Malnutrition in solid organ transplant

A solid organ transplant is a life-saving surgical intervention for people with end-stage organ failure. Malnutrition is commonly seen in both the pre-transplant and post-transplant populations. Undernutrition in the pre-transplant phase can prohibit candidacy on the transplant list due to its negative effect on surgical outcomes. However, the highest risk for malnutrition is seen in the immediate postoperative stage. Identification and correction of malnutrition is essential prior to organ transplant to foster a successful surgery and prevent the risk of organ rejection post-op.   

A variety of validated malnutrition screening tools may be used in this patient population. Most facilities opt to incorporate the adult malnutrition criteria as set forth by the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition. Specific complications associated with organ transplantation and immunosuppression therapy can put these patients at a higher risk of developing or worsening malnutrition. In fact, research has shown that nutrition interventions can significantly reduce the incidence of mortality and sepsis for patients with malnutrition during their hospital stay.   

The complications of malnutrition for hospitalized and immunocompromised patients are well-known including increased rate of mortality, longer hospital stay, decreased functional status, and an overall diminished quality of life. Within the transplant population, malnutrition can also contribute to frailty and the success of the newly transplanted organ.  

In the immediate post-operation phase after transplant surgery, general critical care nutrition guidelines are often most appropriate. Indirect calorimetry, when available, is preferred for assessing energy expenditure. As the patient progresses beyond the critical care phase, predictive energy equations are appropriate depending on the patient’s current medical status.   

Generally, patients have increased nutrition needs in the immediate postoperative period, in some cases, estimating as high as 130% of basal energy expenditure. Protein is essential for post-operative healing and recovery. Estimated protein needs can range from 1.5-2/kg/day using dry body weight in the postoperative period. Fluid needs may vary depending on the type of organ transplantation and the patient’s fluid balance post-op.

As in all critical-care patients, if an oral diet is not able to be pursued, enteral tube feeding is the next best option to promote gut integrity. It is important to keep in mind that many immunosuppression medications can be unkind to the gut. Medication side effects should be investigated further with the interdisciplinary team should any feeding intolerance occur. 

Long-term, transplant patients can follow an overall regular diet. The main diet component discussed prior to discharge is adequate intake of macronutrients and following food safety guidelines. Given the lifelong immunosuppression therapy, these patients are at a higher risk for foodborne illnesses. That said, the importance of following food safety procedures when selecting and preparing foods should be greatly encouraged and reinforced.  

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References

Lorden, H., Engelken, J., Sprang, K., Rolfson, M., Mandelbrot, D., & Parajuli, S. (2023). Malnutrition in solid organ transplant patients: A review of the literature. Clinical transplantation, 37(11), e15138. https://doi.org/10.1111/ctr.15138 

Hahn, M., Wood, A., Hasse, J. (2023). Nutrition support and management of organ transplant recipients in the acute transplant phase. Nutrition in clinical practice, 37(1), 24-58. https://aspenjournals.onlinelibrary.wiley.com/doi/abs/10.1002/ncp.11104 

Karim, A., Aliammal, M., Panhwar, M., Kalra, A. (2020). Impact of malnutrition and interventions on patients receiving heart transplant. The journal of heart and lung transplantation, (39)4, S256-S257. https://www.jhltonline.org/article/S1053-2498(20)30573-8/abstract 

Academy of Nutrition and Dietetics.(2024). Organ Transplant. Nutrition Care Manual. https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=17138&ncm_heading=Nutrition%20Care&ncm_toc_id=17138