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TRANSCRIPT
Optimizing The Transplant Patient From a
Nutritional Perspective: BMI
Kristen Welch, RDN, CD, CNSC
Abdominal Transplant Dietitian
June 11, 2019
Objectives
1. Discuss patient-centered strategies to optimize the nutrition of
the renal transplant patient with a high BMI
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Obesity and BMI
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CDC Prevalence of Self-Reported Obesity 2011
Obesity and BMI
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CDC Prevalence of Self-Reported Obesity 2017
CDC Prevalence of Self-Reported Obesity by State and
Territory 2017
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Summary
No state had a prevalence of obesity less than 20%.
2 states and the District of Columbia had a prevalence of obesity between 20% and <25%.
19 states had a prevalence of obesity between 25% and <30%.
22 states, Guam, and Puerto Rico had a prevalence of obesity between 30% and <35%.
7 states (Alabama, Arkansas, Iowa, Louisiana, Mississippi, Oklahoma, and West Virginia) had a prevalence of obesity of 35% or greater.
BMI: recognized by the WHO and CDC
● Memory jogger: WHO Classification of Weight Status
https://www.nhibi.nihgov
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BMI Clinical Guidelines
< 18.5 Underweight
18.5-24.9 Normal
25-29.9 Overweight
> 30-34.9 Obese, class I
> 35-39.9 Obese, class II
> 40 Extreme obesity, class III
BMI and Obesity
Why is obesity and BMI important to transplant?
Obesity impacts post transplant outcomes…
● Allograft function
○ Increased risk of vascular complications
○ Delayed graft function
○ CKD s/p renal transplant
○ Impacts graft survival
● Wound
○ Infection
○ Hematoma
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Obesity and BMI
● Systemic
○ Higher incidence of thrombolic events
○ Hospital re-admissions
○ Sepsis
○ Patient Death
○ New Onset Diabetes After Transplant (NODAT)
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Post Transplant Weight Gain
● Occurs in 30 % of post transplant patients
● Increases in both BMI and total fat mass can occur in the
first 12 months following transplant
● Weight gain may occur as a result of
○ Improved health and feelings of wellness
○ Hyperphagia
○ Initial inactivity
○ Pharmacological
○ “Going rogue”
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Getting Patients to Listing and Beyond…
Key Players…
● Physicians
● Physician extenders
● ٭ Dialysis teams ٭
● Transplant team Dietitian, Medical Assistants, Social
Services, Pharmacy, Administration Assistants, Financial,
Nursing Coordinators.
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St. Vincent Abdominal Transplant Protocol: Setting
the Patient Up for Success
BMI Guidelines: one size does not fit all, programs should
determine what BMI/adiposity is optimal for their center
St. Vincent Abdominal Transplant Guidelines:
● Engagement begins at a BMI of at or less than 42
● Listing begins at a BMI of at or less than 39.5
● Optimal BMI at time of transplant 35
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Maximizing Nutrition
Dietitian Role: Engagement (BMI 39.5 – 42)
● Patients meet with the Registered Dietitian and complete a
full nutrition assessment
● Nutritional and weight management goals are planned and
provided to the patient
● Written materials/resources are provided to the patient
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Maximizing Nutrition
Dietitian Role: Listed (BMI < 39.5)
● Patients meet with the Registered Dietitian annually and
complete a full nutrition assessment
● Nutritional and weight management goals are planned and
provided to the patient (step down approach/39.53735)
● Written materials/resources are provided to the patient
● Dietitian will follow up for progress at 3 and 6 month intervals
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Maximizing Nutrition
Nutrition interventions:
● Diet modification
○ Modified for renal disease
Mediterranean Diet
DASH Diet
The Transplant Plate
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Maximizing Nutrition
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Maximizing Nutrition
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Maximizing Nutrition
Nutrition Interventions
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● Medical and surgical weight loss options
● Mobile Device Apps○ Foodlogger, Pinto, Care after Kidney Transplant, MyFood Coach, My Fitness Pal, Restaurant Nutrition
SUMMARY
Set patients up for success:
● Engage!
● Step down, achievable goals
● Structured surveillance
● Multidisciplinary approach
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Success
41 year old female
Engagement 9/27/2017: BMI 40.8
Initial Assessment 6/05/2019: BMI 34.3
What the patient said:
● Kindness
● Truthfulness
● Plan
● Empowered
● Appreciation
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References
1. Lentine K, Delos-Santos R, Axelrod D. Schnitzler M, Brennan D, Tuttle-Hewhall J. Obesity and Kidney Transplant
Candidates: How Big is too Big for Transplantation? Am J Nephrol. 2012;36:575-586.
2. Meier-Kriesche, Herwi-Ulf, Arndodrder, J, Kaplan B. The Impact Of Body Mass Index On Renal Transplant
Outcomes: A Significant Independent Risk Factor For Graft Failure And Patient Death. Transplantation.
2002;73(1):70-74.
3. Gore J, Pham P, Danovitch G, Wilkinson A, Rosenthal J, Lipshutz G, Singer J. Obesity and Outcome Following
Renal Transplantation. Am J Transplantation. 2006;6:357-363.
4. Curran S, Famure O, Li Y, Kim S. Increased Recipient Body Mass Index Associataed with Acute Rejection and
Other Adverse Outcomes After Kidney Transplantation. Transplantation 2014;97:64-70.
5. Chakkera HA, Weil EJ, Pham PT, Pomeroy J, Knowler WC. Can new-onset Diabetes after transplant be prevented?
Diabetes Care. 2013;36:1406-1412.
6. Pantik C, Young-Eun C, Hathaway D, Tolley E, Cashion A. Characterization of Body Composition and Fat Mass
Distribution 1 Year After Kidney Tranplantation. Progress in Transplantation. 2017;27(1):10-15.
7. MacLaughlin H, Cook S, Kariyawasam D, Roseke M, van Niekerk M, Macdougall I. Nonrandomized Trial of Weight
loss With Orlistat, Nutrition Education, Diet, and Exercise in Obese Patients With CKD: 2-Year Follow-Up. AJKD.
2009; doi:10.1053/j.ajkd.2009.09.011.
8. Humayun Y, Ball K, Lewin J, Lerant A, Fulop T. Acute oxalate nephropathy associated with orlistat. J Nephropathol.
2016;5(2):79-83.
9. Kim Y, Jung AD, Dhar VK, Tadros JS Schauer DP, Smith EP, Hanseman DJ,Cuffy MC, Alloway RR, Shields AR,
Shah SA, Woodle ES, Diwan TS. Laparoscopic Sleeve Gastrectomy Improves Renal Transplant Candidacy and
Post-Transplant Outcomes in Morbidly Obese Patients. Am J Transplant. 2017. doi 10.1111/ajt.14463.
10. Csaba P. Kovesdy, Susan L. Furth and Carmine Zoccali. Obesity and Kidney Disease: Hidden Consequenes of the
Epidemic. Canadian J Kidney Health and Disease. 2017;4:1-10.
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