The document presents a clinical case study of a 30-year-old female patient, Madison Lupul, admitted for multivisceral transplantation at the University of Alabama at Birmingham. It details her medical history, clinical course, nutritional assessment, medication implications, and post-transplant dietary recommendations, emphasizing the importance of monitoring and managing her nutritional status and medication interactions. The care plan includes dietary education and strategies to address nutrient deficiencies and prevent complications post-surgery.

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