two years ago Has been on hemodialysis last 2 years Placed on transplant list 2 years ago A match has been found and Enez is being prepped

for surgery.

Anthropometrics:

5 ft tall IBW=90 -110lbs ABW=165lbs

%IBW 165/100 x 100 = 165%

BMI 165 x 703= 32.3 obese class I 60²** 60% of patients are overweight or obese at the

time of kidney transplants (Armstrong 2005)**

Anthropometrics cont’d:

BEE= 655 + (9.6x53*) + (1.8x60) – (4.7x26) = 1150 kcals x 1.3 (IF) x 1.3 (AF) = 1943.5 kcals *weight adjusted for obesity

Protein needs: Post surgery: 1.3-2.0 g x 53kg = 69–106 grams

for wound healing Post surgery: 0.8-1.0 g x 53kg = 42-53 grams

for maintenance

Labs:

AdmittanceDischarge

↑PO4 6.2 mg/dl 4.5 mg/dl (N) ↑Glucose 282 mg/dl 200 mg/dl (H) ↑BUN 69 mg/dl 55 mg/dl (H) ↑Creatinine 12 mg/dl 8.5 mg/dl (H) ↓Ca 8.9 mg/dl 9.1 mg/dl (N) ↑Alk phos 131 U/L ↑Chol 200 mg/dl ↑TG 195 mg/dl ↑HgB A1C 7.1%

Medications:

Glucophage 850 mg bid Purpose: ↓ glucose, ↓ Hgb A1c, ↓ cholesterol, ↓Vitamin B12 Side effects: headache, fatigue, muscle pain

Vasotec Purpose: Anti-hypertensive, ↑K, ↓Na, ↑ AST and ALT Side effects: ↓BP, dyspnea, dizziness, headache

Erythropoietin Purpose: Anti-anemic Side effects: ↑BP, bone/muscle pain, headache, fever

Calcitriol Calcium regulator, ↑Ca, ↑Mg, ↓PTH Side effects: weakness, ataxia, headache, bone/muscle pain

Medications cont’d:

Sodium Bicarbonate Purpose: Antacid, ↑Na, ↓K Side effects: peripheral edema, fluid overload

Phos Lo Purpose: Phosphate binder, ↓Iron absorption, ↓PTH in ESRD Side effects: kidney stones

Drug interaction with antacids and Ca supplements Multi vitamin Post surgery:

Immunosuppressant drugs must be continuously taken Purpose: to suppress immune system from rejecting new organ Side effects: Possible weight gain (20lbs), fat facial cheeks

Enez’s intake:

Typical intake: Breakfast:

1 soft cooked egg 2 slices wheat toast w/ 1 tsp. LF margarine 1 c. artificially sweetened cranberry juice

Lunch: 2 beef tamales with ¼ c. chili con carne 1 can diet coke

Dinner: 2 soft-shell tacos w/ ½ c. black beans, 2 flour tortillas, ½ c. lettuce,

¼ c. chopped tomatoes, ¼ c. chopped onions 1 can diet coke

Snacks: 6 vanilla wafers

Diet Analysis:

Total energy intake: 1189 kcals Protein: 43 grams Carbs: 157 grams Fiber: 17 grams Total fat: 45.7 grams Calcium: 363.4 mg Phosphorus: 725.4 mg Sodium: 4225 mg

Diagnosis

1. Increase fiber intake (NI-53.5) related to only 17 grams of fiber consumed and little to no fruits/vegetables as evidenced by usual dietary intake.

2. Excessive carbohydrate intake (NI-53.2) related to large amount of carbohydrate consumed at each meal and total 157 grams/day as evidenced by usual dietary intake.

InterventionDiet Recommendations

Post Recovered Surgery: Breakfast

1 Piece of Whole Wheat toast

1 tsp. peanut butter ½ banana 8 oz coffee 8 oz. water

Snack Cheese quesadilla

1/2 large tortilla folded in half

¼ c. cheese ½ medium orange 8 oz. water

Lunch ½ c. raw carrots 2 chicken tamales ¼ c. con carne 16 oz. water

Snack Peanut butter on celery

Dinner Tacos

2 small corn tortillas ½ c. chicken ½ c. black beans ¼ c. tomatoes ¼ c. onions

2 cups salad ¼ c. dressing

Dessert 4 vanilla wafers ½ c. yogurt

Education before Discharge:

UTIs are common in patients following transplant (Chuang 2005). Drink adequate fluids

Increase fiber intake Increase fruit and vegetable consumption Will help control diabetes Will help with constipation from multiple

prescriptions Carbohydrate counting

Teach patient how to count carbs

Action Goals:

1. Have Enez choose an activity that she like to do and start doing it three days a week.

2. Have more f/v snacks and smaller meals to help control her diabetes

• Patient must control her diabetes to keep her new kidney in good condition

3. Higher protein in first nine weeks• Low in Saturated Fat• Due to post-operative stress and excessive doses of

corticosteroids

4. Have Enez read the book “Intuitive Eating’. This should help her understand the hunger cues.

5. Substitute whole wheat bread for white

Outcome Goals:

Long Term Control Diabetes

Goal 70-110mg/dl for glucose 282 (high) Currently

Weight Loss Increase Physical activity to 30-45 minutes

most days of the week Goal: Loss 5-10% of body weight

BMI 32.3 currently Obese % IBW: 165% currently

Dietary Monitoring:

Have Enez keep a journal for one week of: Food intake Physical activity Glucose reading before and after

mealtime Monitor weight Check HgB A1C every 3 months

Monitoring and Evaluating:

Check every two weeks with RD See how food intake is going

Make changes if needed Evaluate labs from doctor

i.e.: glucose, HgB A1C, creatinine, etc. See how physical activity is working

Incorporate new activities Increase frequency

References:

Armstrong, Kirsten, Scott Campbell, Carmel Hawley, and David Johnson. "Impact of obesity on renal transplant outcomes." Nephrology 10 (2005): 405-13.

Chuang, Peale, Chirag Parikh, and Anthony Langone. "Kidney International." Clinical Transplantation 19 (2005): 230-35.

Hariharan, Sundaram, Maureen A. Maureen, Wida Cherikh, Christine Tolleris, and Barbara Bresnahan. "Post-transplant renal function in the first year predicts long-term kidney transplant survival." Kidney International 62 (2002): 311-18.

References cont’d:

Meier-Kriesche, Herwig-Ulf, Akinlolu Ojo, Julie Hansen, and Bruce Kaplan. "Exponentially increased risk of infectious death in older renal transplant recipients." Kidney International 59 (2001): 1539-543.

Meier-Kriesche, Herwig-Ulf, Friedrich Port, Akinlolu Ojo, and Steven Rudich. "Effect of waiting time on renal transplant outcome." Kidney International 58 (2000): 1311-317.

Nelms, Marcia, Kathryn Sucher, and Sara Long. Nutrition Therapy and Pathophysiology. Belmont: Thomson Brooks/Cole, 2007.