Transplantation

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Organ transplant patients are sometimes at the extreme end of the nutritional status spectrum. Not only have they endured years of suffering from chronic disease, but they are subjected to a surgical procedure and great risks of complications from immunosuppressive drugs. Malnutrition is often present in end-stage disease patients; it is associated with an increased post-transplantation risk of infection, and it may reduce survival.

Malnutrition is common in patients awaiting liver transplantation and may contribute to operative and postoperative mortality, although this is controversial. Pikul and colleagues found that 60% of liver transplant patients were moderately to severely malnourished and had longer intensive care and hospital stays than better nourished patients [122]. Using triceps skinfold and midarm muscle circumference, Harrison et al. reported that malnourished subjects had more cases of bacterial infections and had a reduced 6-month survival [123]. In describing her earlier work with more than 1,200 liver transplant patients, Hasse reported that although there was less frequent transplant rejection in the severely malnourished patients, there was no effect of malnutrition on post-transplant infection rates. One- and three-year graft and patient survival rates were lower in severely malnourished patients than in well-nourished patients [124].

Much as in patients with chronic pulmonary or chronic kidney diseases, low BMI [125] and hypoalbuminemia [126] are associated with increased morbidity and decreased survival in lung transplant and kidney-pancreas transplant recipients. Malnutrition is seen in up to 60% of patients seeking lung transplantation [127]. Post-transplant weight gain may improve survival in this population [128], while transplantation may reverse malnutrition [129].

In transplantation patients, nutritional assessment and education are beneficial in both the pre- and post-transplantation periods [124]. Nutritional support can prevent continued symptoms of end-stage organ failure by, for example, implementing dietary sodium restriction and fluid retention in ESRD patients or branched-chain amino acids supplementation in patients with severe cirrhosis. A small intervention study using oral supplementation in liver transplant candidates reported that the benefit in reducing the frequency of hospitalizations before transplantation could be partly due to increased energy consumption [130]. The post-transplant nutritional goal is to provide adequate nutrition to promote wound healing and anabolism, to prevent infection, and to minimize side effects of medications. Nutritional intervention is documented to be able to provide adequate nutrition and to treat underlying malnutrition, but it is also important to prevent excessive weight gain, as both malnutrition and obesity significantly affect morbidity and length of hospital stay after transplantation [131].

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