Scored Patient-Generated Subjective Global Assessment (PG-SGA)
III. Nutritional Factors Influencing Postoperative Outcomes
A. Malnutrition
1. Malnutrition reduces posttransplant survival.
a) Malnutrition increased risk for morbidity and mortality post liver transplant in several studies,18–23although findings by Figueiredo et al and Stephenson et al did not support this correlation.24,25
b) Madill et al reported that lung transplant recipients with a body mass index (BMI) <17 kg/m2had a 4-fold greater risk of dying within 90 days posttransplant compared with a normal weight group, although the finding was not statistically significant.16 c) Frazier et al reported that mortality was increased in heart
transplant recipients who were malnourished.26
d) Becker et al showed that hypoalbuminemia in kidney trans- plant recipients increased rates of cytomegalovirus infection and graft failure and was associated with a trend for reduced survival.27
2. Malnutrition increases blood loss and use of blood products dur- ing liver transplant surgery.24,25,28
3. Malnutrition increases length of intensive care unit (ICU)22,24and hospital stay after liver transplant.22,25,29
4. Malnutrition impairs wound healing.
5. Physical deconditioning, associated with malnutrition, may also increase length of hospital stay and rehabilitation.
B. Obesity
1. Lung. Madill et al reported that lung transplant patients with a BMI
>27 kg/m2had an increased mortality within 90 days posttrans- plant as well as an increased length of ICU stay.16
2. Kidney and kidney/pancreas
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172 A.S.P.E.N. Nutrition Support Practice Manual 2nd Ed. © 2005 A.S.P.E.N. www.nutritioncare.org.
TABLE 12-1. Common Diagnoses Leading to Organ Transplantation
Adult Pediatric
Organ
• Alcoholic cirrhosis
• Viral hepatitis—hepatitis B and C (fulminant and chronic)
• Cholestatic disease—primary biliary cirrhosis, primary sclerosing cholangitis
• Metabolic disease—hemochromatosis, Wilson’s disease, alpha 1-antitrypsin deficiency, glycogen storage disease
• Nonalcoholic steatohepatitis
• Autoimmune disease
• Miscellaneous—cryptogenic liver failure, polycystic liver disease, hepatocellular carcinoma, Budd-Chiari syndrome, sarcoidosis
• Diabetes mellitus
• Hypertension
• Chronic glomerulonephritis
• Systemic lupus erythematosus
• Chronic pyelonephritis
• Polycystic kidney disease
• Hyperoxaluria
• Vasculitis
• Nephritis
• Type 1 diabetes mellitus is the indication for 99% of pancreas transplants
• Islet cell transplantation is another option for patients with type 1 diabetes mellitus
• Indicated for patients with irreversible intestinal failure who cannot tolerate parenteral nutrition due to life- threatening complications such as cholestatic liver disease, loss of venous access, repeated central line sepsis
• Causes of intestinal failure include mesenteric thrombosis, necrotizing enterocolitis, Crohn’s disease, desmoid tumor, Gardner’s syndrome, ischemia, pseudo-obstruction, trauma, intestinal volvulus, radiation enteritis
• Primary cardiomyopathy
• Coronary artery disease
• Inoperable ischemic coronary disease
• Cystic fibrosis
• Chronic obstructive pulmonary disease
• Pulmonary hypertension
• Bronchiectasis
• Pulmonary fibrosis
• Emphysema
• Eisenmenger’s syndrome
• Bronchiolitis obliterans
• Alpha-1-antitrypsin deficiency
• Scleroderma Liver transplant1–4
Kidney transplant3,5,6
Pancreas transplant3,7,8
Small-bowel transplant3,9–13
Heart transplant3,14,15
Lung transplant3,14,16,17
• Pediatric
• Acute and chronic hepatitis—fulminant hepatic failure, chronic viral hepatitis with cirrhosis
• Intrahepatic cholestasis—idiopathic neonatal hep- atitis, Alagille’s syndrome, familial intrahepatic cholestasis (Byler’s disease)
• Cholestatic disease—extrahepatic biliary atresia, sclerosing cholangitis
• Metabolic disease—alpha-1-antitrypsin deficiency, tyrosinemia, Wilson’s disease, perinatal hemochro- matosis, glycogen storage disease
• Obstructive uropathy
• Aplastic/hypoplastic/dysplastic kidneys
• Focal segmental glomerulosclerosis
• Reflux nephropathy
• Chronic glomerulonephritis
• Syndrome of agenesis of abdominal musculature
• Medullary cystic disease/juvenile nephronophthisis
• Hemolytic uremic syndrome
• Congenital nephritic syndrome
• Polycystic kidney disease
• Pancreas transplantation is uncommon in pediatric patients
• A pancreas graft is sometimes included in a multi- visceral transplant
• Complex congenital heart disease
• Primary cardiomyopathy
• Hypoplastic left heart syndrome
• Endocardial fibroelastosis
• Acquired heart disease
• Cystic fibrosis
• Primary pulmonary hypertension
• Chronic obstructive pulmonary disease
• Alpha-1-antitrypsin deficiency
• Idiopathic pulmonary fibrosis
• Interstitial lung disease
• Congenital heart disease
• Bronchiolitis obliterans
• Desquamative interstitial pneumonitis
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Drug
TABLE 12-2. Immunosuppressant Drugs, Nutritional Side Effects, and Interventions
Activity Nutritional side effects Suggested nutrition therapy Antilymphocyte
serum (ATGAM, Thy- moglobulin) Azathioprine (Imuran)
Basiliximab (Simulect)
Corticosteroids (methyl- prednisone, prednisone, prednisolone, Solu-Medrol, Solu-Cortef)
Cyclosporine (Neoral, Sandimmune)
Daclizumab (Zenapax)
Binds with lymphocytes, resulting in phagocytosis
Inhibits and destroys lymphocytes Inhibits purine nucleotide synthesis,
blocking T- and B-lymphocyte proliferation
Acts against the interleukin-2R-alpha chain (CD25) on activated T-lymphocytes and inhibits interleukin-2-mediated activation of lymphocyte
Anti-inflammatory properties Inhibits cell-mediated—and, to a
lesser degree, humoral—
immunity
Inhibits lymphocyte proliferation Inhibits lymphokine production
Inhibits cell-mediated immunity;
inhibits T-cell proliferation Suppresses interleukin-2 production Prevents gamma-interferon release
Fever and chills
Increased risk of infection, profound leukopenia Nausea, vomiting Diarrhea
Sore throat/mucositis Altered taste acuity Macrocytic anemia Pancreatitis
None reported
Hyperglycemia Sodium retention Ulcers Osteoporosis Hyperphagia
Impaired wound healing and increased infec- tion risk
Hypertension Pancreatitis
Hyperkalemia Hypomagnesemia Hypertension Hyperglycemia Hyperlipidemia
None reported
Provide nutrient-dense foods patient will eat Ensure that patient is receiving adequate
protein
Try antiemetic medications; if vomiting does not subside, consider tube feeding or PN Review drugs and substitute for those that may
be causing diarrhea; make sure that patient is receiving adequate fluid to replace losses Provide foods that will not irritate throat Offer a variety of foods with different tastes Make sure folate intake is adequate Initiate EN or PN if pancreatitis is severe
Monitor blood sugar and need for long-term diabetes diet and hypoglycemic agents Avoid high-sodium foods
Avoid foods that irritate stomach
Ensure adequate calcium and vitamin D intake;
consider need for calcitriol, fluoride, or estro- gen
Behavior modification to prevent overeating Ensure adequate protein intake; consider need
for vitamins A or C or zinc
Avoid high-sodium foods, maintain healthy weight
Initiate EN or PN if pancreatitis is severe Restrict high-potassium foods
Supplement with high-magnesium foods or supplements
Avoid high-sodium foods, maintain healthy weight
Monitor blood sugar and need for long-term diabetes diet and hypoglycemic agents Limit fat intake to <30% calories during long-
term phase; maintain healthy weight
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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