MEDICAL NUTRITION THERAPY IN PEDIATRIC SOLID ORGAN TRANSPLANT. Callie Coburn, MS, RD, CSP, LD Christine DeVore, MS, RD, LD September 15, 2017

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1 MEDICAL NUTRITION THERAPY IN PEDIATRIC SOLID ORGAN TRANSPLANT Callie Coburn, MS, RD, CSP, LD Christine DeVore, MS, RD, LD September 15, 2017

2 OBJECTIVES Review medical nutrition therapy for pre-transplant phase Review medical nutrition therapy for post-transplant phase

3 According to UNOS (United Network for Organ Sharing): Organ transplantation has saved and enhanced the lives of more than 500,000 people in the United States.

4 WHICH ORGANS CAN BE TRANSPLANTED? Kidney Pancreas Dual Kidney/Pancreas Heart Lung Dual Heart/Lung Intestine Liver Vascularized Composite Allografts (VCAs), such as face and hand transplantation

5 PRESERVING ORGANS Donated organs require special methods of preservation to keep them viable between the time of procurement and transplantation. Common maximum organ preservation times include:

6 TRANSPLANT STATISTICS As of 8/18/2017, there are 116,808 people waiting for lifesaving organ transplants in the United States per UNOS.

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8 ORGAN DONATION Two types: Living donor Kidney Pancreas Liver Lung Deceased donor All organs

9 DECEASED ORGAN DONATION Donor organs are matched to waiting recipients by a national computer registry called the National Organ Procurement and Transplantation Network (OPTN). This computer registry is operated by an organization known as the United Network for Organ Sharing (UNOS), which is located in Richmond, Virginia. -National Kidney Foundation

10 HISTORY OF TRANSPLANT 1954: First successful human organ transplant performed. It was a kidney. 1966: First simultaneous kidney/pancreas transplant performed. 1967: First successful liver transplant performed. 1968: First successful heart transplant performed 1981: First successful heart-lung transplant performed. 1989: First successful living donor liver transplant performed. 1990: First successful living donor lung transplant performed.

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12 ARKANSAS CHILDREN S HOSPITAL 345 Heart Transplants Est Kidney Transplants Est. 1986

13 TRANSPLANT PHASES Solid Organ Transplantation is regulated by CMS (Centers for Medicare and Medicaid Services). CMS categorizes transplant into phases: Pre-Transplant/Evaluation Transplant Inpatient Stay/Discharge Post-Transplant

14 PRE-TRANSPLANT NUTRITION PROCESS 1) Pre-Transplant Nutrition Evaluation Patient Living Donor, if applicable 2) Multidisciplinary Transplant Selection Committee 3) If selected, patient added to transplant waiting list

15 PRE-TRANSPLANT NUTRITION EVALUATION Anthropometric evaluation Height, Weight, BMI ACH Pediatric Transplant Recipient Selection Criteria Relative Contra-indications Weight <12kg (*kidney only) Obesity with BMI >40 (*kidney only) Current feeding regimen Appetite GI tolerance Medical, Surgical history

16 PRE-TRANSPLANT NUTRITION EVALUATION Medications Vitamin/Mineral/Herbal supplements Laboratory Values Particularly those associated with concerns for overweight/malnutrition Social, Psychosocial, Cultural, Food-Related Attitudes and Beliefs Assess for limited food supply or food insecurity Is patient currently participating in governmental or community resources? WIC, SNAP, local food banks

17 PRE-TRANSPLANT NUTRITION EVALUATION Expectations for diet/lifestyle adherence Education: Importance of maximizing pre-transplant nutritional status. Present common post-transplant nutrition topics Post-transplant diet prescriptions Low Sodium Low Fat Food Safety Well water Food thermometer

18 PRE-TRANSPLANT NUTRITION EVALUATION In evaluation, document any potential nutrition-related barriers to transplant Examples: Malnutrition BMI z-score Underweight Overweight/Obese Compliance Learning needs How will you address this as the Registered Dietitian?

19 When they get THE CALL (or have a scheduled living donor transplant)

20 NUTRITION REQUIREMENTS AFTER KIDNEY TRANSPLANT Common early post-operative transplant nutrition management needs: Bowel function, ileus Wound healing (increased kcal, protein needs) HTN Hyperglycemia Electrolyte imbalances

21 NUTRITION REQUIREMENTS AFTER KIDNEY TRANSPLANT Low Sodium diet If HTN present, recommend starting restriction at ~2000 milligrams per day Titrate as clinically indicated. AND recommends limit of 1-2 meq Na+/kg/day Daily fluid goal Set by transplant Nephrologist Very challenging for patients High Phosphorus diet No Concentrated Sweets diet, as applicable Transition to standard oral nutrition supplements, as applicable

22 NUTRITION REQUIREMENTS AFTER HEART TRANSPLANT Aggressive early post-transplant MNT (PN/EN) facilitates wound healing decreases infectious complications shortens ventilation time Detect & prevent late-onset complications obesity, hyperglycemia, hyperlipidemia, osteoporosis Adequate nutrition to correct malnutrition growth retardation Vitamin/mineral deficiencies Operative procedures can increase REE by 24-79% Nutrition in children post-transplantation & Nutrition Management After Pediatric Solid Organ Transplantation

23 NUTRITION REQUIREMENTS AFTER HEART TRANSPLANT Heart Healthy Diet 30% fat from total calories mg/day Any Fluid Restrictions Any alternative feeding routes Educating family on formulas and home feeds

24 POST-TRANSPLANT IMMUNOSUPPRESION MEDICATIONS Tacrolimus/Prograf Hold 30 minutes pre/post feeds or meals; Taken BID Cellcept Can cause diarrhea Imuran Prednisone Steroid-induced Diabetes Osteoporosis

25 POST-TRANSPLANT NUTRITION EDUCATION Food and Drug interaction Grapefruit Sunny D Squirt soda Fresca soda Pomegranate? Star fruit? Seville oranges?

26 POST-TRANSPLANT NUTRITION EDUCATION Food Safety guidelines FDA/USDA booklet Wash hands before meal preparation or eating Cook meats to minimum internal temperatures Pasteurized milk and cheese Wash all fruits and vegetables thoroughly Try to think from kid s perspective No 5-second rule Avoid drinking after others Heat deli meats and hot dogs until steaming hot

27 POST-TRANSPLANT NUTRITION EDUCATION Calcium and Vitamin D intake KDOQI Calcium and Vitamin D intakes of at least 100% of the DRI are suggested for children with CKD stages 1 to 5T. Total Calcium intake should not exceed 200% of DRI. AND Recommends % DRI for Calcium while on corticosteroids. Ensure an intake of 800-1,000 IU Vitamin D for transplant patients. Achieving goal: Food Sources/Goals Supplements

28 POST-TRANSPLANT DISCHARGE NUTRITION EDUCATION Heart Healthy or Low Sodium diet, as applicable Daily fluid goal, as applicable Food Safety guidelines Food and Drug interaction Calcium and Vitamin D intake Weight management, as applicable Underweight formula transition Overweight

29 DISCHARGE REQUIREMENTS POST-TRANSPLANT Consult for Discharge Assessment & Goals Facility recommends wording Discharge Goals in documentation Formula/Supplement/GT needs Orders for discharge planning, WIC, formula/supplement supplies Family/Patient must be able to show understanding of all education Outpatient follow up RD/medical team rounds & nutrition screening indicates need for Nutrition consult and follow up frequency

30 CHRONIC POST-TRANSPLANT NUTRITION Achieving goal weight Promote oral skills and decrease enteral supplementation, as feasible Reduce excessive weight gain, obesity Dyslipidemia HTN Hyperglycemia, Diabetes Steroid-induced Osteoporosis

31 CONCLUSION There are 3 phases to transplant per CMS: Pre-Transplant/Evaluation Transplant Inpatient Stay/Discharge Post-Transplant The nutrition prescription for each phase varies, each organ and each patient.

32 REFERENCES Academy of Nutrition & Dietetics Nutrition Care Manual. Centers for Medicaid and Medicare. Certification/SurveyCertificationGenInfo/Downloads/Surveyand-Cert-Letter pdf Healthline (Coram s Continuing Education Program). Nutrition in Transplantation Volume 16, pages 1-6. KDOQI Clinical Practice Guideline for Nutrition in Children with CKD: 2008 Update. National Kidney Foundation. Texas Children s Hospital, Pediatric Nutrition Reference Guide. United Network for Organ Sharing.

33 QUESTIONS