1. + MNT Case Study:
Accelerated (Acute)
Renal Failure,
Secondary to Renal
Transplant Rejection
Rachael G. Joseph
Oakwood University Dietetic Intern 2015-2016
5/5/2016
2. +
Objectives
To understand:
The pathophysiology of acute
renal failure
The causes of transplant
rejection
The appropriate nutrition
interventions for renal transplant
patients
3. +
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.
4. +
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
5. +
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
6. +
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.
7. +
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.
8. +
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.
10. +
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
11. +
Kidney Transplant Procedure
Deceased (cadaveric)- Organ comes from someone that has just
died
Living Related Donor
Living Unrelated Donor
12. +
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
13. +
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.
14. +
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, Mycophenolate
mofetil, Mycophenolate sodium, Sirolimus
Cytokine Inhibitors: Cyclosporine, Tacrolimus. Lowers T-
cell activity
Antilymphocyte Medications
15. +
Patient Profile
Admit Date: 2/15/2016
31 y/o, Caucasian male with a past medical history for Alport
syndrome
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
16. +
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
17. +
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
18. +
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
20. +
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
21. +
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
22. +
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
23. +
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
24. +
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
25. +
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
26. +
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
27. +
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
