Nutrition assessment and support of organ transplant recipients

Timely nutrition assessment and intervention in organ transplant recipients may improve outcomes surrounding transplantation. A pretransplant nutrition assessment should include a variety of parameters including physical assessment, history, anthropometric measurements, and laboratory tests. Malnutrition compromises posttransplant survival; prolonged waiting times worsen outcomes when patients are already malnourished. Severe obesity may decrease graft function and survival in kidney transplant recipients. In the pretransplant phase, nutritional goals include optimization of nutritional status and treatment of nutrition-related symptoms induced by organ failure. Enteral tube feeding is indicated for patients with functional gastrointestinal tracts who are not eating adequately. Parenteral nutrition is rarely needed pretransplant except in cases of intestinal failure. When determining pretransplant nutrient requirements, nutritional status, weight, age, gender, metabolic state, stage and type of organ failure, malabsorption, induced losses, goals, and comorbid conditions must be considered. During the acute posttransplant phase, adequate nutrition is required to help prevent infection, promote wound healing, support metabolic demands, replenish lost stores, and perhaps mediate the immune response. Nutrient recommendations reflect posttransplant metabolic changes. The appropriateness of posttransplant nutrition support depends on the prevalence of malnutrition among patients with a specific type of organ failure and the benefits when nutrition support is given. Organ transplantation complications including rejection, infection, wound healing, renal insufficiency, hyperglycemia, and surgical complications require specific nutritional requirements and therapies. Many potential applications of nutrition in the pre- and posttransplant phases exist and require further study.     

Nutrition management of small bowel transplant patients.

Nutrition therapy after small bowel or combined liver/small bowel transplantation is challenging. The objective is to restore enteral autonomy to a patient with a complex past surgical history and equally complex posttransplant immunosuppressive regimen in the context of a newly created surgical anatomy. Improved surgical techniques and immunosuppressive regimens have led to superior outcomes. Accompanying these advances is a range of nutrition issues that require specific management strategies. This review outlines the current clinical practice and decision making used to create individualized nutrition regimens for small bowel or combined liver/small bowel transplant recipients. Successful small bowel transplant outcomes require a coordinated effort from a transplant team to restore nutritional autonomy to transplant recipients and free them from parenteral nutrition.     

Nutrition, pregnancy, and transplantation.

One benefit of transplantation, along with the restoration of health, is the opportunity for successful pregnancies. A growing number of pregnancies have been reported among all types of solid-organ recipients. There is an increasing need for practice guidelines that include nutrition information in order to assist practitioners caring for and counseling these high-risk patients. In the transplant community, guidelines for managing pregnancies in transplant recipients have been evolving but lack specific nutrition recommendations. As for all pregnancies, there is a need to optimize nutrition for the mother and her infant, with additional consideration given to the transplant recipient's graft. This article reviews outcomes of posttransplant pregnancies and management guidelines, with special emphasis on nutrition in this unique population.     

Examining the role of tube feeding after liver transplantation.

The rates of morbidity and mortality after liver transplantation are related to the degree of malnutrition. Because malnutrition is prevalent among liver transplant recipients, nutrition care practitioners must be aggressive in providing nutrition support to these patients in the perioperative period. Postoperative tube feeding (TF) has been studied for its role in improving short-term posttransplant outcomes. This paper evaluates published research that studied postoperative TF in liver transplant recipients; the methodology and outcomes are reviewed and drawbacks of these studies are considered. Case studies of liver transplant patients who received postoperative TF illustrate the variability of patient profiles and posttransplant complications that influence the provision and duration of posttransplant TF.     

Intestinal and multivisceral transplantation: dynamics of nutritional management and functional autonomy

OBJECTIVE: The objective of this study was to describe the dynamics of nutrition management of intestinal transplant recipients and allograft functional autonomy. METHODS: Intestinal absorptive functions and recipient nutritional status were monitored during the 12-month study period. Absorption was evaluated with D-xylose absorption and fecal fat excretion. Indices for nutrition were body weight, anthropometric measures, and serum albumin. RESULTS: Before transplant, all patients were total parenteral nutrition (TPN) dependent and well nourished. By the first postoperative month, all 22 recipients were tolerating enteral feeding. By 3 months, all recipients had begun oral feeding, with 13 off TPN and 7 off enteral feeds. By 6 months, 16 recipients were off TPN, and by the end of the 12th month, 17 (77%) were free of TPN. Although all 22 recipients were completely weaned off TPN during the first posttransplant year, 10 required temporary reinstitution of therapy at different points. Full nutritional autonomy was achieved at 3 months by 3 recipients, at 6 months by 8 recipients, and at 12 months by 12 (55%) recipients. CONCLUSIONS: These results reflect our early experience that led to surgical refinement of the operation and evolution of the recipient postoperative management. Nonetheless, even in this initial cohort, most of the engrafted intestines restored the recipient nutritional autonomy, and all survivors remained well nourished.     

Review of incidence and management of chylous ascites after small bowel transplantation.

Nutrition management of intestinal transplant recipients continues to be a challenging and essential component of the early postoperative care of this patient population. The absorptive capacity of the graft can be affected by immunologic and nonimmunologic factors, including enteric lymphatic disruption, preservation injury, central denervation, viral enteritis, systemic infections, and rejection. Chylous ascites, the extravasation of milky chyle into the peritoneal fluid, defined by elevated triglycerides levels of > or = 200 mg/dL, can occur as a result of trauma, obstruction, or interruption of the lymphatic system. It seems the incidence of chylous ascites after small bowel transplantation is low; however, this may be due in part to the limitation of enteral long-chain triglycerides in the early posttransplant period of 2-6 weeks. After this time frame, clinical evidence suggests that fat assimilation normalizes. In the event that chylous ascites develop as a posttransplant complication, limitation of oral or enteral nutrition support to a very-low-fat regimen may be required, or parenteral nutrition (PN) will need to be provided until clinical status improves. Long-term posttransplant, lymphatic regeneration generally occurs and the majority of intestinal transplant recipients achieve the ultimate goal of nutrition autonomy.     

Weight gain and cardiovascular risk after organ transplantation

Organ transplantation has become a common and effective approach to the management of patients with organ failure. The improvement in long-term survival has resulted in the emergence of cardiovascular disease as the primary cause of death in renal transplant patients and a significant complication in other organ recipients. A number of factors explain this trend, including a high incidence of hypertension, posttransplant diabetes, hyperlipidemia, and obesity-risk factors that are mediated by direct effects of immunosuppressive medications. Weight gain posttransplant affects approximately 50% of patients and represents a significant problem because of the potential synergism between obesity and immunosuppressive medication-induced effects on cardiovascular disease risk factor development. This review discusses the incidence and implications of cardiovascular disease risk factors in organ transplant recipients, strategies for clinical management, and future research directions.     

Prevalence of nutrition-related problems among long-term survivors of allogeneic marrow transplantation

The nutritional status and prevalence of nutrition-related problems in 192 adult and child allogeneic marrow transplant recipients were evaluated 1 year after transplant in a retrospective chart review. Among these patients, 63% exhibited evidence of chronic graft-versus-host disease (GVHD) at the time of nutrition evaluation, including 44% with extensive disease who were receiving immunosuppressive therapy. Oral sensitivity was observed in 23% of all patients reviewed, and frank stomatitis occurred in 8%. The frequency of xerostomia was 18%; anorexia, 8%; reflux symptoms, 7%; diarrhea, 7%; steatorrhea, 5%; dysgeusia, 3%; and limited exercise tolerance because of dyspnea or joint contractures, 4%. Weight loss 3 to 12 months after transplant was experienced by 28%. Nutrition-related problems, changes in anthropometric indexes indicative of suboptimal nutritional status, and inadequate energy intake were observed more frequently in patients with extensive chronic GVHD than in patients without GVHD or in those with limited GVHD. Our findings indicate a high prevalence of nutrition problems among recipients of allogeneic marrow transplantation 1 year after transplant and, further, suggest the need for ongoing, community-based nutrition monitoring after discharge from a transplant center.     

Nutritional complications and management of intestinal transplant

Advances in intestinal transplantation provide a promising alternative to patients with intestinal failure and chronic dependence on total parenteral nutrition. However, many physiologic complications arising from the surgical procedure and high-dose immunosuppression, along with potential for rejection and infection, make successful graft function after transplantation a challenge. Nutrition issues unique to this patient population include recovery of normal intestinal motility and absorptive capacity. Diarrhea and high stomal output, which are common postoperatively, lead to deficits in macronutrients and Micronutrients, especially electrolytes. Impaired gastrointestinal function affects ability to wean patients off hyper alimentation and enable them to tolerate nutrients enterally. In pediatric recipients of intestinal transplant, lack of experience with food or prior food aversions can lead to refusal to eat after transplant— additional challenges to achieving oral intake. Early and aggressive nutrition intervention is necessary for resolution of nutritional deficits and health of donor small bowel. This article presents an overview of the surgical procedure of intestinal transplantation and describes the physiologic adaptations that occur after the process. A case study demonstrates the clinical and nutritional hurdles associated with an intestinal transplant in a child and how dietitians can provide nutrition management. The potential role of individual nutrients in recovery of the transplanted bowel is also discussed. J Am Diet Assoc. 2000;100:680-684, 687-689.     

肺移植病人的围手术期营养支持

目的:探讨营养支持对肺移植病人的作用.方法:对病人进行围手术期的肠内营养和代谢调理.结果:病人术前经营养支持营养状况即有改善,各项营养指标基本正常,术后短期内达到正氮平衡,恢复顺利,肺功能明显改善,无并发症发生.结论:合理的围手术期营养支持和代谢调理能够有效改善病人的营养状态,提高其对手术的耐受性,促进伤口愈合,减少严重并发症的发生.     

Role of nutrition in liver transplantation for end-stage chronic liver disease

Patients with end-stage liver disease often reveal significant protein-energy malnutrition, which may deteriorate after listing for transplantation. Since malnutrition affects post-transplant survival, precise assessment must be an integral part of pre- and post-surgical management. While there is wide agreement that aggressive treatment of nutritional deficiencies is required, strong scientific evidence supporting nutritional therapy is sparse. In practice, oral nutritional supplements are preferred over parenteral nutrition, but enteral tube feeding may be necessary to maintain adequate calorie intake. Protein restriction should be avoided and administration of branched-chain amino acids may help yield a sufficient protein supply. Specific problems such as micronutrient deficiency, fluid balance, cholestasis, encephalopathy, and comorbid conditions need attention in order to optimize patient outcome.     

Nutritional and metabolic support in patients undergoing bone marrow transplantation

Bone marrow transplantation (BMT) is a sophisticated procedure consisting of the administration of high-dose chemoradiotherapy followed by intravenous infusion of hemopoietic stem cells to reestablish marrow function when bone marrow is damaged or defective. BMT is used in the treatment of solid tumors, hematologic diseases, and autoimmune disorders. Artificial nutrition, total parenteral nutrition in particular, is provided to patients undergoing BMT to minimize the nutritional consequences of both the conditioning regimens (eg, mucositis of the gastrointestinal tract) and complications resulting from the procedure (eg, graft versus host disease and venoocclusive disease of the liver). Although artificial nutrition is now recognized as the standard of care for BMT patients, defined guidelines for the use of artificial nutrition in this clinical setting are lacking. During the past 2 decades, artificial nutrition in BMT patients has moved from simple supportive care to adjunctive therapy because of the possible benefits, not strictly nutritional, of specialized nutritional intervention. Although data exist documenting the beneficial role of special nutrients, such as lipids and glutamine, in the management of BMT recipients, the results obtained to date are controversial. The reasons for this controversy may reside in the heterogeneity of the patients studied and of the study designs. This review focuses on the need to correctly identify the different patterns of BMT to achieve reproducible and reliable data, which may in turn be used to devise precise guidelines for the use of specialized artificial nutrition in BMT patients.     

Therapeutic efficacy of intestinal and multivisceral transplantation: survival and nutrition outcome.

The clinical introduction of intestinal transplantation has added a new dimension and offered a valid therapeutic option for patients with irreversible intestinal failure. In the year 2000, the Center for Medicare & Medicaid Services (CMS) recognized intestinal, combined liver-intestinal, and multivisceral transplantation as the standard of care for patients with irreversible intestinal and parenteral nutrition (PN) failure. Accordingly, the indications for the procedure are currently limited to those who develop life-threatening PN complications. However, a recent improvement in survival similar to other solid organ transplant recipients should justify lifting the current restricted criteria, and the procedure should be considered before the development of PN failure. Equally important is the awareness of the recent evolution in nutrition management and outcome after transplantation. Early and progressive enteral feeding using a complex polymeric formula is safe and effective after successful transplantation. Full nutrition autonomy is universally achievable among most intestinal and multivisceral recipients, with enjoyment of unrestricted oral diet. Such a therapeutic benefit is commonly maintained among long-term survivors, with full rehabilitation and restoration of quality of life.     

肝移植围手术期的营养支持管理

目的:总结肝移植围手术期病人的营养支持管理,提高器官移植的成功率,减少术后并发症,促进康复. 方法:对71例肝移植病人围手术期的营养治疗方法和营养状况进行回顾性分析.术前给予适当热量、蛋白质和高维生素的肠内营养,同时加用支链氨基酸(BCAA)和谷氨酰胺(Gln),使病人尽快改善全身营养状况.术后给予静脉营养,同时尽早实施肠内营养,直至全肠内营养. 结果:除5例病人死于呼吸衰竭、2例死于出血性休克外,其余64例病人肝功能逐渐恢复,营养指标明显改善,移植肝功能良好. 结论:肝移植围手术期病人的营养管理十分必要,合理的营养支持有利于移植器官功能的早期恢复和受者营养状态的改善.     

Posttransplant diabetes mellitus: cause, impact, and treatment options.

The incidence of diabetes mellitus (DM) is increased in adult organ transplant recipients. As many as 30% to 45% of solid organ adult transplant patients have DM before transplantation or develop posttransplant diabetes mellitus (PTDM). Risk factors for PTDM include family history, ethnic or genetic background, insulin resistance, and diabetogenic effects of immunosuppressive medications. Posttransplant hyperglycemia may result in increased platelet aggregation, increased wound infections, dehydration, and loss of lean body mass. More significantly, long-term complications of DM such as coronary artery disease and peripheral vascular disease may be exacerbated with the use of immunosuppressive medications whose known side effects include hyperglycemia, hyperlipidemia, and hypertension; these effects may lead to premature transplant graft dysfunction. Treatment goals for PTDM reflect those of the American Diabetes Association guidelines; long-term management is linked with early, patient-centered education and optimizing minimally diabetogenic immunosuppressive medication regimens. A multidisciplinary team including the patient, family/support people, transplant surgeon, transplant physician, transplant nurse coordinator, transplant social worker, pharmacist, dietitian, and diabetes educator is crucial to long-term management of PTDM.     

Nutritional implications of liver transplantation

Malnutrition is a common problem of patients undergoing liver transplantation. To treat malnutrition, it must first be identified through a nutritional assessment. Because many objective nutritional assessment parameters have limitations in end-stage liver disease, subjective nutritional indicators may be used as an alternative. Nutritional needs following transplantation are categorized as short and long term. The short-term nutritional goal, anabolism, can be complicated by the nutritional status of the patient, surgical procedures, and necessary medications. The increased nutrient needs during the early posttransplant phase require particular nutritional support. Nutrition-related problems following transplantation may include obesity, hyperlipidemia, hypertension, diabetes mellitus, hyperkalemia, edema, or osteoporosis. Dietetic advice relative to the nutritional needs of the liver transplant recipient can improve both the short- and long-term outcomes.     

Nutritional aspects of liver transplantation

Most adult and pediatric liver transplantation candidates present several metabolic disturbances that lead to malnutrition. Because malnutrition may adversely affect morbidity and mortality of orthotopic liver transplantation, it is very important to carefully assess the nutritional status of the waiting list patients. Pretransplant nutritional therapy -- enteral or parenteral -- may positively influence liver metabolism, muscle function, and immune status. Nutrition therapy should continue in the short- and also in the long-term post-transplant periods. For malnourished patients, early post-transplant enteral or parenteral nutrition have been useful in improving nutritional status. Finally, the metabolic and nutritional care of the liver transplant donor must be considered to reduce allograft dysfunction indices.     

A practical approach to tuberculosis diagnosis and treatment in liver transplant recipients in a low-prevalence area

Solid organ transplant candidates/recipients are at risk of mycobacterial infections. Although guidelines on the management of latent tuberculosis infection and active tuberculosis are available for solid organ transplant recipients, limited guidance focuses on end-stage liver disease or liver transplant recipients who require management in a referral center. Therapeutic challenges arise from direct antituberculosis drug-related hepatotoxicity, and substantial metabolic interactions between immunosuppressive and antituberculosis drugs. Another issue is the optimal timing of therapy with regards to the time of transplantation. This review focuses on the importance of tuberculosis screening with immunological tests, challenges in the diagnosis, management, and treatment of latent tuberculosis infection and active tuberculosis, as well as risk assessment for active tuberculosis in the critical peri-liver transplantation period. We detail therapeutic adjustments required for the management of antituberculosis drugs in latent tuberculosis infection and active tuberculosis, particularly when concomitantly using rifampicin and immunosuppressive drugs.     

Reliable bioelectrical impedance analysis estimate of fat-free mass in liver, lung, and heart transplant patients

BACKGROUND: Bioelectrical impedance analysis (BIA) can be valuable in evaluating the fat-free (FFM) and fat masses (FM) in patients, provided that the BIA equation is valid in the subjects studied. The purpose of the clinical evaluation was to evaluate the applicability of a single BIA equation to predict FFM in pre- and posttransplant patients and to compare FFM and FM in transplant patients with healthy controls. METHODS: Pre- and posttransplant liver, lung, and heart patients (159 men, 86 women) were measured by two methods-50-kHz BIA-derived FFM (FFM(BIA)) by Xitron instrument and DXA-derived FFM (FFM(DXA)) by Hologic QDR-4500 instrument-and compared with healthy controls (196 men, 129 women), aged 20 to 79 years. RESULTS: The high correlation coefficient (r = .974), small bias (0.3 +/- 2.3 kg), and small SEE (2.3 kg) suggest that BIA using the GENEVA equation is able to predict FFM in pre- and posttransplant patients. The study shows that the lower weight seen in transplant men and women than in controls was due to lower FFM, which was partially offset by higher FM in men but not in women. Furthermore, the higher weights in posttransplant than in pretransplant patients were due to higher FM and % FM that was confirmed by lower FFM/FM ratio in posttransplant patients. CONCLUSIONS: Single 50-kHz frequency BIA permits measurement of FFM in pre- and posttransplant patients.