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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 14  |  Issue : 1  |  Page : 15-18

Malnutrition in kidney transplantation: Our experience and review of literature


Department of Nephrology, Madras Medical Mission Hospital, Chennai, Tamil Nadu; Department of Nephrology, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission26-Aug-2019
Date of Acceptance05-Jan-2020
Date of Web Publication31-Mar-2020

Correspondence Address:
Dr. Georgi Abraham
Madras Medical Mission Hospital, Chennai - 600 037, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_40_19

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  Abstract 


Malnutrition is a well-known determining factor in the clinical outcome of a patient posttransplant. Malnutrition encompasses the entire spectrum ranging from excess to deficiencies of calorie, protein, and macronutrient and micronutrient intake. Pre- and posttransplant nutritional status of the patient is directly proportional to the graft survival. The misperception that transplantation would appease dietary restrictions in conjunction with inadequate physical activity adds to the burden of posttransplant complications. Commonly encountered complications posttransplant include weight gain, hypertension, cardiovascular disease, and new-onset diabetes mellitus. While various studies have shown the effect of pretransplant serum phosphorus albumin, alkaline phosphatase, and body mass index on posttransplant functional graft survival, posttransplant malnutrition leading to an array of metabolic disorders can equally affect the same. The lack of standardized guidelines for the assessment and prevention of malnutrition specifically targeted at reducing posttransplant morbidity and mortality is the need of the hour. The focus must be on the implementation of a comprehensive patient-specific dietary and lifestyle plan made in collaboration by the patients treating physician, a skilled nutritionist, and family, taking into consideration adequate micronutrient and macronutrient requirements and patients' socioeconomic background.

Keywords: Graft survival posttransplantation, micronutrient and macronutrient deficiency, posttransplant malnutrition


How to cite this article:
Anupama SH, Abraham G, Parthasarathy R, Anupama PH, Mathew M. Malnutrition in kidney transplantation: Our experience and review of literature. Indian J Transplant 2020;14:15-8

How to cite this URL:
Anupama SH, Abraham G, Parthasarathy R, Anupama PH, Mathew M. Malnutrition in kidney transplantation: Our experience and review of literature. Indian J Transplant [serial online] 2020 [cited 2020 Jul 6];14:15-8. Available from: http://www.ijtonline.in/text.asp?2020/14/1/15/281764




  Introduction Top


In India, nearly 8000–11,000 transplants are performed every year, mostly kidney followed by heart and lung. The posttransplant period is handicapped with multiple complications, a significant percentage of which can be attributed to malnutrition. Malnutrition refers to deficiencies, excesses, or imbalances in a person intake of energy and/or nutrients. The term “malnutrition“ addresses three broad groups of conditions, namely undernutrition, micronutrient-related malnutrition, and overweight, obesity, and diet-related noncommunicable diseases. While malnutrition, both before and after transplant, contributes significantly to the clinical outcome of the patient posttransplant clinical outcome, the significance of nutrition after transplant has not been adequately emphasized upon. This could be ascribed to the lack of orientation of the patient and his family toward the requirement of a comprehensive diet and lifestyle plan coupled with misinformation on the side of the patient regarding food habits posttransplant.

Standard nutrient composition in the body consists of macronutrient and micronutrients. While the effects of macronutrient deficiencies are majorly systemic, micronutrient deficiencies commonly give rise to cutaneous abnormalities involving skin, hair, and nails, and these are indirect markers of the underlying deficiency.[1] Hence, corroboration of a holistic diet bearing in mind adequate micro and macronutrient requirements and metabolic profile to correct pretransplant malnutrition and prevent progression or development of malnutrition posttransplant is of paramount importance in improving patient and graft survival.[2]


  Review of Literature and Discussion Top


A false notion is that organ transplantation alleviates the dietary restrictions imposed by chronic kidney disease (CKD) and CKD-D. Special attention to the nutritional and metabolic state of the organ transplant recipient is warranted. Before the transplant, formulation of a dietary plan in collaboration with the treating physician, skilled nutritionist, and close family and implementation in the immediate posttransplant period, can reduce the incidence of metabolic disorders occurring after the transplantation. The dietary plan is made taking into account adequate energy and protein intake, micro- and macronutrient requirement, and the patient and his family should be counseled regarding medication and nutrition-related side effects, necessary food safety and sanitation measures, and therapeutic diet as needed. Commonly encountered complications posttransplant include weight gain, obesity, hypertension, cardiovascular disease (hyperlipidemia, insulin resistance, and heart dysfunction) and glomerular hyperfiltration, and new-onset diabetes mellitus (NODAT). Obesity is an established risk factor for renal graft loss. The impact of undernutrition in transplant recipients and its effect on the outcome are underrated. Appropriate nutritional supplementation is essential through the following three phases of transplantation: pre-acute, post-acute, and long-term posttransplantation to ensure the optimal clinical outcome. Undernutrition coupled with immunosuppression in the posttransplant period is associated with a wide range of metabolic adverse effects such as protein hypercatabolism, hyperlipidemia, hyperglycemia, hypertension, hyperkalemia, and interference with the metabolism and action of Vitamin D.

The fundamental pathophysiology behind metabolic changes seen postrenal transplantation is the changes in body composition due to the reversal of the existing uremic state leading to the accumulation of fat distribution and muscle wasting.

Nutritional assessment for a transplant candidate is done based on appropriate history, biochemical parameters, anthropometric and nutrition-focused physical findings based on subjective global assessment and Malnutrition Inflammation Score. Anthropometric assessment includes the measurement of parameters such as skinfold thickness, waist circumference, and radiological assessment such as dual-energy X-ray absorptiometry (DEXA) scan. Skinfold thickness is measured using Harpender's skinfold calipers. Body cell mass has a normal value of 2.5 mm in men and 18 mm in women. Normal waist circumference in Indian men is 90 cm and 80 cm in women. Waist–hip ratio in men is 0.88 and women 0.81.


  The Occurrence of Various Serum Abnormalities in the Posttransplant Period Top


A wide variety of metabolic abnormalities impact the graft survival posttransplant. Reduced pretransplant serum albumin levels have been linked to poorer clinical outcomes following the transplant.[3] Studies have implied the occurrence of new-onset diabetes after kidney transplantation having a genetic predisposition.[4] Pretransplant serum phosphorus levels more than 7.5 mg/dl have been known to increase risk of functional graft failure and raise the risk of all-cause and cardiovascular mortality[5] A cohort study by Molnar et al. showed that hemodialysis patients with pretransplant serum alkaline phosphatase of >120 U/L have hostile posttransplant mortality.[6] The incidence of NODAT, wound complications posttransplant and posttransplant weight gain, particularly visceral fat gain, dyslipidemia, and cardiovascular diseases are higher with a pretransplant body mass index (BMI) >25 m2/kg.[2],[7] The implications of serum abnormalities and undernutrition upon graft survival have been known to significantly affect morbidity and duration of hospital stay after the transplant. Of the six criteria, two need to be achieved for an individual to be diagnosed as undernourished. The six criteria are as follows: insufficient energy intake, unintentional weight loss (BMI <18.5 kg/m2), loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation that may sometimes mask weight loss, and diminished functional status.[7] Nutrition management of renal transplantation can be divided into several phases: pretransplant period, transplant surgery, early posttransplant period, and late posttransplant period. Daily nutritional recommendations post kidney transplantation is as shown in [Table 1].
Table 1: Dietary advice following kidney transplantation

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Here, we illustrate the parameters assessed in a 54-year-old female on maintenance hemodialysis before and after deceased-donor kidney transplantation [Table 2].
Table 2: Deceased-donor transplant recipients-serial nutritional assessment

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KDIGO guidelines do not shed light on dietary recommendations for kidney transplant recipients. Instead, the focus of the guidelines is directed to the management of metabolic derangements such as diabetes mellitus, NODAT, hypertension, dyslipidemia, obesity, cardiovascular disease, and transplant bone disease. A review by Chadban et al. inferred that there is no definitive guideline regarding protein recommendations perioperatively for kidney transplant patients.[8] A retrospective cohort study by Abraham et al. showed that among the South Asian patients, serial eGFR, BMI, and smoking were potential predictors of graft survival following kidney transplantation.[9] Energy metabolism seen in patients is due to the false perception of being relieved from dietary restrictions posttransplant and the resultant binge eating of favored foods.[10]

In our nutritional analysis, using DEXA and other parameters in 249 kidney transplant recipients, 150 males and 99 females, 76% of our study population comprised of meat-based diet consumers, whereas 24% were vegetarians. We found the posttransplant serum albumin of >4 g/dl in 46% of nonvegetarians, whereas 66% of the vegetarians had serum albumin value of <3.3–4 g/dl. Prednisolone dose and serum albumin (P = 0.005), fat mass (P = 0. 006), fat percentage (P = 0. 002), and serum creatinine (P = 0.013) displayed negative correlations. A positive correlation between hemoglobin levels and low-density lipoprotein (P = 0.005), fat mass (P = 0.004), HCO3 (P = 0. 015) and Cl (P = 0.012), and hemoglobin levels and potassium levels (P = 0.015) were seen. Serum albumin had no significant co-relation with patient survival.[11]


  Conclusion Top


Emphasis on an appropriate nutritional and physical activity plan tailor-made to each patient to reduce weight gain and the ensuing adverse effects is essential. The need of the hour is of dietary guidelines specific to kidney transplant recipients targeted at overcoming the myriad of complications known to strike them in the posttransplant period impeding recovery and graft survival. Enhanced quality of research and an in-depth analysis of the areas of improvement are key to combating malnutrition posttransplant, thereby increasing patient and graft survival.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
DiBaise M, Tarleton SM. Hair, nails, and skin: Differentiating cutaneous manifestations of micronutrient deficiency. Nutr Clin Pract 2019;34:490-503.  Back to cited text no. 1
    
2.
Nolte Fong JV, Moore LW. Nutrition trends in kidney transplant recipients: The importance of dietary monitoring and need for evidence-based recommendations. Front Med (Lausanne) 2018;5:302.  Back to cited text no. 2
    
3.
Molnar MZ, Kovesdy CP, Bunnapradist S, Streja E, Mehrotra R, Krishnan M, et al. Associations of pretransplant serum albumin with post-transplant outcomes in kidney transplant recipients. Am J Transplant 2011;11:1006-15.  Back to cited text no. 3
    
4.
Reddy YN, Abraham G, Sundaram V, Reddy PP, Mathew M, Nagarajan P, et al. Is there a genetic predisposition to new-onset diabetes after kidney transplantation? Saudi J Kidney Dis Transpl 2015;26:1113-20.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Sampaio MS, Molnar MZ, Kovesdy CP, Mehrotra R, Mucsi I, Sim JJ, et al. Association of pretransplant serum phosphorus with posttransplant outcomes. Clin J Am Soc Nephrol 2011;6:2712-21.  Back to cited text no. 5
    
6.
Molnar MZ, Kovesdy CP, Mucsi I, Salusky IB, Kalantar-Zadeh K. Association of pre-kidney transplant markers of mineral and bone disorder with post-transplant outcomes. Clin J Am Soc Nephrol 2012;7:1859-71.  Back to cited text no. 6
    
7.
Kent PS. Issues of obesity in kidney transplantation. J Ren Nutr 2007;17:107-13.  Back to cited text no. 7
    
8.
Chadban S, Chan M, Fry K, Patwardhan A, Ryan C, Trevillian P, et al. The CARI guidelines. Protein requirement in adult kidney transplant recipients. Nephrology (Carlton) 2010;15 Suppl 1:S68-71.  Back to cited text no. 8
    
9.
Abraham G, Ali MA, Mathew M, Fathima N, Saravanan S, Varun S, et al. EGFR, body mass index predict can serial renal allograft survival in South Asian pateints. Transplantation. 2008;Suppl 86:467.  Back to cited text no. 9
    
10.
Varsha K, Abraham G, Soundar Rajan P, Prabhakara KS. Energy metabolism in renal transplant patients? Solution analysis. Indian J Nephrol 1997;7:100-2.  Back to cited text no. 10
    
11.
Georgi Abraham G. Nutritional assessment of renal transplant recipients using DEXA and biochemical parameters. J Nutr Disord Ther 2013;4.  Back to cited text no. 11
    



 
 
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