Beruflich Dokumente
Kultur Dokumente
KNH 411
November 18, 2012
Case 27
Renal Transplant
4. Mrs. Joaquin’s transplant evaluation took place 2 years ago and included each of
the following. What were each of these procedures used to evaluate?
Procedure Used to Evaluate
Abdominal and renal ultrasound A radiology study that evaluates the
liver, gallbladder and native kidneys
for abnormalities.
EKG and echocardiogram EKG - shows heart function and
reveals any past damage.
Echocardiogram - to check the heart
structures & valves.
Chest X-ray A picture of your lungs and lower
respiratory tract, which will identify
any abnormalities.
Meeting with transplant nurse, social -To help the doctor coordinate his care
worker, surgeon, and financial -To make sure learn about the
counselor emotional aspects of a kidney
transplant
-To help choose the best foods to eat.
Blood typing and tissue typing Check to see if it is type A, B, AB or
O blood type and what tissue typing it
is.
Dental exam To detect any infections, cavities, or
gum disease, which may be a source
of infection after transplant.
Viral testing on blood Blood for viruses, such as Epst Epstein
Bar ein Barr Virus r Virus (EBEBV)
V), Cytomegalovir ytomegalovirus us
(CMV) and BK
5. Describe why the immunological characteristics of the donated organ must match
with the recipient’s medical and immunological characteristics.
Since the presence of a MHC antigen on the transplanted organ or tissue that is
different from the MHC antigens on the recipient’s tissues signals the presence of
the transplanted tissue and initiated an immune response, MHC antigens for MHC
play an important role in transplant rejection. The immune system attacks the
transplanted cells presenting MHC antigens that are different from those found on
the recipient’s tissues. Therefore, the match is necessary to make the immune
system less offensive to the new organ. (529)
6. Explain the role of the major histocompatibility complex (MHC).
7. What are the differences between nutrition therapy during the acute phase (up to 8
weeks following transplant) and during the chronic phase (starting ninth week
following transplantation) post-transplantation? Explain the rationale for each.
9. How would you interpret Mrs. Joaquin’s BMI? Explain your rationale.
Based on Mrs. Joaquin’s BMI, she is considered to fall in the obese state one
category. It might be related to her type 2 DM.
30 – 35 kcal/kg
Range = 30*75-35*75 = 2250 kcal – 2625 kcal
11. What will Mrs. Joaquin’s protein requirements be after the transplant?
12. Compare her energy and protein needs prior to and post-transplant. Explain how
and why they are different.
Compared to her energy and protein needs prior-transplant, post-transplant has the
higher requirements of both protein and energy amount. This is basically due to the
postoperative stress and the excessive doses of corticosteroids.
C. Intake Domain
13. Explain the importance of food safety education for transplant patients.
Organ transplant patients are included on the list of immune compromised persons
at highest risk of foodborne illness. Organ transplant patients are at high risk for
infection during medical treatment and at continuing risk for the rest of their lives
due to drug treatment used to prevent rejection of the transplanted organ.
Therefore, food safety education is extremely important for transplant patients to
prevent foodborne illness.
D. Clinical Domain
14. On POD #2, Mrs. Joaquin was doing well and transferred to the medical floor.
Her Results showed good perfusion and function of the kidney. Her intake and
output were good. During the remainder of her hospitalization, Mrs. Joaquin
received detailed instructions about postoperative care and medications. The
instructions were:
Keep incision clean and dry
Staples will be removed in 3 weeks
Avoid lifting over 5 pounds
Can resume driving and sexual activity in 2-4 weeks or when pain free
Follow prescribed diet
Explain why the following medications were prescribed, and indicate any
nutrition implications.
17. How will taking prednisone for her transplant affect her glycemic control?
Acute rejection is where the WBC put up a defense against the organ
because it doesn’t recognize it and the organ can don’t function to its full ability.
However, there are medications that can reverse the rejection and the organ can
regain full function. Acute rejections are not likely after the first year of
transplantation.
Chronic rejection is where the body’s antigens attack the organ slowly and
continuously either leaving the organ impaired or unable to function altogether.
This would require immediate hospitalization and the need for another transplant
quickly.
Signs of transplant rejection: the organ’s function may start to decrease;
general discomfort, uneasiness, or ill feeling; pain or swelling in the area of the
organ (rare); fever (rare); flu-like symptoms, including chills, body aches,
nausea, cough, and shortness of breath. (549)
19. What will happen if Mrs. Joaquin does reject her transplanted kidney?
E. Behavioral-Environmental Domain
20. Mrs. Joaquin tells you that she’s heard transplant patients gain weight after
surgery, and she wants to know if this will happen to her. How do you answer her
question?
I would tell Mrs. Joaquin, many transplant patients develop nutrition-related problems
in the months and years following transplant. The most common are excessive weight
gain (as fat) and high blood cholesterol that are usually caused by steroids and other
medications. The best management for you includes weight control by following a
"heart healthy" diet and exercising. Here are some guidelines that will help decrease
the amount of total fat and cholesterol in your diet. They will help reduce your risk for
heart disease and excessive weight gain.
A good way to manage this problem would be reading food labels carefully to avoid
foods that are high in saturated fats and cholesterol. Some of these foods include lard,
butter, shortening, ice cream, sausage, and bacon. Coconut and palm oils are saturated
fats found in many convenience baked goods, whipped toppings, coffee creamers and
fried foods.
In addition, you could follow these guidelines:
21. Prioritize the nutrition diagnoses by listing them in the order in which you would
expect interventions to be developed.
Overweight/obesity NC-3.3
Altered Nutrition related laboratory values BUN, Creatinine,
Phosphorus NC-2.2
Inadequate mineral intake of Phosphorus (6) NI-5.10.1
Inadequate protein-energy intake NI-5.3
Excessive mineral intake of Potassium (5) NI-5.10.2
Undesirable food choices NB-1.7
22. Select two high-priority nutrition problems and complete the PES statement for
each.
v. Nutrition Intervention
23. Using your PES statement, establish an ideal goal (based on the signs and
symptoms) and appropriate intervention (based on the etiology).
Goals:
Average daily caloric intake will be no more than the range of
estimated needs about 2250-2625 kcal/day.
Lab values will be controlled as BUN levels between 8-18
mg/dL, Creatinine levels between 0.6-1.2 mg/dL, and phosphorus
between 30-120 mg/dL.
Interventions:
Though the client is overweight, she still needs to follow the
EER to get enough energy intake which might affect her post surgery
recovery. Instruct client on 2250-2625 kcal diet and educate client with
basic post-transplant knowledge and better food choices knowledge
Educate client how to achieve altered nutrition related
laboratory values BUN, Creatinine, and Phosphorus control and how to
manage those values by increasing the kidney functions.
24. Using Mrs. Joaquin’s typical intake and the prescribed diet, write a sample menu
for her post-transplant nutritional needs.
(Sclafani)
25. Write an initial medical record note for your consultation with Mrs. Joaquin.
A (Assessment)
Mrs. Joaquin is a 26-yo obese Native American female (60”, 165#, BMI 32.46kg/m2).
She was diagnosed with T2DM at 13 years of age and with stage 5 CKD 2 yrs ago
when she was placed on hemodialysis. Her kidney function has progressively declined
and she was admitted to the hospital for preparation for kidney transplantation and
nutrition consult. She has elevated serum phosphorus, potassium, creatinine, BUN,
glucose, TG, HbA1c and cholesterol, which places her at stage 5 CKD. She reported a
good appetite and has following the diet prescribed when she began hemodialysis.
D (Diagnosis)
1. Overweight/obesity related to increase calorie needs and medication as evidence
by high LDL, chols and BMI.
2. Altered Nutrition related laboratory values BUN, Creatinine, Phosphorus related
to kidney dysfunction as evidence of CKD and lab values.
I (Intervention)
Goals:
Average daily caloric intake will be no more than the range of
estimated needs about 2250-2625 kcal/day.
Lab values will be controlled as BUN levels between 8-18
mg/dL, Creatinine levels between 0.6-1.2 mg/dL, and phosphorus
between 30-120 mg/dL.
Interventions:
Though the client is overweight, she still needs to follow the
EER to get enough energy intake which might affect her post surgery
recovery. Instruct client on 2250-2625 kcal diet and educate client with
basic post-transplant knowledge and better food choices knowledge
Educate client how to achieve altered nutrition related
laboratory values BUN, Creatinine, and Phosphorus control and how to
manage those values by increasing the kidney functions.
(Kidney transplants)
References:
Sclafani, N. (2004). Diet after transplantation . aakpRENALIFE, 19(5), Retrieved
from http://www.aakp.org/aakp-library/diet-after-transplantation/
Kidney transplantation. (2011). Retrieved from
http://www.kidney.org/atoz/content/kidneytransnewlease.cfm
Yasumuan, T., Oka, T, & Nakane , Y . (1997). Long-term prognosis of renal
transplant surviving for over 10 yr, and clinical, renal and rehabilitation features
of 20-yr successes. Clin Transplant , 5(1), Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/9361928
Kidney transplants . (2007). Informally published manuscript, Allegheny General
Hospital , Pittsburgh , Pennsylvania . Retrieved from
http://www.wpahs.org/agh/services/index.cfm?mode=view&medicalspecialty=48
1
Nelms, M., Sucher, K., & Long, S. (2007). Nutrition therapy and
pathophysiology. Belmont, CA: Thomson Wadsworth.
Rolfes, S.R., Pinna, K., & Whitney, E. (2009). Understanding normal and clinical
nutrition. Belmont, CA: Wadsworth.
Drugs and supplements . (08-11). Retrieved from
http://www.ncbi.nlm.nih.gov/pubmedhealth/s/drugs_and_supplements/a/
Pellegrrino , B. (2011). Immunosuppression . Medscape, Retrieved from
http://emedicine.medscape.com/article/432316-overview