Energy expenditure, spontaneous physical activity and with weight gain in kidney transplant recipients

Sleepiness and Health-Related Quality of Life Among Kidney Transplant Recipients in a Low-Middle Income Country: A Cross-Sectional Study

This study aims to describe daytime sleepiness and health-related quality of life (HRQoL) among Lebanese kidney transplant (KT) recipients and to examine the medical, psychosocial and transplant factors related to them. It is a cross-sectional multi-center study involving KT recipients >18 years. Daytime sleepiness was assessed using ESS Questionnaire. HRQoL was measured using the SF-36 questionnaire. Social support was self-reported. A multivariable regression analysis evaluated factors associated with daytime sleepiness and HRQoL in our sample. 118 patients were recruited over a 2 years period. Excessive daytime sleepiness was prevalent in 12.7%. It was associated with Diabetes Mellitus (OR 3.97, 95% CI 0.94-16.81, p = 0.06) and obesity (OR 1.13, 95% CI 1.02, 1.27, p = 0.02). Social support and higher eGFR were associated with better scores on the MCS (β 24.13 p < 0.001 and β 0.26 p < 0.01) and the PCS (β 15.48 p < 0.01 and β 0.22 P 0.02). Conversely, depression and hospitalization were negatively associated with the MCS (β -27.44, p < 0.01 and β -9.87, p < 0.01) and the PCS (β -0.28.49, p < 0.01 and β -10.37, p < 0.01).

High Alternative Health Eating Index-Taiwan Scores Are Associated With Prevention of Graft Dysfunction in Taiwanese Renal Transplant Recipients

BACKGROUND

Various dietary quality indices demonstrate that a higher dietary quality score is associated with a reduced risk of several chronic diseases. However, creating an index tailored to the national population is crucial. The study investigated the association between the Alternative Healthy Eating Index-Taiwan (AHEI-Taiwan) and graft dysfunction in Taiwanese renal transplant recipients (RTRs).

METHODS

A prospective cohort study recruited 102 RTRs with a functioning allograft without acute rejection in the last 3 months from September 2016 to June 2018. Laboratory data were obtained from the medical records of patients. Graft dysfunction was indicated by an estimated glomerular filtration rate (eGFR) <60 mL/min per 1.73 m² in accordance with the Kidney Disease Outcomes Quality Initiative guideline. The dietary quality index AHEI-Taiwan was adapted from the AHEI based on Taiwanese dietary recommendations.

RESULTS

Mean age, renal transplant time, and eGFR were 48.9 ± 12.8 years, 8.5 ± 5.8 years, and 54.9 ± 17.8 mL/min per 1.73 m², respectively, in 102 RTRs. The RTRs with the highest quartile of AHEI-Taiwan scores were older and had a higher eGFR. Logistic regression analysis adjusted for age, sex, calories, Charlson comorbidity index, transplant time, and dialysis time showed that the highest quartile of the AHEI-Taiwan was associated with an 88% (odds ratio, 0.12; 95% CI, 0.03-0.59, P < .01) lower risk of graft dysfunction.

CONCLUSION

A high AHEI-Taiwan score was associated with a reduced risk of graft dysfunction in Taiwanese RTRs.

Obesity and Lifestyle Habits among Kidney Transplant Recipients

Background: Obesity may negatively impact clinical outcomes in kidney transplant (KT) recipients. Limited information is available on the prevalence of obesity in this population, and on the lifestyle habits associated with obesity. Methods: we conducted an online, anonymous survey to assess of the proportion of KT recipients with obesity, adherence to the Mediterranean diet (i.e., a dietary regimen with proven renal and cardiovascular outcomes) using the MEDI-Lite questionnaire, and level of physical activity using the International Physical Activity Questionnaire (IPAQ) short form among KT recipients. Results: 255 KT recipients participated. Median (25th−75th quartile) age was 56.0 (48.0; 62.0) years, 43.9% female, median BMI 23.9 (21.6; 26.5) kg/m2. The proportion of KT recipients with obesity was 9.8% (95% confidence interval, 6.4 to 14.1%). Adequate adherence to the Mediterranean diet (Medi-Lite score >9) was overall low (44.7%; 40.0 vs. 45.2% in those with or without obesity, respectively; p = 0.618). In participants with obesity the Medi-Lite score inversely correlated with BMI (R = −0.45; p < 0.025). Overall, 30.6% of participants had a low level of physical activity (44.0 vs. 29.1% of those with or without obesity, respectively; p = 0.125). The amount of energy expended walking was significantly lower among participants with obesity (462 (0.0; 1436) vs. 1056 (433; 2005) METs/week, p = 0.017). Conclusions: the burden of obesity among KT recipients is similar to that of the general population. Adherence to the Mediterranean diet was generally low, and nearly one-third of participants had a low level of physical activity. Building specialized multidisciplinary teams to manage obesity in KT recipients is urgently needed.

Pre-Kidney Transplant Unintentional Weight Loss Leads to Worse Post-Kidney Transplant Outcomes

BACKGROUND

Weight loss before kidney transplant (KT) is a known risk factor for weight gain and mortality; however, whereas unintentional weight loss is a marker of vulnerability, intentional weight loss might improve health. We tested whether pre-KT unintentional and intentional weight loss have differing associations with post-KT weight gain, graft loss, and mortality.

METHODS

Among 919 KT recipients from a prospective cohort study, we used adjusted mixed effects models to estimate post-KT BMI trajectories, and Cox models to estimate death-uncensored graft loss, death-censored graft loss, and all-cause mortality by one-year pre-KT weight change category [stable weight (change≤5%), intentional weight loss (loss>5%), unintentional weight loss (loss>5%), and weight gain (gain>5%)].

RESULTS

Mean age was 53 years, 38% were Black, and 40% were female. In the pre-KT year, 62% of recipients had stable weight, 15% had weight gain, 14% had unintentional weight loss, and 10% had intentional weight loss. In the first three years post-KT, BMI increases were similar among those with pre-KT weight gain and intentional weight loss, and lower compared to those with unintentional weight loss (difference +0.79 kg/m2/year, 95% CI: 0.50-1.08 kg/m2/year, p < 0.001). Only unintentional weight loss was independently associated with higher death-uncensored graft loss (adjusted Hazard Ratio [aHR]=1.80, 95% CI:1.23-2.62), death-censored graft loss (aHR=1.91, 95% CI:1.12-3.26) and mortality (aHR=1.72, 95% CI:1.06-2.79) relative to stable pre-KT weight.

CONCLUSIONS

This study suggests that unintentional, but not intentional, pre-KT weight loss is an independent risk factor for adverse post-KT outcomes.

Physical Function in Kidney Transplantation: Current Knowledge and Future Directions

Purpose of review

Low physical function (PF) is common among individuals with end-stage kidney disease. In this review, we explore data on the impacts of PF on access to kidney transplantation (KT) and KT outcomes. We also discuss the latest interventions to improve PF in pre- and post-KT settings.

Recent Findings

Many US KT programs measure PF or related constructs when assessing KT candidacy. Although carefully selected KT candidates with low PF can benefit from KT with respect to survival and quality of life, low PF decreases the likelihood of being listed for KT and increases the risk of adverse post-KT outcomes. Recent trials suggest that exercise is a promising strategy to improve PF among KT candidates and recipients.

Summary

PF is a potentially modifiable risk factor for adverse pre- and post-KT outcomes. Research is needed to determine the ideal PF metric for use in KT evaluations and interventions to improve PF.

Evolution of body composition following successful kidney transplantation is strongly influenced by physical activity: results of the CORPOS study

BACKGROUND

Weight gain (mainly gain of fat mass) occurs quickly after successful kidney transplantation and is associated with metabolic complications (alterations of glycaemic control, hyperlipidaemia). Determinants of weight gain are multifactorial and are mainly related to the transplant procedure itself (glucocorticoid use, increased appetite). In the modern era of transplantation, one challenge is to limit these metabolic alterations by promoting gain of muscle mass rather than fat mass. This prospective study was performed to assess determinants of fat mass, fat-free mass and body cell mass changes after kidney transplantation with a focus on physical activity and nutritional behaviour before and after transplantation.

METHODS

Patients were included at the time of listing for deceased donor kidney transplantation. Body composition was determined using dual X-ray absorptiometry and bioimpedance spectroscopy to assess fat mass, fat-free mass and body cell mass (= fat-free mass - extracellular water) at the time of inclusion, 12 months later, and 1, 6, 12 and 24 months after transplantation. Recall dietary data and physical activity level were also collected.

RESULTS

Eighty patients were included between 2007 and 2010. Sixty-five had a complete 24-month follow-up after kidney transplantation. Fat mass, fat-free mass and body cell mass decreased during the waiting period and early after kidney transplantation. The nadirs of body cell mass and fat-free mass occurred at 1 month and the nadir for fat mass occurred at 6 months. Maximum levels of all parameters of body composition were seen at 12 months, after which body cell mass and fat-free mass decreased, while fat mass remained stable. In multivariate analysis, male recipients, higher physical activity level and lower corticosteroid dose were significantly associated with better body cell mass recovery after kidney transplantation.

CONCLUSIONS

Lifestyle factors, such as physical activity level, together with low dose of corticosteroids seem to influence body composition evolution following kidney transplantation with recovery of body cell mass. Specific strategies to promote physical activity in kidney transplant recipients should be provided before and after kidney transplantation.

Risk factors associated with weight gain after kidney transplantation: A cohort study

BACKGROUND

Renal transplantation is the best modality of renal replacement therapy for patients with end-stage renal disease. However, it is associated with weight gain and metabolic abnormalities, which adversely impact transplant outcomes.

OBJECTIVE

The objective of this study was to identify the risk factors of one-year weight gain after renal transplantation.

METHODS

A retrospective cohort study was conducted with 374 patients that underwent kidney transplantation between January 2006 and July 2013. Clinical and laboratory variables were collected from electronic records, and the outcome of interest was weight gain during the first year after renal transplantation. The data were reported as mean ± standard deviation, median (interquartile range) or number of subjects (%). The association between variables were assessed via chi-square test and ANOVA. For analysis of risk factors related to the outcomes of interest, multivariable logistic regression models were used.

RESULTS

There were 181 (48.4%) female patients, 334 (89.3%) with white ethnicity and the mean age was 44.4 ± 12.8 years. The mean BMI pre-transplant was 24.7 ± 4.1 kg/m2, and 35 (9.9%) patients were classified as obese; 119 (33.6%) as overweight; 187 (52.8%) as normal weight; and 13 (3.7%) as malnourished. After one year of follow-up, the mean BMI was 26.2 ± 5.0 kg/m2, and 61 (17.3%) patients were classified as obese; 133 (37.8%) as overweight; 148 (42.0%) as normal weight; and 10 (2.8%) as malnourished. Weight gain was observed in 72.7% patients, and the average increase was 7.12 ± 5.9 kg. The female gender, lower pre-transplant body weight, lower number of hospitalizations, and a kidney received from a living donor were associated with weight gain by more than 5% in the first year post-transplant.

CONCLUSION

Female gender and lower pre-transplant body weight were independently associated with weight gain by more than 5% in the first year after kidney transplantation; lower rates of hospitalization and donation from living donors were also risk factors for this outcome.

Day and night changes in energy expenditure of patients on automated peritoneal dialysis

RATIONALE

Automated peritoneal dialysis (APD) treatment for end-stage kidney disease affords patients a degree of autonomy in everyday life. Clinical investigations of their energy expenditure (EE) are usually based on resting EE, which could mask day and night variations in EE. The aim of this study, therefore, was to compare the components of EE in APD patients and healthy control (C) subjects.

MATERIAL AND METHOD

Patients treated with APD for more than 3 months were compared with C volunteers matched for age and lean body mass (LBM). Biochemical analyses were performed and body composition was determined by DEXA to adjust EE to LBM. Total EE, its different components and respiratory quotients (RQ) were measured by a gas exchange method in calorimetric chambers. Spontaneous total and activity-related EE (AEE) were also measured in free-living conditions over 4 days by a calibrated accelerometer and a heart rate monitor.

RESULTS

APD (n = 7) and C (n = 7) patients did not differ in age and body composition. REE did not differ between the two groups. However, prandial increase in EE adjusted for dietary energy intake was higher in APD patients (+57.5 ± 12.71 kcal/h) than in C subjects (+33.8 ± 10.5 kcal/h, p = 0.003) and nocturnal decrease in EE tended to be lower in APD patients undergoing dialysis sessions (- 4.53 ± 8.37 kcal/h) than in subjects (- 11.8 ± 7.69 kcal/h, p = 0.059). Resting RQ (0.91 ± 0.09 vs 0.81 ± 0.04, p = 0.032) and nocturnal RQ (0.91 ± 0.09 vs 0.81 ± 0.04, p = 0.032) were significantly higher in APD patients, indicating a preferential use of glucose substrate potentially absorbed across the peritoneum. AEE was lower in APD patients (595.9 ± 383.2 kcal/d) than in C subjects (1205.2 ± 370.5 kcal/d, p = 0.011). In contrast, energy intakes were not significantly different (1986 ± 465 vs 2083 ± 377 kcal/d, p = 0.677).

CONCLUSION

Although the two groups had identical resting EE, APD patients had a higher prandial increase in EE, a lower activity-related EE and higher resting and nocturnal RQ than healthy subjects.

Feasibility and acceptability of a televideo physical activity and nutrition program for recent kidney transplant recipients

Background

Post-transplant weight gain affects 50-90% of kidney transplant recipients adversely affecting survival, quality of life, and risk for diabetes and cardiovascular disease. Diet modification and physical activity may help prevent post-transplant weight gain. Methods for effective implementation of these lifestyle modifications are needed. The objective of this study is to assess the feasibility and acceptability of a remotely delivered nutrition and physical activity intervention among kidney transplant recipients. Secondary aims were to estimate the effectiveness of the intervention in producing changes in physical activity, qualify of life, fruit and vegetable intake, and consumption of whole grains and water from baseline to 6 months.

Methods

A randomized controlled study for stable kidney transplant recipients between 6 and 12 months post-transplantation was conducted. Participants were randomly assigned 1:1 to a technology-based, lifestyle modification program (intervention) or to enhanced usual care (control).

Results

The first 10 kidney transplant recipients screened were eligible and randomized into the intervention and control groups with no significant between-group differences at baseline. Health coaching attendance (78%) and adherence to reporting healthy behaviors (86%) were high. All participants returned for final assessments. The weight in controls remained stable, while the intervention arm showed weight gain at 3 and 6 months. Improvements were found for physical activity, quality of life, and fruit and vegetable intake in both groups. All participants would recommend the program to other transplant recipients.

Conclusions

Our data suggest that a remotely delivered televideo nutrition and physical activity intervention is feasible and valued by patients. These findings will aid in the development of a larger, more prescriptive, randomized trial to address weight gain prevention.

Trial registration

Clinicaltrials.gov Identifier NCT03697317. Retrospectively registered on October 5, 2018.

Weight Gain, Energy Intake, Energy Expenditure, and Immunosuppressive Therapy in Kidney Transplant Recipients

BACKGROUND

Weight gain after kidney transplantation is a common health problem. The factors in weight gain after kidney transplant include many factors such as age, ethnicity, gender, change in lifestyle (eg, kilocalorie intake and physical activity level), and immunosuppressive therapy.

RESEARCH QUESTIONS

This study aimed to evaluate the relationship between weight gain and energy intake in dietary, energy expenditure in physical activity, and immunosuppressive therapy in kidney transplant recipients.

DESIGN

This prospective, observational study included 51 participants who underwent kidney transplant, during 6 months from the start of the study. Anthropometric measurements were performed at first week, third- and sixth-month follow-ups of transplant recipients. Participants also completed 3-day "Dietary Record Form" and the "Physical Activity Record Form" at each follow-up. Simple frequency, analysis of variance analysis, and correlation analysis were used for data analysis.

RESULTS

Weight gain in sixth month follow-up compared to baseline value was positively related to energy intake in first week (r = 0.59), third month (r = 0.75), and sixth month (r = 0.67) follow-ups, and energy expenditure in first week (r = 0.35) and sixth month (r = 0.34) follow-ups. However, weight gain was negatively related to mycophenolate mofetil dose (mg/d) in sixth month (r = -0.31) follow-up (P < .05).

DISCUSSION

The results of this study provide an opportunity to reflect and discuss on modifiable risk factors such as energy intake and energy expenditure that affect weight gain posttransplantation in participants. It also examines the relationship between immunosuppressive therapy. Additionally, these results can be effective in designing interventions and managing risk factors to achieve weight management goals.

A Comparison of the Indirect Calorimetry and Different Energy Equations for the Determination of Resting Energy Expenditure of Patients With Renal Transplantation

OBJECTIVE

We aimed to evaluate the agreement between the resting energy expenditure (REE) obtained by indirect calorimetry and eight prediction equations in adult patients with renal transplantation and a newly developed REE prediction equation for use in patients with renal transplantation in the clinic.

METHODS

A total of 51 patients (30 males and 21 females) were involved in the study. The REE was measured by indirect calorimetry and compared with the previous prediction equations. The agreement was assessed by the interclass correlation coefficient and by Bland-Altman plot analysis.

RESULTS

No significant difference was found in terms of age and body mass index between the genders. Differences between the predicted and measured REEs were maximum in the Bernstein equation (-478 kcal) and minimum in the Cunningham equation (-69 kcal). It was found that underprediction values varied from 27.5% (chronic kidney disease equation) to 98.0% (Bernstein equation). The highest overprediction value was found in the Schofield equation (17.7%). The Cunningham equation and the new equation had the lowest root mean square error (265 kcal/day). In this study, fat-free mass (FFM) was found to be the most significant variable in multiple regression analysis (r²: 0.55). The new specific equation based on FFM was generated as 424.2 + 24.7∗FFM (kg). Besides that, it was found that the new equation and Cunningham equation were distributed randomly according to Bland-Altman analysis. A supplementary new equation based on available anthropometric measurements was developed as -1996.8 + 19.1∗height (cm) + 7.2∗body weight (kg).

CONCLUSION

This study showed that most of the predictive equations significantly underestimated REE. In patients with renal transplantation, if the REE is not measurable by indirect calorimetry, the use of the proposed equations will be more accurate.

Dietary Diversity Score: Implications for Obesity Prevention and Nutrient Adequacy in Renal Transplant Recipients

Obesity affects both medical and surgical outcomes in renal transplant recipients (RTRs). Dietary diversity, an important component of a healthy diet, might be a useful nutritional strategy for monitoring patients with obesity. In this cross-sectional study, the data of 85 eligible RTRs were analyzed. Demographic data, routine laboratory data, and 3-day dietary data were collected. Participants were grouped into nonobesity and obesity groups based on body mass index (BMI) (for Asian adults, the cutoff point is 27 kg/m²). Dietary diversity score (DDS) was computed by estimating scores for the six food groups emphasized in the Food Guide. The mean age and BMI of participants were 49.7 ± 12.6 years and 24.0 ± 3.8 kg/m², respectively. In the study population, 20.0% (n = 17) were obese. DDS was significantly lower in obese participants than in those who were not obese (1.53 ± 0.87 vs. 2.13 ± 0.98; p = 0.029). In addition, DDS was correlated with nutrition adequacy of the diet. Multivariate analysis showed that the odds of obesity decreased with each unit increase in DDS (odds ratio, 0.278; 95% confidence interval, 0.101–0.766; p = 0.013). We conclude that patients with higher dietary diversity have a lower prevalence of obesity.

Living-donor transplantation leads to a major improvement in physical functioning: an observational study on the impact on potential donors and their recipients

Background

Prospective studies combining physical functioning (PF), physical activity (PA), and body composition (BC) after living donor transplantation/donation are scarce. We aimed to study differences in these parameters between kidney transplant recipients and their living donors by examining changes in these parameters in the first post-operative year in both groups.

Methods

Twenty-two kidney transplant recipients and 22 healthy kidney donors were included in this prospective longitudinal study with a follow-up until twelve months. PF was assessed by handgrip strength (HGS), and by the physical domains of health-related quality of life (HRQOL) using the Short Form-36 questionnaire [PF (SF-36 PF) and physical component summary (PCS) score]. BC was measured by the Body Composition Monitor©, and PA was measured by the SenseWear™ pro3.

Results

At baseline, recipients had significantly lower HGS (after adjustment for sex and body weight), SF-36 PF, PCS, and PA, as compared with their donors. In recipients HGS significantly increased in the first year after transplantation, but PA did not change in the first six months after transplantation. Furthermore, no significant increase in lean tissue mass was observed. For healthy donors no significant changes in these parameters were observed, with exception of SF-36 PF, which declined in the first three months after donation, but equaled baseline values after twelve months.

Conclusion

Recipients showed impressive improvements in PF and the physical domains of HRQOL in the first year after transplantation, reaching levels of healthy kidney donors already three to six months after transplantation. On the contrary, living kidney donation did not show any deterioration of the investigated parameters, supporting little impact for well-screened donors, while there is high benefit for transplant recipients.

A Randomized Controlled Trial of an Intensive Nutrition Intervention Versus Standard Nutrition Care to Avoid Excess Weight Gain After Kidney Transplantation: The INTENT Trial

OBJECTIVE

Excessive weight gain is common after kidney transplantation and increases cardiovascular risk. The aim of this randomized controlled trial was to determine whether an intensive nutrition and exercise intervention delivered alongside routine post-transplant care would reduce post-transplant weight gain.

DESIGN

Single-blind, randomized controlled trial.

SUBJECTS AND SETTING

Adult kidney transplant recipients at a regional transplant center were recruited during routine outpatient clinic visits in the first month after transplant. Patients with a body mass index >40 kg/m² or <18.5 kg/m², severe malnutrition, or ongoing medical complications were excluded.

INTERVENTION

Participants were randomized to intensive nutrition intervention (individualized nutrition and exercise counselling; 12 dietitian visits; 3 exercise physiologist visits over 12 months) or to standard nutrition care (guideline based; 4 dietitian visits).

MAIN OUTCOME MEASURES

The primary outcome was weight at 6 months after transplant adjusted for baseline weight, obesity, and gender, analyzed using analysis of covariance. The secondary outcomes included body composition, biochemistry, quality of life, and physical function.

RESULTS

Thirty-seven participants were randomized to the intensive intervention (n = 19) or to standard care (n = 18); one intensive group participant withdrew before baseline. Weight increased between baseline, 6 and 12 months (78.0 ± 13.7 [standard deviation], 79.6 ± 13.0 kg, 81.6 ± 12.9 kg; mean change 4.6% P < .001) but at 6 months did not differ significantly between the groups: 77.0 ± 12.4 kg (intensive); 82.2 ± 13.4 kg (standard); difference in adjusted means 0.4 kg (95% confidence interval: -2.2 to 3.0 kg); analysis of covariance P = .7. No between-group differences in secondary outcomes were observed. Across the whole cohort, total body protein and physical function (gait speed, sit to stand, grip strength, physical activity, and quality of life [all but 2 domains]) improved. However, adverse changes were seen for total body fat, HbA1c, and fasting glucose across the cohort.

CONCLUSIONS

Kidney transplant recipients in the first year after transplant did not benefit from an intensive nutrition intervention compared with standard nutrition care, although weight gain was relatively modest in both groups.