CASE STUDY FORMAT (Kidney Transplantation)

 PATIENTS PROFILE
NAME: Mr. XYZ
AGE: 38 years SEX: Male
COMMUNITY: Hindu
OCCUPATION:
ECONOMIC STATUS:
 ANTROPOMETRIC MEASUREMENTS

HEIGHT: 172 cm WEIGHT: 96.5 kg

BMI: 32.6 kg/m² IBW: 72 kg

 ADMISSION DETAILS

DATE OF ADMISSION: 11/4/18

ADMITTED UNDER: Dr. B.V. Gandhi

PRESENT COMPLAINTS: Patient got admitted with the c/o facial and leg swelling.

PAST MEDICAL HISTORY: Hypertension since 2 years

Hypothyroidism

FINAL DIAGNOSIS: Kidney Transplantation

 BIOCHEMICAL PARAMETERS

PARAMETERS 11/4/18 13/4/18 14/4/18 15/4/18 16/4/18 17/4/18 UNITS NORMAL

RANGE
Serum creatinine 8.74 4.65 3.93 2.63 2.14 1.81 mg/dl 0.5-1.5
SGOT 14 - - - - - U/L 15-46
SGPT 17 - - - - - U/L 13-69
Bilirubin total 033 - - - - - mg/dl 02-1.3
Sodium - 132 133 133 139 135 mmol/L 137-145
Potassium - 4.4 4.5 4.9 4.5 4.5 mmol/L 3.5-5.1
BUN - - 26.4 22.7 - 28.1 mg/dl 7-17
Total protein 7.25 - - - - - gm/dl 6.3-8.2
Albumin 4.06 - - - - - g/dl 3.5-5
Globulin 3.19 - - - - - g/dl 2.4-3.5
HGT (Hemo Glucose Test)
DATE TIME VALUE UNITS
16/4/18 12 pm 153 mg/dl
7 pm 204 mg/dl
17/4/18 12 pm 222 mg/dl
7 pm 143 mg/dl

 MEDICATION PRESCRIBED BY HOSPITAL

MEDICATION DOSAGE ACTION

Tab. Ceftum 500mg 1-0-1 Anti-bacterial
Tab. Tacsant 1mg 3-0-2 Immunosuppressant
Tab. Wysolone 30mg 1-0-0 Corticosteroid
Tab. Cellcept 500mg 1-1-1 Immunosuppressant
Tab. Septran 0-0-1 Anti-bacterial
Tab. Valgan 450mg 0-1-0 Anti-viral
Tab. Zintac 150mg 1-0-1 Antacid
Tab. Plavix 75mg 0-1-0 Anti-platelet
Tab. Lasix 40mg ½-0-0 Fluid retention

 PATHOPHYSIOLOGY
ESRD (End Stage Renal Disease) is a condition when kidneys have lost all or most of their
ability to function with glomerular filteration rate (GFR) less than 5ml/minute i.e. kidney's
inability to excrete waste products, maintain fluid and electrolyte balance and produce hormones.

As renal failure progresses, the level of circulating waste products eventually leads to symptoms
of uremia, weakness, nausea and vomiting, muscle cramps and itching, metallic taste in the
mouth and neurological impairment.

Most adult patients with ESRD are never referred for evaluation for transplantation, and have a
70% 5-year mortality on dialysis. Marked improvements in early graft survival and long-term
graft function have made kidney transplantation a more cost-effective alternative to dialysis.

Abrupt deterioration of renal structural integrity

Decrease in renal function ------- (Stage 1)

Decrease in glomerular filteration rate (GFR) 50%

 ↓

More than 75% damage of nephrons

Renal insufficiency -------- (Stage 2)

Decrease in glomerular filteration rate (GFR) 20-50%

BUN, creatinine levels continue to rise

Hypertrophy of nephrons (80-90%)

Renal failure -------- (Stage 3)

Decrease in glomerular filteration rate (GFR) 10-20%

Impaired kidney function

(Inability of the kidney to rid body of all waste products)

End Stage Renal Disease (ESRD) ------- (Stage 4)

  HOME RECALL
TIMINGS MEAL MENU INGR. AMT ENERGY CHO PRTN FATS

8.30AM Breakfast 1 cup (with sugar , Cow's milk 50 33 2 1.6 2

cow’s milk Sugar 5 20 5 - -
50ml) Biscuits 50 50 12 1.5 0.2
+ 2-3 biscuits
2.00PM Lunch 2no. roti (with oil) Wheat flour 60 200 42 5 1
+1 vati rice Rice 30 100 21 2.5 0.5
+1 vati sabzi Sabji 100 100 24 - -
+1 vati dal Dal 30 100 17 7 0.5
Oil 15 135 - - 15
Evening 1 cup (with sugar , Cow's milk 50 33 2 1.6 2
cow’s milk Sugar 5 20 5 - -
50ml) 10- 15
cups tea
9.30PM Dinner 2no. roti (with oil) Wheat flour 60 200 42 5 1
+1 vati rice Rice 30 100 21 2.5 0.5
+1 vati sabzi Sabji 100 100 22 - -
+1 vati non veg - Dal 30 100 17 7 0.5
chicken Chicken 90 100 - 24 0.5
Oil 20 180 - - 20

 NUTRITIONAL PROFILE OF DIET

ENERGY - 1571 kcal

PROTEINS - 56.2 gms

CARBOHYDRATES - 232 gms

FATS - 43.5 gms

 3 DAY HOSPITAL RECALL
DAY-1 Date:- 12/4/18

TIME MEAL MENU INGREDIENTS AMT ENERGY CHO PROTEIN FATS

8:00 am Breakfast Daliya Daliya 30 100 2.5 21 0.5

upma Onion 25 25 2.5 0.2 -
Brown Tomato 25 12.5 1.5 0.2 -
bread Oil 5 45 - - 5
Jam Brown bread 100 100 2.5 21 0.5
Butter Butter 5 35 - - 5
Porridge Milk 50 33 2 1.2 2
Tea Sugar 5 20 5 - -
 Muskmelon Muskmelon 100 50 10 - 0.3

1:00 pm Lunch Mix veg Vegetables 100 25 7 1 -

soup Corn 50 25 5 0.5 -
Milli juli Peas - - - - -
veg Onion - - - - -
Dal with Tomato - - - - -
tadka Capsicum - - - - -
Plain rice Oil 5 45 - - 5
Curd Moong 30 100 17 7 0.5
Vermicilli Oil 5 45 - - 5
Kheer Rice 30 100 21 2.5 0.5
Chapati Curd 100 66 4 3.3 4
Vermicilli 30 100 21 2.5 0.5
Milk 100 66 4 3.3 4
Sugar 5 20 5 - -
Wheat flour 30 100 21 2.5 0.5

8:00 pm Dinner Carrot and Carrot 100 50 10 1 -

dill soup Dill - - - - -
Pahadi Paneer 40 100 2 7 8
paneer Oil 5 45 - - 5
Plain rice Rice 30 100 21 2.5 0.5
Curd Curd 100 66 4 3.3 4
Chapati Wheat flour 30 100 21 2.5 0.5
Veg kadhai Vegetables 50 25 5 0.5 -
Oil 5 45 - - 5

DAY-2 CLEAR LIQUID DIET Date:- 14/4/18

TIME MEAL MENU INGREDIENTS AMT ENERGY CHO PROTEIN FATS

7:00 am NBM

8.30 am NBM

10:00 Barley - - - - -
am water
11.30 Dal water - - - - - -
am
1:00 pm Rice kanji+ - 100ml - - - -
Jelly - 50 10 - -
2.30 pm Strewed Apple 100ml 25 5 - -
apple
puree + Apple 100ml 50 10 - 0.3
apple
juice
4.00 pm Barley Barley water - - - - -
water
5.30 pm Dal water Dal water - - - - -
7:00 pm Rice kanji Rice kanji + - - - - -
+ Jelly Jelly 50 10 - -
8:30 pm Strewed Apple 100ml 25 5 - -
apple
puree
10:00 Apple juice Apple 100ml 50 10 - 0.3
pm

DAY-3 SOFT DIET Date:- 15/4/18

TIME MEAL MENU INGREDIENTS AMT ENERGY CHO PROTEIN FATS

7.00 am Early Milk Milk 100ml 66 4 3.3 4

morn.
8:30 am Breakfast Upma Semolina 30 100 21 2.5 0.5
Onion 25 25 2.5 0.2 -
Tomato 25 12.5 1.5 0.2 -
Oil 5 45 - - 5
10:30 Mid - Juice Oranges 100g 100
am morning
1:30 am Lunch Curd Curd 100ml 66 4 3.3 4
Egg Egg white 17g 15 - 4 -
white Soft rice 50g 50 10.5 1.25 0.25
Soft rice
7:30 am Dinner Khichdi Rice + dal 100ml 75 14.75 3 0.35
Soup Veg soup 100ml 50 - - -
Boiled Whole egg 30g 90 0 7 7
egg
  DIET FOLLOWED DURING HOSPITAL STAY:

Renal diet (before surgery)

↓
Clear liquids
↓
Soft diet (after surgery)
↓
Full diet

 NUTRITIONAL PROFILE OF DIET

ENERGY- 2160 kcal(30 kcal/Kg IBW)

PROTEINS - 72 gms (1g/kg IBW) (13%)

CARBOHYDRATES - 351 gms (65%)

FATS - 52.8 gms (22 %)

 MEDICAL NUTRITION THERAPY

 GOALS:
 To maintain Ideal Body Weight
 To maintain optimum nutrition
 To prevent further complications

 ENERGY: 30-35 kcal/kg is recommended to prevent negative nitrogen balance and to

maintain appropriate weight.

 CARBOHYDRATES: 50-65% of CHO is recommended. Combination of both simple

and complex CHO should be included in the diet.

 PROTEINS: During the first month after transplantation, a high protein diet is
recommended (1.3-1.5gm/kg body weight). Higher amount of protein 1.6-2.0gm/kg body
weight are required in case of increased need such as fever, infection, and increased
surgical or traumatic stresses.

 FATS: Transplant patients have elevated triglycerides or cholesterol levels or both.

Cholesterol intake limited to less than 300 mg/day and limit the total intake of fat.
Maintaining the ratio of SFA:MUFA:PUFA i.e. 1:1.5:1 is essential.

 SODIUM: Sodium intake is based on fluid retention and blood pressure.

 POTASSIUM: Hyperkalemia is commonly associated with cyclosporine therapy, hence,

dietary potassium restriction is usually temporary.
 FLUID: Hydration must also be monitored closely after transplantation. Since, kidney
transplantation patients required fluid restriction while on dialysis, but intake of fluid
after transplant should be properly monitored. 2 liter/day is recommended but overall
need depend on the patient's increased urine output.

 EXCHANGE LIST

Food No. Of Amounts Energy CHO Proteins Fats

Exchange Exchange (Gms) (Kcal) (Gms) (Gmd) (Gms)

Cereals 6½ 195 650 136.5 17.25 3.25

Pulses 1 30 100 17 7 0.3
Soyabean 1 20 90 4 9 4
Egg 1 50 85 - 6.7 6.7
SMP 1 30 100 2 7 -
Paneer 1 40 100 2 7 5
Nuts 1 15 100 30 3 8.5
Veg A 2 200 50 12 2 -
Veg B 2 200 100 20 2 -
Veg C 1½ 150 150 36 1.5 -
Curd 2 300 200 13.2 10 12
Fruits 2 200 100 25 - -
Sugar 5 25 100 25 - -
Oil 4 20 180 - - 20
Total 2105 322.7 72.4 gms 59.7
kcals gms gms
% Energy 65% 13% 22%
Distribution
 DISTRIBUTION OF EXCHANGES BETWEEN THE VARIOUS MEALS OF THE DAY

Food group Breakfast Mid- Lunch Snacks Mid Dinner

morning evening

Cereals 1 2 1½ 2
Pulses 1
Soyabean 1
Egg 1
SMP 1
Paneer 1
Nuts ½ ½
Veg A 1 ½ ½
Veg B ¼ ½ ¼
Veg C 1 ½
Curd 1 1
Fruits 2
Sugar 2 1 1
Oil 1 2 1 1

 MENU PLANNING

Time Meal Menu Ingredients Justification Variation

9:00 am Breakfast Sheera SMP Provides calories, Upma
Semolina protein (HBV) Poha
Sugar
Nuts
Oil

11:00 am Mid Boiled Egg Egg Provides calories, Omlette

morning Nuts Almonds protein (HBV)

1:30 pm Lunch Dal Moong dal Good combination Dal fry

Rice Rice of pulse and Rice
Chapati Wheat flour cereal and Curd rice
Soyabean Soyabean provides HBV Soyabean
Curd Onion protein, pulao
Tomato calories Raita
 Potato Sabji
Oil
Curd
Sugar

4:00 pm Snacks Veg Roll Wheat flour Good combination Veg pattis
Onion of cereal and Spring roll
Tomato vegetables and
Potato also provides
Green peas calories, fibre
Cauliflower
Capsicum
Oil

6:00 pm Mid evening Fruit Mix Curd Provides HBV Smoothie

Sugar protein,
Apple calories and
Pear fibre
Orange
Muskmelon

8:00 pm Dinner Palak Paneer Spinach Provides calories, Paneer pulao

Chapati Paneer protein, Paneer bhurji
Onion vitamin and with roti,
Tomato minerals Paneer
Oil paratha
Wheat flour
  DETAILED MENU PLAN

Meal & Menu Ingredients Amt Energy CHO Protein Fat Na K

Time gm kcal gm gm gm mg mg
9:00 am Sheera SMP 30 100 2 7 - - -
Breakfast Semolina 30 100 21 3 0.5 - -
Sugar 10 40 10 - - - -
Nuts 7.5 50 - - 5 - -
Oil 5 45 15 1.5 4.2 - -
11:00 am Boiled Egg Egg 50 85 - 6.7 6.7 - -
Mid evening Nuts Almonds 7.5 50 15 1.5 4.2 - -
1:30 pm Dal Moong dal 30 100 17 7 0.5 - -
Lunch Rice Rice 30 100 21 2.5 0.5 3 42.9
Chapati Wheat flour 30 100 21 2.5 0.5 3 42.9
Soyabean Soyabean 20 90 4 9 4 - -
Curd Onion 25 25 2.5 0.2 - 8.9 27
Tomato 25 12.5 1.5 0.2 - 3.2 36.5
Potato 50 50 12 0.5 - 2.5 10
Oil 2.5 22.5 - - 2.5 - -
Curd 150 100 6.6 5 2 111.7 69.7
Sugar 10 40 10 - - - -

4:00 pm Veg Roll Wheat flour 45 150 30.5 3.7 1 8 18.9

Snacks Cauliflower 25 12.5 1.5 0.2 - 1 30
Green peas 10 10 2 0.2 - - -
Tomato 25 12.5 1.5 0.2 - 3.2 36.5
Onion 25 25 2.5 0.2 - 8.2 27
Capsicum 10 7.5 1 0.2 - - -
Potato 100 100 24 1 - 2.7 61.7
Oil 7.5 67.5 - - 7.5 - -

6:00 pm Fruit Mix Curd 150 100 6.6 5 6 56.3 69.7

Mid evening Sugar 5 20 5 - - - -
Apple 50 25 6.2 - - 11.7 38.5
Pear 50 25 6.2 - - 4.5 -
Orange 50 25 6.2 - - 14 9.3
Muskmelon 50 25 6.2 - - 1.5 5.6

8:00 pm Palak Paneer Spinach 100 25 6 1 - 58.5 206

Dinner Chapati Paneer 40 100 2 7 5 - -
Onion 25 25 2.5 0.2 - 8.9 27
Tomato 25 12.5 1.5 0.2 - 3.2 36.5
 Oil 5 45 - - 5 - -
Wheat flour 60 200 42 2.5 0.3 4 9.4

 RECCOMENDATIONS:

DO’S

 Small frequent meals are recommended.

 High Biological Protein (HBV) such as egg, lean meat, chicken, fish, curd, Skim Milk
Powder (SMP), soya chunks, soya granules, soyabeans should be included in the diet.
 Use salt packets for daily intake.
 Low potassium fruits should be included in the diet such as guava, apple, pear, pineapple,
papaya, muskmelon, etc.
 Colorful vegetables should be included as they are rich in anti-oxidants and low in
potassium.
 Leaching of vegetables should be done to decrease the potassium content.
 To improve the taste can add mint leaves, lemon, cloves, cardamom, bay leaves.

DONT’S

 Do not skip meals or go for many hours without eating.

 Do not add salt while cooking.
 Avoid adding salt to your food.
 Avoid foods that list salt, sodium, or monosodium glutamate (MSG) as an ingredient.
 Limit processed foods, fast food as these types of foods are high in sodium.
 Avoid smoked, cured, salted and canned meat, fish and poultry.
 Do not use salt substitute or lite salt unless the doctor says it is okay, as salt substitutes
and lite salt are high in potassium.
 Avoid banana as it is high in potassium.
 Avoid carbonated beverages, commercial soft drinks.
 Avoid nuts, peanut butter, lentils, beans, organ meats, sardines etc.
 Avoid preservatives such as papad, pickles, chutney, sauce, etc.
 Avoid chips, nuts, popcorn, salty biscuits.
 Avoid drinking alcohol.
 Diet should be low in saturated fats, cholesterol, refined sugars to control elevated blood
lipids.
 Avoid bakery products, canned, tinned products.