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Nutritional support of critically ill organ transplantation patients
Abstract
Organ transplantation has become a life-saving procedure for patients with end stage kidney, liver, lung, and heart disease. However, these patients are typically debilitated and malnourished prior to undergoing transplantation. The surgical literature is replete with studies documenting the increased morbidity and mortality following non-transplant surgery on malnourished patients. In an effort to achieve the best outcomes following organ transplantation transplant surgeons have also tried to study the effects of malnutrition on outcomes following organ transplantation. They have looked at the relationship of malnutrition to infectious complications, graft function, hospital length of stay, intensive care unit length of stay, and mortality. The etiology of malnutrition in patients with end stage disease is complex and multifactorial. In patients with renal failure the loss of kidney function results in acidosis that induces protein catabolism and alters amino acid uptake thus negatively affecting nitrogen balance. There is also a negative effect on albumin synthesis and albumin concentration. The hormonal milieu is deranged as well. In addition, nutritional intake can be poor due to anorexia, hospitalization, gastroparesis, nausea, vomiting, and poor tasting specialized diets among other things.
... Vitaminler (B grubu, C) ile mikronütrientler (özellikle çinko, fosfor, magnezyum) nütrisyon tedavisine eklenmeli ve mümkünse kan düzeyleri izlenmelidir. Özellikle parenteral nütrisyon uygulanan hastalarda kontaminasyon oluşmamasına ve kateter kaynaklı enfeksiyonlara dikkat edilmelidir (138)(139)(140)(141)(142). ...
Critical care management after liver transplantation requires a sophisticated monitoring and multi-disciplinary team work. An experienced team and advanced critical care/hospital facilities are necessary for an ideal critical care treatment today. Critical care management after liver transplantation has shown a rapid development since the introduction of liver transplantation. While one-year survival rate after liver transplantation was 79% in 1998, it raised to 90% in 2008 related to the improvements in preoperative optimization, surgical technique, anesthetic management, organ preservation, critial care and immunosuppressive treatment. Treatment of severe coagulopathy, prompt hemodynamic and respiratory stabilization, early weaning from mechanical ventilation, proper fluid-electrolyte therapy, prevention of graft rejection, protection of renal functions and prophylaxis/treatment of infection are particularly important in critical care management after liver transplantation. As early postoperative period of liver transplantation is a critical phase; close monitoring, stabilization of cardiopulmonary functions, frequent evaluation of graft function, early diagnosis of complications and rapid treatment of extrahepatic organ failure are mandatory in order to reduce mortality/morbidity.
10.1177/0148607109335234
The association between pretransplant serum albumin concentration and post-transplant outcomes in kidney transplant recipients is unclear. We hypothesized that in transplant-waitlisted hemodialysis patients, lower serum albumin concentrations are associated with worse post-transplant outcomes. Linking the 5-year patient data of a large dialysis organization (DaVita) to the Scientific Registry of Transplant Recipients, we identified 8961 hemodialysis patients who underwent first kidney transplantation. Mortality or graft failure and delayed graft function (DGF) risks were estimated by Cox regression (hazard ratio [HR]) and logistic regression (Odds ratio [OR]), respectively. Patients were 48 ± 13 years old and included 37% women and 27% diabetics. The higher pretransplant serum albumin was associated with lower mortality, graft failure and DGF risk even after multivariate adjustment for case-mix, malnutrition-inflammation complex and transplant related variable. Every 0.2 g/dL higher pretransplant serum albumin concentration was associated with 13% lower all-cause mortality (HR = 0.87 [95% confidence interval: 0.82-0.93]), 17% lower cardiovascular mortality (HR = 0.83[0.74-0.93]), 7% lower combined risk of death or graft failure (HR = 0.93[0.89-0.97]) and 4% lower DGF risk (OR = 0.96[0.93-0.99]). Hence, lower pretransplant serum albumin level is associated with worse post-transplant outcomes. Clinical trials to examine interventions to improve nutritional status in transplant-waitlisted hemodialysis patients and their impacts on post-transplant outcomes are indicated.
In modern surgical practice it is advisable to manage patients within an enhanced recovery protocol and thereby have them eating normal food within 1-3 days. Consequently, there is little room for routine perioperative artificial nutrition. Only a minority of patients may benefit from such therapy. These are predominantly patients who are at risk of developing complications after surgery. The main goals of perioperative nutritional support are to minimize negative protein balance by avoiding starvation, with the purpose of maintaining muscle, immune, and cognitive function and to enhance postoperative recovery. Several studies have demonstrated that 7-10 days of preoperative parenteral nutrition improves postoperative outcome in patients with severe undernutrition who cannot be adequately orally or enterally fed. Conversely, its use in well-nourished or mildly undernourished patients is associated with either no benefit or with increased morbidity. Postoperative parenteral nutrition is recommended in patients who cannot meet their caloric requirements within 7-10 days orally or enterally. In patients who require postoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice. The main consideration when administering fat and carbohydrates in parenteral nutrition is not to overfeed the patient. The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements. Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weights. In those patients who are unable to be fed via the enteral route after surgery, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basis.
Presented and described in detail is a clinical technique called subjective global assessment (SGA), which assesses nutritional status based on features of the history and physical examination. Illustrative cases are presented. To clarify further the nature of the SGA, the method was applied before gastrointestinal surgery to 202 hospitalized patients. The primary aim of the study was to determine the extent to which our clinician's SGA ratings were influenced by the individual clinical variables on which the clinicians were taught to base their assessments. Virtually all of these variables were significantly related to SGA class. Multivariate analysis showed that ratings were most affected by loss of subcutaneous tissue, muscle wasting, and weight loss. A high degree of interobserver agreement was found (kappa = 0.78, 95% confidence interval 0.624 to 0.944, p less than 0.001). We conclude that SGA can easily be taught to a variety of clinicians (residents, nurses), and that this technique is reproducible.
Enhanced recovery of patients after surgery ("ERAS") has become an important focus of perioperative management. From a metabolic and nutritional point of view, the key aspects of perioperative care include: Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and if necessary tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in surgical patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1980. The guideline was discussed and accepted in a consensus conference. EN is indicated even in patients without obvious undernutrition, if it is anticipated that the patient will be unable to eat for more than 7 days perioperatively. It is also indicated in patients who cannot maintain oral intake above 60% of recommended intake for more than 10 days. In these situations nutritional support should be initiated without delay. Delay of surgery for preoperative EN is recommended for patients at severe nutritional risk, defined by the presence of at least one of the following criteria: weight loss >10-15% within 6 months, BMI<18.5 kg/m(2), Subjective Global Assessment Grade C, serum albumin <30 g/l (with no evidence of hepatic or renal dysfunction). Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.
This article reviews nutrition support in patients with liver disease, including those who are undergoing surgery or liver transplant. The topics covered include the multifactorial etiology of malnutrition, nutritional assessment, and nutritional therapy. Recommendations for use of both enteral and parenteral nutrition are given in patients with alcoholic hepatitis, cirrhosis, and acute liver failure and in patients undergoing surgery or liver transplant.
Vitamin D deficiency is prevalent among patients with end-stage organ failure awaiting transplant. Low serum 25-hydroxyvitamin D (25-OHD) levels in these patients may be related to many disease-specific factors, as well as decreased sunlight exposure and limited intake of foods containing vitamin D. Low serum 25-OHD levels are also extremely common following solid organ transplantation, both during the immediate postoperative period and in long-term graft recipients. Demographic and lifestyle factors are important in determining D status in transplant recipients. Worse vitamin D status is associated with poorer general health, lower albumin, and even decreased survival among these patients. Although several studies have demonstrated that active forms of vitamin D and its analogues prevent bone loss following transplantation, the data do not show consistent benefit. These therapies may have particular utility after renal transplantation. However, given the narrow therapeutic window with respect to hypercalcemia and hypercalciuria, and the demonstrated efficacy of bisphosphonates to prevent post-transplantation bone loss, we regard these agents as adjunctive rather than primary therapy for transplantation osteoporosis. The effects of 1,25(OH)(2)D on the immune system, which are still being elucidated, may have potential for reducing infections and preventing allograft rejection after transplantation.
A significant number of patients hospitalized with heart failure are malnourished. Depletion of micronutrients, which is known to occur in heart failure for a variety of reasons, may contribute to myocardial abnormalities noted in heart failure. In this review, we focus on nutritional supplementation strategies that might improve myocardial performance and, as a consequence, decrease mortality and morbidity in these patients.
The available data suggest that micronutrient and macronutrient supplementation may play a role in improving the myocardial metabolic abnormalities noted in heart failure. A recent trial of omega-3 fatty acid macronutrient supplementation showed a modest decrease in mortality and hospitalizations when used in patients with New York Heart Association class II-IV heart failure.
Recommendations for nutritional support in patients with heart failure are difficult to make due to a lack of large randomized trials. Supplementation with omega-3 fatty acids, and micronutrients such as thiamine, coenzyme Q-10 and carnitine has shown promise in several studies. Since the data is not conclusive, large trials are needed to address whether these positive findings are reproducible in a wider subset of patients. In addition, these trials should study the combination of different micronutrients and macronutrients since heart failure patients are rarely deficient in just one micronutrient or macronutrient.
An adequate nutritional status may improve outcomes after renal transplantation. This review article presents the impact of major nutritional risk factors, such as malnutrition, obesity, dislipidemia, and other associated or independent metabolic complications on the results of renal transplantation. Malnutrition that exists prior to transplant may be associated with an increased risk of infection, delayed wound healing, and muscle weakness. Obesity, which may also be preexisting or developing after transplantation, can lead to adverse effects, such as poor wound healing or increased risk of cardiovascular disease, although some recent studies suggest no major consequences. Hypercholesterolemia and hypertrigliceridemia (risk factors for cardiovascular disease) are common post-renal transplantation complications. All of these possible complications may be prevented or treated through early nutritional intervention and follow-up. This article reviews important nutritional recommendations to provide guidelines for adult posttransplant recipients.
Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in patients with liver disease (LD). It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for patients with chronic LD in whom undernutrition is very common. ONS improve nutritional status and survival in severely malnourished patients with alcoholic hepatitis. In patients with cirrhosis, TF improves nutritional status and liver function, reduces the rate of complications and prolongs survival. TF commenced early after liver transplantation can reduce complication rate and cost and is preferable to parenteral nutrition. In acute liver failure TF is feasible and used in the majority of patients.