Mini Case Study

Samantha Walters Sodexo Mid-Atlantic Dietetic

Intern

Patient: A.B.

54 y/o AA male

Reference height: 167.6 cm (5’6”)

Reference weight: 91.4 kg (201.1 lbs)

Admitted: 12/2/14 for DDKT

Two intern contactso one follow-up with patient’s nurse

Family/Social Hx

Patient is single and lives with his brother

On disability, no longer working as a landscaper (left in 2008)

Denies tobacco, EtOH, and illicit drug use

Family hx includes: • older brother who was dx with Alport syndrome • HTN• CAD• CA

Past Medical Hx

Dx with hearing loss at an early age

CKD was dx approximately 14 years ago (early 2000)

Began HD in December 2010o Arteriovenous fistula on left arm

o Dialysis M/W/F for 4 hours

Hx of ESRD 2/2 HTN and Alport Syndrome that runs in the family

Gout

What is Alport Syndrome?

An inherited disease that primarily effects the glomeruli in the kidneys, which filter wastes from the blood.

Caused by mutations that affect type IV collagen, a protein that is important to the normal structure and function of the inner ear and the eye.

The most common and earliest symptom of this disease is hematuria. Others include proteinuria, high BP, and swelling in the legs, ankles, feet, and eyes.

Hospital Course

Operative Day:

Admitted December 2 for deceased donor kidney transplanto Transplanted to right sideo 22 y/o DCD with cause of death 2/2 MVAo High term Cr donoro 23 hours Cold Ischemia Timeo Campath Induction

Hospital Course

POD 1:

Pt transferred from PACU to ZAYED 9W Delayed Graft Function 2/2 minimal urine output

(0 mL) and K 6.5 Received HD at beside Clinical Nutrition consult received for assessment

and education Visited patient POD 1, and he was NPO. Observed

HD and had nurse walk me through the process.

Delayed Graft Function

Caused by issues between the donor or recipient Fairly common, occurring in about 30% of

deceased-donor kidneys and 5% of living-related kidneys

Transplanted kidney is called a graft Occurs right after surgery and can take some

time for the kidney to heal after transplant. Can take from weeks, even months for kidney to

resume its normal functions Often times requires short-term HD in order to get

it functioning properly

Hemodialysis: POD 1

Why? Resolve Hyperkalemia

Vascular access: L. AV Fistula Blood Flow Rate: 400 mL/min

o Venous BP was 150 mmHgo Arterial BP was -200 mmHg

Spoke with patient after HD and let him know we would be back the following day to complete the nutrition assessment After HD, A.B.’s diet was advanced to Regular with no

restrictions

Hospital Course

POD 2: Patient still with minimal urine output (25 mL over

24 hrs) Hyperkalemia resolved Patient seen for nutrition assessment and

education s/p DDKT Significant Labs:

• BUN: 42 (H)• Cr: 10.2 (H)• Ca: 8.1 (L)• Phos: 5.4 (H) • DEXIS: 12/4—161, 124

12/3—124, 109. 99, 120, 131, 105

Noteworthy Medications

Bisacodyl (Constipation) Docusate (stool softener) Pantoprazole (reflux common after transplant d/t

meds—Prednisone especially) Senna (stool softener) Pravastatin (statin) MVI Insulin Sliding Scale

Immunosuppressants

CellCept (Mycophenolate Mofetil) o Inhibits enzyme needed for growth of T and B cells

Prednisoloneo Block the T cell activation/expression cascade

WAS on Thymoglobulin POD1o Used immediately after transplanto Uses antibodies directed against T cell antigens, making

T cells non-responsive Prograf (Tacrolimus)

o Reduces interleukin 2 production by T cellso IL2 responsible for regulation of WBCs

Nutrition Assessment

Pt reports good appetite; no N/V/D/C or chewing/swallowing difficulties

Generalized Edema States he still has little urine output and last BM was

prior to transplant Recent estimated dry weight was 92.8 kg

CBW: 91.4 kgUBW: 95.5 kg (98.5%) DBW: 64.5 kg (142%)

Nutrition Assessment

Estimated Needs:

All needs based on DBW of 64.5 kg: (KDIGO/KDOQI)

-Kcal: 1950-2300 kcal/day (30-35 kcal/kg)

-Protein: 85-95 gm/day (1.3-1.5 gm/kg)

-Fluid: No restriction, per team

Nutrition Diagnosis

Increased nutrient needs (NI 5.1) (calories, protein) related to wound healing as evidenced by s/p kidney transplant and catabolic effect of steroids

Food and nutrition-related knowledge deficit (NB 1.1) related to limited post-transplant diet education as evidenced by s/t DDKT on 12/2/2014

Nutrition Education Provided NCM: Post-Transplant Nutrition Therapy

Handout

Post Kidney Transplant Diet Recommendations: o Heart-Healthy diet o Avoid concentrated sweets/moderate CHO dieto Food Safety

• Check expiration dates• Thaw foods properly• Cook/Chill foods thoroughly • Wash all fruits/vegetables• Heat cold cuts, hot dogs, deli meats, and sausages to steaming before eating• Avoid grapefruit, raw meats, unpasteurized dairy/juice/cider, fresh sprouts, moldy foods, and alcohol

Recommendations

Continue Regular Diet with no restrictions as tolerated Continue vitamin/mineral supplement QD Suggest checking Vitamin D and supplement if low Continue to monitor renal labs and checking DEXIS to

monitor BG response to steroids Pt encouraged to contact RD with questions/concerns

regarding diet – Provided with RD contact information Will f/u per standards of care

Follow-up

POD 3:

Was given Lasix overnight with no response (15 mL urine output all night)

5 mL total POD 3, and given 100 mg Lasix again today

Removing Foley later today HD later today d/t labs not trending per note:

• Cr: 13.1 (H)• BUN: 71 (H)• Ca: 7.9 (L)• Phos: 6.8 (H)

References

NCM: Organ Transplant Nutrition Therapy

National Kidney Foundation. Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease: A Concise, Practical Resource for Comprehensive Nutrition Care in CKD

National Kidney Foundation (website)

J.S. Gill, J. Lan, J. Dong, et al. The Survival Benefit of Kidney Transplantation in Obese Patients. American Journal of Transplantation 2013; 13: 2083-2090.

Chitra U and Sunitha Premalatha K. Nutritional Management of Renal Transplant Patients. Indian Journal of Transplantation 2013; 7(3):88-93

Questions?