Needs of Transplant Patients Challenge Food Professionals

Currently nearly 120,000 people are waiting for an organ transplant. Of these people, approximately 81% need a kidney transplant, a surgical procedure with excellent survival rates.

Rejection and infection are the two greatest challenges with organ transplants. Clinical intervention following rejection requires critical assessment of an array of modalities or therapeutic algorithms prior to introducing an immunosuppression regimen (Lucey et al., 2012). Sepsis management following liver transplant is most challenging since infection is the primary cause of post-transplant death. Interventions to reduce severe infections call for a combination of treatments (Dellinger et al., 2008).

Ischemia reperfusion injury is another major hurdle in tissue resection and organ transplant (Datta et al., 2013). Restoration of blood flow to tissues initiates a cascade of metabolic events, including the generation of reactive oxygen species (ROS). ROS and other reactive metabolites, such as advanced glycation endproducts (AGE) through receptor for advanced glycation endproducts (RAGE), can contribute to significant tissue injury shortly following reperfusion (Brenner et al., 2013; Fleming et al., 2011).

Numerous animal studies that examined ischemia and reperfusion-induced injury reveal imbalance of antioxidant compounds related to ROS may be central to the inflammatory injury process (Hines & Grisham, 2011). Other research findings suggest excessive expression of NF-κB and other cytokines along with other inflammatory mediators modulate ischemia and reperfusion insult, at least in animal models (Wang et al., 2006). Experimental models to minimize this insult suggest a reduction of oxidative stress may be possible through the enteral introduction of grape seed extract (Sehirli et al., 2008), bilberry (Jakesevic et al., 2013), Acanthopanax divaricatus extract (Lim et al., 2013), and hydrolyzed whey peptide (Hanaoka et al., 2013). However, none of these observations has translated to clinical relevance. From a pharmaceutical  perspective, an alternative to nutritional intervention may be the development of antagonists to AGE production and or introduction of RAGE blockers (Chen et al., 2013; Yamagishi & Mitsui, 2011).

Personal clinical experience in the early 1980s at Children’s Hospital of Los Angeles within the pediatric gastroenterology department suggests the introduction of fish oil, vitamin E, and even dietary fiber may reduce complications associated with cholestasis and improve enterohepatic circulation. These observations have been reaffirmed in several rodent models (Depner et al., 2013; Parnell et al., 2012). More contemporary observations indicate these nutritional interventions can improve liver function in humans, particularly among those diagnosed with nonalcoholic steatohepatitis or nonalcoholic fatty liver disease (Hoofnagle et al., 2013), both of which are common complications with liver transplants (Mouzaki & Allard, 2012).

Nutrition therapy for patients with endstage liver disease or recipients of an organ transplant is frequently compromised due to their initial nutritional status. Recent evidence suggests that nearly 70% of these patients presented vitamin A deficiency, and about 81% were vitamin D deficient (Venu et al., 2013). Approximately 97% of these patients were normal for vitamin E status, however. These observations stress the importance of specialized nutrition for rehabilitation support of patients prior to liver transplantation. Nutrition support or dietary therapy depends on factors including clinical history, genetics, and anthropometrics. Ultimately, a specialized nutrition support regimen should be designed to optimize metabolism, restore deficient nutrients, maintain adequate muscle and fat stores, and promote weight loss in obese patients (Weseman et al., 2012). This support is critical to reduce the risk of malnutrition, lower inflammation, assure adequate growth and quality of life, and avoid infection prior to liver transplant.

Current information from animal models suggests dietary components and specific foods along with lowering environmental pollutants and microbial toxin or even airborne particulate exposure may be important to optimize metabolic and immune function, reduce inflammation, and reduce the risk of perioperative liver dysfunction (Zheng et al., 2013; Mikaqi et al., 2011). In addition to improving patient outcomes, well-designed enteral feeds for these patients may be cost-effective by reducing hospital stay, presenting fewer complications, and improving cost-benefits (Abunnaja et al., 2013). However, a recent analysis of the potential health benefits of enteral immunonutrition or the use of dietary supplements among those with liver disease (Korestz et al., 2012) indicates inconsistent results among liver transplant patients (Langer et al., 2012).

These inconsistencies and the growing wait list for liver transplantation emphasize the importance of efforts in the food science, nutrition, medicine, and health continuum to design, develop, and deliver enteral products that meet the variable nutritional needs of these patients.

Roger Clemens, Dr.P.H., CFS,
Contributing Editor
Chief Scientific Officer,
Horn Company, La Mirada, Calif.
[email protected]