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.
