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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 3  |  Page : 382-386
Nutritional Status in Renal Transplant Recipients


1 Sri Ramachandra Medical College and Research Institute, Chennai, India
2 Madras Medical Mission Hospital, Chennai, India

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   Abstract 

We performed this study to observe the nutritional status in our renal transplant recipients using serum parameters, body mass index (BMI), and dual energy x-ray absorptiometry (DEXA) that measured the fat distribution. We studied 109 patients who had chronic kidney disease due to different etiologies, and received mean hemodialysis before they underwent successful renal transplantation. The body mass index and the prevalence of type 2 diabetes mellitus revealed a significantly positive correlation with older age (p<0.05). The mean values of serum sodium, chloride, potassium, calcium, and phosphorous were found to be within the normal range. There were no significant differences in these parameters according to age distribution. However, the mean serum creatinine was elevated, 154 ± 18 µmol/L, which was compatible with a significant but stable renal dysfunction. iPTH levels in most of our patients were within two times the normal values (101± 81 pg/ml). The mean hemoglobin levels were low in all our patients (91.6 ± 19.4 g/L). The mean bicarbonate levels were within normal limits (23 ± 3.5 mmol/L), however there were some patients below normal. The plasma proteins and albumin were lower than normal; 62.2 ± 8.6 g/L, and 36.1 ± 5.1gms/L, respectively. We conclude that the BMI, fat distribution and percentage as measured by DEXA scan, as well as the prevalence of type 2 diabetes mellitus in our transplant population revealed a significantly positive correlation with older age. The elevated mean plasma iPTH levels, decreased mean serum bicarbonate, albumin, and hemoglubin levels are most likely related to renal allograft dysfunction which is usually inherent with the grafts and may eventually affect the nutritional status of the patients. Subsequently, the initial weight gain may be hampered by the graft dysfunction. Prospective long-term studies are required to confirm our findings on larger transplant populations.

Keywords: Transplantation, Malnutrition, Nutrition, Renal, Failure, DEXA, Body Mass Index.

How to cite this article:
Mantoo S, Abraham G, Pratap GB, Jayanthi V, Obulakshmi S, Bhaskar S S, Lesley N. Nutritional Status in Renal Transplant Recipients. Saudi J Kidney Dis Transpl 2007;18:382-6

How to cite this URL:
Mantoo S, Abraham G, Pratap GB, Jayanthi V, Obulakshmi S, Bhaskar S S, Lesley N. Nutritional Status in Renal Transplant Recipients. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2020 May 26];18:382-6. Available from: http://www.sjkdt.org/text.asp?2007/18/3/382/33756

   Introduction Top


A total and regional body composition analysis by dual energy x-ray absorption­metry (DEXA) is based on the principle that when a beam of X-rays passes through the body it is attenuated (reduced in intensity) in proportion to the size and composition of the individual tissue components. Soft tissues (fat and bone-free, fat-free tissue) restrict the flux of X-rays less than bone. The ratio of the restriction at the low and high X-ray levels employed in DEXA is a function of the ratio of fat to lean body mass.

The applicability of DEXA for assessing body composition in disease states has not been extensively investigated. [1] Studies of the sensitivity of DEXA to small changes in hydration levels (1-3 Kg) sustain the accuracy of this technique for detecting dehydration. [1] Inconsistent results in DEXA are due partially to the use of different equipment, variability of body composition, and the soft tissue analysis software from the different manufa­cturers. However, DEXA is considered superior to other non-invasive methods for determining body tissue composition despite the availability of the normal values of the body composition.

Malnutrition is very frequent in chronic renal failure. After successful kidney transplantation, malnutrition may persists despite the body weight gain. [2] Malnutrition is observed more in females, those with allograft dysfunction, and those with co-morbid conditions. [3] New evidence reveals that the activation of the enzyme adenosine monophosphate protein kinase (AMPK) increases the appetite through leptin signaling, whereas the non­lysosomal ATP dependent Ubiquitin­proteosome pathway accelerates protein break down. [4]

We performed this study to observe the nutritional status using serum parameters, body mass index (BMI), and a DEXA scan that measured the fat distribution in our renal transplant recipients.


   Materials and Methods Top


We included in our study 109 patients who had chronic kidney disease due to different etiologies, and received a mean hemodialysis duration of 7.3 ± 7.7 months (range 1-48 months) before they underwent successful renal transplantation. To obtain a demogra­phical distribution and assess the co-morbid conditions in the patients, we evaluated their age, sex, BMI, diabetic status, diet, and smoking history. The serum levels of sodium, potassium, chloride, bicarbonate, calcium, phosphorous, intact parathyroid hormone, blood sugar, hemoglobin, total protein, and albumin levels were measured. Using the DEXA scan (General Electric Lunar Prodigy type, USA), we measured the lean body mass, fat mass, and the fat percentage in each patient towards the end of the first month after transplantation. The patients had stable graft function at the time of evaluation.


   Statistical Analysis Top


Variables were expressed as the mean ± standard deviation (SD) and range where appropriate comparisons were performed using Pearson's coefficient. The results were considered to be statistically significant if the p values were < 0.05.


   Results Top


[Table - 1] shows the demographical data. The body mass index and the prevalence of type 2 diabetes mellitus revealed a significantly positive correlation with older age (p<0.05). In the whole study group, 14.7% were diabetic on treatment with insulin.

[Table - 2] displays the mean values and range of BMI, fat mass, lean body mass, and fat percentage values in each age group.

The means of the serum sodium, chloride, potassium, calcium, and phosphorous were found to be within the normal range. There were no significant differences in these para­meters according to age distribution. However, the mean serum creatinine was elevated, to 154 ± 18 µmol/L, which was compatible with a significant but stable renal dysfunction. iPTH levels in most of our patients were within two times the normal values (101± 81 pg/ml). The mean hemoglobin levels were low in all our patients (91.6 ± 19.4 g/L). The mean bicarbonate levels were within normal limits (23 ± 3.5 mmol/L), however there were some patients below normal. The plasma proteins and albumin were lower than normal; 62.2 ± 8.6 g/L, and 36.1 ±5.1gms/L, respectively.


   Discussion Top


Weight gain, obesity, dyslipidemia and post transplant diabetes mellitus are common problems in the recipients of successful renal transplants. [2] The hemoglobin levels were low in the anemic range in all our patients, which is not surprising in view of the sub­optimal use of recombinant human erythro­poietin and other contributory factors.

Amongst the demographical variables analy­zed, the body mass index and the prevalence of type II diabetes mellitus revealed a significantly positive correlation with older age. Amongst our patients, 14.7% were diabetic on treatment with insulin.

The intact parathyroid hormone levels (iPTH) in our study reinforce the notion that significant secondary hyperparathyroidism is not seen in Indian patients on dialysis as the iPTH levels in most of our patients in the early post transplant period was less than two times the normal value.

Our cohort of patients belonged to the upper or upper middle class, were predominantly non-vegetarians who underwent regular, un­interrupted hemodialysis, and were subjected to adequate dietary counseling by the dietician in the dialysis unit pre and postoperatively. These patients were treated with recombinant erythropoietin, carnitine and iron supplements as required. This is in contrast with the category of the lower socio-economic status patients who are usually unable to get access to high quality dialysis treatment along with dietary counseling.

A long-term follow-up of the transplant recipients should include the nutritional status of the patients and impact of the function of the graft and immunosuppressive drugs on it. This is extremely important since studies performed, in the long-term renal allograft recipients, have indicated an increased inci­dence of obesity, post transplant diabetes mellitus, dyslipidemia, and hypertension, which are risk factors for the development or aggravation of artherosclerosis. [5] Amongst our patients, 13.9% of our patients had a BMI of > 30 and are at increased risk for post transplant diabetes mellitus, hypertension, and dyslipidemia that require close monitoring. Moreover, in another study, the comparison of the pre and post transplantation weights demonstrated greater gain in the malnourished group compared with the well-nourished group. [6] We did not perform such a compa­rison in our study.

The accumulation of fat mass, alterations of fat distribution, and muscle wasting after transplantation may be related to steroid treatment, lack of exercise, and increase of daily calorie intake. [7] The majority of the Indian patients continue on a long-term glucocorticoids dose of > 10 milligrams daily, which could be a contributory factor. Though obesity is the dominant feature in the transplant population, weight loss may occur after the initial weight gain due to allograft dysfunction and associated acidosis. [8] The bicarbonate was normal in most of our patients although some were frankly acidotic. Psychological factors such as depression, socio-economic factors, acute concurrent ill­ness and inadequate dietary prescription are the other factors that should also be addressed as causes of post transplant malnutrition.

It is very important to provide adequate nutritional consultation and management after renal transplantation; Distinct protocols for the nutritional evaluation and management should be available for pre-transplant, post-transplant and late-transplant phases in the follow-up clinics in order to improve the quality of care for patients rendered to patients. [5] This is usually difficult in the developing countries, due to limited financial resources. [2]

We conclude that the BMI, fat distribution and percentage as measured by the DEXA scan, as well as the prevalence of type 2 diabetes mellitus in our transplant population, revealed a significantly positive correlation with older age. The elevated mean plasma iPTH levels, decreased mean serum bicarbo­nate, albumin, and hemoglubin levels are most likely related to renal allograft dys­function which is usually inherent with the grafts and may eventually affect the nutritional status of the patients. Subsequently, the initial weight gain may be hampered by the graft dysfunction. Prospe-ctive long-term studies are required to confirm our findings on larger transplant populations.

 
   References Top

1.Locatelli F, Fouque D, Heimburger O, et al. Nutritional status in dialysis: a European consensus. Nephrol Dial Transplant 2002; 17:563-72.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Abraham G, Varsha P, Mathew M, Sairam VK, Gupta A. Malnutrition and nutritional therapy of chronic kidney disease in developing countries: The Asian perspective. Adv Ren Replace ther 2003; l0:213-21.  Back to cited text no. 2    
3.Djukanovic L, Lezaic V, Blagojevic R, et al. Co-morbidity and kidney graft failure-two main causes of malnutrition in kidney transplant patients. Nephrol Dial Transplant 2003; 18:68-70.  Back to cited text no. 3    
4.Mitch W E, Medine R, Grieber S, et al. Metabolic acidosis stimulates muscle protein degeneration by activation of the ATP dependent pathway involving ubiquitin and proteosomes. J Clin Invest 1994; 93:2127-33.  Back to cited text no. 4    
5.Toigo G, Aparico M, Attman PO, et al. Expert working group report on nutrition in adult patients with renal insufficiency. Clin Nutr 2000; 19(4): 281-91.  Back to cited text no. 5    
6.Varsha P, Abraham G, Soundarrajan P, Prabhakar KS. Energy Metabolism in renal transplant patients - Situation Analysis. Indian J Nephrol 1997; 7(3):100-2.  Back to cited text no. 6    
7.Ulivieri FM, Piodi LP, Aroldi A, Cesana BM. Effect of kidney transplantation on bone mass and body composition in males. Transplantation 2002; 17(4):612- 615.  Back to cited text no. 7    
8.Heaf J, Jakobsen U, Tvedegaard E, Kanstrup I, Andersen NF. Dietary habits and nutritional status of renal transplant patients. J Ren Nutr 2004; 14(1):20-5.  Back to cited text no. 8    

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Correspondence Address:
Georgi Abraham
Sri Ramachandra Medical College and Research Institute, Chennai - 600 116
India
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PMID: 17679750

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    Tables

  [Table - 1], [Table - 2]

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    Abstract
    Introduction
    Materials and Me...
    Statistical Analysis
    Results
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