Week 9 Chronic Renal Disease II: Renal Transplantation

Question 1

Nutrition goals for renal transplant

Answer 1

Preserve & maintain renal function which includes:
* Blood Pressure within target
* Blood Glucose levels within target
* Healthy weight

Minimize side effects of the immunosupressive therapy medications

Question 2

Post Transplant Nutritional Concerns

Answer 2

• Maintenance lean body mass (usually see loss so want to prevent this)
• Adequate hydration (need to keep kidney perfused and working well)
• Hypophosphatemia
• Hypomagnesemia (drugs/meds)
• Hyperkalemia
• Hypertension
• Diabetes
• Food Safety, Food/Drug Interactions (some foods cannot take with immunosuppressive drugs)

Question 3

Protein requirements post kidney transplant

Answer 3

Generally 1.3-1.4 g/kg/day of protein within the first 6-8 weeks post transplant
* can be up to 1.5 g/kg/d in the ICU
* 0.8g/kg/day acceptable onwards for protein

Question 4

Calorie requirements post kidney transplant

Answer 4

individual
* can range from 25-35kcal/kg/day

Question 5

Fluid requirements post kidney transplant

Answer 5

• In immediate post-operative period patients may still have a TFI (particularly in the ICU). Patients may still have ongoing edema that they experienced pre-treatment and hence fluid restrictions may be slowly lifted.
• By 2-3 months post-treatment; most patients will need 10- 12 cups (2.5-3L) required daily; often by this time no restriction if the new organ is completely working.
• Watch for edema and BP; monitor urine output

Question 6

How can kidney transplant effect the electrolytes?

Answer 6

Potential for:
* hypophosphataemia
* hypomagnesiumia
* hyperkalemia

Question 7

Issues of hypophosphatemia

Answer 7

Usually <0.7 mmol/L if severely low? (worried about hyper pre-transplant)
* Cardiac
* Hematologic
* Neuromuscular
* Pulmonary
* Skeletal

Question 8

Issues of hypomagnesiumia

Answer 8

Can tolerate low levels down to 0.6 mmol/L is else is stable, but less than 0.5 mmol/L is too low
* Cardiac
* Gastrointestinal
* Neuromuscular

Question 9

Roles of magnesium

Answer 9

Functions as a cofactor in manyintracellular reactions
* 20% of the Mg in plasma is protein bound (correct for low Alb)
* Regulated by gut, kidney and bone

Question 10

Repletion of phosphate and magnesium

Answer 10

• If serum phosphorous level low, consider supplement and/or encourage PO4-rich foods (dairy, etc.)
• If serum magnesium level low, consider supplement and/or encourage Mg rich foods (legumes, nuts, whole grains)

Question 11

What is an important caution of phosphate and magnesium supplements?

Answer 11

Caution: Both supplements can = diarrhea. Diarrhea will result in further depletion of both phosphorus and magnesium.

Question 12

What might result in hyperkalemia post kidney transplant?

Answer 12

If graft is working well, K+ levels usually normal, yet, Tacrolimus (potassium sparing diuretics) can cause hyperkalemia
* Monitor for other causes of hyperkalemia including hyperglycemia, metabolic acidosis & catabolism

Question 13

What needs to be considered with bone health post kidney transplant?

Answer 13

1500mg Calcium & 1000-2000 IU/D vitamin D daily via diet and/or supplementation should be suggested as long term steroid use increases the risk of developing osteoporosis:
* Direct inhibition of osteoblast function
* Direct enhancement of bone resorption
* Inhibition of gastrointestinal calcium & phos absorption
* Increases in urine calcium loss

Question 14

What needs to be considered with lipids post kidney treatment?

Answer 14

hyperlipidemia
* Immunosuppressive meds = elevations in LDL and TG levels
* 1st intervention - heart healthy diet!
* 2nd intervention = drug therapy with diet and lifestyle modification

Question 15

Hypertension recommendations for post kidney transplant

Answer 15

• NAS diet (2.0-2.3 gm sodium/d max) recommended
• Weight Management
• Caffeine >400 mL/d may affect BP

Question 16

How might post kidney transplant effect diabetes onset?

Answer 16

Latrogenic (steroid-induced) Diabetes:
* Tacrolimus & corticosteroids can increase BG by causing insulin resistance, upregulated TG resistance, glucose abnormalities
* Adequate intake of carbohydrate throughout the day emphasized
* Glucose levels hardest to manage during the first 4-6 weeks when medication doses are at their highest (greatest risk for rejection)

Question 17

What is the recommendation vitamin supplement for people posy kidney transplant?

Answer 17

Replavite daily:
* vitamin A can stay elevated years post transplant
* Research shows that the average Canadian does not meet the DRI for folic acid
* hyperhomocysteinemia is prevalent in people who have kidney disease and folic acid, vitamin B6 and vitamin B12 are involved with it’s metabolism
* Also for pre-transplant/ patients with kidney disease/ dialysis

Question 18

Use of herbal medications post kidney transplant

Answer 18

Caution people to avoiding herbal preparations:
* lack of research regarding interactions with immunosuppressant medications
* Herbal products are not regulated
* Some herbal products are thought to boost immune response (ie: ginsing)

Question 19

Grapefruit and grapefruit juice post kidney transplant

Answer 19

Should be avoided post transplant
* Grapefruit and Grapefruit juice inhibit P450 3A (CYP3 A) activity and therefore raise the levels of tacrolimus (prevents it from breaking down) in the blood. This can be harmful for the new organ.
* Potential Interaction also exhibited with Pomegranate, Starfruit, Bergamot Orange (oil found in Earl Grey Tea)

Question 20

What is the major complication for renal transplant recipients?

Answer 20

CVD and weight gain after transplantation can contribute to:
* high blood pressure
* high blood cholesterol
* the development of diabetes
* heart disease
* loss of function in your transplanted kidney

Question 21

How can the immunosuppressive drugs affect weight gain?

Answer 21

Drugs can increase appetite and so sometime eat more food post transplant

Question 22

Mr. JR case study

Answer 22

Notes

Question 23

Dialysis Case Study I

Answer 23

Notes

Question 24

Dialysis case study II

Answer 24

Notes

Question 25

What needs to be included in nutrition prescriptions?

Answer 25

• Energy
• Protein
• potassium
• phosphorous
• sodium
• fluid

Question 26

Nutrition education options

Answer 26

• Phosphorous and your kidney diet handout provided and reviewed
• Binder timing and compliance reviewed
• Healthy diet and lifestyle choices
• Reading labels for phosphorous additives

Question 27

Monitoring and Evaluation with kidney disease/ transplant

Answer 27

• anthropometrics (body weight)
• biochemical data (lytes)
• food and nutrition (recommendations)
• medications (adherence/ dosage)

Question 28

Developing nutrition diagnosis

Answer 28

• PES statement
• goals
• nutrition prescription
• nutrition intervention (nutrition education and food and nutrient delivery)
• monitoring and evaluation