Transcript 470-Renal Transplant final2

Renal Transplant
A Clinical Case Study
By: 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 (MeierKriesche 2001).
Background cont’d:

Transplant:

105,742 adult transplants were performed between 19881999 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 (MeierKriesche 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:


Stage 2,3,4:




Kidney damage w/ normal or ↑ GFR
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:




Acute



Fever
Pain
Tenderness of transplant site
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


Sodium restriction



This is to help control blood sugar levels
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


IBW=90 -110lbs
ABW=165lbs
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:

↑PO4
↑Glucose
↑BUN
↑Creatinine
↓Ca
↑Alk phos
↑Chol
↑TG

↑HgB A1C







Admittance
Discharge
6.2 mg/dl
4.5 mg/dl (N)
282 mg/dl
200 mg/dl (H)
69 mg/dl
55 mg/dl (H)
12 mg/dl
8.5 mg/dl (H)
8.9 mg/dl
9.1 mg/dl (N)
131 U/L
200 mg/dl
195 mg/dl
7.1%
Medications:

Glucophage 850 mg bid



Vasotec



Purpose: Anti-hypertensive, ↑K, ↓Na, ↑ AST and ALT
Side effects: ↓BP, dyspnea, dizziness, headache
Erythropoietin



Purpose: ↓ glucose, ↓ Hgb A1c, ↓ cholesterol, ↓Vitamin B12
Side effects: headache, fatigue, muscle pain
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:



Dinner:



2 beef tamales with ¼ c. chili con carne
1 can diet coke
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.
Intervention
Diet Recommendations
Post Recovered Surgery:

Breakfast






1 Piece of Whole Wheat
toast
1 tsp. peanut butter
½ banana
8 oz coffee
8 oz. water
Snack








Lunch






1/2 large tortilla folded in
half
¼ c. cheese
½ medium orange
8 oz. water
½ c. raw carrots
2 chicken tamales
¼ c. con carne
16 oz. water
Tacos

Cheese quesadilla

Peanut butter on celery
Dinner
Snack




2 cups salad


2 small corn tortillas
½ c. chicken
½ c. black beans
¼ c. tomatoes
¼ c. onions
¼ c. dressing
Dessert


4 vanilla wafers
½ c. yogurt
Education before Discharge:

UTIs are common in patients following
transplant (Chuang 2005).


Increase fiber intake




Drink adequate fluids
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.
2.
Have Enez choose an activity that she like to do
and start doing it three days a week.
Have more f/v snacks and smaller meals to help
control her diabetes
•
3.
Higher protein in first nine weeks
•
•
4.
5.
Patient must control her diabetes to keep her new kidney in
good condition
Low in Saturated Fat
Due to post-operative stress and excessive doses of
corticosteroids
Have Enez read the book “Intuitive Eating’. This
should help her understand the hunger cues.
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


Evaluate labs from doctor


Make changes if needed
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.