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Owner's Manual: Nutrition Care for Your Kidney Transplant

  • Nava Billet Teger
    Correspondence
    Address correspondence to Nava Billet Teger, MS, RD, CDN, Clinical Nutrition Coordinator, Liver Transplant and Living Donor, Mount Sinai Medical Center, 1 Gustave L. Levy Place, New York, NY 10029-6574.
    Affiliations
    Clinical Nutrition Coordinator, Liver Transplant and Living Donor, Mount Sinai Medical Center, New York, New York
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      Intended Audience: Kidney Transplant Patients, Practitioners

      Chronic kidney failure is well known to have a detrimental impact on nutritional status, and in particular, patients with end-stage renal disease (ESRD) are at increased risk for malnutrition.
      • Chan M.
      • Patwardhan A.
      • Ryan C.
      • et al.
      Evidence-based guidelines for the nutritional management of adult kidney transplant recipients.
      Renal transplantation is the preferred treatment for ESRD, but the procedure can have increased risks with critical nutritional challenges related to recovery from major surgery, immune-suppressive pharmacotherapy, or preexisting comorbidities.
      • Veroux M.
      • Corona D.
      • Sinagra N.
      • et al.
      Nutrition in kidney transplantation.
      The guidance of a registered dietitian is required by the Centers for Medicare and Medicaid Services for patients in advance of the renal transplantation procedure and as needed throughout the process.
      Center for Medicare and Medicaid Services
      Organ transplant interpretive guidelines update.
      Many ESRD patients are nutritional compromised and can optimize recovery from the transplantation procedure in conjunction with adherence to dietary recommendations under the guidance of a registered dietitian. Because recovery of renal function after successful renal transplantation generally leads to improvement in nutritional status, it is often assumed that nutritional intervention is not needed in the posttransplant phase.
      • Chan M.
      • Patwardhan A.
      • Ryan C.
      • et al.
      Evidence-based guidelines for the nutritional management of adult kidney transplant recipients.
      • Martins C.
      • Pecoits-Filho R.
      • Riella M.C.
      Nutrition for the post-renal transplant recipients.
      It is important for patients to understand, however, that renal transplantation comes with its own set of nutritional risks.
      • Chan M.
      • Patwardhan A.
      • Ryan C.
      • et al.
      Evidence-based guidelines for the nutritional management of adult kidney transplant recipients.
      Even as it should result in nutritional improvement, appropriate nutritional interventions after surgery are associated with improved health and quality of life.
      • van den Ham E.C.
      • Kooman J.P.
      • van Hoof J.P.
      Nutritional considerations in renal transplant patients.
      • Phillips S.
      • Heuberger R.
      Metabolic disorders following kidney transplantation.
      The focus of this article is on the often overlooked posttransplant phase and recommended nutritional “best practices” in patient status after a successful renal transplant procedure. Different guidelines are needed in the case where there is postoperative rejection. There are several short term and long term health and medical risks that are notable in patients after renal transplantation. These are due to a variety of factors. Patients are at risk for pharmacological factors, which include potential reactions to anti-rejection medications. Pre-existing comorbidities and sedentary lifestyle also factor into posttransplant risk. In addition, improved appetite and metabolic changes associated with successful renal transplantation can lead to risks if the diet is unregulated by nutrition interventions. To highlight a few complications that are specific risks for posttransplant patients, there is increased risk for weight gain and obesity, posttransplant insulin resistance (or drug-induced diabetes from steroids), hypertension, hyperkalemia, cardiovascular disease, bone disease, and food-borne infection (related to immune-suppressing medication).
      • Chan M.
      • Patwardhan A.
      • Ryan C.
      • et al.
      Evidence-based guidelines for the nutritional management of adult kidney transplant recipients.
      • Anderson C.
      • Nguyen H.
      • Rifkin D.
      Nutrition intervention in chronic kidney disease.
      In all these cases, nutrition (along with adequate physical activity) can be a first-line modifiable intervention for management or prevention.
      • Anderson C.
      • Nguyen H.
      • Rifkin D.
      Nutrition intervention in chronic kidney disease.
      Diet therapy approaches vary slightly from acute posttransplant phase to chronic posttransplant phase. The early phase after transplantation (4-6 weeks postoperatively) needs to focus on optimizing nutrition for the patient who enters transplant surgery in a malnourished state and addresses provision of adequate nutrients for postoperative catabolism.
      • Phillips S.
      • Heuberger R.
      Metabolic disorders following kidney transplantation.
      During this period, nutrition intervention should focus on recovery. Patients who have developed malnutrition from being on dialysis or from a prolonged uremic state are at higher risk for complications postsurgically. The focus for these individuals is on gaining adequate nutrition with a functional organ and to successfully recover muscle mass and fat losses.
      • Anderson C.
      • Nguyen H.
      • Rifkin D.
      Nutrition intervention in chronic kidney disease.
      There is also some risk for obese patients, but effortful weight loss is not a focus at this stage. Recommended nutrient needs for energy are 30-35 kcal/kg/day and 1.2-2.0 g of protein/kg/day.
      • Anderson C.
      • Nguyen H.
      • Rifkin D.
      Nutrition intervention in chronic kidney disease.
      • McCann L.
      Pocket Guide to Nutrition Assessment of the Patient with Kidney Disease: A Precise Resource for Comprehensive Nutrition Care in Kidney Disease.
      As far as the chronic post-transplant maintenance (beyond the first 6 weeks), a general healthy diet is the appropriate approach, with an emphasis on disease prevention.
      • Zeltzer S.M.
      • Taylor D.O.
      • Tang W.
      Long-term dietary habits and interventions in solid-organ transplantation.
      As long as there are no other underlying issues, diet recommendations for this population should not differ vastly from the general population. Energy needs can be calculated based on 23-35 kcal/kg/day or adequate intake to meet a healthy weight goal.
      • McCann L.
      Pocket Guide to Nutrition Assessment of the Patient with Kidney Disease: A Precise Resource for Comprehensive Nutrition Care in Kidney Disease.
      Protein recommendations in the chronic posttransplant population can vary based on diabetes status. A patient without diabetes (DM) may have estimated protein needs of 0.6-0.8 g/kg/day, whereas a patient with a DM diagnosis would have slightly higher protein needs that are estimated as 0.8-0.9 g/kg/day.
      • McCann L.
      Pocket Guide to Nutrition Assessment of the Patient with Kidney Disease: A Precise Resource for Comprehensive Nutrition Care in Kidney Disease.
      General food safety is recommended, and information can be found through the Centers for Disease Control. Owing to the risk for excessive weight gain, maintaining a healthy weight (body mass index <30) and emphasizing consumption of a healthy diet in appropriate portions can address other potential comorbidities associated with obesity, such as increased risk for DM, hypertension, hyperlipidemia, and cardiovascular disease.
      • Martins C.
      • Pecoits-Filho R.
      • Riella M.C.
      Nutrition for the post-renal transplant recipients.
      • Phillips S.
      • Heuberger R.
      Metabolic disorders following kidney transplantation.
      Aim to control lipids through diet by consumption of <30% of total calories from fat per day. It is important to emphasize consumption of monounsaturated and polyunsaturated fat, low intake of saturated fat, and minimal intake of trans fat. Should lipids be persistently elevated, a medical doctor may need to evaluate for the need of a lipid-lowering medication. Maintain moderate sodium intake, approximately 2,000 mg/day, and emphasize high fiber, whole grain, and complex carbohydrate consumption. This can help to control lipid levels, reduce the risk for posttransplant DM, or manage a preexisting diagnosis of DM. According to the National Kidney Foundation, carbohydrates should provide 50-70% of nonprotein calories in the acute posttransplant phase.
      • McCann L.
      Pocket Guide to Nutrition Assessment of the Patient with Kidney Disease: A Precise Resource for Comprehensive Nutrition Care in Kidney Disease.
      However, in the chronic posttransplant phase, they should be reduced to 45-50% of total calories.
      • McCann L.
      Pocket Guide to Nutrition Assessment of the Patient with Kidney Disease: A Precise Resource for Comprehensive Nutrition Care in Kidney Disease.
      Bone health is also important as prolonged use of steroids and (prior) renal dysfunction can be detrimental to bones. As needed, consider supplementation of calcium, vitamin D, magnesium, or phosphorus.
      • Martins C.
      • Pecoits-Filho R.
      • Riella M.C.
      Nutrition for the post-renal transplant recipients.
      Exercise should be encouraged as a conjunctive therapy for weight management, glycemic improvement, and benefits to heart and bone health.
      • Chan M.
      • Patwardhan A.
      • Ryan C.
      • et al.
      Evidence-based guidelines for the nutritional management of adult kidney transplant recipients.
      • Phillips S.
      • Heuberger R.
      Metabolic disorders following kidney transplantation.
      In conclusion, medical nutrition therapy plays an important role in posttransplant recovery. It is important to monitor routine markers in laboratories, vitals, and anthropometric measurements to address appropriate nutrition intervention. Diet education and modification play an important role in reducing comorbid risk factors for long-term maintenance of the renal allograft. Diet compliance remains a challenge in the transplant population, and therefore, routine follow-up with a registered dietitian may be indicated to maintain motivation and promote optimal results.
      • McCann L.
      Pocket Guide to Nutrition Assessment of the Patient with Kidney Disease: A Precise Resource for Comprehensive Nutrition Care in Kidney Disease.
      Tabled 1Medical Nutrition Therapy Considerations After Kidney Transplant
      • McCann L.
      Pocket Guide to Nutrition Assessment of the Patient with Kidney Disease: A Precise Resource for Comprehensive Nutrition Care in Kidney Disease.
      Medical Nutrition TherapyAcute Posttransplant PhaseChronic Posttransplant Phase
      Optimize nutrition statusIncreased energy and protein needs to address postoperative catabolismWith a well-functioning allograft, diet recommendations align with those of healthy individuals
      Estimated calorie needs30-35 kcal/kg/d23-35 kcal/kg/d or adequate intake to meet healthy weight goal
      Estimated protein needs1.2-2.0 g of protein/kg/dWithout DM: 0.6-0.8 g/kg/d

      With DM: 0.8-0.9 g/kg/d
      Medication side effectsAdjust diet to address the potential for hyperglycemia and hyperkalemia; observe food safety practices to minimize the risk for food-borne infections
      Bone healthMonitor laboratory values. Consider need for supplementation of calcium, magnesium, phosphorus, and vitamin D

      Websites of Interest

      Centers for Disease Control and Prevention (CDC)—https://www.cdc.gov/foodsafety/index.html.
      Centers for Medicare and Medicaid Services (CMS)—http://www.cms.gov.
      National Kidney Foundation (NKF)—https://www.kidney.org/.
      Organ Procurement and Transplantation Network (OPTN)—https://optn.transplant.hrsa.gov/.

      References

        • Chan M.
        • Patwardhan A.
        • Ryan C.
        • et al.
        Evidence-based guidelines for the nutritional management of adult kidney transplant recipients.
        J Ren Nutr. 2011; 21: 47-51
        • Veroux M.
        • Corona D.
        • Sinagra N.
        • et al.
        Nutrition in kidney transplantation.
        Int J Artif Organs. 2013; 36: 677-686
        • Center for Medicare and Medicaid Services
        Organ transplant interpretive guidelines update.
        (2016;64. Available at:)
        www.cms.gov
        Date: 2016
        (Accessed September 6, 2017)
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        • Pecoits-Filho R.
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        Nutrition for the post-renal transplant recipients.
        J Trans Proceed. 2004; 36: 1650-1654
        • van den Ham E.C.
        • Kooman J.P.
        • van Hoof J.P.
        Nutritional considerations in renal transplant patients.
        Blood Purif. 2002; 20: 139-144
        • Phillips S.
        • Heuberger R.
        Metabolic disorders following kidney transplantation.
        J Ren Nutr. 2012; 22: 451-460.el
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        Nutrition intervention in chronic kidney disease.
        Med Clin North Am. 2016; 100: 1265-1283
        • McCann L.
        Pocket Guide to Nutrition Assessment of the Patient with Kidney Disease: A Precise Resource for Comprehensive Nutrition Care in Kidney Disease.
        5th ed. National Kidney Foundation, New York, NY2015 (11-39-11-45)
        • Zeltzer S.M.
        • Taylor D.O.
        • Tang W.
        Long-term dietary habits and interventions in solid-organ transplantation.
        J Heart Lung Transplant. 2015; 34: 1357-1365