Dr. Charu KartikDr. Charu KartikSenior Clinical DietitianSenior Clinical Dietitian

KFSH&RC,RiyadhKFSH&RC,Riyadh

Dr. Charu KartikDr. Charu KartikSenior Clinical DietitianSenior Clinical Dietitian

KFSH&RC,RiyadhKFSH&RC,Riyadh

NUTRITIONAL CO-MORBITIES POST RENAL

TRANSPLANT: REQUIRING INTERVENTION

IntroductionIntroduction Renal transplantation is the preferred method of Renal transplantation is the preferred method of

treatment of End Stage Renal Disease patients treatment of End Stage Renal Disease patients and is the most common solid organ transplant.and is the most common solid organ transplant.

Successful transplantation of a kidney into a Successful transplantation of a kidney into a patient with renal failure restores near normal patient with renal failure restores near normal renal function and is expected to correct the renal function and is expected to correct the nutritional abnormalities arising from renal nutritional abnormalities arising from renal insufficiency. insufficiency.

Nutrition plays a vital and often overlooked role Nutrition plays a vital and often overlooked role in the care of such patients on a surgical service in the care of such patients on a surgical service particularly post renal transplant. particularly post renal transplant.

In minds of both patients and physicians, one of In minds of both patients and physicians, one of the major benefits of renal transplantation is an the major benefits of renal transplantation is an end to the dietary restrictions required for end to the dietary restrictions required for therapy during periods of progressive renal therapy during periods of progressive renal failure and dialysisfailure and dialysis. .

Transplanted KidneyTransplanted Kidney

Impact of Obesity on Impact of Obesity on KidneyKidneyFat cell Kidney

Microalbuminuria/proteinuriaGlomerulopathyFat secretes inflammatory cytokinesIncreased renal plasma flow (RPF)Enhances progression of otherrenal diseasesDiabetic nephropathyReduced renal survival aftertransplant

Rutkowski et al. J Ren Nutr. 2006;16:216-223

Obesity and Obesity and TransplantTransplant

Receiving a transplant with a BMI of greater Receiving a transplant with a BMI of greater than 25 is associated with a significantly than 25 is associated with a significantly higher incidence of higher incidence of

1.1. New onset diabetes mellitusNew onset diabetes mellitus

2.2. Wound complications post-transplant Wound complications post-transplant

3.3. Post-transplant weight gainPost-transplant weight gain

Kent.. J Ren Nutr. 2007;17:107-113

Other Metabolic Other Metabolic Abnormalities after Abnormalities after

TransplantationTransplantation

• DiabetesDiabetes

• Hypertension Hypertension

• HyperlipidemiHyperlipidemiaa

• GoutGout

Kent.. J Ren Nutr. 2007;17:107-113

Study of renal transplant Study of renal transplant recipients at KFSH&RC, recipients at KFSH&RC,

RiyadhRiyadh

ObjectivesObjectives

To assess the weight change post renal To assess the weight change post renal transplant over the period of one yeartransplant over the period of one year

Inclusion criteriaInclusion criteria

Renal transplants done from 1Renal transplants done from 1stst Jan 2007 to Jan 2007 to 3131stst Dec 2007 at KFSH&RC, Riyadh Dec 2007 at KFSH&RC, Riyadh

Age 18 to 40 yearsAge 18 to 40 years Patients with functioning graft Patients with functioning graft BMI- less than 30 kg/m2BMI- less than 30 kg/m2

Exclusion criteriaExclusion criteria

Age less than 18 or more than 40 yearsAge less than 18 or more than 40 years BMI – more than 30kg/m2.BMI – more than 30kg/m2. Patients who lost their Kidney graft before Patients who lost their Kidney graft before

one year.one year. Patients of multi-organ transplantsPatients of multi-organ transplants

Material and MethodsMaterial and Methods

Retrospective observational studyRetrospective observational study Total of 146 renal transplants were done Total of 146 renal transplants were done

during 2007.during 2007. Total of 43 patients were included in the study.Total of 43 patients were included in the study. Data of renal transplant recipients including Data of renal transplant recipients including

pre and post one year transplant weight & pre and post one year transplant weight & BMI collected.BMI collected.

SPSS 15.0 is used for statistical analysis.SPSS 15.0 is used for statistical analysis.

ResultsResults

Total No of PtsTotal No of Pts 4343 Age 26.8 (19-39)Age 26.8 (19-39) Male 23 (53.5%)Male 23 (53.5%) Female 20 (46.5%)Female 20 (46.5%)

Tx TypeTx Type LRD 37 (86%)LRD 37 (86%) DD 6 (14%)DD 6 (14%)

18

20

22

24

Male Female

0

5

10

15

20

25

30

35

40

LRD CAD

ResultsResults

Tx Wt 61.6 (35-97)Tx Wt 61.6 (35-97) Tx BMI 23 (16-30)Tx BMI 23 (16-30) Post 1 yr Wt 72.4 (47-Post 1 yr Wt 72.4 (47-

111)111) Post 1 yr BMI 28 (20-40) Post 1 yr BMI 28 (20-40)

p value <0.05p value <0.050

1020

3040

506070

80

Tx Wt Post1 YrWt

TxBMI

Post1 YrBMI

ResultsResults

Male 23Male 23 Tx TypeTx Type

LRD 20 (87%)LRD 20 (87%) DD 3 (13%)DD 3 (13%)

Age 26.3 (19-39)Age 26.3 (19-39) Tx Wt 65.15 (41-85)Tx Wt 65.15 (41-85) Tx BMI 23.3 (16-30)Tx BMI 23.3 (16-30) Post Tx Wt 77.4 (49-Post Tx Wt 77.4 (49-

100)100) Post Tx BMI 27.4 (20-Post Tx BMI 27.4 (20-

32)32)p value <0.05p value <0.05

Female 20Female 20 Tx TypeTx Type

LRD 17 (85%)LRD 17 (85%) DD 3 (15%)DD 3 (15%)

Age 27.4 (19-39)Age 27.4 (19-39) Tx Wt 57.6 (36-97)Tx Wt 57.6 (36-97) Tx BMI 22.5 (16-30)Tx BMI 22.5 (16-30) Post Tx Wt 66.7 (47-111)Post Tx Wt 66.7 (47-111) Post Tx BMI 28.2 (20-Post Tx BMI 28.2 (20-

40)40)p value <0.05p value <0.05

ResultsResults

Pts with Normal BMI Pts with Normal BMI Pre Tx (19-25) n-25Pre Tx (19-25) n-25

Age 26.7 (20 -39)Age 26.7 (20 -39) Tx Wt 55.2 (36-78)Tx Wt 55.2 (36-78) Tx BMI 21 (19-25)Tx BMI 21 (19-25) Post Tx Wt 71 (49-100)Post Tx Wt 71 (49-100) Post Tx BMI 26.6 (20-Post Tx BMI 26.6 (20-

32)32)

p value <0.05p value <0.05

Patients with high BMI Patients with high BMI Pre Tx (>25) n-14Pre Tx (>25) n-14

Age 27.8 (19-37)Age 27.8 (19-37) Tx Wt 78 (66-97)Tx Wt 78 (66-97) Tx BMI 28 (25.7-30)Tx BMI 28 (25.7-30) Post Tx Wt 79.5 (59-111)Post Tx Wt 79.5 (59-111) Post Tx BMI 31.5 (27-40)Post Tx BMI 31.5 (27-40)

p value >0.05p value >0.05

ConclusionConclusion

Renal transplant remains the treatment of Renal transplant remains the treatment of choice for renal failure patients but due to choice for renal failure patients but due to the immunosuppressive medications and lack the immunosuppressive medications and lack of lifestyle modifications, these patients are of lifestyle modifications, these patients are at increased risk of weight gain and at increased risk of weight gain and associated complications.associated complications.

Pre-transplant patients with normal BMI Pre-transplant patients with normal BMI gained more weight resulting in obesity as gained more weight resulting in obesity as compared to the patients with the ones who compared to the patients with the ones who had high BMI.had high BMI.

Nutrition Nutrition ManagementManagement

Nutrition Care of the renal transplant Nutrition Care of the renal transplant recipient is a dynamic process. recipient is a dynamic process.

It involves integrating knowledge of the It involves integrating knowledge of the patient’s complex medical condition related patient’s complex medical condition related to chronic renal disease and the impact of to chronic renal disease and the impact of ongoing therapeutic interventions on the ongoing therapeutic interventions on the patient’s nutritional status. patient’s nutritional status.

Nutrition Nutrition ManagementManagement

Three phases of care have been identified for Three phases of care have been identified for organ transplant recipients.organ transplant recipients. Pre-transplantation phase: Pre-transplantation phase:

The goal is to meet current education and nutrition The goal is to meet current education and nutrition needs, optimize the patient’s nutritional status and needs, optimize the patient’s nutritional status and assist the patient in meeting body weight criteria assist the patient in meeting body weight criteria for transplantation.for transplantation.

Acute post-transplantation phase:Acute post-transplantation phase: The goal is to support the increased metabolic The goal is to support the increased metabolic

demands of surgery and high dose demands of surgery and high dose immunosuppressive therapy.immunosuppressive therapy.

Chronic post-transplantation phase:Chronic post-transplantation phase: The goal is to provide adequate nutrition, prevent The goal is to provide adequate nutrition, prevent

infection and manage nutritional complicationsinfection and manage nutritional complications. .

Nutrition Nutrition ManagementManagement

Table source:McCann L.Pocket guide to nutrition assessment of the patient with chronic kidney disease. 3rd ed. Satellite healthcare 2002.

Nutrition Nutrition ManagementManagement

Proposed Research Proposed Research BackgroundBackground

Renal transplantation is currently considered Renal transplantation is currently considered the treatment of choice for most patients with the treatment of choice for most patients with end-stage renal failure. Based on previous end-stage renal failure. Based on previous studies obesity is a significant risk factor for studies obesity is a significant risk factor for renal transplantation. renal transplantation.

Obesity in non transplant patients has been Obesity in non transplant patients has been associated with hypertension, hyperlipidemia, associated with hypertension, hyperlipidemia, type II diabetes, proteinuria and type II diabetes, proteinuria and glomerulopathy. glomerulopathy.

Given this evidence it is possible that renal Given this evidence it is possible that renal transplant recipients with an elevated BMI may transplant recipients with an elevated BMI may have worse long term graft survival .have worse long term graft survival .

HypothesisHypothesis

Dietary intervention will reduce the incidence of Dietary intervention will reduce the incidence of Obesity in renal transplant patients thus improve Obesity in renal transplant patients thus improve

survival rates.survival rates.

Primary ObjectivePrimary Objective

To evaluate the effect of dietary intervention on To evaluate the effect of dietary intervention on the incidence of obesity in patients receiving the incidence of obesity in patients receiving kidney transplants.kidney transplants.

To measure the change in weight/BMI among To measure the change in weight/BMI among patients receiving dietary intervention compared patients receiving dietary intervention compared to control group.to control group.

Secondary ObjectiveSecondary Objective

To measure the proportion of patients developing To measure the proportion of patients developing a new onset of Diabetes Mellitus after the renal a new onset of Diabetes Mellitus after the renal transplantation and compare the incidence among transplantation and compare the incidence among the study group.the study group.

Methodology: Sample Methodology: Sample SelectionSelection

Inclusion criteria Non-obese patients. BMI less than 30. Age group –More than 18 years who received

LRD/DD Renal Transplant over next one year Willing to participate and give consent.

Exclusion criteria BMI more than 30 at the time of Renal

Transplant. Multi-organ transplants. Age less than 18 years or over 40 years.

Tools & TechniquesTools & Techniques

Develop a dietary intervention tool to Develop a dietary intervention tool to reduce obesity and upcoming risk reduce obesity and upcoming risk factors among the study group after factors among the study group after the transplantation which will the transplantation which will include:include:

One to one nutrition teaching One to one nutrition teaching Group discussions Group discussions Dietary intervention bookletDietary intervention booklet Questionnaire Questionnaire

Tools & TechniquesTools & Techniques

Post-transplants patients are followed in Post-transplants patients are followed in the clinic twice weekly for a period of 3 the clinic twice weekly for a period of 3 months initially. Lab tests will be months initially. Lab tests will be conducted twice a week and will include conducted twice a week and will include renal profile, weight and glucose levels. renal profile, weight and glucose levels.

After 3 months of transplant, monthly After 3 months of transplant, monthly visits are scheduled and the above-visits are scheduled and the above-mentioned lab tests and assessments mentioned lab tests and assessments would be performed.would be performed.

After 6 months, follow up visits are After 6 months, follow up visits are

scheduled every three months up-to one scheduled every three months up-to one year post transplant.year post transplant.

Study DesignStudy Design

Prospective cohort studyProspective cohort study

Study DesignStudy Design

Phase I : Pre transplant contact or familiarizingPhase I : Pre transplant contact or familiarizing

Examine the patient physically (BMI , weight)Examine the patient physically (BMI , weight) Bio chemical investigations ( Electrolyte, Blood Bio chemical investigations ( Electrolyte, Blood

sugar)sugar)

Phase II : Post transplant - intervention.Phase II : Post transplant - intervention.

Examine the patient physically ( BMI , weight Examine the patient physically ( BMI , weight and Blood Pressure )and Blood Pressure )

Bio chemical investigations.Bio chemical investigations. Nutrition education , one to one basisNutrition education , one to one basis Nutrition intervention booklet will be provided.Nutrition intervention booklet will be provided.

Study DesignStudy Design

Phase III : Monthly follow-up for a period Phase III : Monthly follow-up for a period of next three monthsof next three months

Examine the patient physically ( BMI , Examine the patient physically ( BMI , weight)weight)

Bio chemical investigations.Bio chemical investigations. Nutrition education , one to one basis.Nutrition education , one to one basis.

Study DesignStudy Design

Phase IV & V : Nine and twelve months post Phase IV & V : Nine and twelve months post transplant follow-uptransplant follow-up

Examine the patient physically ( BMI , Examine the patient physically ( BMI , weight)weight)

Bio chemical investigations ( Electrolyte, Bio chemical investigations ( Electrolyte, Blood sugar)Blood sugar)

Nutrition reinforcement Nutrition reinforcement

Phase VI : Data compilation and statistical Phase VI : Data compilation and statistical analysis would be done at the end of the analysis would be done at the end of the study.study.

RecommendationsRecommendations

Appropriate Nutrition Counseling should be provided during the transplant work-up.

Appropriate nutrition protocol should be developed to ensure weight management using appropriate nutrition intervention.

Regular nutrition follow ups are highly recommended for these patients to avoid obesity and associated complications.

RecommendationsRecommendations

The nutrition goals post transplantation are to achieve The nutrition goals post transplantation are to achieve and maintain good overall nutritional status, manage and maintain good overall nutritional status, manage nutrition related pre-existing medical concerns, and nutrition related pre-existing medical concerns, and prevent or minimize the side effects of prevent or minimize the side effects of immunosuppressive therapy (hyperlipidemia, obesity, immunosuppressive therapy (hyperlipidemia, obesity, hypertension, glucose intolerance and bone disease).hypertension, glucose intolerance and bone disease).

Specialized weight loss programs - pre and post Specialized weight loss programs - pre and post transplantation should be developed which will improvetransplantation should be developed which will improve transplant outcomestransplant outcomes..

Thank YouThank You