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Renal Nutrition Mastery > Transplant > Flashcards

Transplant Flashcards

1
Q

What is considered a normal weight gain for a transplant patient?

A

20-40 lbs int eh first 6 months due to no more cachectic effects of dialysis, diet liberalization, lack of physical activity, increased appetite from steroid medications

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2
Q

which medications cause hyperlipidemia?

A

Cyclosporine, Crticosteriods, tacrolimus

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3
Q

Which medications are nephrotoxic?

A

calcineuin inhibitors, cyclosporine, and tactrolimus
sirolimus is not nephrotoxic

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4
Q

Which medications interact with grapefruit?

A

Grapefruit and grapefruit juice impacts absorption of medications, including immunosuppressants (cyclosporine, tacrolimus), calcium channel blockers, and antilipideimcs via the inhibition of CYP3A4 in the gut wall.

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5
Q

Food safety in transplant

A

Regarding dairy –

Higher Risk: unpasteurized (raw) milk and soft cheeses made from unpasteurized (raw) milk such as feta, brie, camembert, blue-veined, queso fresco are higher risk foods
Lower Risk: hard cheeses, processed cheese, cream cheese, mozzarella, soft cheeses labeled “made from pasteurized milk”
Mayonnaise uses raw egg in the recipe so must be avoided unless pasteurized eggs are used.

Correct because raw sprouts are a higher risk food.

Sashimi is raw fish and must be cooked to 145F to lower risk.

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6
Q

Side effects of Cyclosporine A?

A

hyperkalemia, oral candida, weight gain, hyperlipidemia, hypomagnesia, HTN, hyperglycemia, GI distress including abdominal pain, decreased appetite, N/V/D;
Gingival hyperplasia, oral candida

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7
Q

side effects of Tacrolimus

A
  • Insulin resistance / hyperglycemia
  • Hyperkalemia or hypokalemia
  • Hypophosphatemia
  • Hypomagnesemia
  • GI distress: abdominal pain, anorexia, N/V/D/C
  • Mouth / throat sores
  • Peripheral edema
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8
Q

Recommended intervention for a pt on Azathioprine?

A

Increase folate intake

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9
Q

What is the protein recommendation during acute post-transplantation phase?

A

1.2-2.0 gm/kg

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10
Q

How long is the acute post-transplantation phase?

A

up to 8 weeks post transplant

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11
Q

which mineral might be low with corticosteroid use?

A

zinc

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12
Q

which herbal supplement can increase risk of rejection due to its ability to enhance the immune system?

A

Echinacea

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13
Q

Describe the 2 types of immunosuppressive
therapy commonly used in transplantation

A
  1. Induction therapy: use antilymphocyte antibody medications for a short period of time immediately post-transplant to prevent early
    rejection episodes; minimal side effects
  2. Antirejection therapy: used in immediate post- transplant phase, but continued indefinitely
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14
Q

What are the 4 classes of immunosuppressive
medications commonly used for antirejection tx?

A
  1. Corticosteroids
  2. Calcineurin inhibitors
  3. Antimetabolites
  4. Target-of-rapamycin inhibitors
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15
Q

Why would a multidrug therapy be prescribed
instead of using just one class of medication?

A
  • Each class of drug mediates the immunocompetence cascade at a different point
  • To lower doses of individual agents to minimize associated adverse effects associated with each medication
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16
Q

What is Neoral and what are some of its benefits?

A
  • Microemulsion preparation of cyclosporine A and has better absorption because it is not dependent on bile
  • Preferred over cyclosporine in pts with gastroparesis, diarrhea, biliary diversion, cholestasis, and malabsorption
  • Fewer adverse effects
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17
Q

What are some recommended interventions for a
pt on Tacrolimus?

A
  • Monitor blood glucose level; address CHO load & distribution
  • If hyperlipidemia, limit fat intake to <30% kcal in maintenance phase
  • Restrict potassium intake
  • Magnesium supplement as needed
  • High phosphorus foods and/or phos supplements as needed
  • Nutrient dense foods & adequate protein & fluids
18
Q

What are some adverse effects of Sirolimus?

A
  • Dyslipidemia (hypertriglyceridemia and hypercholesterolemia) d/t inhibition of lipoprotein lipase or reduced catabolism of apoB100-containing lipoproteins
  • Increased liver enzymes
  • Delayed wound healing
  • Anemia
  • HTN
  • Hypokalemia
  • Mouth ulcers
  • Peripheral edemas
  • GI: N/V/D/C, feeling of fullness
19
Q

What are some recommended interventions for a
pt on Sirolimus?

A
  • Monitor blood glucose, manage CHO load/distribution
  • Increased protein intake & vitamin supplementation to help with wound healing
  • Potassium supplements
  • Diet texture/modifications for mouth ulcers
20
Q

What are some adverse effects of Azathioprine?

A
  • Thrombocytopenia & leucopenia
  • GI: stomach pain, N/D, fullness, loss of appetite
  • Cholestasis
  • Wt loss
  • Mouth ulcers
  • Infection
  • Folate deficiency
21
Q

What are some recommended interventions for a
pt on Azathioprine?

A
  • Address increased nutrient demands to prevent infection
  • Diet texture/modifications for mouth ulcers
  • Folate supplements as needed
  • Nutrient dense foods & adequate protein & fluids for GI distress
22
Q

What are some adverse effects of Corticosteroids?

A

Side effects are dose dependent!
- Impaired wound healing
- Avascular necrosis of long bones, osteopenia
- GI: upper GI ulceration, GI hemorrhage, abdominal distension
- Protein catabolism
- HTN
- Cushingoid appearance
- Sodium / fluid retention
- Hyperkalemia
- Steroid-induced DM
- Cataract formation
- Increased appetite & wt gain
- Retard growth in pediatric transplant population

23
Q

What are some recommended interventions for a
pt on corticosteroids?

A
  • Monitor blood glucose; address CHO load / distribution
  • Restrict sodium intake
  • Rec. low-calorie snacks & eating behavior modification
  • Increase protein needs
  • Limit or restrict caffeine if sensitive r/t GI ulcers
  • Adequate calcium & vitamin D; consider need for bisphosphonates, calcitriol, and estrogen/testosterone for maintenance of bone health
24
Q

What is the kcal recommendation during the
acute post-transplantation phase?

A

30-35 kcal/kg/d or 130-150% calculated BEE
- Increased kcal needs r/t high dose corticosteroids & post-operative stress
- Pts on dialysis prior to transplant may display protein-energy malnutrition
and negative nitrogen balance with loss of LBM
- Increased needs with fever and infection

25
Q

What is the CHO recommendation during the
acute post-transplantation phase?

A

50-70% of nonprotein calories
- Glucose intolerance d/t immunosuppression, surgical stress, genetic,
obesity, increased age, infection
- High fiber (25-30 g/d)

26
Q

What is the fat recommendation during the acute
post-transplantation phase?

A

30-50% of nonprotein calories
- Follow the National Heart, Lung, and Blood Institute Adult Treatment Panel III Guidelines, although temporary liberalization may be needed to meet increased energy needs
- High fiber (25-30 g/d) for cholesterol management

27
Q

What is the sodium recommendation during the
acute post-transplantation phase?

A
  • Unrestricted if BP and fluid balance WNL
  • Restriction only in the acute phase in the presence of poor
    allograft function, posttransplant HTN
  • Restriction to 2-4 g/d (or <2.3 g per KDOQI 2020 Rec 6.5.1) may be
    needed with medications that cause HTN and fluid restriction
28
Q

How is potassium affected in the acute
post-transplantation pt?

A
  • Hyperkalemia associated with poor graft function, immunosuppressive medications (calcineurin inhibitor), and/or catabolic cell lysis r/t surgery or corticosteroids
  • Interventions: K restriction, adequate calories & protein to minimize catabolism, binding resin (sodium polystyrene) may be used if it persists
29
Q

What are the calcium/vitamin D recommendations
during the acute post-transplantation phase?

A
  • Calcium supplementation 1200-1500 mg/d or total <2000 mg/d
  • Cholecalciferol supplementation to correct vitamin D deficiency,
    which may occur even with stable graft function
  • Goal: treat bone loss d/t pretransplant renal osteodystrophy &
    corticosteroid tx, correct vitD deficiency, reduce hyperparathyroidism
30
Q

What is the zinc recommendation for the acute
post-transplantation pt?

A
  • Zinc deficiency associated with corticosteroid tx
  • Evaluate zinc status if wound complications present
  • Supplement if dietary intake is insufficient
31
Q

What is the magnesium recommendation for the
acute post-transplantation pt?

A
  • Hypomagnesemia associated with use of calcineurin inhibitors, cyclosporine and tacrolimus
  • Dietary sources often inadequate, may need supplement (oral or IV) if serum levels are low
  • Supplements should be taken apart from MMF
32
Q

What is the recommendation for using herbals &
botanicals in the acute post-transplantation pt?

A
  • Dietary supplements require no proof of efficacy, safety, or QC standards
  • Herbals that enhance the immune system may increase risk of organ rejection (ginseng, echinacea, astragalus, noni juice)
  • St. John’s wort may cause drug-drug interactions
  • Green tea, dong quai, ginseng, milk thistle, ginger have varying effects on in-vitro immune assays → avoid or use w/ extreme caution
33
Q

Why is hyperglycemia a common post-surgical
problem in the acute phase?

A
  • Prednisone → insulin resistance
  • Calcineurin inhibitors → impair insulin secretion
  • Increased risk with personal / family hx of DM, age, obesity
  • New-onset diabetes after transplant (NODAT) increases risk of graft loss, infection, CVD, reduced pt survival after transplant
34
Q

Why are GI issues common in the acute
post-transplant phase?

A
  • GI issues associated with use of immunosuppressive agents
  • GI complications may be secondary infection, mucosal injury, ulceration at any point in the GI tract (mouth to anus)
35
Q

What foods can cause drug-nutrient interactions
in the acute post-transplant pt?

A
  • Grapefruit and grapefruit juice impacts absorption of medications, including immunosuppressants (cyclosporine, tacrolimus), calcium channel
    blockers, and antilipideimcs
  • Mechanism: inhibits CYP3A4 in the gut wall
  • Pomegranates & Seville (sour) oranges may have similar drug interactions
36
Q

What is the goal for pt care during the chronic
post-transplantation phase?

A
  • Nutrition needs mostly stabilized at week 4-6 posttransplant
  • With functioning graft, diet similar as healthy populations, with monitoring of healthy wt, serum glucose & lipids, bone health
  • Nutrition management of long-term complications r/t long-term immunosuppressive tx, esp. those with higher risk for diabetes & CVD
37
Q

What is the general nutrition recommendations
for a pt in the chronic post-transplant phase?

A
  • Heart healthy, moderate sodium & fat
  • Kcal: 23-35 kcal/kg or 1.1-1.3 * BEE to achieve/maintain healthy wt
  • Protein: 0.8-1 g/kg
  • Per NKF Pocket Guide: 0.6-0.8 g/kg without DM or 0.8-0.9 g/kg with DM
38
Q

How do you manage steroid-induced
hyperglycemia in the chronic post-transplant pts?

A
  • Increased BG → higher risk for infection, decreased graft survival, increased mortality
  • Causes: calcineurin inhibitors & steroids (mainly), obesity, ethnicity, family hx
  • Oral hypoglycemic agents or insulin
  • May normalize as steroid doses are tapered down
39
Q

How prevalent is dyslipidemia in the chronic
post-transplant pts?

A
  • Occurrence in post-transplant pts as high as 60-79%, may cause CVD & increased mortality
  • Causes: immunosuppressive tx, obesity, age, gender, hx of diabetes, sedentary lifestyle
40
Q

How prevalent is hyperhomocysteinemia in the
chronic post-transplant pts and what is the
recommendation for it?

A
  • Hyperhomocysteinemia in post-transplant pts have been reported and may be a risk factor for CVD, although unclear evidence
  • KDOQI 2020 5.1.1 - In adults with CKD 3-5D or posttransplantation who have hyperhomocysteinemia associated with kidney disease, we recommend not to routinely supplement folate with or without B-complex since there is no evidence demonstrating reduction in
    adverse cardiovascular outcomes (1A).
41
Q

Would you recommend routine vitamin
supplementation for the chronic post-transplant pts?

A
  • Lack of evidence showing benefits, especially for long-term use; usually not needed with return to normal food intake
  • Iron supplement may be needed in some pts
  • Per NKF Pocket Guide: DRI daily MVI is reasonable (pg 11-43)

Renal Nutrition Mastery (5 decks)

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