Nutrition And Transplant – How To Help Patients on
Dialysis Prepare

Maureen P. McCarthy

While in-center hemodialysis is the most common choice for renal replacement therapy (RRT) in the United States, federal regulations state that each patient must be evaluated regularly to assess readiness for other modalities of RRT, including transplant (Federal Register, 1974). Because of their close relationships with patients, dialysis staff members are in a unique position to encourage patients and to assist them in being well prepared for the transplant evaluation and the actual transplant surgery when that is the patient’s choice. This article will offer some practical suggestions for the dialysis team to support patients who pursue the option of kidney transplant.

Preparing for Transplant

Many transplant centers have limits on body mass index (BMI); most centers will only accept transplant candidates with a BMI of 35 or less, while a few go as high as a BMI of 40 , and some go even higher (see Table 1 for categories of BMI). Sometimes the transplant surgeon will evaluate individuals who exceed the transplant center’s limits on a case by case basis.

The decision regarding a BMI cut-off is based on each transplant team’s interpretation of related literature. Some researchers describe longer hospitalizations, more complications (wound and other), and high incidence of rejection in patients with higher BMIs (Meier-Kriesche, Arndorfer, & Kaplan, 2002). Others have reported a lack of complications in patients who have received a transplant even with very high BMIs (Marks, Florence, Chapman, Precht, & Perkinson, 2004).

Because this is a very controversial topic, it is crucial for dialysis staff members to be aware of the local transplant center’s position regarding BMIs. Consult your center to understand their policy and ask for references that support their decision. When weight loss before transplant is recommended, the patient will usually be given a target weight that meets the transplant center’s BMI guidelines.

Peritoneal dialysis. Because of the calories that are absorbed from the peritoneal dialysate, losing weight while on peritoneal dialysis (PD) is quite a challenge. These patients need constant support and encouragement to select dialysate solutions optimally for minimum dextrose load to accomplish adequate fluid removal. They should also be encouraged to control their food intake and to be as active as possible. Every team member who works with the patient and his/her family – nurse, dietitian, social worker, receptionist, technician, physician – must reinforce encouraging messages to promote weight control and send a positive message about working towards the transplant.

Hemodialysis. Patients on hemodialysis (HD) face struggles of their own related to weight control, including the all-too-common dialysis fatigue, which means that dialysis days are often very low in activity. Transplant candidates should be especially encouraged to take advantage of in-center exercise programs or programs in the community. Again, all staff members need to send consistent messages to encourage increased physical activity and more controlled food intake.

Preparing For Transplant – More Issues

Diabetes management. If glucose control is not acceptable while a patient is on dialysis, staff members should encourage the patient to follow through on referrals for diabetes care and diabetes education. Perhaps the dialysis unit has a certified diabetes educator (CDE) among the staff, and this staff member can work closely with the patient to teach better diabetes control.

Immunosuppression exacerbates poor glucose control, particularly in the months immediately following transplant while the doses of these medicines are still high. Even patients who have very good self-management skills can be frustrated by poor blood sugar control in the early weeks after a transplant. Farther out from transplant, glucose control usually will be more manageable.

The Diabetes Control and Complications Trial (DCCT) established, without doubt, the hazards of poor glucose control, including its effect on the kidneys (Diabetes Control and Complications Trial Research Group, 1993). These hazards are just as significant after transplant, perhaps more so. Ultimately, patients with poor blood sugar control while on dialysis should do all they can to improve blood sugar control before transplant, and dialysis staff members can provide technical advice and support.

Weight gain. The hazard of weight gain after transplant is widely recognized. Johnson et al. (1993) reported that younger patients and African American patients were most likely to gain weight after transplant. Patients in these groups should know about this risk, and should be encouraged to pursue weight management and reasonable increased activity before a transplant.

Issues of adherence. Transplant teams often look to calcium and phosphorus control to provide some insight into the patient’s ability to adhere to post-transplant medications, which are dosed several times a day. This may motivate better serum phosphorus control in a patient who is seeking transplant.

Other medications, herbals, non-prescription vitamins/minerals. In a similar vein, it is very important for the patient to follow physician advice about vitamins (preferably renal-specific multivitamins or a very similar product) and over-the-counter medications. Many herbal medications act by enhancing the immune response and thus are contra-indicated in the transplant recipient. Dialysis staff members usually are aware when a patient is using alternative treatments, such as herbals, and may be able to use their positive relationship with a transplant candidate to encourage discontinuation of such products. This will make it easier to adjust post-transplant, when these medications are strongly contraindicated.

Nutrition Issues After Transplantation –
Initial Recovery Period

In the first 2-3 months after transplant, dietary protein needs are higher than the Dietary Reference Intake (DRI). Though patients no longer have the regular protein losses associated with chronic dialysis, they do have high needs for healing the surgical wound and replenishing other losses. Guidelines for the patient post-transplant suggest about 1.2 to 1.3 grams per kilogram for the first 8 to 12 weeks (Blue, 2002). This is almost 50% more than the recommendations for healthy individuals.

By 12 months post-transplant, about 16% of transplant recipients are likely to develop post-transplant diabetes mellitus (PTDM), also called new onset diabetes after transplant (NODAT); at 3 years, 24%. Those at highest risk are older recipients, African Americans, Hispanics, and those with a BMI greater than 30 kg/m2, among others (Kasiske, Snyder, Gilbertson, & Matas, 2003). In one center, individuals with autosomal-dominant polycystic kidney disease have been observed to have a 17% incidence of PTDM, compared to 7.4% incidence in controls (deMattos et al., 2005).

Glucose control is likely to be most challenging immediately after the transplant. As medications that affect glucose control, especially prednisone and tacrolimus, are tapered down to maintenance levels, the patient will have a better idea of what his new baseline for glucose control is likely to be and can adjust. This usually happens within the first 2 to 3 months after transplant. There may be an early post-transplant referral to an endocrinologist for medication adjustment to optimize glucose control as quickly as possible.

Several researchers have reported that weight gain, especially in the first few months after transplant, is largely due to increased fat mass (Kooman, van den Ham, van Hooff, Christiaans, & Leunissen, 2000). Physical activity, especially appropriate activity that gets the transplant recipient out of the house and away from food, is essential.

One of the great ironies for patients in the first weeks after transplant is that they often need mineral supplements for potassium and phosphorus, as well as magnesium. As the serum levels of these minerals normalize, indicating that the new kidney is maintaining homeostasis, these supplements will be stopped and the patient will be counseled to continue to enjoy foods rich in potassium and phosphorus, within the limits of the new kidney’s function.

Occasionally, slow graft function may require continued control of potassium and phosphorus in the diet. The transplant team, including the dietitian, will monitor blood chemistries several times a week, and the patient will be counseled about the safe intake of potassium and phosphorus. Eventually the large majority of patients who have received transplants can be much more liberal with potassium and phosphorus in their foods than they were during dialysis.

Most transplant centers will start patients on a multivitamin. Calcium and vitamin D will be dosed in accordance with the individual’s estimated dietary calcium intake and bone mineral density (BMD). Because of medication side-effects, BMD is usually assessed pre-transplant and then followed post-transplant.

Another irony after transplant is the need to drink 8 to 12 cups of fluid per day as soon as a good urine output is achieved from the transplanted organ (Blue, 2002). It may be hard to return to drinking liberal amounts of fluid for health but is essential to maintain good hydration and to protect the viability of the transplant.

References
Barbagallo, C.M., Cefalu, A.B., Gallo, S., Rizzo, M., Noto, D., Cavera, G., et al. (1999). Effects of Mediterranean diet on lipid levels and cardiovascular risk in renal transplant recipients.  Nephron, 82, 199-204.

Blue, L.S. (2002). Adult kidney transplantation. In J.M. Hasse & L.S. Blue (Eds.), Comprehensive guide to transplant nutrition (pp. 44-57). Chicago: American Dietetic Association.

DeLongeril, M., Renaud, S., & Mamelle, N. (1994). Mediterranean alpha-linoleic acid-rich diet in secondary prevention of coronary heart disease. Lancet, 343, 1454-1459.

deMattos, A.M., Olyaei, A.J., Prather, J.C., Golconda, M.S., Barry, J.M., & Norman, D.J. (2005). Autosomal-dominant polycystic kidney disease as a risk factor for diabetes mellitus following renal transplantation. Kidney International, 67, 714-720.

Diabetes Control and Complications Trial Research Group. (1993). The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New England Journal of Medicine, 329, 977-986.

Federal Register. (1974). 42 CFR 405, Subpart U. Social Security Amendments of 1972, PL 92-603.

Foley, R.N., Parfrey, P.S., & Sarnak, M.J. (1998). Clinical epidemiology of cardiovascular disease in chronic renal disease. American Journal of Kidney Disease, 32(Suppl 5), S112-S119.

Johnson, C.P., Gallagher-Lepak, S., Zhu, Y.R., Porth, C., Kelber, S., Roza, A.M., et al. (1993). Factors influencing weight gain after renal transplantation. Transplantation, 56, 822-827.

Kasiske, B.L., Snyder, J.L., Gilbertson, D., & Matas, A.J. (2003). Diabetes mellitus after kidney transplantation in the United States. American Journal of Transplantation, 3,178-185.

Kooman, J.P., van den Ham, E.C.H., van Hooff, J.P., Christiaans, M.H.L., & Leunissen, K.M.L. (2000). Posttransplantation weight gain is predominantly due to an increase in body fat mass. Transplantation 70, 241-242.

Marks, W.H., Florence, L.S., Chapman, P.H., Precht, A.F., & Perkinson, D.T. (2004). Morbid obesity is not a contraindication to kidney transplantation. American Journal of Surgery, 187, 635-638.

Meier-Kriesche, H.U., Arndorfer, J.A., & Kaplan, B. (2002). The impact of body mass index on renal transplant outcomes: A significant independent risk factor for graft failure and patient death. Transplantation, 73(1), 70-74.

National Academy of Science Food and Nutrition Board. (2005). Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients). Washington, DC: Government Printing Office.

National Heart Lung and Blood Institute (NHLBI). (2000). The practical guide: Identification, evaluation, and treatment of overweight and obesity. Washington, DC: Government Printing Office, NHLBI publication 00-4084.

National Kidney Foundation (NKF). (2003). Clinical practice guidelines for managing dyslipidemias in chronic kidney disease. American Journal of Kidney Disease, 41(Suppl 3), S1-S92.