| Abstract|| |
Bioelectrical impedance analysis (BIA) is a method for the assessment of nutritional status. We studied the effect of graft function on nutritional status in postrenal 45 transplant patients with borderline to good allograft function using BIA. The patients had a mean serum creatinine of 1.42 ± 0.42 mg% and mean glomerular filtration rate (GFR) of 45.1 ± 14.1 mL/min. Based on BIA-derived GFR, the patients were divided into two groups; group 1: borderline graft function GFR <40 mL/min and a mean of 27.34 ± 9.1 mL/min and group 2: good graft function GFR ≥40 mL/min and a mean of 51.60 ± 9.16 mL/min. The patient data were compared with 30 healthy individuals. There was a significant difference between healthy controls and the posttransplant patients. There were significant differences between the study groups in body weight (P <0.01), serum creatinine (P <0.005), body mass index (BMI) (P <0.000), fat free mass (FFM) (P <0.003), fat mass (FM) (P <0.003), body cell mass (P <0.000), and dry weight (P <0.001). Group 1 had significantly lower body weight, BMI, FFM, FM, and dry weight, indicating poorer nutritional status compared with those in group 2. Based on phase angle, there were significant differences between group A (phase angle <4.0) and group B (phase angle >4.0) in extracellular water (P <0.015), intracellular water (P <0.002), plasma fluid (P <0.016), interstitial fluid (P <0.016), and body cell mass (P <0.024). Subjective global assessment (SGA) scores showed that transplant patients had normal nutritional status, but when compared with healthy individuals as assessed by BIA, there were significant differences in FM, FFM, and body cell mass. In conclusion, BIA was more sensitive to evaluate nutritional depletion than SGA in transplant patients with borderline.
|How to cite this article:|
Saxena A, Sharma R K, Gupta A. Graft function and nutritional parameters in stable postrenal transplant patients. Saudi J Kidney Dis Transpl 2016;27:356-61
|How to cite this URL:|
Saxena A, Sharma R K, Gupta A. Graft function and nutritional parameters in stable postrenal transplant patients. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2020 Jan 23];27:356-61. Available from: http://www.sjkdt.org/text.asp?2016/27/2/356/178563
| Introduction|| |
Accurate nutritional assessment is becoming an integral part of the clinical evaluation of individuals with compromised organ systems. Calculations of biochemical and anthropometric indices, immunological tests, and subjective global assessments (SGA) are currently now used to determine patients' nutritional status. , Use of the conventional anthropometric indices are questionable because of inherent limitations due to their poor inter-and-intra examiner reproducibility, variability in calibration of skinfold circumference, inconsistency in identification of the measurement site, and possible presence of generalized edema that limits the performance of accurate anthropometry. 
Bioelectrical impedance analysis (BIA) is a safe, noninvasive, rapid, validated, and reproducible method for assessment of body composition and nutritional status both in health and disease. 
Patients with end-stage renal-disease are of the worst affected in terms of nutritional intake. With a successful renal transplant, it is expected that nutritional intake of the patients improve and steadily they return to normal health and nutritional status. Renal transplant patients have received little attention concerning nutritional markers and body composition.
The aim of our study was to evaluate the effect of graft function on nutritional status using BIA in post renal transplant patients with borderline to good allograft function.
| Patients and Methods|| |
Forty five post-renal transplant patients (41 males and 4 females) were subjected to anthropometry and wrist-to-ankle multi-frequency BIA using 915/916 Bioscan (Meltron, UK). The research project was approved by the Institute's Ethics Committee. Controls were defined as patients who were healthy and did not undergo transplant of solid organ. The SGA scoring was done for the assessment of nutritional status of the patients. Patients had normal SGA scores. All the patients were on 2 or 3 immunosuppressive drug regimen including prednisolone, azathioprine, mycophenolate mofetil, and cyclosporine. Based on glomerular filtration rate (GFR mL/min) as calculated by BIA, the patients were divided into two groups; group 1: borderline graft function GFR <40 mL/min and group 2: good graft function GFR ≥40 mL/min.
Phase angle, which is a good indicator of health, is associated with cell death and catabolic processes; phase angle score between 4 and 15 reflects good health. The transplant patients were compared with 30 healthy individuals (male 21 and female 9). BIA parameters included phase angle, dry weight, total body water (TBW), extracellular water (ECW), intra-cellular water (ICW), fat-free mass (FFM), fat mass (FM), body cell mass (BCM), muscle mass (MM), total body potassium (TBP), total body calcium (Ca) and glycogen, plasma fluid, interstitial fluid (Ints. fl), and extracellular solids (ECS).
| Statistical Analysis|| |
Analysis of data was carried out by the SPSS version 10.0. Mean, standard deviation for all the parameters were calculated. The Student's t test was used to study the differences between the groups.
| Results|| |
[Table 1] shows the descriptive statistics of patients and the controls. There were significant differences in the parameters between the controls and the transplant patients [Table 2].Compared with the controls, the patients revealed low body weight, impedance, phase angle, resistance, reactance, body mass index (BMI), BCM, FM, FM%, GFR, and dry weight, but high serum creatinine, ECM, and FFM%. Though BMI of both the transplant patients and the controls fell within the normal range, yet there were statistically significant differences between the two. There was a difference between the actual weight and the dry weight; this is reflected in high FFM% of the transplant patients.
|Table 1: Descriptive statistics of the study patients and the healthy controls.|
Click here to view
|Table 2: Differences in nutritional parameters of patients and controls.|
Click here to view
[Table 3] shows differences between the GFRbased patients groups (GFR <40 mL/min and GFR >40 mL/min). Patients with good graft function had higher body weight, BMI, FFM, FM and BCM, TBW, ICW, ECW, TBP CA, and glycogen compared with those with borderline graft function indicating poorer nutritional status in this latter group.
|Table 3: Descriptive statistics of transplant patients groups based on GFR.|
Click here to view
On analyzing the data based on phase angle (group A phase angle <4.0 and group B phase angle >4.0), there were significant differences in the nutritional parameters [Table 4]. Group A patients had significantly high ECW and ECW%, plasma fluid, and interstitial fluid, but lower GFR, ICW, BCM, TBP, Ca, and ECS compared with group B, indicating that patients with phase angle more than 4 had better nutritional status compared to those with low phase angle.
|Table 4: Differences in nutritional status among patients groups based on phase angle.|
Click here to view
| Discussion|| |
Kidney failure causes several abnormalities of the nutritional status and body composition.  These have been documented in patients with end-stage-renal-failure, either before or after commencement of dialysis therapy. The catabolic effect of chronic uremia, along with the significant perturbations of many aspects of metabolism and of water and electrolytes balance, contributes to the alterations in body composition an nutritional status that are associated with increased morbidity and mortality. ,
Renal allografts sometimes cannot reach the level of normal kidney function, and in significant number of cases following both immune-dependent processes, allograft function slowly involutes toward a chronic renal failure condition. As a consequence, the development of an abnormal nutritional condition is anticipated. Furthermore, anorexia, compounded by medically advised restriction of dietary proteins, results in a variable degree of protein-energy malnutrition, particularly concerning fat mass and lean body mass, which constitute late markers of nutritional status and risk factors for cardiovascular diseases in transplant patients. ,,,
This study shows that there is a significant difference in nutritional parameters of healthy controls and kidney transplant patients. Between transplant groups those with good graft function were nutritionally better off compared to those with borderline graft function. Labile protein reserve is similar in weight to glycogen stores. Cells contain high concentration of potassium and TBP also indicate cellular and hence protein mass.  Between the patient groups, the difference in glycogen store, TBP, BCM, FFM, and muscle mass clearly indicates early malnutrition, especially in patients with borderline graft function and normal SGA scores.
Phase angle of BIA, an indicator of health, is an important nutritional parameter. This clearly indicates that subjective evaluation is not sensitive enough to detect early signs of nutritional depletion in transplant patients. Extracellular fluid volume expansion is an important factor for hypertension and subsequent graft loss.  Compared with the controls, the patients had higher ECW and ECW% and lower ICW%. Furthermore, the patients had a significant difference between the actual and BIA-derived dry weight, although the patients were clinically not edematous indicating the expansion of water compartments (fluid overload). The significant difference in the water compartments was observed when the patients were grouped on the basis of GFR more than 40 mL/min and less than 40 mL/minute. Our study also found an association between overhydration and GFR. BIA may be a useful tool for the clinical assessment of overhydration in non-edematous patients. These findings are supported by other studies. 
Renal transplant patients are at risk for increased weight, centripetal obesity, and muscle atrophy because of their long-term glucocorticoid requirements. ,,,, Such changes in body composition are associated with an increased risk of cardiovascular complications, ,,,,, a major cause of morbidity and mortality in renal transplant patients. ,,,, Hence, body composition data might provide insight into the relation with outcome, survival, and posttransplant complications; it might also affect approaches to nutritional therapy and to therapy in the field of physical activity. To be able to preserve appropriate nutritional status, noninvasive and more sensitive techniques such as BIA should be brought into use for routine monitoring of posttransplant patients. Timely dietary intervention will be of immense help in preserving normal health of posttransplant patients.
In conclusion, our study suggests that nutritional deficiency starts very early with borderline GFR reduction (<40 mL/min) in kidney transplant patients. This may not be picked up by the usual clinical assessment such as SGA, but is objectively detected by BIA measurements.
This study was funded by Young Scientist FAST TRACK Scheme of Department of Science and Technology (DST), New Delhi, India.
| Acknowledgement|| |
We thank our patients for their cooperation during the study.
Conflicts of interest: None declared.
| References|| |
Baker JP, Detsky AS, Wesson DE, et al. Nutritional assessment: A comparison of clinical judgement and objective measurements. N Engl J Med 1982;306:969-72.
Jeejeebhoy KN, Detsky AS, Baker JP. Assessment of nutritional status. JPEN J Parenter Enteral Nutr 1990;14 5 Suppl:193S-6S.
Bencich JJ, Twyman DL, Fierke A. The failure of anthropometry as a nutritional assessment tool. Henry Ford Hosp Med J 1986;34:95-8.
Robert S, Zarowitz BJ, Hyzy R, Eichenhorn M, Peterson EL, Popovich J Jr. Bioelectrical impedance assessment of nutritional status in critically ill patients. Am J Clin Nutr 1993; 57:840-4.
Coroas A, de Oliveira JG, Sampaio S, et al. Bioimpedance analysis highlights changes in body composition at the early stages of impairment of kidney transplant function. J Ren Nutr 2004;14:157-63.
Foley RN, Parfrey PS, Harnett JD, Kent GM, Murray DC, Barre PE. Hypoalbuminemia, cardiac morbidity, and mortality in end-stage renal disease. J Am Soc Nephrol 1996;7:728-36.
Ishimura E, Okuno S, Kim M, et al. Increasing body fat mass in the first year of hemodialysis. J Am Soc Nephrol 2001;12:1921-6.
van den Ham EC, Kooman JP, van Hooff JP. Nutritional considerations in renal transplant patients. Blood Purif 2002;20:139-44.
van den Ham EC, Kooman JP, Christiaans MH, et al. Body composition in renal transplant patients: Bioimpedance analysis compared to isotope dilution, dual energy X-ray absorptiometry, and anthropometry. J Am Soc Nephrol 1999;10:1067-79.
Dumler F, Kilates C. Use of bioelectrical impedance techniques for monitoring nutritional status in patients on maintenance dialysis. J Ren Nutr 2000;10:116-24.
Garlick PJ, Reeds PJ. "Proteins". In: Garrow JS, James WP, eds. Human Nutrition and Dietetics. 9th ed. Churchill Livingstone London WC1X 8RW United Kingdom; 1993. p. 63.
First MR, Neylan JF, Rocher LL, Tejani A. Hypertension after renal transplantation. J Am Soc Nephrol 1994;4 8 Suppl:S30-6.
Saxena A, Sharma RK. Hypertension in postrenal transplant patients: Pilot study. Saudi J Kidney Dis Transpl 2014;25:22-8.
Moore LW, Gaber AO. Patterns of early weight change after renal transplantation. J Ren Nutr 1996;6:21-5.
Merion RM, Twork AM, Rosenberg L, et al. Obesity and renal transplantation. Surg Gynecol Obstet 1991;172:367-76.
Yanovski JA, Cutler GB Jr. Glucocorticoid action and the clinical features of Cushing's syndrome. Endocrinol Metab Clin North Am 1994;23:487-509.
Horber FF, Zürcher RM, Herren H, Crivelli MA, Robotti G, Frey FJ. Altered body fat distribution in patients with glucocorticoid treatment and in patients on long-term dialysis. Am J Clin Nutr 1986;43:758-69.
Danovitch GM. Immunosuppressive medications and protocols for kidney transplantation. In: Danovitch GM, edr. Handbook of Kidney Transplantation. 1st ed. Boston: Little Brown and Company; 1992. p. 67-104.
Chan MK, Varghese Z, Persaud JW, Fernando ON, Moorhead JF. The role of multiple pharmaco-therapy in the pathogenesis of hyperlipidemia after renal transplantation. Clin Nephrol 1981;15:309-13.
Vathsala A, Weinberg RB, Schoenberg L, et al. Lipid abnormalities in renal transplant recipients treated with cyclosporine. Transplant Proc 1989;21:3670-3.
Isoniemi H, Tikkanen M, Häyry P, et al. Lipid profiles with triple drug immunosuppressive therapy and with double drug combinations after renal transplantation and stable graft function. Transplant Proc 1991;23(1 Pt 2): 1029-31.
Lapidus L, Bengtsson C, Larsson B, Pennert K, Rybo E, Sjöström L. Distribution of adipose tissue and risk of cardiovascular disease and death: A 12 year follow up of participants in the population study of women in Gothenburg, Sweden. Br Med J (Clin Res Ed) 1984;289: 1257-61.
Larsson B, Svärdsudd K, Welin L, Wilhelmsen L, Björntorp P, Tibblin G. Abdominal adipose tissue distribution, obesity, and risk of cardiovascular disease and death: 13 year follow up of participants in the study of men born in 1913. Br Med J (Clin Res Ed) 1984; 288:1401-4.
Nephrology Department, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
[Table 1], [Table 2], [Table 3], [Table 4]