ijot_40_19R2
Review Article
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Malnutrition in Kidney Transplantation: Our Experience and
Review of Literature
Sneha Haridas Anupama1,2, Georgi Abraham1,2,*, Rajeevalochana Parthasarathy1,2, Priya Haridas Anupama1,2, Milly Mathew1,2
1
???, Madras Medical Mission Hospital, Chennai, Tamil Nadu, 2???, Pondicherry Institute of Medical Sciences, Puducherry, India
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
Introduction
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
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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
A false notion is that organ transplantation alleviates the dietary
restrictions imposed by chronic kidney disease (CKD) and
Corresponding Author: Dr. Georgi Abraham,
Madras Medical Mission Hospital, Chennai ‑ 600 037, Tamil Nadu, India.
E‑mail: abraham_georgi@yahoo.com
Received: 26-08-2019; Revision: 19-12-2019; Accepted: 05-01-2020;
Published: ***
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
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;XX:XX-XX.
© 2020 Indian Journal of Transplantation | Published by Wolters Kluwer ‑ Medknow
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Anupama, et al.: Kidney transplantation and malnutrition
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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.
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.
Here, we illustrate the parameters assessed in a 54‑year‑old
female on maintenance hemodialysis before and after
deceased‑donor kidney transplantation [Table 2].
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
Table 1: Dietary advice following kidney transplantation
The Occurrence of Various Serum Abnormalities
in the Posttransplant Period
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
2
BW: Body Weight
Indian Journal of Transplantation ¦ Volume XX ¦ Issue XX ¦ Month 2020
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Anupama, et al.: Kidney transplantation and malnutrition
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Table 2: Deceased‑donor transplant recipients‑serial nutritional assessment
Parameter
December 19, 2016
April 3, 2017
August 17, 2017
December 4, 2017 After transplant
Normal values
Weight (kg)
48.5
48.7
50.5
45.3
45.7-61.9
BMI (kg/m2)
18.9
19
19.7
17.7
18.5-23
BCM (kg)
24.9
25
25.1
24.4
24.3-29.7
ICW (L)
17.4
17.5
17.5
17.1
17-20.8
ECW (L)
11.3
11.5
11.0
10.5
10.4-12.8
TBW (L)
28.7
29.0
28.5
27.6
27.4-33.4
BMC (kg)
2.65
2.57
2.36
2.25
2.09-2.55
MAMC (cm)
21
21.2
21.7
20.6
22.7
WC (cm)
67.9
67.5
74.5
65.3
<80
Protein (kg)
7.5
7.6
7.5
7.3
7.4-9
SLM (kg)
36.6
37
36.5
35.4
35.2-43
SMM (kg)
20.7
20.8
20.8
20.3
20.3-24.9
FFM (kg)
39.3
39.6
38.9
37.7
37.3-45.5
Fat (kg)
9.2
9.1
11.6
7.6
10.8-17.2
PBF (%)
18.9
18.6
23.1
16.8
18-28
Mineral (kg)
3.07
2.98
2.87
2.75
2.53-3.09
Phase angle (°)
3.52
3.48
4.54
7.14
6.5
BCM: Body cell mass, ICW: Intracellular water, ECW: Extracellular water, BMC: Bone mineral content, BMI: Body mass index, SLM: Soft lean mass,
SMM: Skeletal muscle mass, FFM: Fat‑free mass, PBF: Percentage body fat, WC: Waist circumference, MAMC: Mid‑arm muscle circumference, TBW:
Total body water
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‑with patient survivals.[11]
Conclusion
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
1.
DiBaise M, Tarleton SM. Hair, nails, and skin: Differentiating
cutaneous manifestations of micronutrient deficiency. Nutr Clin Pract
2019;34:490‑503.
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.
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.
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.
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.
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.
7. Kent PS. Issues of obesity in kidney transplantation. J Ren Nutr
2007;17:107‑13.
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.
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.
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.
11. Georgi Abraham G. Nutritional assessment of renal transplant
recipients using DEXA and biochemical parameters. J Nutr Disord Ther
2013;4: ???.
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