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Summer 1996Volume 3, Number 1 |
Malnutrition is common among organ transplant recipients and adversely affects transplant outcomes by prolonging hospital stays and increasing costs.1,2 Perioperative nutrition provides nutrients to meet patients' requirements for energy and healing. With the exception of kidney transplant patients, transplant recipients often are unable to consume adequate calories and protein for 5-10 days following surgery, despite being allowed to eat within three days postoperatively. Specialized nutrition support is required by approximately the fifth postoperative day for those patients who are unable to eat or when it is apparent that a patient will not be able to consume adequate amounts of nutrients from an oral diet. If a patient has a history of poor intake pretransplant or is severely malnourished, it is beneficial to initiate nutrition support earlier.
When nutrition support is required, tube feeding (TF) is preferred over total parenteral nutrition (TPN) for several reasons. Compared with TPN, TF preserves gut mass,3 attenuates the injury stress response,4 and maintains immunocompetence.5 Bacterial translocation, a process whereby indigenous bacteria colonizing the gut relocate extraluminally to mesenteric lymph nodes and systemic organs, can occur as a result of disruption in gut integrity, bacterial overgrowth in the gut, or impairment in the systemic and/or gut immune response.6 Although controversy exists as to the clinical significance of bacterial translocation in humans, TF reduces overall infection rates compared with TPN.7,8 Also, TF costs about one-eighth as much as TPN. The indications for tube feeding in transplant patients are listed in the table below.
INDICATIONS FOR TUBE FEEDING IN TRANSPLANT PATIENTS
- Inability to eat
- Ventilator dependency
- Additional surgery
- Altered mental status affecting ability to eat
- Diminished nutrient intake
- Anorexia
- Dysgeusia from medications
- Gastrointestinal problems including nausea, vomiting, diarrhea, and distention
- Increased nutrient requirements
- Hypermetabolism
- Nitrogen loss caused by surgery and corticosteroid administration
- Malabsorption
Patients are commonly selected for post-transplant TF on the basis of preexisting malnutrition or poor pretransplant nutrient intake. Posttransplant recovery in many organ transplant recipients is unpredictable, however, and well-nourished patients can suffer from postoperative complications that necessitate nutrition support as often as malnourished patients. Because it is difficult to predict which patients will have posttransplant problems, and several studies have shown positive outcomes from early (<48 hours) postoperative TF in other surgical populations, early posttransplant TF should be considered for transplant patients because nutritional inadequacy represents a frequent problem.
Three studies have investigated the role of early posttransplant TF among liver transplant recipients. In the first study, investigators randomly assigned 24 liver transplant patients to receive either enteral or parenteral nutritional support following transplantation.9 Fourteen patients began receiving tube feedings via a nasojejunal tube 18 hours after surgery, and TPN was initiated within 60 hours following transplantation in 10 patients. An equal amount of time was required for both patient groups to begin eating. No significant differences in anthropometric measurements, intestinal absorptive capacity, or infection rates were seen between the two groups.
Another transplant group retrospectively reviewed the experiences of 108 of their patients who had jejunostomy tubes placed while undergoing liver transplant surgery.10 These investigators concluded that jejunostomy tube feeding was well tolerated and reduced postoperative ileus and the need for TPN. However, complications related to the jejunostomy tube occurred in 16 patients, and surgery was required to correct these complications in seven cases.
Finally, we prospectively randomized 31 liver transplant patients to receive either immediate posttransplant TF or intravenous hydration.11 Tube feeding was initiated 12 hours posttransplant in 14 liver transplant patients via a nasointestinal tube, which did not cause any major complications. All patients began eating by approximately the third postoperative day. Tube-fed patients had superior nutrient intakes for the first 5 to 6 days posttransplant and better nitrogen balance on day 4 posttransplant. Viral infections occurred in 17.7% of control patients compared with 0% of TF patients (p=0.05). In addition, there was a trend for fewer tube-fed patients to have a bacterial or any type of infection compared with controls.
Adequate nutrition is vital for the recovery of transplant recipients. When oral feedings are not feasible or adequate, enteral feeding is preferred over TPN. Placement of nasointestinal feeding tubes during surgery alleviates problems and delays in providing enteral feeding access during the immediate posttransplant period. Early posttransplant TF via nasointestinal tubes is a low-risk, low-cost option and should be considered for patient groups in which adequate nutrition is frequently problematic.
Jeanette Hasse, PhD, RD
Baylor Institute of Transplantation Sciences
Baylor University Medical
Center
Dallas, Texas
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