Solid Organ Transplant

solid organ transplants at UIHC

heart, lung, liver, kidney, pancreas

Pre-transplant nutrition assessment

- medical history

- labs

- medications

- diet history

- anthropometrics

- NFPE

heart transplant

- failing heart is replaced with a healthy heart from a suitable deceased donor

Heart transplant candidate

severe end-stage heart failure but healthy enough otherwise to have the transplant

Heart transplant not likely candidate

- advanced age

- poor blood circulation throughout body, including brain

- irreversible kidney, lung, or liver diseases

- history of cancer or malignant tumors

- inability or unwillingness to follow lifelong medical instructions after a transplant

- irreversible pulmonary hypertension

- active infection throughout the body

post-heart transplant

- recovery 1-2 weeks in hospital

- 3 months monitoring by transplant team for organ rejection

- immunosuppressant meds and inotropic agents to prevent complications and rejection

long-term complications of heart transplant

- failure of donor heart

- side effects of medications

- infection

- osteoporosis

- cancer

- 70% of recipients develop hypertension

- 50% have high levels of blood cholesterol and triglycerides within 1 yr of surgery

- 13.4% develop steroid induced diabetes

MNT post-heart transplant acute phase (up to 8 weeks)

- labs: serum levels of magnesium, phosphorus, calcium, vitamin D may decrease

- energy: 1.3-1.5 x BEE or 30-35 kcal/kg

- CHO: 55-60% of calories

- protein: 1.5-2 g/kg

- lipid: 30% of calories (focus on omega-3s)

MNT post-heart transplant acute phase nutrition diagnosis

- pre transplant diagnosis that may still apply

- malnutrition

- food-medication interactions for immunosuppressing and inotropic meds

- knowledge deficit regarding intake of unsafe food

MNT post-heart transplant acute phase interventions

- supply adequate nutrients so body can heal and fight infections

- oral route preferred; EN or PN if oral diet doesn't meet nutritional needs

- education on food safety guidelines

MNT post-heart transplant chronic phase (after 8 weeks)

- achieve energy intake to support rehabilitation and activities of living

- protein: 1 g/kg

MNT post-lung transplant acute phase nutrition assessment

- labs: serum levels of magnesium, phosphorus, calcium, vitamin D may decrease

- energy: 1.3-1.5 x BEE or 35 kcal/kg

- protein: 1.5-2 g/kg

- fluid: dependent of fluid status

MNT post-lung transplant acute phase nutrition diagnosis

- pre transplant diagnosis that may still apply

- malnutrition

- food-medication interactions for immunosuppressing and inotropic meds

- knowledge deficit regarding intake of unsafe food

MNT post-lung transplant acute phase interventions

- supply adequate nutrients so body can heal and fight infections

- oral route preferred; EN or PN if oral diet doesn't meet nutritional needs

- education on food safety guidelines

MNT post-lung transplant chronic phase

- achieve energy intake to support rehabilitation and activities of living

- protein: 1 g/kg

kidney transplant

- to improve quality of life

- donor types: living or deceased

- length of stay: 3-5 days pending graft function

kidney transplant nutriton complications

delayed graft function...

- occurs more frequently with deceased donors

- may require potassium or phosphorus restriction

- difficult to meet increased energy needs

MNT in kidney transplant

Metabolic effects of immunosuppressive therapy

- increase protein first 6 weeks.

- Limit sodium to 2 to 3 g/day.

- Adequate calcium, phosphorus, and vitamin D

- Encourage fluid.

- Treat dyslipidemia.

- Monitor for weight gain.

- Food safety

MNT in post-kidney transplant acute phase

- energy: 30-35 kcal/kg

- protein: 1.3-2 g/kg

- CHO: limit simple sources with hyperglycemia

- fat: to meet additional energy needs

- sodium: 2-4000 mg

- potassium: 2-4000 mg if hyperkalemia

- calcium: 1200-1500 mg

- phosphorus: DRI

- fluid: no restriction unless graft not functioning

MNT in post-kidney transplant chronic phase

- energy: 25-30 kcals/kg

- protein: 0.8-1 g/kg

- CHO: emphasize complex sources distributed throughout day

- fat: 25-35% of calories, sat. fat

islet cell tranplant

no done in U.S.

pancreas transplant indications

reserved for type 1 diabetics with

- metabolic complications from hypoglycemia

- hypoglycemic unawareness

- failure of insulin therapy

pancreas transplant

- donor types: deceased donor only

- length of stay: 7-10 days

pancreas transplant nutritional considerations

diet course

- clear liquids on days 5-7

- diabetes should be cured for the life of the transplant

- graft should start to function within 2 days

pancreas transplant nutritional complications

- ileus or pancreatitis

- patients are normally NPO x 4-5 days

- may need parenteral nutrition support for ileus

MNT post-pancreas transplant acute phase

- calories: 30-35 kcal/kg

- protein: 1.3-2 g/kg

- fluid: 30-40 mL/kg/day

MNT post-pancreas transplant chronic phase

- calories: 25-30 kcal/kg

- protein: 0.8-1 g/kg

- fluid: 25-35 mL/kg/day

liver transplant

- established treatment for ESLD

- malnutrition is common

- donor types: deceased or living

- length of stay 7-10 days

MNT pre-liver transplant

- calories: 35 kcals/kg

- protein: 1-1.5 g/kg

- CHO: reduce if diabetes or obesity present

- fat: as needed to meet caloric needs

- sodium: 2000 mg/day

- calcium: 800-1200 mg/day

- fluid: restrict to 1-1.5 L if hyponatremic

liver posttransplant

- increased nutrient needs for recovery, deter infections and replenish body stores

- early EN with probiotics and fiber associated with decreased infections

- multiple medications after transplantation have nutrition-related side effects

liver transplant indications

- acute or chronic liver failure ESLD

- alcohol abuse (cannot drink for 6 months prior to transplant)

- hepatitis B, C

- fulminate hepatic failure

- cancer, PSC, PBC

liver transplant nutritional considerations

diet course

- clear liquids ~ day 3

- may need nutrition support

- 80% of patients are malnourished prior to transplant

- start calorie counts and supplements when diet advances

medications commonly used after liver transplantation

- asathioprine

- antithymocyte globulin

- cyclosporine

- glucocrrticoids

- mycophenolate mofetil

- sirolimus

- tacrolimus

nutrition considerations for liver transplantation long-term

- obesity

- hyperlipidemia

- hypertension

- diabetes

- osteopenia

MNT post-liver transplantation acute phase

- calories: 20-30% above basal (35-40 kcal/kg)

- protein: 1.2-1.75 g/kg

- CHO: reduced if diabetes or obesity present

- Fat: ~30% of calories

- Sodium: 2 g/day

- calcium: 800-1200 mg/day

- fluid: as needed

MNT post-liver transplantation chronic phase

- calories: 20% above basal

- protein: maintenance 1 g/kg

- CHO: reduce simple carbs, especially if diabetes or obesity present

- Fat: moderate 30% of calories

- Sodium: 2 g/day

- calcium: 1200-1500 mg/day

- fluid: as needed

immunosuppression

- drug regimens to prevent rejection of the new organ

- induction: used at the time of transplant (thymoglobulin, daclizumab)

immunosuppression possible complications

- viral/bacterial infections

- cancer

- drug specific side effects

- hyperglycemia, hyperlipidemia

immunosuppression maintenance (oral)

- mycophenolate mofetil

- prednisone

- tacro or cyclosporine

- sirolimus

immunosuppression and nutrition

- increased appetite

- weight gain

- hyperlipidemia

- hyperglycemia- drug induced diabetes

- hypertension

- bone disease

- hyperkalemia

- GI toxicity

- N/V/D/C

- edema

post transplant nutrition

- food safety is critical

- risk of infection decreases as time from transplant increases

- balanced diet

UNOS

provides a network for registered donors and recipients

Model for End-stage Liver Disease (MELD)

- used to assess severity of chronic liver disease

- may be sued to prioritize need for transplant

- uses serum bilirubin, INR, and serum creatinine