Steps to Transplant

1. Steps to Transplant Terry Podolak, RD Upstate University Hospital

2. Objectives • Understand transplant process and the role of the RD- pre and post • Review nutrition evaluation and education • Identify nutrition concerns associated with immuno- suppressants

3. Benefits • Improved quality of life • Longer survival rates • Live donor advantages-greater graft and patient survival-shorter waiting-improved HLA matching • Less time on dialysis, more successful transplant

4. Renal Transplant • SUNY Upstate Hospital • Only hospital in CNY that provides kidney transplants • April is National Donate Life month

5. Renal Transplant • United Network for Organ Sharing (UNOS) • Online database created in 1999 • Keeps current records of people on the waiting list for every type of transplant • Currently ~117,330 people on the national waiting list for a kidney transplant

6. Organ Compatibility • Blood typing: ABO • Tissue typing • HLA Antigens (6) (Genetic markers specific to you) • Crossmatching • Identify presence of preformed antibodies in recipient • Also known as PRA (Panel Reactive Antibody)

7. Pre-Transplant Evaluations • Medicare requirement for patients to have a nutrition assessment • 4 hour multidisciplinary session • Nutrition assessment prior to visit

8. Team Members • Meetings with our Team Members : • Social Worker • Financial Coordinator • Dietitian • Transplant Surgeon • Transplant Coordinator • Transplant Nephrologist • Support services

9. (photo)

11. Pre-transplant goals • Maintain good nutritional status • Good calcium, phosphate, potassium, glucose control • Healthy weight

12. Interview Form • Healthy weight, weight changes, dry wt • Appetite • Digestion • Alcohol consumption • Exercise • Sleep

13. Interview Form cont’ • Diet history • Prior diet education • Vitamins/ supplements • Type of dialysis/ pre-dialysis • Who do you live with? • Who does the cooking/ shopping?

14. BMI? • Individual assessment • BMI goal= 34 • Waist circumference goals: • Females < 35’’ • Males <40’’

15. Medical Concerns • Obesity, Obesity, Obesity • Uncontrolled diabetes • Cardiovascular disease • Overall compliance with medications and dialysis attendance, labs

16. Healthy Weight for Transplant • Decreased complexity of surgery • Improved healing, decreased infection risk • Decreased ICU and LOS • Improved graft function • Decreased risk of developing diabetes post transplant • Better transplant survival rate

17. Educate- pre • Goal: preparation for surgery to optimize nutritional status • Compliance- listen to renal dietitian • Practice healthy lifestyle/ exercise • Sodium restriction

18. Exclusion Criteria • Severe cardiomyopathy with EF <30% • Severe pulmonary disease • Chronic active Hepatitis B infection • Advanced cirrhosis or hepatic fibrosis • Recent (<5 years) history of breast, colon, lung, pancreatic, malignant melanoma, thyroid, ovarian, or cervical cancer or lymphoma

19. Exclusion Criteria • GFR>20 • Severe peripheral vascular disease • Morbid obesity (BMI>40) • Active local or systemic infection • Unable to participate in own care (i.e. dementia, mental illness)

20. Social/ Financial Concerns • Insurance • Social • Mental health evaluation • Recreational drug use • Non-compliance/poor motivation • Lack of social support

21. Medical Clearance Laboratory and medical tests • Chest x-ray • EKG • Renal ultrasound • History and physical exam

22. Additional tests per team • Stress test • PFT • Mammogram, pap • Colonoscopy • Dental • Immunizations • Carotid and LE doppler • CT scan

23. Nutritional Implications of Immunosuppressants

24. Nutritional Implications of Immunosuppressants

25. Educate – post • Low sodium • Phosphorus, potassium, magnesium • Food safety • No herbals, no grapefruit • >2 liters water daily • Healthy eating/lifestyle

26. Weight Management- pre and post • Mindfulness (www.tcme.org) • Exercise • BMI chart • Stress reduction • Sleep • Improved digestive health • Sample menus (Kidneyschool.org)

27. Probiotic- Florajen3 • Pre- constipation or diarrhea • Bacteriologists- Chairman of U W • 20 billion live cultures ( at least 10 billion CFUs) • Lactobacillus acidophilus, bifidobacterium lactis and longum • ~3# microflora in gut • Bifidobacteria-produce short chain fatty acids-beneficial

28. “Probiotics Reduce Immunosuppression-Related Diarrhea in Kidney Transplant Patients” • Am Society of Transplant surgeons in 2010 • CellCept side effect- immunosuppression-associated diarrhea • Randomized controlled trial • Multi-strain probiotic vs placebo • 10/16 placebo had IAD • 3/19- probiotic had IAD, less severe

29. Team Meeting • Friday conference • Letter • To advise of listing and what further testing or health goals are needed – wt, psych clearance • Unable to list due to unsafe surgical candidate

30. Waiting List • Locally is ~ 4 years • Status- Active or Inactive • Active- Ready to Go • Inactive- accruing time, but not ready-(hospitalizations or sickness) • Annual re-evaluation visits

31. Weight Management (Inactive) Contact every three months • Status 7 - • If requirements not met in 1 year- taken off list

32. Types of Donors • Living ( usually blood relative) • Deceased donor without kidney injury

33. Live Donor Candidates • Anyone who is ABO compatible can donate • Must be consenting adult (18+ years) • Healthy- BMI <30 • Free from medical conditions that would make it risky to donate • Must have health insurance • The most common conditions that prevent kidney donation are high blood pressure, diabetes, and heart disease • No details of testing or evaluation are released to the recipient

34. Extended Criteria Donors • 50 years of age or older with 2 of 3 criteria: • History of HTN • Cause of death due to CVA • Serum creatinine >1.5 • The donor is from an older age group (>65)

35. Deceased Donor • Brain death • Cardiac death within 1 hour of discontinued life support • High risk- prison or IV drug abuse

37. Blue Book • Medication List • Times and Amounts • Daily Record • Weight, Intake/Output, Vital Signs • Instructional Guide • High Phos, High Mg food sources

38. Acute needs ( Up to 1 month –post) • Surgical stress and high dose immuno-suppression • Hypophosphatemia – working kidney • Hypomagnesia- urinary losses • Hyperkalemia- poor graft function or prograf • Liberal fluid • Inadequate intake- pain, GI • Glucose intolerance

39. Acute Needs

40. Post Follow-up • Twice/week visits – 1st month • Once/week-2nd month • Every 2 weeks- 3rd month • Monthly up to ~6 months

41. Recommendations-post • Encourage water as a beverage • Healthy phosphorus and magnesium sources • No concentrated sweets • Sugar: The Bitter Truth by Dr. Lustig • Low sodium • Food safety • “shifting gears”

42. RD post involvement • Newly-diagnosed with diabetes • Weight gain/loss • Management of complications with meds • Consulted for any nutrition related issues

44. References • Mahony LR. Kidney presentation. University of California, San Diego Medical Center. • Marroquin CE. Giving While Living presentation. University of Rochester. • McCann L. Pocket guide to nutrition assessment of the patient with chronic kidney disease. 4th edition. National Kidney Foundation. • United Network Organ Sharing. http://www.unos.org/ • Danovitch G. Handbook of Kidney Transplantation Fifth edition