Case study presentation on I patient I had the opportunity to follow during my clinical rotations at UAB Hospital.

1. CLINICAL CASE STUDY
PRESENTATION: ABTX
Maddison Lupul, BSc
NUTR 589 Fall 2018 - Clinical Supervised Practice
University of Alabama at Birmingham - Department of Nutritional
Sciences

2. AGENDA
 Case Presentation
 Clinical Course Summary
 Research Article Review
 Assessment
 Medications
 Nutritional Implications
• Post-transplant
• Nutrition Support
• Medical Hx
• Surgical Hx
 Diagnosis
 Intervention
• Plan & Recommendations
• Counselling & education
 Monitoring & Evaluation

3. CASE PRESENTATION

4. INTRODUCTION:
30yoF admitted to UABH for multivisceral Tx currently in
post-operative recovery.
PMH (prior to admission):
• Ehler’s Danlos Syndrome
• Cystic Fibrosis
• Iron-Deficiency Anemia
• Gastric dysmotility
• Pancreatectomy with autologous islet cells Tx. (2012)
• Gastrojeujenal ulcer w/ hemorrhage s/p small bowel sectioning
(2015)
• Colonic Inertia s/p subtotal Colectomy (2017)

5. CLINICAL COURSE SUMMARY:
• Admitted to UAB – 08/07/2018
• Subtotal Multi-visceral TX (SICU) – 08/20
• Partial stomach, partial small bowel, liver and pancreas
• Transferred to ABTX – 08/27
• Transferred back to SICU – 9/10
• Embolization of L-gastric artery
• Transferred back to ABTX - 9/24
• PICC line placement -10/18

6. GASTROINTESTINAL TX: 1,2
Types of Gut Tx:
• Depends on etiology of intestinal failure, organ functional status, and surgical history
• Isolated small bowel transplant
• Liver-small bowel combined transplant
• Multivisceral transplant (stomach, small bowel, pancreas and liver
Who is Candidate?
• Failure of PN resulting from hepatic failure, frequent sepsis, frequent dehydration despite IVF therapy.
• Various conditions affecting nutrient absorption
• Short bowel syndrome**, tumors, congenital mucosal disorders
• Patients with intestinal failure with poor tolerance to PN
• Frequent hospitalization, narcotic dependence
• Patient not willing to accept long term PN – younger patients.
Prevalence: ~10-20,0000 peopled in the US diagnosed with short bowel syndrome.
(Crohn’s colitis foundation) 14

8. ARTICLE REVIEW 3

9. ASSESSMENT
Anthropometric:
• Admit BW: 79.3kg
• CBW: 69.5kg (~12% wt.
loss)
• Ht 178cm
• BMI 21.5
Clinical Findings:
• 2-5 episodes emesis
• Ileostomy 250mL
• UOP 1450mL
• Thin, pale appearance
Nutrition:
• 1960 - 2262 kcal (BEE x 1.3-1.5)
• 83 – 104 g protein (1.2-1.5g/kg)
• Fluids: ~ 1800 – 2300 mL (1mL/kcal)
• TPN: Not ordered but has PICC insertion
• PO: 40mEq potassium diet order
Labs:
• K 5.9 ↑
• LFTS ↑ (consistent w/ pain meds)
• RBC/Hct/Hgb/MCV ↓
• Glu 98

10. ASSESSMENT
Subjective:
Per mother’s report: “appetite has been great. I
usually bring her food and she will eat it most all of
it. The other day I brought her a turkey avocado
sandwich from Jimmy John’s. She ate 4 hard boiled
eggs and a sausage patty the other morning from
the hospital cafeteria. She also loves eating
strawberries.”

11. NUTRITIONALLY PERTINENT MEDS
Class Drug Nutritional Implications
Prednisone4
(Glucocorticoid)
• Opposes action of insulin  Hyperglycemia
• ↑ gluconeogenesis, ↑ catabolism
• Hyperphagia, Hyperlipidemia
• Calcinuria  osteopenia/osteoporosis
Tacrolimus4
• HTN, Hyperlipidemia, Hyperkalemia
• Grapefruit juice interferes with pharmacokinetics/
pharmacodynamics
Dapsone5 • Depletion of gut flora
• Depletion of potassium, vitamin K and various B-vitamins
• Reduced bioavailability of mg and znCeftriaxone6
Iron Sucrose • Replenishment of depleted stores or blood levels associated with
deficiency
• Excess administration may lead to toxicityMagnesium
Oxide
Abx
Immuno-
SuppressionMinerals

12. NUTRITIONAL IMPLICATIONS

13. POST TRANSPLANT 4,7
Primary Objective: Prevent rejection, infection, and other complications.
Short term:
• Emphasis on healing from surgery, maintaining immunity, energy replenishment
• Potential complications from drug-nutrient interaction
• Particularly related to elevated blood glucose, hyper-catabolism and vulnerability to
infection.
• Increased energy/protein needs: BEE x 1.3-1.5/1.2-2.0 g/kg
Long term:
• Focus on immune system support.
• Immune suppressants weaned over time but still risk for rejection.
• Important to practice food safety due to compromised immune function
• Some pts are at risk for obesity and other comorbidities from medication use
• HTN, HLD, DM
• Weight maintenance or loss if needed
• 0.8-1.2g protein/kg with <30% of fat kcal

14. NUTRITION SUPPORT4

15. MEDICAL HX
Cystic Fibrosis:8
• Genetic condition characterized by excessive of phlegm production in body’s secretory
glands. Particularly in the lungs, sinuses, liver, pancreas, and GI tract.
• S/S: difficulty breathing, coughing, frequent respiratory infections, salty skin, stool abnormalities from poor
nutrient digestion, altered metabolism from decreased pancreatic function.
• SOB, infections and pancreatic insufficiency can lead to nutrition risk.
Ehler’s Danlos Syndrome: 10
• Inherited disorder characterized by weakened fabrication of body’s connective
tissues
• S/S: Joint hypermobility, stretchy and fragile skin and other tissues.
• Complications: Early onset arthritis; joint dislocations; in severe cases, rupturing
of blood vessels and other organs like the intestines.
Iron Deficiency Anemia (Microcytic, Hypochromic): 9
• ↓ RBCs, ↓Oxygen carrying capacity for cellular metabolism.

16. SURGICAL HX
• Risk of Organ Rejection  Most acute rejections occur within 3mos of tx
 nutrient deficiency from poor nutrient
digestion/absorption
 altered nutrient metabolism
• Cholecystectomy  Bile can have laxative effect due to being less concentrated and
draining more continuously into small bowel. 11
• Decreased nutrient uptake
• Chronic diarrhea
• Ileostomy  Accelerated transit time can lead to poor nutrient and fluid absorption.
12
• Small, frequent meals. Sip on fluids throughout the day.
 Increased gas production and discomforts from foods may decease

17. DIAGNOSIS

18. PES STATEMENTS
• Increased protein needs RT post-transplant therapy AEB
high dose administration of immunosuppressive drugs
and 12% weight loss in last 2 months.
• Excessive potassium intake RT unsupported
beliefs/attitudes about food drug interaction AEB
frequent consumption of high potassium foods
alongside high dose Tacrolimus administration and
elevated blood potassium.

19. INTERVENTION

20. PLAN & RECOMMENDATIONS
• Encourage oral intake.
• Order supplement: Ensure High Protein (160kcal, 16g protein,170mg potassium)
• Inform patient and mother on compliance to prescribed diet order.
• Outline effects of increased potassium intake with prescribed meds.
• Explain different types of foods patient can eat and should avoid.
• Consider nausea meds if emesis persists.
• Recommend therapeutic multivitamin to ensure 100% of RDIs are met.
• Consider PN if patient shows signs/symptoms of poor nutrient
absorption related to organ rejection,
• Correct electrolytes as needed. Noted ↑ potassium.
• Continue iron supplement to help correct anemia

21. EDUCATION & COUNSELLING 4,13
Pertinent nutrition topics:
• Post transplant diet
• No grapefruit
• Low microbial diet
• Food safety
• Eating for weight maintenance
• Consider patient’s BMI and dx of cystic fibrosis.
• Dietary minerals and/or supplementation
• Calcium, iron
• Blood sugar management.
• Provide resources for outpatient counselling if needed.

22. MONITORING/EVALUATION

23. Subjective:
• Evaluation of patient and mother’s agreement and understanding of
potassium restricted diet during hospital stay.
• Evaluation of patient’s potassium intake in one week follow up if still
admitted.
• Evaluation of patient and mother’s understanding to diet educations given
prior to discharge.
Objective:
• Monitor patient’s weight daily. Goal is to avoid weight loss.
• Monitor electrolytes. Goal is for serum potassium to decrease.
• Monitor blood glucose. Goal is for blood glucose to remain stable.
• Monitor patient for GI abnormalities.

24. ACKNOWLEDGEMENTS
• University of Alabama at Birmingham
Department of Nutritional Sciences
• University of Alabama at Birmingham Hospital
Department of Clinical Nutrition
• Judy Walthaw RD, LD
• Sarah Martin RD, LD, MSc

25. RESOURCES
1. Matarese, L. E., Costa, G. , Bond, G. , Stamos, J. , Koritsky, D. , O'Keefe, S. J. and Abu‐Elmagd, K. (2007), Therapeutic Efficacy of Intestinal and
Multivisceral Transplantation: Survival and Nutrition Outcome. Nutr Clin Pract, 22: 474-481. doi:10.1177/0115426507022005474
2. Bharadwaj S, Tandon P, Gohel TD, et al. Current status of intestinal and multivisceral transplantation. Gastroenterology Report. 2017.
doi:10.1093/gastro/gow045.
3. Rovera G, Schoen R, Goldbach B, et al. Intestinal and multivisceral transplantation: dynamics of nutritional management and functional
autonomy. Journal of Parenteral and Enteral Nutrition. 2003;27(4):252-259. doi:10.1177/0148607103027004252.
4. Mueller C. The ASPEN Adult Nutrition Support Core Curriculum. Vol Third edition. Silver Spring, MD: American Society for Parenteral and
Enteral Nutrition; 2017. http://search.ebscohost.com.ezproxy3.lhl.uab.edu/login.aspx?direct=true&db=nlebk&AN=1831579&site=ehost-
live. Accessed November 4, 2018.
5. Dapsone Drug Information. kaiserpermanente.org . https://wa.kaiserpermanente.org/kbase/topic.jhtml?docId=hn-1131009. Reviewed
March 2015.
6. Ceftriaxone Drug Information. kaiserpermanente.org . https://wa.kaiserpermanente.org/kbase/topic.jhtml?docId=hn-10000722. Reviewed
March 2015.
7. Rutledge L. Renal Disease and Transplantation. UAB Department of Nutritional Sciences Core Curriculum: Principles and Practices of
Nutrition Support . October 2018.
8. Cystic Fibrosis . MedlinePlus. https://medlineplus.gov/cysticfibrosis.html. Published August 1, 2018.
9. Rutledge L. Nutritional Anemias. UAB Department of Nutritional Sciences Core Curriculum: Principles and Practices of Nutrition Support .
September 2018.
10. Ehlers-Danlos syndrome. U.S. National Library of Medicine. https://ghr.nlm.nih.gov/condition/ehlers-danlos-syndrome. Published October
2018.
11. Cholesystectomy and Diet. Mayo Clinic. https://www.mayoclinic.org/tests-procedures/cholecystectomy/expert-answers/gallbladder-
removal-diet/faq-20057813. Published May 30, 2018.
12. Ileostomy and diet. MedlinePlus. https://medlineplus.gov/ency/patientinstructions/000070.htm. Reviewed December 2016.
13. Organ Transplant . Nutrition Care Manual. https://www.nutritioncaremanual.org/auth.cfm?p=/index.cfm?&err=NotLoggedIn. Updated
2018

26. QUESTIONS