Yajie Zhang

KNH 411
November 18, 2012

Case 27

Renal Transplant

i. Understanding the Disease and Pathophysiology

1. Describe the physiological functions of the kidneys.

The primary functions of the kidney include maintenance of homeostasis through

control of fluid, pH, and electrolyte balance and blood pressure; excretion of
metabolic end-products and foreign substances; and the production of enzymes
and hormones. (522)

2. What diseases/conditions can lead to chronic kidney disease (CKD)?

Chronic kidney disease (CKD) is a syndrome of progressive and irreversible loss

of the excretory, endocrine, and metabolic functions of the kidney secondary to
kidney damage. CKD progresses slowly over time, and there may be intervals
during which kidney functions remain stable. Having a glomerular filtration rate
(GFR) of less than 60 mL/min/1.73m2 for three months or longer and/or
albuminuria of more than 30 mg or urinary albumin per gram of urinary creatinine
has been defined as CKD. Diabetes, hypertension, and glomerulonephritis are the
leading causes of kidney failure. Ethnicity, family history, hereditary factors such
as polycystic kidney disease (PKD), a direct and forceful blow to the kidneys, and
prolonged consumption of over-the-counter painkillers that combine aspirin,
acetaminophen, and other medicines such as ibuprofen are also risk factors
associated with CKD. (526)

3. What was the likely cause of Mrs. Joaquin’s CKD?

Mrs. Joaquin’s blood pressure is 130/85 which is in the range of prehypertension.

She has type 2 diabetes. She is a Native American that Native American is nearly
two times as likely to develop kidney failure. The factors listed above were the
likely causes of Mrs. Joaquin’s CKD.

4. Mrs. Joaquin’s transplant evaluation took place 2 years ago and included each of
the following. What were each of these procedures used to evaluate?
 Procedure
Abdominal and renal ultrasound
EKG and echocardiogram
Chest X-ray
Meeting with transplant nurse, social
worker, surgeon, and financial
counselor
Blood typing and tissue typing
Dental exam
Viral testing on blood
Used to Evaluate
A radiology study that evaluates the
liver, gallbladder and native kidneys
for abnormalities.
EKG - shows heart function and
reveals any past damage.
Echocardiogram - to check the heart
structures & valves.
A picture of your lungs and lower
respiratory tract, which will identify
any abnormalities.
-To help the doctor coordinate his care
-To make sure learn about the
emotional aspects of a kidney
transplant
-To help choose the best foods to eat.
Check to see if it is type A, B, AB or
O blood type and what tissue typing it
is.
To detect any infections, cavities, or
gum disease, which may be a source
of infection after transplant.
Blood for viruses, such as Epst Epstein
Bar ein Barr Virus r Virus (EBEBV)
V), Cytomegalovir ytomegalovirus us
(CMV) and BK

Mammogram and PAP test Gynecologic exam, pap smear (age≥

18 or sexually active), and
mammograms (x-ray of breast) for
cancer screening (age>40 or family
history of breast cancer) are needed.
(Kidney transplantation)

5. Describe why the immunological characteristics of the donated organ must match
with the recipient’s medical and immunological characteristics.

Since the presence of a MHC antigen on the transplanted organ or tissue that is
different from the MHC antigens on the recipient’s tissues signals the presence of
the transplanted tissue and initiated an immune response, MHC antigens for MHC
play an important role in transplant rejection. The immune system attacks the
transplanted cells presenting MHC antigens that are different from those found on
the recipient’s tissues. Therefore, the match is necessary to make the immune
system less offensive to the new organ. (529)
 6. Explain the role of the major histocompatibility complex (MHC).

The role of the major histocompatibility complex (MHC) in determining

acceptability for a transplanted organ is important. The antigens for MHC (often
referred to as human leukocyte antigens [HLA]) provide the basis for the MHC
haplotype (a combination of closely linked genes on a chromosome inherited as a
unit from one parent). The presence of a MHC antigen on the transplanted organ
or tissue that is different from the MHC antigens on the recipient’s tissues signals
the presence of the transplanted tissue and initiated an immune response; MHC
antigens for MHC play an important role in transplant rejection. (529)

ii. Understanding the Nutriton Therapy

7. What are the differences between nutrition therapy during the acute phase (up to 8
weeks following transplant) and during the chronic phase (starting ninth week
following transplantation) post-transplantation? Explain the rationale for each.

Nutrient Acute Phase Chronic Phase Rationale

Protein 1.3-1.5g/kg; 1.0g/kg; limit -postoperative stress
based on with chronic and the excessive
standard or graft doses of
adjusted body dysfunction corticosteroids
weight -manage
dyslipidemia,
diabetes, obesity,
and cardiovascular
disease
Energy 30%-35% Maintain -postoperative stress
kacl/kg; may desirable weight and the excessive
increase with doses of
postoperative corticosteroids
complications -manage
dyslipidemia,
diabetes, obesity,
and cardiovascular
disease
Carbohydrates 50%-60% of 50%-60% of -impaired glucose
total kcal; limit total kcal; tolerance and the
simple CHO if emphasis on potential for
intolerance is complex CHO development of
apparent and 20-30g posttransplant
dietary fiber (5- diabetes mellitus
 10 g per day
soluble fiber)
Fats 25%-35% of 25%-35% of -cardiovascular
total kcal total kcal with disease is the
saturated fat < leading cause of
7% of total kcal; mortality in kidney
up to 10% of transplant patients
kcal from
PUFA, and up to
20% of kcal
from MUFA
Cholesterol --- <200 mg per -cardiovascular
day; consider disease is the
plant leading cause of
stanols/sterols, 2 mortality in kidney
g per day transplant patients
Potassium 2000-4000 mg No restriction -help to regulate
if hyperkalemia unless hyperkalemia
exists hyperkalemia
exists
Sodium 2000-4000 mg 2000-4000 mg -help to regulate
may be with hypertension
necessary hypertension
Calcium 1200-1500 mg 1200-1500 mg -to prevent
osteoporosis and
altered vitamin D
metabolism
Phosphorus 1200-1500 mg 1200-1500 mg -to prevent
(supplements (supplements hyperparathyroidism
may be needed) may be needed) issue
Vitamins/minerals Dietary Dietary -Corticosteroids
reference intake reference intake; leaded reduced
may need intestinal absorption
additional of calcium and
vitamin D hypercalciuria
Fluids No restriction No restriction NA
unless graft not unless graft not
functioning functioning

iii. Nutrition Assessment

A. Evaluation of Weight/Body Composition

8. Calculate Mrs. Joaquin’s BMI.
HT = 5 feet * 12 inch / 39.37 inch / m = 1.52 m
 WT = 165 lb / 2.2 lb/kg = 75 kg
BMI = WT/HT2 = 75 kg/1.522 m = 32.46 kg/m2 (Obese State One)

9. How would you interpret Mrs. Joaquin’s BMI? Explain your rationale.
Based on Mrs. Joaquin’s BMI, she is considered to fall in the obese state one
category. It might be related to her type 2 DM.

B. Calculation of Nutrient Requirements

10. What are the recommendations for estimating energy requirements for (post)
renal transplantation? Calculate Mrs. Joaquin’s energy needs accordingly.

30 – 35 kcal/kg
Range = 30*75-35*75 = 2250 kcal – 2625 kcal

11. What will Mrs. Joaquin’s protein requirements be after the transplant?

1.3 – 1.5 g/kg

Range = 1.3 * 75 – 1.5 * 75 = 97.5 g – 112.5 g

12. Compare her energy and protein needs prior to and post-transplant. Explain how
and why they are different.

Compared to her energy and protein needs prior-transplant, post-transplant has the
higher requirements of both protein and energy amount. This is basically due to the
postoperative stress and the excessive doses of corticosteroids.

C. Intake Domain

13. Explain the importance of food safety education for transplant patients.

Organ transplant patients are included on the list of immune compromised persons
at highest risk of foodborne illness. Organ transplant patients are at high risk for
infection during medical treatment and at continuing risk for the rest of their lives
due to drug treatment used to prevent rejection of the transplanted organ.
Therefore, food safety education is extremely important for transplant patients to
prevent foodborne illness.

D. Clinical Domain
14. On POD #2, Mrs. Joaquin was doing well and transferred to the medical floor.
Her Results showed good perfusion and function of the kidney. Her intake and
output were good. During the remainder of her hospitalization, Mrs. Joaquin
received detailed instructions about postoperative care and medications. The
instructions were:
 Keep incision clean and dry
 Staples will be removed in 3 weeks
 Avoid lifting over 5 pounds
 Can resume driving and sexual activity in 2-4 weeks or when pain free
 Follow prescribed diet
Explain why the following medications were prescribed, and indicate any
nutrition implications.
Medication Indications/Mechanism
Neoral Indicated for the
prevention of organ
rejection in kidney, liver,
and heart transplants.
Imuran Immunosuppressant
works as an adjunct for
the prevention of rejection
in renal transplantation.
Prednisone Corticosteroid that
prevents inflammation.
Magnesium oxide Can be used as a
magnesium supplement,
but also commonly as an
antacid.
Bactrim Treats bacterial infections
(due to suppressed
immune system)
Neutral-phos Used as a phosphorus
supplement
Nutritional
Implications
No potassium
supplements or salt
substitutes. Avoid
grapefruit and red wine.
Anorexia is a concern.
Anorexia, steatorrhea.
Take with food to
prevent upset stomach.
Caution with DM
patients, highly protein
bound; may need
increased K, PO4, CA,
and vitamins A, C, and
D, increased protein,
decreased dietary
sodium; avoid alcohol
Diarrhea is common
side effect.
Nausea and vomiting are
common side effects.
Should be taken on an
empty stomach. Limit
alcohol intake
Must closely monitor
potassium levels while
 taking medication

Persantine Indicated as an adjunct to Vomiting, diarrhea.

coumarin Dizziness is common so
anticoagulants in the alcohol should be
prevention of
limited/ avoided.
postoperative clot
formations Caffeine may interfere
with the drug’s effects.

Omeprazole Prevents and/or treats Nausea. Vomiting,

stomach ulcers caused by diarrhea. May deplete or
other medications interfere with the
absorption of calcium.
Folic acid, and vitamin
C. supplementation may
be necessary.
Glucophage Antihyperglycemic agent, Anorexia, weight stable
biguanide; increases effect or declines, decreases
of insulin, lowers GI folate and vit B12
glucose absorption, absorptaion; caution
decreases hepatic glucose with severe decrease
production renal function
(Drugs and supplements)

15. Explain the role of immunosuppression in organ transplantation.

After transplantation, patients are maintained on a variety of immunosuppressive

regiments to prevent rejection of the donated kidney. (530)

16. How long will Mrs. Joaquin require immunosuppression?

Immunosuppressive treatment of Mrs. Joaquin will begin with the induction

phase, perioperatively and immediately after transplantation. Maintenance therapy
then continues for the life of the allograft. Induction and maintenance strategies
use different medicines at specific doses or at doses adjusted to achieve target
therapeutic levels to give her the best hope for long-term graft survival.
Maintenance immunosuppression is the key to prevention of acute and chronic
rejections throughout the life of the graft. (Pellegrrino)

17. How will taking prednisone for her transplant affect her glycemic control?

Prednisone might negatively affect her glycemic control by increasing appetite

and causing hyperglycemia. (548)
18. Mrs. Joaquin is also instructed to watch for signs of rejection. Explain what is
meant by rejection and list at least three signs of transplant rejection.

Acute rejection is where the WBC put up a defense against the organ
because it doesn’t recognize it and the organ can don’t function to its full ability.
However, there are medications that can reverse the rejection and the organ can
regain full function. Acute rejections are not likely after the first year of
transplantation.
Chronic rejection is where the body’s antigens attack the organ slowly and
continuously either leaving the organ impaired or unable to function altogether.
This would require immediate hospitalization and the need for another transplant
quickly.
Signs of transplant rejection: the organ’s function may start to decrease;
general discomfort, uneasiness, or ill feeling; pain or swelling in the area of the
organ (rare); fever (rare); flu-like symptoms, including chills, body aches,
nausea, cough, and shortness of breath. (549)

19. What will happen if Mrs. Joaquin does reject her transplanted kidney?

She might experience decreased kidney function; general discomfort, uneasiness,

or ill feeling and pain or swelling in the area of the organ (rare); fever (rare); flu-like
symptoms, including chills, body aches, nausea, cough, and shortness of breath. If her
new kidney fails, she can resume dialysis or consider a second transplant. She may
also choose to discontinue treatment. (Yasumuan)

E. Behavioral-Environmental Domain
20. Mrs. Joaquin tells you that she’s heard transplant patients gain weight after
surgery, and she wants to know if this will happen to her. How do you answer her
question?

I would tell Mrs. Joaquin, many transplant patients develop nutrition-related problems
in the months and years following transplant. The most common are excessive weight
gain (as fat) and high blood cholesterol that are usually caused by steroids and other
medications. The best management for you includes weight control by following a
"heart healthy" diet and exercising. Here are some guidelines that will help decrease
the amount of total fat and cholesterol in your diet. They will help reduce your risk for
heart disease and excessive weight gain.

A good way to manage this problem would be reading food labels carefully to avoid
foods that are high in saturated fats and cholesterol. Some of these foods include lard,
butter, shortening, ice cream, sausage, and bacon. Coconut and palm oils are saturated
fats found in many convenience baked goods, whipped toppings, coffee creamers and
fried foods.
 In addition, you could follow these guidelines:

 Choose low-fat milk and other low-fat or nonfat dairy products.

 Limit egg yolks to 3 or 4 per week. Many recipes can be made with egg
whites or an egg substitute without compromising taste.
 Choose the leanest varieties of beef and pork; avoid fried meats.
 Poultry (without skin), beans, and fish are excellent main course selections
when cooked without fat.
 To increase the fiber in your diet, eat more fresh fruits, raw vegetables, and
whole grains. A high-fiber diet may also help lower your cholesterol.
 Reduce your total calories by eating smaller portions and avoiding second
helpings.
 Choose low-calorie snacks, such as fresh fruit, low-fat cookies or crackers
and unsalted pretzels. Remember, just because a food is "low-fat" does not
mean that you won't gain weight if you eat too much.
 Continue to limit salt intake and high-sodium foods to control blood pressure.
 Continue to limit simple sugars, especially if you are overweight.
 Do not eat sushi or any other raw or undercooked meat or fish.

iv. Nutrition Diagnosis

21. Prioritize the nutrition diagnoses by listing them in the order in which you would
expect interventions to be developed.

 Overweight/obesity NC-3.3
 Altered Nutrition related laboratory values BUN, Creatinine,
Phosphorus NC-2.2
 Inadequate mineral intake of Phosphorus (6) NI-5.10.1
 Inadequate protein-energy intake NI-5.3
 Excessive mineral intake of Potassium (5) NI-5.10.2
 Undesirable food choices NB-1.7

22. Select two high-priority nutrition problems and complete the PES statement for
each.

 Overweight/obesity related to increase calorie needs and medication

as evidence by high LDL, chols and BMI.
 Altered Nutrition related laboratory values BUN, Creatinine,
Phosphorus related to kidney dysfunction as evidence of CKD and lab values.

v. Nutrition Intervention
23. Using your PES statement, establish an ideal goal (based on the signs and
symptoms) and appropriate intervention (based on the etiology).

Goals:
 Average daily caloric intake will be no more than the range of
estimated needs about 2250-2625 kcal/day.
 Lab values will be controlled as BUN levels between 8-18
mg/dL, Creatinine levels between 0.6-1.2 mg/dL, and phosphorus
between 30-120 mg/dL.

Interventions:
 Though the client is overweight, she still needs to follow the
EER to get enough energy intake which might affect her post surgery
recovery. Instruct client on 2250-2625 kcal diet and educate client with
basic post-transplant knowledge and better food choices knowledge
 Educate client how to achieve altered nutrition related
laboratory values BUN, Creatinine, and Phosphorus control and how to
manage those values by increasing the kidney functions.

24. Using Mrs. Joaquin’s typical intake and the prescribed diet, write a sample menu
for her post-transplant nutritional needs.

Meal Sample Menu

Breakfast Corn flakes, 1 c
Milk (1%), 1/2 c
Bread (white), 1 slice
Margarine, whipped, 2t
Scrambled egg, 1 lg
Tangerine, 1 med
Water, 2 fo
Snack Pita bread, white, 2med
Green bell pepper, ¼c
Margarine, whipped,
unsalted 1 T
Water, 2 fo
Lunch Sandwich:
Bread (white) 2 slices
Deli turkey, low-
sodium, fat-free, 3oz
Mustard 1 tsp
Tortilla chips, unsalted,
1 oz
Plum, med
 Root beer, 8 fo

Snack Dried cranberries, 1.5 oz

Dinner Lean beef, 3 oz
Rice, 1 c
Green beans, 1 c
Pita bread, 1 med
Margarine, 1 T
Snack Saltine crackers, low
sodium, 6
Peanut butter, unsalted,
1T
Grapes, 1 c
Goals
Energy 2,250 kcal
Protein 97 g
Sodium 2,013 mg
Potassium 1,952 mg
Phosphorus 945 mg
Water 1,327 mL

(Sclafani)

25. Write an initial medical record note for your consultation with Mrs. Joaquin.

A (Assessment)
Mrs. Joaquin is a 26-yo obese Native American female (60”, 165#, BMI 32.46kg/m2).
She was diagnosed with T2DM at 13 years of age and with stage 5 CKD 2 yrs ago
when she was placed on hemodialysis. Her kidney function has progressively declined
and she was admitted to the hospital for preparation for kidney transplantation and
nutrition consult. She has elevated serum phosphorus, potassium, creatinine, BUN,
glucose, TG, HbA1c and cholesterol, which places her at stage 5 CKD. She reported a
good appetite and has following the diet prescribed when she began hemodialysis.

D (Diagnosis)
1. Overweight/obesity related to increase calorie needs and medication as evidence
by high LDL, chols and BMI.
2. Altered Nutrition related laboratory values BUN, Creatinine, Phosphorus related
to kidney dysfunction as evidence of CKD and lab values.

I (Intervention)
Goals:
  Average daily caloric intake will be no more than the range of
estimated needs about 2250-2625 kcal/day.
 Lab values will be controlled as BUN levels between 8-18
mg/dL, Creatinine levels between 0.6-1.2 mg/dL, and phosphorus
between 30-120 mg/dL.

Interventions:
 Though the client is overweight, she still needs to follow the
EER to get enough energy intake which might affect her post surgery
recovery. Instruct client on 2250-2625 kcal diet and educate client with
basic post-transplant knowledge and better food choices knowledge
 Educate client how to achieve altered nutrition related
laboratory values BUN, Creatinine, and Phosphorus control and how to
manage those values by increasing the kidney functions.

M & E (Monitoring & Evaluation)

Behavior regarding self-reported adherence (BE-2.4.1) to dietary requirements
Behavior regarding self-monitoring ability (BE-2.8.1) related to recording foods and
beverages
Mineral intake including potassium and sodium (FI-6.2)
Oral fluid amounts (FI-2.1.1)
Electrolyte and renal profile including, potassium (S-2.2.7) and sodium (S-2.2.5)

(Kidney transplants)
References:
Sclafani, N. (2004). Diet after transplantation . aakpRENALIFE, 19(5), Retrieved
from http://www.aakp.org/aakp-library/diet-after-transplantation/
Kidney transplantation. (2011). Retrieved from
http://www.kidney.org/atoz/content/kidneytransnewlease.cfm
Yasumuan, T., Oka, T, & Nakane , Y . (1997). Long-term prognosis of renal
transplant surviving for over 10 yr, and clinical, renal and rehabilitation features
of 20-yr successes. Clin Transplant , 5(1), Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/9361928
Kidney transplants . (2007). Informally published manuscript, Allegheny General
Hospital , Pittsburgh , Pennsylvania . Retrieved from
http://www.wpahs.org/agh/services/index.cfm?mode=view&medicalspecialty=48
1
Nelms, M., Sucher, K., & Long, S. (2007). Nutrition therapy and
pathophysiology. Belmont, CA: Thomson Wadsworth.
Rolfes, S.R., Pinna, K., & Whitney, E. (2009). Understanding normal and clinical
nutrition. Belmont, CA: Wadsworth.
Drugs and supplements . (08-11). Retrieved from
http://www.ncbi.nlm.nih.gov/pubmedhealth/s/drugs_and_supplements/a/
Pellegrrino , B. (2011). Immunosuppression . Medscape, Retrieved from
http://emedicine.medscape.com/article/432316-overview