+ MNT Case Study:

Accelerated (Acute)

Renal Failure,

Secondary to Renal

Transplant Rejection

Rachael G. Joseph

Oakwood University Dietetic Intern 2015-2016

5/5/2016

+

Objectives

To understand:

The pathophysiology of acute

renal failure

The causes of transplant

rejection

The appropriate nutrition

interventions for renal transplant

patients

+Organ System & Function

The urinary system is comprised of the kidneys, ureters, bladder, and the urethra. The function of the kidneys it to filter wastes and fluids from the bloodstream, and also:

keep levels of electrolytes, such as potassium and phosphate, stable

help regulate blood pressure (renin)

make red blood cells (erythropoietin)

keep bones strong

urine from the kidneys and store it until releasing it from the body.

+Disease Pathophysiology &

Progression

What is renal failure?

Renal failure refers to temporary or permanent damage to the

kidneys that results in loss of normal kidney function.

Acute Renal Failure

Causes/Etiology: Usually occurs in people with diabetes,

existing kidney disease, liver disease conditions that cause

decreased blood flow to the kidneys, direct damage to the

kidneys, or blocked ureters

+Disease Pathophysiology &

Progression Cont’d

Symptoms:

Decreased urine output (although occasionally urine output remains

normal)

Edema

Shortness of breath

Fatigue

Confusion

Nausea

Seizures or coma in severe cases

Chest pain or pressure

+Treatments: Treating the

underlying causes of AKF

If caused by a lack of fluids in

blood, IV fluids may be

recommended by MD

In other cases, AKF may

cause edema. Diuretics may

be recommended to remove

excess fluid

Temporary hemodialysis to

remove the toxins and excess

fluids.

+Alport Syndrome & Chronic

Kidney Disease

Alport syndrome is a genetic condition characterized by kidney

disease, hearing loss, and eye abnormalities. It affects

approximately 1 in 50,000 newborns.

Almost all affected individuals have hematuria. Many people

with Alport syndrome also develop proteinuria. As this condition

progresses, the kidneys become less able to function thus

resulting in end-stage renal disease (ESRD).

Significant hearing loss, eye abnormalities, and progressive

kidney disease are more common in males with Alport

syndrome than in affected females.

+Alport Syndrome & Chronic

Kidney Disease Cont’d

Mutations in genes result in abnormalities of the type IV

collagen in glomeruli, which prevents the kidneys from properly

filtering the blood and allows blood and protein to pass into the

urine.

Gradual scarring of the kidneys occurs, eventually leading to

kidney failure in many people with Alport syndrome.

Type IV collagen is also an important component of inner ear

structures, such as the area that transforms sound waves into

nerve impulses for the brain. Mutations that disrupt type IV

collagen can result in misshapen lenses and an abnormally

colored retina.

+Alport Syndrome & Chronic

Kidney Disease Cont’d

+Nutrition Therapy for Kidney

Transplant Patients

Diet is less restricting than when on HD

Medications will affect the way the body works

Cyclosporine- Vitamin E (reduces the required amount of drug needed, Grapefruit and pomegranate increase level of drug in blood)

Prednisolone make it harder for the body to use extra carbohydrates which lead to high BG levels

Limiting salt after surgery is usually standard, especially in use with steroids that cause water retention. Water retention can cause, high BP and sodium can amplify the problem.

Protein needs increase immediately after surgery, but can return to normal after healing

Potassium intake can return to normal so long as the transplant is working well

+Kidney Transplant Procedure

Deceased (cadaveric)- Organ comes from someone that has just

died

Living Related Donor

Living Unrelated Donor

+Transplant Surgery

The surgery is performed under general anesthesia and usually takes 2-4 hours

A kidney transplant is considered a heterotrophic

The surgeon will make a small incision on the lower abdomen, just above the groin

The new kidney is placed in the front part of the lower abdomen, in the pelvis

The surgeon connects the pre-existing artery that carries blood to the kidney, and the pre-existing vein that carries blood away from the kidney

The ureter is then connected to the bladder

+Causes of Transplant Rejection

Up to 30% of people will experience a form of kidney

transplant rejection.

Most rejections happen within six months after

transplantation, but it can still happen years down the

road.

In most cases, if treated quickly the rejection can be

reversed.

Caused by: clots, fluid collection, infection, side effect of

medication, problems with the donor kidney, Non-

compliance, recurrent disease, acute/chronic rejection.

+Medications Used to Suppress

Kidney Rejection

Immunosuppressive agents are used to protect the kidney from being recognized as a foreign object in the body Prednisone (glucocorticoid): Anti-inflammatory drug

administered via IV or orally. Immunosuppressive drug used to prevent organ rejection.

Anti-proliferative drugs: Azathioprine, Mycophenolatemofetil, Mycophenolate sodium, Sirolimus

Cytokine Inhibitors: Cyclosporine, Tacrolimus. Lowers T-cell activity

Antilymphocyte Medications

+

Patient Profile

Admit Date: 2/15/2016

31 y/o, Caucasian male with a past medical history for Alportsyndrome

Admit Dx: Accelerated Renal Failure with Renal Transplant Rejection. Also w/inflammation and edema.

Presented to the ER for elevated creatinine

Past Hx of ESRD, secondary to Alport syndrome

Dialyzed from 2008-2009

Past surgeries include: Peritoneal catheter placement, Perm-A-Cath placement and removal, and Kidney Transplant

+

Patient Profile Cont’d

Current Rx regimen:

Amplodipine- High BP

Ferrous Sufate- Anemia

Lansoprazole- decreases stomach acid

Losartan- vasodilating effects

Mycophenolic acid- immunosuppressant

Prednisone- immunosuppressant

Sodium bicarbonate- slow the rate of progression of

CKD/acid-base balance

Tacrolimus- immunosuppressant

+

Medical History Pt. missed his office visit with nephrologist in fall of 2015

Patient telephone MD in mid December from San Francisco stating he had swollen legs and elevated BP

Patient came to ER on 1/8/2016 with elevated creatinine, potassium, and lowered bicarbonate

Pt. already showed signs of antibody mediated rejection

Received a pulse dose of steroids and immunosuppression was continued.

Required dialysis for a short period in January 2016

Pt. was able to recover his renal function and was discharged home

+

Medical Data

Admit Weight: 83.2 kg

Current Weight: 83.2 kg

Height: 182.9 cm

BMI: 24.9

Nutrition Related Labs Upon Admission (2/15/2016):

BUN -65/Creatinine -3.8

Phosphorous N/A

CO2 -12

+Nutrition Assessment (ADIME)

Initial assessment, Screening: Performed on

2/18/2016

Appetite: Good-75%

Food Preference: Likes food, but hydralazine causes

decreased appetite, describes hazy feeling

Nutrition Medication Review: amlodipine, ferrous sulfate,

furosemide, heparin, hydralazine, metoprolol, protonix,

tacrolimus, prednisone

Dx- accelerated renal transplant rejection, acute-on-chronic

renal failure

Hx- kidney transplant

+

Assessment Cont’d

Current Diet Order: Renal Diet

PO intake: 75% (per RN)

Current Nutrition Risk Level: Moderate

Nutrition Status: Appetite Good

Skin Intact, Braden 22, No wounds to review

Nutrition Related Labs

BUN - 56/Creatinine - 3.0

Phosphorous - 4.6

CO2 - 18

+Assessment Cont’d & Nutrition

Diagnosis

Estimated Nutrition Needs

Protein: 58-75 g/day (0.7-0.9 g/kg)

Energy: 1830-2163 kcal/day (22-26 kcal/kg)

Fluid: 1664-2084 mL/day (20-25 mL/kg)

Pt. PO intake meets 78/96% of estimated low-end

kcal/protein needs. Fluid per MD due to renal

transplant rejection.

Nutrition Diagnosis #1

P: Impaired nutrient utilization NC-2.1

E: Related to altered nutrient metabolism

S: As evidenced by abnormal BUN/Creatinine

+Intervention &

Monitoring/Evaluation

Nutrition Goals

#1 Meet 75% of estimated needs/all sources

#2 Tolerate oral diet by discharge

#3 Be weighed within 7 days

#4 Maintain skin integrity during hospitalization

Nutrition Plan/Recommendations: Check lab results

Monitoring: Oral intake, Calorie and protein needs, Labs results and Weight

*Pt. expressed a prior knowledge of Renal Diet education

+Summary of Treatment &

Progress

RD followed up once.

Pt. was experiencing transplant rejection resulting from non-

compliance with medications

MD noted no acute indication for dialysis at the time, but

informed Pt. if no evidence of recovery he may need PD vs. HD

+Follow Up Assessment: 2/19/2016

Pt. seen at bedside. He is very knowledgeable about the renal diet and how to control his blood glucose. He mostly tries to follow a ketogenic diet, appetite varies based on meds, specifically hydralazine. Continued with renal diet with 100% PO intake recorded.

Labs: K+ 3.4, Cl 113, BUN 55, Creatinine 3, Albumin 2.4

Meds: furosemide, mycophenolic acid, protonix, prednisone, tacrolimus

Skin: Braden 21, Nutr 3

GI: I/O +4334 mL, Last BM on 2/17

Admit Wt: 84.1 kg, Current Wt: 83.2 kg

Wt. change likely due to fluids

Estimated needs: 1700-2100 kcal/day 59-76 gm pro/day

Currently meeting needs

+Follow Up Assessment: 2/19/2016

Cont’d

Nutri Dx: Altered nutrient utilization, related to altered nutrition

related labs, altered protein metabolism as evidenced by

abnormal BUN/Creatinine

Recommendation:

1. Continue Renal Diet

2. Monitor weight, labs, PO intake, I&O

Goals:

1. Nutrition meets more than 75% of needs

2. Maintain and preserve lean body mass

+Outcomes and Post Discharge

Analysis

The nephrologist saw the patient while in the hospital. Creatinine level has improved significantly(3.8 to 2.9),

however BP remained high. The MD adjusted the Pt.’s medication, and is no longer on prednisone, Lansoprazole, and losartan.

The Pt. is staying on the same medications upon admission with furosemide, hydralazine, metoprolol added.

Pt. was discharged and was to follow up with nephrologist within 3-5 days.

* It is not known if the patient met with the nephrologist after *discharge, if they recovered enough renal function to avoid HD or

PD, or if they were compliant with their medications

+

Role of the RD

Nutrition Education to prolong

kidney function

Introduce and explain

functions of kidney friendly

foods to Pt.’s diets

Advising Pt.’s on the

nutritional needs at the

different stages of CKD,

ESRD, as well as life after

the transplant takes place

+

Sources/References

https://www.kidney.org/kidneydisease/howkidneyswrk

http://www.yourhormones.info/glands/kidneys.aspx

http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_system_disorders/end_stage_renal_disease_esrd_85,P01474/

http://www.niddk.nih.gov/health-information/health-topics/Anatomy/urinary-tract-how-it-works/Pages/anatomy.aspx

http://alportsyndrome.org/alport-syndrome/alport-syndrome-treatment/

http://www.kidneylink.org/TypesofDonors.aspx

http://transplant.surgery.ucsf.edu/conditions--procedures/kidney-transplantation.aspx

+

Sources/References Cont’d

https://www.kidney.org/transplantation/transaction/TC/summer09/TCsm09_TransplantFails

http://transplant.surgery.ucsf.edu/conditions--procedures/kidney-transplantation.aspx

www.drugs.com

http://www.ncbi.nlm.nih.gov/pubmed/14510627

https://www.aakp.org/education/resourcelibrary/ckd-resources/item/slowing.html

https://www.ghc.org/kbase/topic.jhtml?docId=hn-1129000

https://www.kidney.org/atoz/content/nutritrans

http://www.emedicinehealth.com/acute_kidney_failure/page9_em.htm#acute_kidney_failure_prognosis