Nutritional management in renal transplant recipients: A transplant team opportunity to improve graft survival

The impact of high intrapatient variability of tacrolimus in peripheral blood mononuclear cells on the outcomes of kidney transplantation

BACKGROUND

Tacrolimus (TAC) is a key immunosuppressive agent for kidney transplantation, but its narrow therapeutic window and high intra-patient variability (IPV) complicate therapeutic drug monitoring. The clinical significance of PBMC-based IPV in predicting graft rejection and infection remains unclear.

METHODS

A total of 47 renal transplant recipients were enrolled. Intracellular TAC concentrations were analyzed and quantified using liquid chromatography-tandem mass spectrometry. The primary endpoint was the occurrence of the first adverse event, including acute rejection or infection of any etiology. The IPV of peripheral blood mononuclear cells (IPVPBMC) and whole blood (IPVWB) was calculated as the coefficient of variation of dose-corrected concentrations from day 14 to month 12 post-transplantation. A Cox proportional hazards model was employed to identify risk factors associated with kidney transplant outcomes.

RESULTS

Within the first year post-transplantation, the incidence of acute rejection was significantly higher in the High-IPVWB group compared to the Low-IPVWB group (P = 0.024). Moreover, the IPVWB in the rejection group was significantly higher than in the stable group (P = 0.034), and High-IPVWB and extended post-operative hospital stay served as independent predictors of rejection within the first year. Additionally, High-IPVPBMC, deceased donors, and longer hospital stay were the main risk factors for early infection following transplantation.

CONCLUSIONS

Both IPVPBMC and IPVWB are significantly associated with graft rejection and infection. Monitoring IPVPBMC and IPVWB within the first six months post-transplantation could help identify high-risk patients and improve clinical management strategies.

Effect of an intensive nutrition intervention of a high protein and low glycemic load diet on weight of kidney transplant recipients: a randomized clinical trial

PURPOSE

The purpose of this study is to evaluate the effect of a high protein and low glycemic load diet in preventing weight gain after kidney transplantation.

METHODS

We designed a prospective, single-center, open-label, randomized controlled study to compare the efficacy of a high protein (1.3-1.4 g/kg/day) and low glycemic load diet versus a conventional diet (0.8-1.0 g/kg/day of protein and no recommendations on glycemic load) in preventing weight gain (ClinicalTrials.gov identifier: NCT02883777). A total of 120 patients were evaluated. Patients were followed for 12 months, and the primary outcome was weight maintenance or weight gain lower than 5%.

RESULTS

There were no differences in total energy intake, carbohydrates, and total fats between groups. Intervention group (IG) increased protein intake to 1.38 ± 0.56 g/kg/day and decreased the glycemic load to 87.27 ± 4.54 g/day, while control group (CG) had a dietary protein intake of 1.19 ± 0.43 g/kg/day and a glycemic load of 115.60 ± 7.01 g/day. Total fiber intake was greater and trans-fat was lower in IG. Dietetic cholesterol increased in IG over time and was significantly different between groups. Overall, patients had an increase in body weight over time, with a mean increment of 4.1 ± 5.5 kg (5.75%). The percentage of patients who achieved the primary outcome was 50% of sample size, without differences between groups. The glomerular filtration rate improved over time in both groups. Considering 24-h proteinuria and albuminuria, a similar rise was observed in both groups.

CONCLUSION

The present dietary intervention was safe, but had no effect on weight gain in kidney transplant subjects. Our findings suggest that other strategies, including alternative dietary and/or pharmacological and psychological interventions might be tested in randomized control trials in order to improve patients' body weight outcomes after transplant.

Assessing health literacy in transplant patients to better tailor the content of their therapeutic education: an observational study

OBJECTIVES

Evaluate health literacy in transplant patients to better tailor the content of their continuing therapeutic education.

METHODS

A 20-item questionnaire divided into five themes (sport/recreation, dietary measures, hygiene measures, recognition of the signs of graft rejection and medication management) was sent to transplant patient associations. Participants' responses (a score out of 20 points), were analysed according to demographic characteristics, transplanted organ (kidney, liver or heart), type of donor (living or deceased), participation in a therapeutic patient education (TPE) programme, management of end-stage renal disease (with or without dialysis) and the date of transplant.

RESULTS

327 individuals completed the questionnaires (mean age 63.3±12.7 years, mean time post-transplant 13.1±12.1 years). From 2 years after transplantation, the patients' score decreases significantly compared with the score obtained at hospital discharge. Patients who received TPE had significantly higher scores than patients who did not receive it, but only in the first 2 years post-transplant. The scores were different depending on the organs transplanted. Patients' knowledge varied according to the theme; the percentage of errors being higher for questions related to hygienic and dietary rules.

CONCLUSION

These findings highlight the importance of the role of the clinical pharmacist in maintaining the transplant recipient's health literacy level over time to increase graft life. We show the topics on which pharmacists must acquire solid knowledge to best meet the needs of transplant patients.

Tacrolimus Pharmacokinetics is Associated with Gut Microbiota Diversity in Kidney Transplant Patients: Results from a Pilot Cross-Sectional Study

Clinical use of tacrolimus (TAC), an essential immunosuppressant following transplantation, is complexified by its high pharmacokinetic (PK) variability. The gut microbiota gains growing interest but limited investigations have evaluated its contribution to TAC PKs. Here, we explore the associations between the gut microbiota composition and TAC PKs. In this pilot cross-sectional study (Clinicaltrial.gov NCT04360031), we recruited 93 CYP3A5 non-expressers stabilized kidney transplant recipients. Gut microbiota composition was characterized by 16S rRNA gene sequencing, TAC PK parameters were computed, and additional demographic and medical covariates were collected. Associations between PK parameters or diabetic status and the gut microbiota composition, as reflected by α- and β-diversity metrics, were evaluated. Patients with higher TAC area under the curve AUC/(dose/kg) had higher bacterial richness, and TAC PK parameters were associated with specific bacterial taxa (e.g., Bilophila) and amplicon sequence variant (ASV; e.g., ASV 1508 and ASV 1982 (Veillonella/unclassified Sporomusaceae); ASV 664 (unclassified Oscillospiraceae)). Building a multiple linear regression model showed that ASV 1508 (co-abundant with ASV 1982) and ASV 664 explained, respectively, 16.0% and 4.6% of the interindividual variability in TAC AUC/(dose/kg) in CYP3A5 non-expresser patients, when adjusting for hematocrit and age. Anaerostipes relative abundance was decreased in patients with diabetes. Altogether, this pilot study revealed unprecedented links between the gut microbiota composition and diversity and TAC PKs in stable kidney transplant recipients. It supports the relevance of studying the gut microbiota as an important contributor to TAC PK variability. Elucidating the causal relationship will offer new perspectives to predict TAC inter- and intra-PK variability.

Metabolic Syndrome and Dietary Intake are Associated With Quality of Life in Kidney Transplant Recipients

BACKGROUND

Although metabolic syndrome (MetS) is a significant risk factor, and dietary intake may affect the quality of life (QoL) of kidney transplant recipients (KTRs), the association between them are unclear. This study identified MetS and nutritional factors associated with the QoL of KTRs.

METHODS

This study reports baseline data from a longitudinal study that was conducted at a hospital in Vietnam. KTRs aged ≥18 years and >3 months post-transplantation were recruited. Assessments included sociodemographic and blood biomarkers. Dietary intake was estimated from 24-hour recalls. A Short Form-36 Health Survey, comprising physical (PCS) and mental component summaries (MCS), was administered to assess QoL. Multivariate linear regression models were performed.

RESULTS

The study included 106 patients (79 men) with a mean age of 43.2 years (± 11.9). Mean duration after kidney transplantation was 28.5 months (± 14.9). Patients with MetS had 6.43 lower PCS score (P < .05) and 3.20 lower MCS score (P < .05) than their counterparts without MetS. Calcium intake (β = -0.01; 95% CI, -0.03 to 0.00) and inadequate protein (β = -14.8; 95% CI, -23 to -6.65) were negatively associated with PCS score. MCS score was negatively associated with calcium intake (β = -0.02; 95% CI, -0.04 to -0.01) and inadequate protein intake (β = -15.1; 95% CI, -24.3 to -5.86), and positively associated with fat intake (β = 0.43, 95% CI, 0.02-0.85).

CONCLUSIONS

MetS and poor dietary intake are independently associated with the QoL of KTRs. Nutritional intervention plans developed specifically for the recipients will improve dietary intake, reduce the incidence of MetS, and help enhance QoL.

Nutritional Risk of Candidates for Simultaneous Pancreatic-Kidney Transplantation-A Narrative Review

INTRODUCTION

Not much is known about the significance of nutritional status and support in transplant surgery, least of all in simultaneous pancreatic and kidney transplantation. Malnutrition in the context of simultaneous pancreatic-kidney transplantation seems to be complex and a still poorly investigated problem. Since SPKTX is highly qualified and also has a small volume procedure, it is difficult to obtain data from large cohorts of patients. The aim of this article is to gather existing evidence and information about the subject, as well as to elicit some questions and goals for the future.

METHODS

We searched through the Pub-Med database using the keywords "pancreas and kidney transplantation" combined with "nutritional risk", "nutritional status", "malnutrition", "nutritional intervention", and "frailty", finding a total of 4103 matching results. We then narrowed it down to articles written in English with the full text available. We also researched through the references of articles most accurately matching our researched terms.

RESULTS

There are numerous tools that have been investigated for the screening of malnutrition, such as the NRI index, PNI index, NLR, SGA scale, and NRS-2002 scale, each of which proved to be of some use in predicting patient outcomes in different surgical settings. Since all of them differed in components and assessed parameters and, in the absence of more sensitive or infallible indicators, the most reasonable approach seems to evaluate them jointly.

CONCLUSION

It is important to underline the necessity of nutritional screening and the subsequent introduction of adequate therapy while awaiting transplantation in an attempt to improve results. Considering the complexity of surgical procedures and the severity of underlying diseases with their intense metabolic components, the patient's nutritional status seems to significantly influence results. Consequently, nutritional risk assessments should be a part of the routine care of patients qualified for transplantation.

Gut microbiome modulates tacrolimus pharmacokinetics through the transcriptional regulation of ABCB1

BACKGROUND

Following solid organ transplantation, tacrolimus (TAC) is an essential drug in the immunosuppressive strategy. Its use constitutes a challenge due to its narrow therapeutic index and its high inter- and intra-pharmacokinetic (PK) variability. As the contribution of the gut microbiota to drug metabolism is now emerging, it might be explored as one of the factors explaining TAC PK variability. Herein, we explored the consequences of TAC administration on the gut microbiota composition. Reciprocally, we studied the contribution of the gut microbiota to TAC PK, using a combination of in vivo and in vitro models.

RESULTS

TAC oral administration in mice resulted in compositional alterations of the gut microbiota, namely lower evenness and disturbance in the relative abundance of specific bacterial taxa. Compared to controls, mice with a lower intestinal microbial load due to antibiotics administration exhibit a 33% reduction in TAC whole blood exposure and a lower inter-individual variability. This reduction in TAC levels was strongly correlated with higher expression of the efflux transporter ABCB1 (also known as the p-glycoprotein (P-gp) or the multidrug resistance protein 1 (MDR1)) in the small intestine. Conventionalization of germ-free mice confirmed the ability of the gut microbiota to downregulate ABCB1 expression in a site-specific fashion. The functional inhibition of ABCB1 in vivo by zosuquidar formally established the implication of this efflux transporter in the modulation of TAC PK by the gut microbiota. Furthermore, we showed that polar bacterial metabolites could recapitulate the transcriptional regulation of ABCB1 by the gut microbiota, without affecting its functionality. Finally, whole transcriptome analyses pinpointed, among others, the Constitutive Androstane Receptor (CAR) as a transcription factor likely to mediate the impact of the gut microbiota on ABCB1 transcriptional regulation.

CONCLUSIONS

We highlight for the first time how the modulation of ABCB1 expression by bacterial metabolites results in changes in TAC PK, affecting not only blood levels but also the inter-individual variability. More broadly, considering the high number of drugs with unexplained PK variability transported by ABCB1, our work is of clinical importance and paves the way for incorporating the gut microbiota in prediction algorithms for dosage of such drugs. Video Abstract.

What is Known About Dietary Interventions and Body Weight Management After Kidney Transplantation? A Scoping Review

OBJECTIVE

Several studies report weight gain after kidney transplantation, which is commonly related to poor outcomes. However, recommendations for dietary interventions aiming to manage these patients' weight are still scarce in the literature. Thus, this review seeks to describe the state of literature on the effect of dietary interventions on weight after kidney transplantation.

DESIGN

Scoping review.

METHODS

This review was designed according to the recommendations for scoping reviews elaborated by the Joanna Briggs Institute. Studies assessing the effect of dietary interventions on body weight after kidney transplantations were searched in MEDLINE, EMBASE, and Clinicaltrials.gov databases up to June 28, 2021. Two independent reviewers summarized the data collected.

RESULTS

Thirteen (503 patients) of the 4.983 articles identified in the searched databases were included in our study. Most studies were published before 2010 and presented incomplete methodology descriptions. Nutritional counseling and dietary prescriptions according to the Step 1 diet of the American Heart Association (AHA) were the most common interventions. Only 2 studies evaluated changes in body weight as primary outcome. Three studies were randomized clinical trials (RCT), and none of these found the adopted interventions to demonstrate benefits.

CONCLUSION

Our scoping review evinced a scarcity of data available in the literature addressing this topic. Most studies were not controlled and presented poor methodological quality. Moreover, these studies included small sample sizes, so that the assessment of dietary interventions in these patients still lacks power for definitive conclusions. Prospective RCT should be conducted to define effective in preventing weight gain or weight loss after kidney transplant.

Number of Teeth and Nutritional Status Parameters Are Related to Intima-Media Thickness in Dalmatian Kidney Transplant Recipients

Although kidney transplantation significantly improves the quality of life of patients with end-stage renal disease (ESRD), the prevalence of cardiovascular disease (CVD) in kidney transplant recipients (KTRs) remains high. Atherosclerosis, post-transplantation metabolic changes, immunosuppressive therapy, and periodontitis contribute to elevated cardiovascular risk in this population. The aim of the study was to evaluate carotid intima-media thickness (IMT) as a surrogate marker of atherosclerosis and to analyze the possible risk factors for IMT in Dalmatian KTRs. Ninety-three KTRs were included in this study. Data on clinical and laboratory parameters, body composition, anthropometry, advanced glycation end-product (AGE) measurements, blood pressure, and arterial stiffness were collected. All participants underwent ultrasound examination of IMT and evaluation of periodontal status. KTRs with carotid IMT ≥ 0.9 were significantly older, had a lower level of total cholesterol, fat mass, end-diastolic velocity (EDV), and had fewer teeth. They also had significantly higher values of pulse wave velocity (PWV) and resistive index (RI). We found positive correlations between carotid IMT and duration of dialysis, age, PWV, AGE, RI, and average total clinical attachment level (CAL). The regression model showed that IMT in KTRs is associated with higher PWV, lower fat mass, and fewer teeth. The results of our study suggest that nutritional and periodontal status are associated with carotid IMT in KTRs.

Dyslipidemia in Renal Transplant Recipients

Dyslipidemia is a frequent complication after kidney transplantation (KT) and is an important risk factor for cardiovascular disease (CVD). Renal transplant recipients (RTRs) are considered at high, or very high, risk of CVD, which is a leading cause of death in this patient group. Despite many factors of post-transplant dyslipidemia, the immunosuppressive treatment has the biggest influence on a lipid profile. There are no strict dyslipidemia treatment guidelines for RTRs, but the ones proposing an individual approach regarding CVD risk seem most suitable. Proper diet and physical activity are the main general measures to manage dyslipidemia and should be introduced initially in every patient after KT. In the case of an insufficient correction of lipemia, statins are the basis for hypolipidemic treatment. Statins should be introduced with caution to avoid serious side-effects (e.g., myopathy) or drug-drug interactions, especially with immunosuppressants. To lower the incidence of adverse effects, and improve medication adherence, ezetimibe in combination with statins is recommended. Fibrates and bile sequestrants are not recommended due to their side-effects and variable efficacy. However, several new lipid-lowering drugs like Proprotein convertase subtilisin/Kexin type9 (PCSK9) inhibitors may have promising effects in RTRs, but further research assessing efficacy and safety is yet to be carried out.

Medication, Healthcare Follow-up, and Lifestyle Nonadherence: Do They Share the Same Risk Factors?

Barriers to medication adherence may differ from barriers in other domains of adherence. In this study, we assessed the association between pre-kidney transplantation (KT) factors with nonadherent behaviors in 3 different domains post-KT.

METHODS

We conducted a prospective cohort study with patient interviews at initial KT evaluation (baseline-nonadherence predictors in sociodemographic, condition-related, health system, and patient-related psychosocial factors) and at ≈6 mo post-KT (adherence outcomes: medications, healthcare follow-up, and lifestyle behavior). All patients who underwent KT at our institution and had ≈6-mo follow-up interview were included in the study. We assessed nonadherence in 3 different domains using continuous composite measures derived from the Health Habit Survey. We built multiple linear and logistic regression models, adjusting for baseline characteristics, to predict adherence outcomes.

RESULTS

We included 173 participants. Black race (mean difference in adherence score: -0.72; 95% confidence interval [CI], -1.12 to -0.32) and higher income (mean difference: -0.34; 95% CI, -0.67 to -0.02) predicted lower medication adherence. Experience of racial discrimination predicted lower adherence (odds ratio, 0.31; 95% CI, 0.12-0.76) and having internal locus of control predicted better adherence (odds ratio, 1.46; 95% CI, 1.06-2.03) to healthcare follow-up. In the lifestyle domain, higher education (mean difference: 0.75; 95% CI, 0.21-1.29) and lower body mass index (mean difference: -0.08; 95% CI, -0.13 to -0.03) predicted better adherence to dietary recommendations, but no risk factors predicted exercise adherence.

CONCLUSIONS

Different nonadherence behaviors may stem from different motivation and risk factors (eg, clinic nonattendance due to experiencing racial discrimination). Thus adherence intervention should be individualized to target at-risk population (eg, bias reduction training for medical staff to improve patient adherence to clinic visit).

Associations between Depression, Nutritional Status and Mediterranean Diet in Dalmatian Kidney Transplant Recipients

Depression has been addressed as a predictor of worse outcomes in kidney transplant recipients (KTRs). Nutritional status plays a great role in treatment of this population. The Mediterranean diet (MeDi) has been associated with lower levels of depressive symptoms. The aim of this cross-sectional study was to determine the rate of depression and its correlations to nutritional status and dietary habits according to the MeDi in Dalmatian KTRs. We included 115 KTRs, and data about body composition and anthropometric, laboratory and clinical parameters were obtained for each study participant. The Beck Depression Inventory-II (BDI-II) questionnaire was used to assess depressive symptoms and the Mediterranean Diet Serving Score (MDSS) was used to assess adherence to the MeDi. We found the presence of depressive symptoms in 21.73% of the Dalmatian KTRs. BDI-II score was reciprocally associated with fat mass, trunk visceral fat, anthropometric parameters of obesity, triglyceride levels and olive oil consumption. Inverse associations were found between BDI-II score and skeletal muscle mass, handgrip strength, MCV, hemoglobin levels and consumption of fish and white meat, as suggested by the MeDi. Our results showed the interconnections between nutritional status, dietary habits and depression in Dalmatian KTRs.

Factors associated with nutritional risk in patients receiving haemodialysis assessed by Nutritional Risk Screening 2002 (NRS2002)

BACKGROUND

Nutritional Risk Screening 2002 is recommended as a screening tool to identify patients at risk of undernutrition for all patients in hospitals by the European Society of Clinical Nutrition and Metabolism. Nutritional risk is associated with increased morbidity and mortality in patients, and it is common among patients on haemodialysis. Factors associated with nutritional risk that could facilitate the screening/diagnostic procedures are warranted.

OBJECTIVES

Identification of factors that are associated with nutritional risk in patients with end-stage renal disease treated with haemodialysis.

DESIGN AND PARTICIPANTS

Single-centre, cross-sectional study in patients receiving haemodialysis (n = 53) were screened for nutritional risk using Nutritional Risk Screening 2002. Associations were made with data on dietary intake by 24-h dietary recall, and measurement of body composition, anthropometric measurements and biochemical variables.

RESULTS

Nutritional risk was common among patients on haemodialysis (26%), and was associated with low energy and protein intake, and low pre-albumin concentrations also after adjustments for age and sex. Nutritional risk was neither associated with diabetes nor duration of dialysis treatment.

CONCLUSION

Measurement of pre-albumin and dietary assessment using a 24-h dietary recall can support the identification of patients receiving haemodialysis at nutritional risk.

Nutritional status in kidney transplant patients before and 6-month after transplantation: Result of PNSI study

OBJECTIVES

Kidney transplantation is an essential treatment in management of kidney failure patients. The present study evaluated and compared the nutritional status of renal transplant patients before and 6 months after kidney transplantation and in comparison with healthy individuals.

METHODS

A multi-center, case-control study was conducted among 40 kidney transplant recipients and 40 healthy adults. Biochemical tests, anthropometric indices, and dietary intake were collected at baseline and 6 months post-transplant and compared with healthy controls.

RESULTS

Anthropometric indices of the participants increased in post-transplant period compared to baseline (p < 0.05). The calories, fat, carbohydrates, and selenium intakes also increased in patients compared to before transplantation and healthy controls. The mean score of malnutrition index in patients, before transplantation were: good nutrition status (A) = 42.5%, mild to moderate malnutrition (B) = 52.5%, and severe malnutrition (C) = 5%, that changed to A = 75%, B = 20%, and C = 5% six months after surgery. The mean score of malnutrition index in pre-transplant patients were: A = 42.5%, B = 52.5% and, C = 5%, which changed to A = 75%, B = 20% and C = 5% after 6 months. Experimental results showed that mean plasma levels of albumin, total protein, calcium increased as well as mean plasma levels of magnesium and phosphorus decreased over six months (p < 0.001).

CONCLUSION

Kidney transplantation led to improvement in clinical and nutritional status of patients with renal failure. Improving dietary intakes as part of the medical care process can help improve their medical conditions.

Healthy Eating Index of Living Donor Renal Transplantation Recipients During the First Year Posttransplant

BACKGROUND

The aim of this study was to examine the relationship between diet quality and weight gain in kidney transplant recipients from pretransplant baseline through posttransplant at 3 months and 1 year.

METHODS

Data from a prospective, observational cohort study of kidney transplant patients (n = 26) were analyzed. Participants were adult (aged 18-65 years), living donor kidney transplant recipients who were participating in a prospective body composition study. Body weight, body mass index, dietary intake, and Healthy Eating Index scores were used to assess changes in weight, nutrient intake, and diet quality.

FINDINGS

At the time of kidney transplantation, 42% (n = 11) were obese and 27% (n = 7) were overweight. Weight significantly increased from transplantation to 12 months (mean [SD]: 83 [18] kg and 90 [18] kg, respectively; mean change 8.4%, P = .002). At 12 months posttransplant, dietary fat intake significantly increased (P = .033). Body weight was strongly correlated with total dietary fat intake (r = 0.56, P = .003). The Healthy Eating Index total scores at baseline and 1-year posttransplant were not significantly different (45.75 [14.99] and 42.59 [12.70]). Likewise, component scores did not change from pretransplant to posttransplant.

DISCUSSION

Diet quality of transplant recipients was poor both before and after transplantation. Using the Healthy Eating Index confirmed that improvements in food intake are needed. Further research is warranted to identify dietary recommendations for the prevention of excessive weight gain and the potential adverse health complications following kidney transplantation.

Nutrition Trends in Patients Over the Long Term After Kidney Transplantation

OBJECTIVES

Nutritional behaviors may exert important influence on morbidity and graft function in patients after kidney transplantation (KT). Nutritional status is closely related to potential risk factors of developing posttransplant complications, including diabetes mellitus, weight gain, and negative effects on immunosuppressive therapy. The aim of this study was to assess the dietary intake in patients after KT.

DESIGN AND METHODS

Nutritional intake of 154 (61 women and 93 men) patients was assessed based on a questionnaire regarding food intake (proteins, fats, carbohydrates, cholesterol, sugar, phosphorus, calorific value) within 3 working days preceding the routine outpatient posttransplant visit. Patient medical history, concomitant medications, and estimated glomerular filtration rate (eGFR) was obtained from medical charts.

RESULTS

The mean age (years) ± SD of patients was 51.9 ± 14.1. The patients were evaluated 94 ± 67 months after KT, with a median eGFR of 53 (range, 41.2-64.1) mL/min/1.73 m². Sixty-two percent of patients had increased body mass index values. The mean total energy intake was 2159.4 ± 551.9 kcal/day. The patients reported elevated salt (8.5 ± 2.4 g per day) and fat intake (99.4 ± 3.2 g per day) including 57% saturated fatty acids. The patients consumed products containing high amounts of sugars (108.2 ± 107.0 g per day), carbohydrates (238.3 ± 64.3 g per day), and cholesterol (303.6 ± 11.1 mg per day). The diet among kidney recipients consisted predominantly of fats, meat, cured meat, and sweets.

CONCLUSIONS

The nutritional behaviors of patients after KT are in most cases poor. Improvement of eating habits in these patients seems to be a simple method to preserve kidney function over the long term.

Lifestyle, Inflammation, and Vascular Calcification in Kidney Transplant Recipients: Perspectives on Long-Term Outcomes

After decades of pioneering and improvement, kidney transplantation is now the renal replacement therapy of choice for most patients with end-stage kidney disease (ESKD). Where focus has traditionally been on surgical techniques and immunosuppressive treatment with prevention of rejection and infection in relation to short-term outcomes, nowadays, so many people are long-living with a transplanted kidney that lifestyle, including diet and exposure to toxic contaminants, also becomes of importance for the kidney transplantation field. Beyond hazards of immunological nature, a systematic assessment of potentially modifiable-yet rather overlooked-risk factors for late graft failure and excess cardiovascular risk may reveal novel targets for clinical intervention to optimize long-term health and downturn current rates of premature death of kidney transplant recipients (KTR). It should also be realized that while kidney transplantation aims to restore kidney function, it incompletely mitigates mechanisms of disease such as chronic low-grade inflammation with persistent redox imbalance and deregulated mineral and bone metabolism. While the vicious circle between inflammation and oxidative stress as common final pathway of a multitude of insults plays an established pathological role in native chronic kidney disease, its characterization post-kidney transplant remains less than satisfactory. Next to chronic inflammatory status, markedly accelerated vascular calcification persists after kidney transplantation and is likewise suggested a major independent mechanism, whose mitigation may counterbalance the excess risk of cardiovascular disease post-kidney transplant. Hereby, we first discuss modifiable dietary elements and toxic environmental contaminants that may explain increased risk of cardiovascular mortality and late graft failure in KTR. Next, we specify laboratory and clinical readouts, with a postulated role within persisting mechanisms of disease post-kidney transplantation (i.e., inflammation and redox imbalance and vascular calcification), as potential non-traditional risk factors for adverse long-term outcomes in KTR. Reflection on these current research opportunities is warranted among the research and clinical kidney transplantation community.

An interdisciplinary approach to the older transplant patient: strategies for improving clinical outcomes

PURPOSE OF REVIEW

To describe the latest investigations into the role of frailty and assessment of other aging-related issues in the solid organ transplant candidate and recipient. This information is relevant for all involved in the care of transplant patients, but is especially relevant in infectious diseases, given the increased burden of infection seen in older and frailer patients.

RECENT FINDINGS

The Fried Frailty Phenotype (FFP) and Short Performance Physical Battery (SPPB) are well validated tools for measuring frailty in older adults. Recently, these frailty tools have also been used to predict a range of clinical outcomes in adults with endstage organ disease undergoing advanced therapies including mechanical circulatory device (MCSD) or transplantation including death on the waiting list, length of hospital stay, need for readmission, infection, and death. Frailty may also be estimated by chart review and comorbidity assessment. Other aging-related evaluations of interest are cognitive function, sarcopenia, and nutritional status. The strength of association for each tool varies by the type of end organ disease, although there are many findings in common across organ types.

SUMMARY

As trends in the aging of the population continue to impact transplant and MCSD candidates and recipients, it is increasingly important for providers to be cognizant of the methods for assessment of aging-associated dysfunction including frailty and sarcopenia.

Identification of sarcopenia and dynapenia in CKD predialysis patients with EGWSOP2 criteria: An observational, cross-sectional study

OBJECTIVES

Using the new European Working Group on Sarcopenia in Older People (EWGSOP2) criteria, we identified sarcopenic and dynapenic patients in a cohort of predialysis patients with chronic kidney disease (CKD), and evaluated their clinical and laboratory characteristics.

METHODS

The study population consisted of 85 (55 men) clinically stable predialysis CKD patients (92.9% in stages 3-5), with a median age of 65.0 (52.5-72.0) y. We classified as sarcopenic the patients with handgrip strength (HGS) and muscle mass both lower than the respective EWGSOP2 cutoff values and as dynapenic those in whom only HGS was less than these reference values. HGS was measured with a hand dynamometer, whereas muscle mass was measured by bioimpedance analysis. Renal function was evaluated as Modification of Diet in Renal Disease estimated glomerular filtration rate.

RESULTS

The prevalence of sarcopenia and dynapenia was, respectively, 7.1% and 17.6%. As reported in previous studies, serum albumin and hemoglobin were lower in sarcopenic patients than in patients with preserved muscle mass and strength. However, unlike in these studies, sarcopenia prevalence did not increase with CKD stage, and estimated glomerular filtration rate was similar between groups. Moreover, no difference was identified in any of the aforementioned parameters between dynapenic patients and patients with preserved muscle mass and strength.

CONCLUSIONS

The EWGSOP2 criteria identified sarcopenia in CKD with a prevalence similar to previous diagnostic criteria. In addition, they found that dynapenia was highly prevalent. Nevertheless, the EWGSOP2 criteria could be better adapted to CKD patients to improve their ability to detect high-risk sarcopenic and dynapenic patients.

Exercise Prescription in Renal Transplant Recipients: From Sports Medicine Toward Multidisciplinary Aspects: A Pilot Study

Renal transplantation is the choice treatment for end-stage renal disease. In spite of transplantation, cardiovascular morbidity and mortality remains high, possibly due to a prolonged sedentary lifestyle prior to transplantation. This study aimed to evaluate the impact of unsupervised intervention in a tailored home-based aerobic resistance exercise program, based on the anthropometric and cardiovascular parameters in a group of renal transplant recipients (RTRs) followed for 12 months.

METHODS

a group of 21 RTRs (mean age: 46.8 ± 12 years) were enrolled in a combined aerobic and step count unsupervised prescription program. Body composition (BMI, waist circumferences, skin-folds); water distribution (TBW: Total body water; ECW: Extra cellular water; and ICW: Intracellular water) and myocardial function were measured every 6 months for 1 year. The MEDI-LITE score was used to estimate adherence to the Mediterranean diet.

RESULTS

Significant reductions in waist circumference (Waist Cir: 89.12 ± 12.8 cm T0; 89.1 ± 12.5 cm T6 (95% CI: 6.3, 5.7); 88.6 ± 11.4 cm T12; (95% CI: 6.7, 4.7) p < 0.01), weight:71.8 ± 14.8 kg T0; 70.6 ± 14.7 kg T6(95% CI:-8, 6); 70.6 ± 14.7 kg T12(95% CI: 6.6, 7) p < 0.05), as well as an improvement of myocardial function, as shown by the significant increase of contractility and change in the GLS % value (-18.3 ± 3.8% at T0 (95% CI:-16.57, 20.0.2)-20.4 ± 3.0% at T6(95% CI:-4, 0.2);-22.9 ± 3.1%T12(95% CI:-3, 4, -1, 6) p < 0.02), were observed. Adherence to the Mediterranean diet was in the normal range.

CONCLUSIONS

Despite unsupervised intervention, combined moderate physical exercise appears to have a positive effect on the main parameters related to cardiovascular risk factors. The long-term efficacy of this program requires further investigation, particularly for evaluating constant adherence to the home-based physical exercise program.