1.  Samantha Walters Sodexo Mid-Atlantic Dietetic Intern

2.  54 y/o AA male  Reference height: 167.6 cm (5’6”)  Reference weight: 91.4 kg (201.1 lbs)  Admitted: 12/2/14 for DDKT  Two intern contacts o one follow-up with patient’s nurse

3.  Patient is single and lives with his brother  On disability, no longer working as a landscaper (left in 2008)  Denies tobacco, EtOH, and illicit drug use  Family hx includes: older brother who was dx with Alport syndrome HTN CAD CA

4.  Dx with hearing loss at an early age  CKD was dx approximately 14 years ago (early 2000)  Began HD in December 2010 o Arteriovenous fistula on left arm o Dialysis M/W/F for 4 hours  Hx of ESRD 2/2 HTN and Alport Syndrome that runs in the family  Gout

5.  An inherited disease that primarily effects the glomeruli in the kidneys, which filter wastes from the blood.  Caused by mutations that affect type IV collagen, a protein that is important to the normal structure and function of the inner ear and the eye.  The most common and earliest symptom of this disease is hematuria. Others include proteinuria, high BP, and swelling in the legs, ankles, feet, and eyes.

6. Operative Day:  Admitted December 2 for deceased donor kidney transplant o Transplanted to right side o 22 y/o DCD with cause of death 2/2 MVA o High term Cr donor o 23 hours Cold Ischemia Time o Campath Induction

7. POD 1:  Pt transferred from PACU to ZAYED 9W  Delayed Graft Function 2/2 minimal urine output (0 mL) and K 6.5  Received HD at beside  Clinical Nutrition consult received for assessment and education  Visited patient POD 1, and he was NPO. Observed HD and had nurse walk me through the process.

8.  Caused by issues between the donor or recipient  Fairly common, occurring in about 30% of deceased-donor kidneys and 5% of living-related kidneys  Transplanted kidney is called a graft  Occurs right after surgery and can take some time for the kidney to heal after transplant.  Can take from weeks, even months for kidney to resume its normal functions  Often times requires short-term HD in order to get it functioning properly

9.  Why? Resolve Hyperkalemia  Vascular access: L. AV Fistula  Blood Flow Rate: 400 mL/min o Venous BP was 150 mmHg o Arterial BP was -200 mmHg  Spoke with patient after HD and let him know we would be back the following day to complete the nutrition assessment  After HD, A.B.’s diet was advanced to Regular with no restrictions

10. POD 2:  Patient still with minimal urine output (25 mL over 24 hrs)  Hyperkalemia resolved  Patient seen for nutrition assessment and education s/p DDKT  Significant Labs: BUN: 42 (H) Cr: 10.2 (H) Ca: 8.1 (L) Phos: 5.4 (H) DEXIS: 12/4—161, 124 12/3—124, 109. 99, 120, 131, 105

11.  Bisacodyl (Constipation)  Docusate (stool softener)  Pantoprazole (reflux common after transplant d/t meds— Prednisone especially)  Senna (stool softener)  Pravastatin (statin)  MVI  Insulin Sliding Scale

12.  CellCept (Mycophenolate Mofetil) o Inhibits enzyme needed for growth of T and B cells  Prednisolone o Block the T cell activation/expression cascade  WAS on Thymoglobulin POD1 o Used immediately after transplant o Uses antibodies directed against T cell antigens, making T cells non- responsive  Prograf (Tacrolimus) o Reduces interleukin 2 production by T cells o IL2 responsible for regulation of WBCs

13.  Pt reports good appetite; no N/V/D/C or chewing/swallowing difficulties  Generalized Edema  States he still has little urine output and last BM was prior to transplant  Recent estimated dry weight was 92.8 kg CBW: 91.4 kg UBW: 95.5 kg (98.5%) DBW: 64.5 kg (142%)

14. Estimated Needs: All needs based on DBW of 64.5 kg: (KDIGO/KDOQI) -Kcal: 1950-2300 kcal/day (30-35 kcal/kg) -Protein: 85-95 gm/day (1.3-1.5 gm/kg) -Fluid: No restriction, per team

15.  Increased nutrient needs (NI 5.1) (calories, protein) related to wound healing as evidenced by s/p kidney transplant and catabolic effect of steroids  Food and nutrition-related knowledge deficit (NB 1.1) related to limited post-transplant diet education as evidenced by s/t DDKT on 12/2/2014

16.  Provided NCM: Post-Transplant Nutrition Therapy Handout  Post Kidney Transplant Diet Recommendations: o Heart-Healthy diet o Avoid concentrated sweets/moderate CHO diet o Food Safety Check expiration dates Thaw foods properly Cook/Chill foods thoroughly Wash all fruits/vegetables Heat cold cuts, hot dogs, deli meats, and sausages to steaming before eating Avoid grapefruit, raw meats, unpasteurized dairy/juice/cider, fresh sprouts, moldy foods, and alcohol

17.  Continue Regular Diet with no restrictions as tolerated  Continue vitamin/mineral supplement QD  Suggest checking Vitamin D and supplement if low  Continue to monitor renal labs and checking DEXIS to monitor BG response to steroids  Pt encouraged to contact RD with questions/concerns regarding diet – Provided with RD contact information  Will f/u per standards of care

18. POD 3:  Was given Lasix overnight with no response (15 mL urine output all night)  5 mL total POD 3, and given 100 mg Lasix again today  Removing Foley later today  HD later today d/t labs not trending per note: Cr: 13.1 (H) BUN: 71 (H) Ca: 7.9 (L) Phos: 6.8 (H)

19.  NCM: Organ Transplant Nutrition Therapy  National Kidney Foundation. Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease: A Concise, Practical Resource for Comprehensive Nutrition Care in CKD  National Kidney Foundation (website)  J.S. Gill, J. Lan, J. Dong, et al. The Survival Benefit of Kidney Transplantation in Obese Patients. American Journal of Transplantation 2013; 13: 2083- 2090.  Chitra U and Sunitha Premalatha K. Nutritional Management of Renal Transplant Patients. Indian Journal of Transplantation 2013; 7(3):88-93

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