Newsletter

[ Vol. 9 No. 2 ] (May - August 2008 )
The reality of nutrition status in transplantatiion patients

Myung Duk Lee, MD, PhD, FACS
Department of Surgery, The Catholic University of Korea, Korea
Email: lmyungd@catholic.ac.kr

Advances in clinical surgery and consecutive emergence of effective immunosuppressive agents improved the final outcomes in organ transplantation. However, there are still remained problems particularly in nutrition to be explored to accomplish better end-results of transplantation as well as of quality of life of the patients. Malnutrition is known to be fairly prevalent in end-organ failures. There is derangement of protein and energy metabolism in hepatic failures, and excessive losing of the amino acids during hemodialysis in renal failures. Nutritional imbalance could directly affect on the morbidity and mortality of the transplants, and prolong the length of stay (LOS) in ICU and hospital. In Liver transplantation (LT), lower BCAA affected the final outcomes¹.

In addition to that, immunosuppressive therapy could provocate or exacerbate nutritional problems such as fluid and electrolyte imbalances, renal insufficiency, hyperglycemia, and hyperlipidemia. Tacrolimus might cause hyperkalemia and hypomagnesemia. Corticosteroids could induce hyperglycemia and insulin resistance. Other drugs and massive use of anti-microbial agents particularly during the rejection episodes could provoke loss of appetite, nausea, vomiting, inability to eat and metabolic catabolism. Mechanical or paralytic ileus, or massive ascites usually prohibits adequate oral intake. In bowel transplantation, maintenance of the nutritional balance itself is the main goal of transplantation.

Actual nutritional status of the patients in pre- and post-transplant periods seems to be worse than our expectation as is shown by the recent authors’ surveys, presented at this meeting^2,3. The first study of the 23 consecutive cases of the liver or kidney transplantation (LT, KT)² revealed that average daily total calorie intakes (TCI) were between 70-80% of the daily total requirements (TCR) in pre-transplant periods. However, average daily protein intakes (TPI) were 96% of the requirements (TPR) in KT, and 72% in LT. These deficits of calorie and/or protein intakes persisted until 3 to 4 weeks after transplantation. The higher TCI/TCR or TPI/TPR, the shorter LOS.

In the other survey of 74 LT and 106 KT for last two years at Kangnam St. Mary’s Hospital³, 55.7% of LT and 24.4% of KT were in marasmus, kwashiorkor or severe protein-energy malnutrition. By INS classification (Instant Nutritional Score⁴, 88% of LT and 23% of KT before transplantation were INS 4 or 5, which means moderate to severe malnutrition.

The reason is because nutritional care for the transplantation patients is easily dismissed from the first line strategy  to the transplantation surgeons, who usually start to recognize the importance of nutrition when they face up to the delayed recovery, stasis of the hospital stay or evident malnutrition due to complications. Therefore, initial evaluation and management for the nutritional balance in pre-transplant stage have to be enlisted as the base-line practices in transplantation unit. The consecutive post-transplant monitoring should be followed-up. In certain group of patients such as bowel transplantation and selected cases of the other organs, intra-operative setting of the nutritional devices such as tube-enterostomy, gastrostomy or central venous access for enteral or parenteral supplementation should be considered as an easy accessibility for the anticipated difficulty situations.

In conclusion, enlightening of the transplantation surgeon’s enthusiasm on nutrition and keen recognition of the nutritional imbalance of the patients in transplantation unit should be mainly considered in NST activities. In case, more specified nutrients depending on the transplanted organs would be required.

1. Figueiredo F, Dickson ER, Pasha T, et al. Impact of nutritional status on outcomes after liver transplantation. Transplantation 2000;70:1347-52.
2. Chon YN, Chang HW, Kim JH, Lee MD, et al. Nutritional status of the organ transplantation patients. Presented at the 11th PENSA Congress, Oct. 1-4, 2005, Seoul, Korea
3. Kim JH, Ko KM, SJ Ko, Lee MD, et al. Preopertive nutritional status and length of stay in hospital of the organ transplantation patients. Presented at the 11th PENSA Congress, Oct. 1-4, 2005, Seoul, Korea
4. Lee MD, Kim YK, Park SK, Kim IC, et al. Instant Nutritional Score and prognosis of critically ill surgical patients. J Kor Surg Soc 1994: 47(6): 803-10.

From  
The 11^th PENSA Congress
October 1-4 2005, Sheraton Grande Walkerhill Hotel, Seoul, Korea. 
Page: 111