No adverse events occurred with the implementation of bedside feeding tube placement using an ETPD. In addition, SBFT placement with an ETPD by designated ICU RD/RN teams resulted in lower x-ray costs and more timely initiation of enteral feedings compared with blind placement.
Bariatric surgery (BS) is effective in treating morbid obesity, but the impact of prior BS on candidacy for liver transplantation (LT) is unclear. We examined 78 patients with cirrhosis with prior BS compared with a concurrent cohort of 156 patients matched by age, Model for End‐Stage Liver Disease score, and underlying liver disease. We compared rates of transplant denial after evaluation, delisting on the waiting list, and survival after LT. The median time from BS to LT evaluation was 7 years. Roux‐en‐Y gastric bypass was the most common BS procedure performed (63% of cohort). Nonalcoholic fatty liver disease was the leading etiology for liver cirrhosis (47%). Delisting/death on the waiting list was higher among patients with BS (33.3% versus 10.1%; P = 0.002), and the transplantation rate was lower (48.9% versus 65.2%; P = 0.03). Intention‐to‐treat (ITT) survival from listing to 1 year after LT was lower in the BS cohort versus concurrent cohort (1‐year survival, 84% versus 90%; P = 0.05). On adjusted analysis, a history of BS was associated with an increased risk of death on the waiting list (hazard ratio [HR], 5.7; 95% confidence interval [CI], 2.2‐15.1), but this impact was attenuated (HR, 4.9; 95% CI, 1.8‐13.4) by the presence of malnutrition. When limited to matched controls by sex, mortality attributed to BS was no longer significant for females (P = 0.37) but was significant for males (P = 0.046). Sarcopenia, as captured by skeletal muscle index, was calculated in a subset of patients (n = 49). The total skeletal surface area was lower in the BS group (127 [105‐141] cm2 versus 153 [131‐191] cm2; P = 0.005). Rates of sarcopenia were higher among patients delisted after listing (71.4% versus 16.7%; P = 0.04). In conclusion, a history of BS was associated with higher rates of delisting on the waiting list as well as lower survival from the time of listing on ITT analysis. Presence of malnutrition and sarcopenia among patients with BS may contribute to worse outcomes.
Timely nutrition assessment and intervention in organ transplant recipients may improve outcomes surrounding transplantation. A pretransplant nutrition assessment should include a variety of parameters including physical assessment, history, anthropometric measurements, and laboratory tests. Malnutrition compromises posttransplant survival; prolonged waiting times worsen outcomes when patients are already malnourished. Severe obesity may decrease graft function and survival in kidney transplant recipients. In the pretransplant phase, nutritional goals include optimization of nutritional status and treatment of nutrition-related symptoms induced by organ failure. Enteral tube feeding is indicated for patients with functional gastrointestinal tracts who are not eating adequately. Parenteral nutrition is rarely needed pretransplant except in cases of intestinal failure. When determining pretransplant nutrient requirements, nutritional status, weight, age, gender, metabolic state, stage and type of organ failure, malabsorption, induced losses, goals, and comorbid conditions must be considered. During the acute posttransplant phase, adequate nutrition is required to help prevent infection, promote wound healing, support metabolic demands, replenish lost stores, and perhaps mediate the immune response. Nutrient recommendations reflect posttransplant metabolic changes. The appropriateness of posttransplant nutrition support depends on the prevalence of malnutrition among patients with a specific type of organ failure and the benefits when nutrition support is given. Organ transplantation complications including rejection, infection, wound healing, renal insufficiency, hyperglycemia, and surgical complications require specific nutritional requirements and therapies. Many potential applications of nutrition in the pre- and posttransplant phases exist and require further study.
Because of the global increase in prevalence of obesity, many more overweight and obese individuals are undergoing evaluation for transplantation than in the past. Although obesity seems to provide a survival benefit in dialysis patients, obesity has traditionally been considered a contraindication for transplantation of most organs. It is theorized that obesity will contribute to worse transplant outcomes, including lower rates of graft and patient survival and higher rates of delayed graft function and infection. This review evaluates the available literature evaluating outcomes of obese patients with end-stage organ failure who undergo transplantation. Obesity seems to be associated with increased rates of wound infection after transplantation. However, other adverse transplant outcomes related to obesity seem to be dependent on the type of organ being transplanted and the degree of obesity. For example, a body mass index (BMI) of 30 kg/m(2) may reduce short-term survival in lung transplant recipients; however, obesity does not seem to confer an adverse effect on short- or long-term survival in liver transplant patients until a much higher BMI is reached (such as 35 or 40 kg/m(2)). Each transplant center must determine weight guidelines and criteria for identifying the level of obesity as a contraindication for transplantation. This must be based on organ type, each center's transplant and complication statistics, and available donor pools. Guidelines must also consider the morbidity and mortality risks of the obese patient with organ failure who does not receive a transplant.
The coronavirus disease 2019 (COVID‐19) pandemic has impacted all aspects of our population. The “Troubling Trichotomy” of what can be done technologically, what should be done ethically, and what must be done legally is a reality during these unusual circumstances. Recent ethical considerations regarding allocation of scarce resources, such as mechanical ventilators, have been proposed. These can apply to other disciplines such as nutrition support, although decisions regarding nutrition support have a diminished potential for devastating outcomes. The principal values and goals leading to an ethical framework for a uniform, fair, and objective approach are reviewed in this article, with a focus on nutrition support. Some historical aspects of shortages in nutrition supplies and products during normal circumstances, as well as others during national crises, are outlined. The development and implementation of protocols using a scoring system seems best addressed by multidisciplinary ethics and triage committees with synergistic but disparate functions. Triage committees should alleviate the burdens of unilateral decisions by the healthcare team caring for patients. The treating team should make every attempt to have patients and the public at large update or execute/develop advance directives. Legal considerations, as the third component of the Troubling Trichotomy, are of some concern when rationing care. The likelihood that criminal or civil charges could be brought against individual healthcare professionals or institutions can be minimized, if fair protocols are uniformly applied and deliberations well documented.
Nutrition therapy is vital to the overall management of lung transplant recipients. The objective of this review is to outline the current applications of pre- and posttransplant nutrition management of the adult lung transplant recipient. Pretransplant nutrition therapy decisions are based on cause of end-stage lung disease, transplant indications, and pretransplant nutritional status. Maintaining adequate nutrient stores is the major goal of nutrition therapy for patients awaiting transplantation. In the posttransplant course, several gastrointestinal (GI) complications such as gastroesophageal reflux, gastroparesis, and distal intestinal obstruction syndrome complicate nutritional recovery. Long-term nutrition therapy for lung transplant recipients is aimed at management of common comorbid conditions such as obesity, diabetes mellitus, hypertension, osteoporosis, and hyperlipidemia. Lung transplantation outcomes are steadily improving; however, much has yet to be explored to improve the nutrition management of these patients in both the pre- and posttransplantation course.
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