Renal Tranplantation and Nutrition-CPG

44. RENAL TRANSPLANTATION AND NUTRITION

44.1 Dietary modification
The first 21 days after successful transplantation should focus on a diet of optimal protein and energy intake as well as restrictions of total fat, saturated fat, cholesterol and simple sugars to restore nitrogen balance and minimise clinical symptoms of post-transplant diabetes and hyperlipidaemia.1 (Level C)
44.1.1 Calorie intake
Adequate calorie intake of at least 35kcal/kg/day (range of 35 to 50 kcal/kg/day)
a. 40%-50%: Carbohydrate
b. <> 25 kg/m2 is overweight and >30kg/m2 is obese.
c. Increased caloric intake may occur after transplantation primarily because of enhanced appetite associated with steroid use.3
d. May have adverse effect on coronary vascular disease.
44.2.2 Malnutrition
Incidence: 10% of patients exhibit low serum albumin levels at 1 year and 20% at 10 year after transplantation.4
Suspect malnutrition in the presence of low serum albumin (although factors other than calorie intake may contribute to hypoalbuminaemia).
Diagnosed by the presence of low serum albumin levels.
Corticosteroid accelerates the protein catabolic rate and frequently creates a negative nitrogen balance.
Malnutrition is associated with increased risk of infection, delayed wound healing and general debility.

44.2.3 Post transplantation hyperlipidaemia
Incidence: 60% of patients exhibit total cholestrol levels > 240mg/dl (high risk).5
Reported changes in serum lipid levels are:
↑ triglyceride
↑ total cholestrol
↑LDL cholesterol
↑apolipoprotein B
a. Pathogenesis of hyperlipidaemia in renal transplant patients: (multifactorial)6,7,8
• Age
• Body weight
• Sex
• Pretransplantation lipid levels
• Renal dysfunction
• Proteinuria
• Drugs eg. Sirolimus, β Blockers, Diuretics, Prednisolone, Cyclosporin etc
b. Consequences of hyperlipidaemia
• Correlation with chronic allograft nephropathy
• Development of cardiovascular and peripheral vascular disease
c. Treatment
• Weight reduction
• Increase exercise
• Dietary modification as recommended for non transplant population (National Cholesterol Education Programme)

Step 1
Intake of saturated fat 8% to 10% of total calories
Fat intake of 30 % of total calories
Saturated fat intake < 300mg/day

If Step 1 fails, then proceed to Step 2

Step 2
Intake of saturated fat to 7% of total calories
Saturated fat intake < 200mg/day

• Drug therapy
Drug therapy is indicated if dietary modification fails (Refer to chapter 45)

44.2.4 Post transplantation diabetes mellitus (PTDM)
Incidence : Peak incidence in the first year post-transplant affecting 3% to 4% of patients.10
a. Predisposing factors:
• Tacrolimus
• Family history of diabetes mellitus
• Prednisolone
• Cyclosporin
b. Management
• Diet modification
• Exercise
• Weight loss
• Cessation of smoking
• Metformin
• Sulfonylureas
• Insulin - half of patients with PTDM may require insulin. Treatment with insulin is also required during periods of stress and intercurrent illness.11



References
1. Edwards MS, Doster S. Renal transplantation diet recommendations: results of a survey or renal dietitians in the United States J Am Diet Assoc 1990; (6): 843-6
2. Modlin CS Flechner SM Goormastic M. Should obese patients lose weight before receiving a kidney transplant? Transplantation 1997; 64: 597-604
3. Johnson CP Gallagher-Lepak S, Zhu YR et al. Factors influencing weight gain after renal transplantation. Transplantation 1993; 56: 822-27
4. Guijarro C, Massy ZA, Ma JZ et al. Serum albumin and mortality after renal transplantation Am J Kid Dis 1996; 27: 117-123
5. Aakhus S, Dahl K, Wideroe TE Hyperlipidaemia in renal transplant patients. J Int Med 1996; 239: 407-415
6. Cattran DC, Steiner G, Wilson D et al. Hyperlipidaemia after renal transplantation: natural history and pathophysiolology. Ann Inter Med 1991; 79: 554
7. Vathsala A, Weinberg RB, Schoenberg L et al. Lipid abnormalities in cyclcosporin prednisolone treated renal transplant recipients. Transplantation 1989; 48: 37
8. Massy ZA, Kasiske BL: Post transplantation hyperlipidaemia: Mechanisms and management, J Am Soc Nephrol 1996; 7: 971
9. Summary of the second report of the National Cholestrol Education Program (NCEP) Expert Panel on Detection, Evaluation and treatment of high blood cholesterol in adults(Adult Panel 11). JAMA 1993; 269: 3015
10. Roth D, Milgrom M, Esquenazi V et al. Posttransplantation hyperglycaemia: Increased incidence in cyclosporin treated renal allograft recipients Transplantation 1989; 47:278-281
11. Sumrani N, Delaney V, Ding Z et al. Diabetes mellitus after renal transplantation in the cyclosporin era : analysis of risk factors. Transplantation 1991; 51: 343-47