Nutrition Goals for Posttransplant Maintenance Phase

Scored Patient-Generated Subjective Global Assessment (PG-SGA)

VI. Nutrition Goals for Posttransplant Maintenance Phase

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a) Obesity may increase the risk of delayed renal graft function.^30–33 b) Obesity has been shown to adversely affect graft survival in

some31,32,34–37but not all studies.^33,38

3. Liver. Obesity may delay wound healing, prolong ventilator time, and increase postoperative infections.^39–41

IV. Nutrition Assessment.

A combination of objective and subjective parameters form the basis of a comprehensive nutrition assessment (see Table 12-3 for assessment guidelines specific to transplant recipients).

S E C T I O N I I Immune Driven Conditions

Components of

an assessment Assessment parameters

GI, gastrointestinal

TABLE 12-3. Nutrition Assessment Criteria for Organ Transplant Patients5,9,14,42–48

• Patient age

• Etiology, duration, and severity of organ failure prior to transplantation

• Time since transplant and current transplant function

• Other organ damage (eg, renal insufficiency, diabetes, cardiovascular disease)

• GI conditions (eg, nausea, vomiting, diarrhea, GI bleeding) or diseases (eg, Crohn’s disease, celiac sprue, gastro- esophageal reflux)

• Previous surgeries (other than transplant) such as GI surgeries (eg, noting location and extent of intestinal re- sections in small-bowel transplant recipients)

• Other supportive therapies (eg, hemodialysis, oxygen, heart assist devices if pretransplant)

• History of diabetes mellitus and level of glucose control

• Functional ability, energy level, attendance at work or school

• Current diet prescription

• Diet history to assess quality and quantity of intake

• Medication history to identify drug-nutrient interactions

• Previous enteral or parenteral nutrition support; type and amount of formula

• For infants, consideration of route of feeding and type of formula if bottle-fed

• Fluid and electrolyte supplementation

• Use of nutrition supplements, including vitamin, mineral, and herbal preparations

• Psychosocial and economic conditions to determine patient’s or caregiver’s ability to obtain/prepare food and comply with diet

• Changes in appetite, taste acuity, satiety

• Dietary restrictions

• Food allergies and intolerances

• Religious or cultural food preferences

• Mental status

• Muscle and fat stores

• Edema or ascites

• Skin color, dryness, turgor, and integrity

• Oral/dental health

• Height or length

• For children, weight and percentile for age, weight for length percentile, head circumference and percentile for age

• Weight history (to assess degree of fluid retention and weight loss)

• Tricep skinfold and midarm muscle circumference measurements may be helpful if measured serially over time

• Hand grip strength may be an indirect measure of muscle stores

• Tests to evaluate transplant graft function

• Serum electrolytes

• Serum glucose and, if indicated, hemoglobin A1c and C-peptide levels

• Tests to evaluate renal function, such as blood urea nitrogen and creatinine

• Hepatic transport proteins: not especially helpful in the postoperative period because concentrations are affected by fluid status, liver and kidney function, and vitamin status

• Iron studies

• Serum lipid levels

• Fat-soluble vitamin levels (for patients with malabsorption)

• Subjective global assessment may be helpful as an initial assessment tool

• Bioelectrical impedance is probably not an accurate measure of protein calorie malnutrition in fluid-overloaded patients

• Creatinine-height index is influenced by renal function

• Dual-energy x-ray absorptiometry can accurately measure bone density and body fat

• Indirect calorimetry can accurately determine resting energy expenditure

• The D-xylose test is recommended for small-bowel transplant recipients 30 days posttransplant and then weekly to evaluate intestinal graft function and carbohydrate absorption

Medical history

Nutrition history

Physical examination

Anthropo- metric measurements

Laboratory tests

Other tests

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e) Although limited data are available, small-bowel transplant patients appear to be at low risk for posttransplant obesity due to decreased intestinal absorption.⁹

2. Optimize diabetes management.

a) Transplant patients are at higher risk of developing diabetes ^68–72 due to immunosuppressive medications (eg, corticosteroids, tacrolimus, cyclosporine); the incidence of diabetes may lower as corticosteroid doses are reduced.⁷³

(1) Cyclosporine and tacrolimus inhibit insulin secretion, increase insulin resistance, and exert a direct toxic effect on beta cells⁷⁴; tacrolimus may be more diabetogenic than cyclosporine.⁷⁵

(2) Corticosteroids cause insulin resistance, increase gluco- neogenesis and glucagon production, and antagonize peripheral glucose uptake.^74,76,77

b) Other risk factors for the development of diabetes include heredity, obesity, and renal insufficiency.

c) Diabetes treatment should include an appropriate carbohydrate-controlled diet, self-monitoring of blood glucose, and medication as needed (insulin or oral agents).^70–72

d) Weight management, lipid control, and exercise are stressed for patients with diabetes.

3. Prevent and treat bone mass loss.

a) Posttransplant patients are at increased risk for bone loss^78–81 due to

(1) Osteopenic effects of immunosuppressive drugs (specifically, corticosteroids and cyclosporine)

(2) Pretransplant risk factors such as type of pretransplant disease, vitamin D deficiency, hypogonadism, impaired absorption or inadequate intake of calcium, reduced physical activity, and preexisting bone disease

b) Treatment includes

(1) Adequate calcium intake (1500 mg per day) with vitamin D (2) Regular resistance exercise to improve bone density⁸² (3) Smoking avoidance

(4) Annual bone density testing to monitor bone health (5) Treatment with estrogen and/or bisphosphonates (indicated

for certain patients)^83–85 4. Achieve normal serum lipid levels.

a) Risk factors for posttransplant hyperlipidemia include immunosuppressive medications (especially sirolimus, corticosteroids, and cyclosporine)^52,86–88as well as obesity, genetic predisposi- tion, diabetes mellitus, sedentary lifestyle, renal dysfunction, high-fat diet, antihypertensive drugs, and proteinuria.

b) Treatment of hyperlipidemia includes (1) Dietary changes

(2) Lipid-lowering agents

(3) Fish oil supplementation, whose benefits are being studied 5. Achieve normal blood pressure.

a) Transplant patients are at risk for increased blood pressure caused by corticosteroids and cyclosporine.

b) Treatment includes weight management, antihypertensive medications, and a dietary restriction of 2 to 4 g sodium per day.

6. Wean nutrition support.

a) Patients should achieve adequate intake with oral diet.

b) Small-bowel transplant recipients may require a period of nutrition support and/or intravenous (IV) fluids.

B. Pediatric

1. Obtain adequate calories and protein; needs reflect recommended daily allowance (RDA) for age if there is good graft function, min- imal complications, and appropriate growth since transplant.

2. Achieve appropriate catch-up and long-term growth (Table 12-9).

a) Growth retardation often occurs in pediatric patients prior to transplantation.

b) The use of corticosteroids after transplantation can com- pound this problem; however, the use of alternate-day pred- nisone can reduce the growth-depressing effects of steroids⁸⁹; withdrawal of corticosteroids can also result in improved catch-up growth.

c) Liver and heart recipients normally experience catch-up growth during the first posttransplant year if chronic rejection is absent⁹⁰; however, patients with poor graft function, those requiring high-dose corticosteroids due to rejection, or those requiring multiple operations are more likely to continue to experience poor linear growth.⁸⁹

d) Children with renal failure have short stature for multiple rea- sons. Optimizing nutrition support, supplementing with oral bicarbonate, preventing renal osteodystrophy, and treating anemia prior to transplantation can help stabilize growth.⁹¹ (1) The use of recombinant human growth hormone before

transplant in patients with chronic renal failure has been shown to result in improved growth.⁹¹

(2) Some studies indicate that catch-up growth occurs in only 30% to 50% of children after renal transplantation; it occurs most often in children less than 6 years old rather Nutrition Goal

Calorie Needs

Weight 1.2 to 1.3 x basal energy expenditure (by Harris- maintenance Benedict equation), depending on activity level

30 kcal/kg

Weight gain 1.5 x basal energy expenditure 35 to 40 kcal/kg

Weight loss Deficit of 500 to 1000 kcal/day, depending on current intake, anticipated time until transplant, and ability to exercise

Protein Needs Maintenance 0.8 to 1.2 g/kg/d Repletion 1.3 to 2.0 g/kg/d

Dialysis Hemodialysis: 1.2 to 1.5 g/kg/d Peritoneal: 1.5 g/kg/d

TABLE 12-4. Pretransplant Calorie and Protein Goals for Solid Organ Transplant Candidates

Adapted from Hasse JM. Solid organ transplantation. In: Matarese LE, Gottschlich MM, eds. Contemporary Nutrition Support Practice: A Clinical Guide. 2nd ed. Philadel- phia, PA: Elsevier; 2003:560–573 with permission from Elsevier.

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Considerations

CF, cystic fibrosis; PN, parenteral nutrition; RDA, recommended daily allowance.

TABLE 12-5. Nutrition Considerations for Pediatric Transplant Candidates10,45,48–50

• Oral intake can be maximized by concentrating infant formulas

• Modular protein, fat, and carbohydrate components can be added to food or formulas to increase nutrient density

• If early satiety or tiring while feeding occur, offer patients small, frequent meals

• If an infant is breast-feeding, continue as long as he or she gains weight and grows well; increased calorie and protein

needs may make it difficult to meet 100% of nutritional needs with breast milk unless the mother is willing to pump and additives are added to the milk

• Most intestinal transplant candidates will have oral aversions; patients should receive as much oral stimulation as possible: bottles should be offered to children <1 year of age and solid food should be introduced at normal developmen- tal milestones

• Tube feeding is indicated if patients are severely malnour- ished or unable to achieve adequate nutrient intake by mouth; when possible, tube feedings should be administered nocturnally or with a nipple/bolus schedule during the day to preserve as much oral intake as possible and prevent development of oral aversions

• If a patient is not growing adequately despite tube feedings, PN is indicated to maximize nutritional status prior to transplant

• Patients awaiting heart transplantation or requiring extracorporeal membrane oxygenation may also require PN

• Patients with severe esophagitis or gastric varices secondary to liver disease may require PN if oral intake is inadequate and placing a nasogastric tube is contraindicated due to bleeding risk

• Biliary atresia is the most common cause of liver disease in pediatric patients

❍ Calorie requirements may be as high as 180% of the RDA for calories and up to 4 g protein per kg per day due to malabsorption of nutrients

❍ Malabsorption of fat and fat-soluble vitamins also occurs;

fat-soluble vitamin supplementation is frequently required (see TABLE 12-6)

❍ Infant formulas high in medium-chain triglycerides are helpful in reducing steatorrhea and improving growth

• Patients with noncholestatic liver disease require 100% to 120% of the RDA for calories, 2.2 to 2.5 g protein per kg per day for infants, and the RDA for protein for children ages 1 year to 18 years

• Patients awaiting intestinal transplant are dependent upon PN

• Calorie needs are normally less than the RDA

• If the patient is stable, 70 to 80 calories per kg per day are adequate for growth

• Protein requirements are 1.8 to 2.5 g per kg per day

• Hypertriglyceridemia occurs frequently in patients awaiting combined liver and intestinal transplantation

• Adequate fat (0.5 g/kg/day) should be provided to prevent essential fatty acid deficiency

• Calorie and protein requirements vary depending on need for dialysis and type of dialysis

• Electrolyte requirements need to be individualized based on serum levels

Diet factors

Nutrition support considerations

Pre-liver transplant

Pre-intestinal transplant

Pre-kidney transplant Pre-heart transplant

Pre-lung transplant

• Calorie needs vary greatly

• Infants and children requiring ventricular assist devices or extracorporeal membrane oxygenation prior to transplantation are often dependent upon PN

• Calorie requirements are typical for other children requiring PN, approximately 80% to 85% of the RDA

• Calorie needs for children with congenital heart disease vary widely but may be 150 calories per kg per day or higher

• Children with less advanced heart disease will have calorie and protein needs similar to the RDA for their age

• Most children requiring lung transplantation have CF; this population has specific nutrient requirements

• Because the degree of lung disease is quite advanced in many patients with CF awaiting lung transplantation, tube feeding may be required to meet nutrient needs

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than older children⁹²; however, there are reports of significant catch-up growth in children of pubertal age.

e) Lung and intestinal transplant recipients require more im- munosuppression than other organ transplant recipients.

(1) Antirejection medications, specifically corticosteroids, can result in additional growth delay.

(2) After 5 years post small-bowel transplant, it appears that children do begin to experience catch-up growth in the absence of renal failure or chronic rejection.⁹³

3. Overcome oral aversions.

a) This is primarily a complication in intestinal transplant recipients; these children have not developed normal oral motor skills due to long-term dependence on parenteral nutrition (PN).

b) Most small-bowel transplant recipients will require intensive posttransplant feeding therapy to achieve adequate nutritional intake by mouth.¹⁰

c) Patients with a long dependence on tube feedings or PN prior to transplantation will require feeding therapy to meet nutritional needs orally.

4. Achieve normal blood pressure.

a) A sodium-restricted diet is recommended for patients who have posttransplant hypertension (HTN).

b) HTN is common after pediatric kidney transplantation and can be associated with graft failure; higher systolic blood pressure in the first few posttransplant months is associated with decreased renal allograft function in children 1 year after transplantation.⁹⁴

c) By 1 year after liver or heart transplantation, most patients are normotensive and do not require antihypertensive therapy.⁹⁵ d) HTN is also common in lung transplant recipients; patients

with cystic fibrosis should restrict dietary sodium with caution.

5. Prevent and treat bone loss.

a) Long-term corticosteroid use can lead to bone loss over time.⁹⁶ b) Corticosteroids are often discontinued or changed to alternate- day dosing in the first 6 to 12 posttransplant months to maximize long-term growth and minimize bone loss.⁹⁷

c) Calcium intake should meet the RDA for age.

d) Vitamin D levels should be monitored and supplemented with 400 to 1000 International Units per day if needed.

e) Daily exercise is recommended to minimize bone disease.

6. Achieve and maintain normal serum lipid levels.

a) Elevated serum cholesterol and triglyceride levels can occur in children posttransplantation, most commonly in renal and heart transplant recipients.⁹⁸

b) Family history of hyperlipidemia correlates with increased risk.

c) Complete serum lipid profiles should be performed, counseling regarding dietary changes provided, and lipid-lowering agents prescribed as needed.⁹⁹

7. Treat posttransplant diabetes mellitus (PTDM).

a) The incidence of hyperglycemia and PTDM ranges from 4%

to 41%.

b) Significant risk factors for the development of PTDM include first-degree family history of type 2 DM, second-degree family history of type 2 DM, tacrolimus use, and hyperglycemia occurring in the 2 weeks after transplantation.

c) Patients with family history of DM or hyperglycemia may benefit from the avoidance of tacrolimus in the immediate posttransplant period.¹⁰⁰

d) If PTDM develops, patients and families will need in-depth dietary counseling to learn management principles.

8. Avoid obesity.

a) Corticosteroids, inactivity, and poor dietary habits can con- tribute to the development of obesity in children after transplantation.

b) Patients and families should be counseled on healthy eating habits and the importance of daily exercise.

Dalam dokumen The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition (Halaman 194-198)