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

Association of diet quality and weight increase in adult heart transplant recipients

BACKGROUND

Understanding the quality of the diet of heart transplant recipients (HTRs) is essential to developing effective dietary interventions for weight control, but relevant evidence is scarce. We investigated diet quality and its association with post-transplant increase in weight adjusted for height (body mass index [BMI]) in Australian HTRs.

METHODS

We recruited adult HTRs from Queensland's thoracic transplant clinic, 2020-2021. Study participants completed a 3-day food diary using a smart-phone app. Socio-demographic information was collected by self-administered questionnaire, and height, serial weight and clinical information were obtained from medical records. We calculated the Dietary Approaches to Stop Hypertension (DASH) index based on nine food groups and nutrients (index of 90 indicates highest possible quality), and any changes in BMI (≤ 0 kg m-2 or >0 kg m-2) post-transplantation. Median DASH index values were assessed in relation to sex and BMI change using Mann-Whitney U test.

RESULTS

Among 49 consented HTRs, 25 (51%) completed the food diary (median age 48 years, 52% females). Median BMI at enrolment was 27.2 kg m-2; median BMI change since transplant was +3.7 kg m-2. Fruit, vegetable, and whole grain intakes were generally lower than recommended, giving a low overall median DASH index of 30 with no sex differences. HTRs for which the BMI increased post-transplant had significantly lower median DASH indices than those whose BMI did not increase (30 vs. 45, p = 0.013).

CONCLUSIONS

The diet quality of HTRs appears suboptimal overall, with fruit and vegetable intakes especially low. HTRs whose BMI increased post-transplant had substantially lower quality diets than HTRs whose BMI did not increase.

Physical exercise in kidney disease: A commonly undervalued treatment modality

BACKGROUND

Physical inactivity has been identified as a risk factor for multiple disorders and a strong association exists between chronic kidney disease (CKD) and a sedentary lifestyle. Even though physical activity is crucial in the development and progression of disease, the general focus of the current medical practice is the pharmacological perspective of diseases with inadequate emphasis on lifestyle intervention.

METHODS

In this narrative review we explain the pathophysiological mechanisms underlying the beneficial effects of physical exercise on CKD in addition to discussing the clinical studies and trials centred on physical exercise in patients with CKD.

RESULTS

Physical activity influences several pathophysiological mechanisms including inflammation, oxidative stress, vascular function, immune response and macromolecular metabolism. While exercise can initially induce stress responses like inflammation and oxidative stress, long-term physical activity leads to protective countermeasures and overall improved health. Trials in pre-dialysis CKD patients show that exercise can lead to reductions in body weight, inflammation markers and fasting plasma glucose. Furthermore, it improves patients' functional capacity, cardiorespiratory fitness and quality of life. The effects of exercise on kidney function have been inconsistent in these trials. In haemodialysis, peritoneal dialysis and kidney transplant patients exercise interventions improve cardiorespiratory fitness, walking capacity and quality of life. Combined training shows the best performance to increase peak oxygen uptake in haemodialysis patients. In kidney transplant recipients, exercise improves walking performance, quality of life and potentially arterial stiffness. However, exercise does not affect glucose metabolism, serum cholesterol and inflammation biomarkers. Long-term, adequately powered trials are needed to determine the long-term feasibility, and effects on quality of life and major clinical outcomes, including mortality and cardiovascular risk, in all CKD stages and particularly in kidney transplant patients, a scarcely investigated population.

CONCLUSION

Physical exercise plays a crucial role in ameliorating inflammation, oxidative stress, vascular function, immune response and macromolecular metabolism, and contributes significantly to the quality of life for patients with CKD, irrespective of the treatment and stage. Its direct impact on kidney function remains uncertain. Further extensive, long-term trials to conclusively determine the effect of exercise on major clinical outcomes such as mortality and cardiovascular risk remain a research priority.

The feasibility of Technology, Application, Self-Management for Kidney (TASK) intervention in post-kidney transplant recipients using a pre/posttest design

BACKGROUND

Weight gain after a kidney transplant remains a major problem that can lead to adverse effects on morbidity and mortality. The posttransplant phase provides a window of opportunity to improve the engagement of self-management of care for lifestyle modifications for diet and physical activity. The purpose of our study was to (1) test the feasibility of recruitment, retention, and adherence for using the Technology, Application, Self-Management for Kidney (TASK) intervention in post-kidney transplant recipients (≥ 18 years of age) at baseline, 4, 8, and 12 weeks; and (2) estimate the preliminary effects of the TASK intervention in producing change over time for blood pressure (BP), weight, fruits/vegetable intake, fiber intake, sodium intake, self-efficacy to exercise, and perceived stress.

METHODS

This study used a 12-week pre/posttest design using to test the feasibility of the TASK intervention. We applied paired t-tests and McNemar's test to compare the outcomes at weeks 4, 8, and 12.

RESULTS

We met our recruitment goal (N = 20) and found a 15% attrition rate (n = 3) at Week 12. Adherence rate among the study completers for recording daily food intake was 83-94% over the 12 weeks and for recording daily physical activity was 17-33% over the 12 weeks. We observed improvements over time for BP, weight, fruits/vegetable intake, fiber intake, and sodium intake; these differences were non-significant, although clinically important. We did find a significant difference from baseline to 12 weeks in weight reduction (p = 0.02), self-efficacy to exercise (p = 0.003), and perceived stress (p = 0.04).

CONCLUSIONS

The data suggest the TASK intervention was feasible for kidney recipients to use and resulted in weight control, increased self-efficacy to exercise, and decreased perceived stress.

TRIAL REGISTRATION

ClinicalTrials.gov #:NCT05151445.

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.

Interventions for improving health literacy in people with chronic kidney disease

BACKGROUND

Low health literacy affects 25% of people with chronic kidney disease (CKD) and is associated with increased morbidity and death. Improving health literacy is a recognised priority, but effective interventions are not clear.

OBJECTIVES

This review looked the benefits and harms of interventions for improving health literacy in people with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched MEDLINE (OVID) and EMBASE (OVID) for non-randomised studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised studies that assessed interventions aimed at improving health literacy in people with CKD.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility and performed risk of bias analysis. We classified studies as either interventions aimed at improving aspects of health literacy or interventions targeting a population of people with poor health literacy. The interventions were further sub-classified in terms of the type of intervention (educational, self-management training, or educational with self-management training). Results were expressed as mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratios (RR) with 95% CI for dichotomous outcomes.

MAIN RESULTS

We identified 120 studies (21,149 participants) which aimed to improve health literacy. There were 107 RCTs and 13 non-randomised studies. No studies targeted low literacy populations. For the RCTs, selection bias was low or unclear in 94% of studies, performance bias was high in 86% of studies, detection bias was high in 86% of studies reporting subjective outcomes and low in 93% of studies reporting objective outcomes. Attrition and other biases were low or unclear in 86% and 78% of studies, respectively. Compared to usual care, low certainty evidence showed educational interventions may increase kidney-related knowledge (14 RCTs, 2632 participants: SMD 0.99, 95% CI 0.69 to 1.32; I² = 94%). Data for self-care, self-efficacy, quality of life (QoL), death, estimated glomerular filtration rate (eGFR) and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed self-management interventions may improve self-efficacy (5 RCTs, 417 participants: SMD 0.58, 95% CI 0.13 to 1.03; I² = 74%) and QoL physical component score (3 RCTs, 131 participants: MD 4.02, 95% CI 1.09 to 6.94; I² = 0%). There was moderate-certainty evidence that self-management interventions probably did not slow the decline in eGFR after one year (3 RCTs, 855 participants: MD 1.53 mL/min/1.73 m², 95% CI -1.41 to 4.46; I² = 33%). Data for knowledge, self-care behaviour, death and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed educational with self-management interventions may increase knowledge (15 RCTs, 2185 participants: SMD 0.65, 95% CI 0.36 to 0.93; I² = 90%), improve self-care behaviour scores (4 RCTs, 913 participants: SMD 0.91, 95% CI 0.00 to 1.82; I² =97%), self-efficacy (8 RCTs, 687 participants: SMD 0.50, 95% CI 0.10 to 0.89; I² = 82%), improve QoL physical component score (3 RCTs, 2771 participants: MD 2.56, 95% CI 1.73 to 3.38; I² = 0%) and may make little or no difference to slowing the decline of eGFR (4 RCTs, 618 participants: MD 4.28 mL/min/1.73 m², 95% CI -0.03 to 8.85; I² = 43%). Moderate-certainty evidence shows educational with self-management interventions probably decreases the risk of death (any cause) (4 RCTs, 2801 participants: RR 0.73, 95% CI 0.53 to 1.02; I² = 0%). Data for hospitalisation could not be pooled.

AUTHORS' CONCLUSIONS

Interventions to improve aspects of health literacy are a very broad category, including educational interventions, self-management interventions and educational with self-management interventions. Overall, this type of health literacy intervention is probably beneficial in this cohort however, due to methodological limitations and high heterogeneity in interventions and outcomes, the evidence is of low certainty.

Muscle mass, muscle strength and mortality in kidney transplant recipients: results of the TransplantLines Biobank and Cohort Study

BACKGROUND

Survival of kidney transplant recipients (KTR) is low compared with the general population. Low muscle mass and muscle strength may contribute to lower survival, but practical measures of muscle status suitable for routine care have not been evaluated for their association with long-term survival and their relation with each other in a large cohort of KTR.

METHODS

Data of outpatient KTR ≥ 1 year post-transplantation, included in the TransplantLines Biobank and Cohort Study (ClinicalTrials.gov Identifier: NCT03272841), were used. Muscle mass was determined as appendicular skeletal muscle mass indexed for height² (ASMI) through bio-electrical impedance analysis (BIA), and by 24-h urinary creatinine excretion rate indexed for height² (CERI). Muscle strength was determined by hand grip strength indexed for height² (HGSI). Secondary analyses were performed using parameters not indexed for height². Cox proportional hazards models were used to investigate the associations between muscle mass and muscle strength and all-cause mortality, both in univariable and multivariable models with adjustment for potential confounders, including age, sex, body mass index (BMI), estimated glomerular filtration rate (eGFR) and proteinuria.

RESULTS

We included 741 KTR (62% male, age 55 ± 13 years, BMI 27.3 ± 4.6 kg/m²), of which 62 (8%) died during a median [interquartile range] follow-up of 3.0 [2.3-5.7] years. Compared with patients who survived, patients who died had similar ASMI (7.0 ± 1.0 vs. 7.0 ± 1.0 kg/m²; P = 0.57), lower CERI (4.2 ± 1.1 vs. 3.5 ± 0.9 mmol/24 h/m²; P < 0.001) and lower HGSI (12.6 ± 3.3 vs. 10.4 ± 2.8 kg/m²; P < 0.001). We observed no association between ASMI and all-cause mortality (HR 0.93 per SD increase; 95% confidence interval [CI] [0.72, 1.19]; P = 0.54), whereas CERI and HGSI were significantly associated with mortality, independent of potential confounders (HR 0.57 per SD increase; 95% CI [0.44, 0.81]; P = 0.002 and HR 0.47 per SD increase; 95% CI [0.33, 0.68]; P < 0.001, respectively), and associations of CERI and HGSI with mortality remained independent of each other (HR 0.68 per SD increase; 95% CI [0.47, 0.98]; P = 0.04 and HR 0.53 per SD increase; 95% CI [0.36, 0.76]; P = 0.001, respectively). Similar associations were found for unindexed parameters.

CONCLUSIONS

Higher muscle mass assessed by creatinine excretion rate and higher muscle strength assessed by hand grip strength are complementary in their association with lower risk of all-cause mortality in KTR. Muscle mass assessed by BIA is not associated with mortality. Routine assessment using both 24-h urine samples and hand grip strength is recommended, to potentially target interdisciplinary interventions for KTR at risk for poor survival to improve muscle status.

Interventions Against Posttransplantation Diabetes: A Scientific Rationale for Treatment Hierarchy Based on Literature Review

Posttransplant diabetes (PTD) is a common medical complication after solid organ transplantation. Because of adverse outcomes associated with its development and detrimental impact on long-term survival, strategies to prevent or manage PTD are critically important but remain underresearched. Treatment hierarchies of antidiabetic therapies in the general population are currently being revolutionized based on cardiovascular outcome trials, providing evidence-based rationale for optimization of medical management. However, opportunities for improving medical management of PTD are challenged by 2 important considerations: (1) translating clinical evidence data from the general population to underresearched solid organ transplant cohorts and (2) targeting treatment based on primary underlying PTD pathophysiology. In this article, the aim is to provide an overview of PTD treatment options from a new angle. Rationalized by a consideration of underlying PTD pathophysiological defects, which are heterogeneous among diverse transplant patient cohorts, a critical appraisal of the published literature and summary of current research in progress will be reviewed. The aim is to update transplant professionals regarding medical management of PTD from a new perspective tailored therapeutic intervention based on individualized characteristics. As the gap in clinical evidence between management of PTD versus type 2 diabetes widens, it is imperative for the transplant community to bridge this gap with targeted clinical trials to ensure we optimize outcomes for solid organ transplant recipients who are at risk or develop PTD. This necessary clinical research should help efforts to improve long-term outcomes for solid transplant patients from both a patient and graft survival perspective.

Effect of weight change after renal transplantation on outcomes of graft survival

BACKGROUND AND OBJECTIVE

After kidney transplantation, there is an overall increase in weight, which may increase the risk of chronic kidney disease (CKD) and graft loss. But, not all patients gain weight, and the impact on the graft of this different evolution has not been well studied. The objective was to determine the causes of this different evolution and its effect on the graft.

PATIENTS AND METHODS

Retrospective single-center cohort study of 201 patients followed up after transplantation, analyzing the determinants of the variation in weight at one year using logistic regression, and its effect on graft survival at the end of follow-up using Cox regression.

RESULTS

Globally, there was an average weight gain of 4.5 kg in the first year, but 26.6% lost weight. 37.2% increased their BMI, while 9.5% decreased it. The determinants of the different evolution of weight were age (OR for every 10 years: 0.6, p = 0.002), previous dialysis modality (ref. hemodialysis) (OR 0.3, p = 0.003), and BMI before transplantation (OR 0.9, p = 0.017). The different evolution of weight did not influence the final situation of the graft. The BMI at one year did influence as a continuous variable (HR 1.3, p = 0.003), and obesity, with a worse evolution (HR 7.0, p = 0.025).

CONCLUSIONS

Although not all patients gain weight after kidney transplantation, the different evolution of weight does not influence graft survival.

Effects of an individualized nutritional intervention on kidney function, body composition, and quality of life in kidney transplant recipients: Study protocol for a randomized clinical trial

Background

Proteinuria after kidney transplantation (KTx) has been a frequent problem due to several factors, high protein intake being one of them. Individualized nutritional intervention in the late post-KTx period can promote the improvement or the reduction of risks associated with the parameters of evaluation of kidney function, body composition, and quality of life in individuals submitted to KTx.

Methods

This is a single-center, randomized and stratified clinical trial. The study will be conducted in a university hospital in northeastern Brazil with 174 individuals aged ≥19 years submitted to KTx and followed up for 12 months. Assessments will take place at 3-month intervals (T0, T3, T6, T9, and T12). The patients will be allocated to intervention and control groups by random allocation. The intervention group will receive individualized nutritional interventions with normoproteic diets (1.0 g/kg) after 60 days of KTx whereas the controls will receive the standard nutritional guidance for the post-KTx period. The primary efficacy variable is the change from baseline in log proteinuria assessed with the urinary albumin/creatinine ratio. Secondary efficacy variables include body composition, anthropometry, quality of life assessment and physical activity, lipid profile and glycemic control. Ninety-two subjects per group will afford 70% power to detect a difference of 25% between groups in log proteinuria. Primary efficacy analysis will be on the modified intention-to-treat population with between-groups comparison of the change from baseline in log proteinuria by analysis of covariance.

Discussion

The study will assess the effects of an individualized nutritional intervention on proteinuria 12 months after KTx.

Trial registration

REBEC (RBR-8XBQK5).

Can we HALT obesity following lung transplant? A Dietitian- and Physiotherapy-directed pilot intervention

INTRODUCTION

Unintentional weight gain, overweight and obesity following solid organ transplantation (SOT) are well-established and linked to morbidity and mortality risk factors. No interventional studies aimed at prevention have been undertaken among lung transplant (LTx) recipients. The combination of group education and telephone coaching is effective in the general population but is untested among SOT cohorts.

METHODS

A non-randomised, interventional pilot study was conducted among new LTx recipients. The control group received standard care. In addition to standard care, the intervention involved four group education and four individual, telephone coaching sessions over 12-months. Data collection occurred at 2 weeks, 3- and 12 months post-LTx. Measurements included weight, BMI, fat mass (FM), fat mass index (FMI), fat-free mass (FFM), fat-free mass index (FFMI), waist circumference (WC), visceral adipose tissue (VAT), nutrition knowledge, diet, physical activity, lipid profile, HbA_1C , FEV₁ , six-minute walk distance and patient satisfaction.

RESULTS

Fifteen LTx recipients were recruited into each group. One control participant died 120 days post-LTx, unrelated to the study. There were trends towards lower increases in weight (6.7±7.2kg vs 9.8±11.3kg), BMI (9.6% of baseline vs 13%), FM (19.7% vs 40%), FMI, VAT (7.1% vs 30.8%) and WC (5.5% vs 9.5%), and greater increases in FFM and FFMI (all p>0.05), among the intervention group by 12 months. The intervention was well-accepted by participants.

CONCLUSION

This feasible intervention demonstrated non-significant, but clinically meaningful, favourable weight and body composition trends among LTx recipients over 12 months compared to standard care. Australian New Zealand Clinical Trials Registry (ACTRN12619001606178) This article is protected by copyright. All rights reserved.

Weight gain after renal transplant: Incidence, risk factors, and outcomes

Background

Renal transplantation is the definitive treatment for patients with end-stage renal disease (ESRD). It is associated with better quality of life and patient survival. Nevertheless, these benefits come with rising concerns about weight gain and metabolic abnormalities, which adversely impact transplant outcomes.

Objective

The objective of this study is to estimate the incidence of weight gain in the first year post-renal transplant in addition to the assessment of potential risk factors and the resulting outcome of the graft.

Methods

We conducted a single-center retrospective cohort study of all 295 patients who underwent kidney transplantation at King Abdulaziz Medical City (KAMC) between January 2016 and December 2019. Clinical and laboratory variables were collected from electronic records. Continuous variables were reported as mean ± standard deviation. Comparison between groups was assessed by unpaired t-test or Mann-Whitney U test while follow-up data were compared using paired t-test and repeated measures ANOVA. Association between the potential risk factors and the weight gain was assessed by means of binary logistic regression analysis.

Results

Significant weight gain was observed in 161 (54.6%) patients. Females were 119 (40.30%) of the cohort. The mean age was 45.3±15.1 years. The prevalence of diabetes was 234 (79.6%), while hypertensives constituted 77 (26.3%). The comparison between patients who gained weight significantly and patients with stable weight showed a numerical higher prevalence of female gender in patients who had more weight gain (44.1% vs. 35.8%), higher diabetes, higher rate of a living donor, and statistically significant lower dialysis duration before transplant. Other clinical and laboratory variables were comparable between the two groups.

Conclusion

Our study showed a high incidence of clinically significant weight gain among patients post-renal transplantation. Patients with lower dialysis duration, a living kidney donor and those who are obese at baseline were at higher risk of gaining weight. Patients who underwent kidney transplantation should be monitored closely for weight gain and further studies are needed to determine the risk factors and appropriate interventions.

The Effect of Non-Pharmacological and Pharmacological Interventions on Measures Associated with Sarcopenia in End-Stage Kidney Disease: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis provides a synthesis of the available evidence for the effects of interventions on outcome measures associated with sarcopenia in end-stage kidney disease (ESKD). Thirteen databases were searched, supplemented with internet and hand searching. Randomised controlled trials of non-pharmacological or pharmacological interventions in adults with ESKD were eligible. Trials were restricted to those which had reported measures of sarcopenia. Primary outcome measures were hand grip strength and sit-to-stand tests. Sixty-four trials were eligible (with nineteen being included in meta-analyses). Synthesised data indicated that intradialytic exercise increased hand grip strength (standardised mean difference, 0.58; 0.24 to 0.91; p = 0.0007; I2 = 40%), and sit-to-stand (STS) 60 score (mean difference, 3.74 repetitions; 2.35 to 5.14; p < 0.001; I2 = 0%). Intradialytic exercise alone, and protein supplementation alone, resulted in no statistically significant change in STS5 (−0.78 s; −1.86 to 0.30; p = 0.16; I2 = 0%), and STS30 (MD, 0.97 repetitions; −0.16 to 2.10; p = 0.09; I2 = 0%) performance, respectively. For secondary outcomes, L-carnitine and nandrolone-decanoate resulted in significant increases in muscle quantity in the dialysis population. Intradialytic exercise modifies measures of sarcopenia in the haemodialysis population; however, the majority of trials were low in quality. There is limited evidence for efficacious interventions in the peritoneal dialysis and transplant recipient populations.

But Why Weight: Understanding the Implications of Obesity in Kidney Transplant

Obesity is increasing in prevalence among candidates for kidney transplant. Understanding the influence of obesity on candidate evaluation, surgical risk, peritransplant management, and post-transplant outcomes is critical to ensuring equitable access to transplant for this growing population.

Dietary interventions on the prevention and management of diabetes in post-kidney transplantation - A systematic review

Post-transplant diabetes mellitus is associated with long-term immunosuppression and weight gain, and is related to an increased risk of cardiovascular disease, accelerated loss of graft and increased mortality. There is an absence of strong evidence-based dietary guidelines for the prevention and management of post-transplant diabetes mellitus in kidney transplant recipients. The aim of this study was to systematically review all dietary evidence for kidney transplant recipients on clinical outcomes relating to diabetes, patient-reported outcomes and economic outcomes. A comprehensive literature search was conducted in August 2020 using the databases Medline, Embase, CENTRAL and CINAHL. Studies were critically appraised using Cochrane risk of bias tools and GRADE. A total of 12 studies and 1928 participants were included. Four papers focused on diet and exercise, one paper on diet only, two papers on magnesium supplementation, one paper on magnesium and fibre intake, two papers on Mediterranean diet, one paper on marine n-3 fatty acid supplementation and one paper on fruit and vegetable intake. There were no significant effects on outcomes relating to dietary counselling, magnesium supplementation, magnesium and fibre intake or marine n-3 fatty acid supplementation. Low-quality evidence supports the Mediterranean diet in reducing the risk of post-transplant diabetes mellitus and fasting plasma glucose levels. Low-quality evidence suggests vegetable intake being associated with a lower risk of post-transplant diabetes mellitus. This review demonstrates limited evidence for dietary interventions in the prevention and management of diabetes in post-kidney transplantation. The findings suggest that further high-quality research with robust study designs is required.

Effect of weight change after renal transplantation on outcomes of graft survival

BACKGROUND AND OBJECTIVE

After kidney transplantation, there is an overall increase in weight, which may increase the risk of chronic kidney disease (CKD) and graft loss. But, not all patients gain weight, and the impact on the graft of this different evolution has not been well studied. The objective was to determine the causes of this different evolution and its effect on the graft.

PATIENTS AND METHODS

Retrospective single-center cohort study of 201 patients followed up after transplantation, analyzing the determinants of the variation in weight at one year using logistic regression, and its effect on graft survival at the end of follow-up using Cox regression.

RESULTS

Globally, there was an average weight gain of 4.5kg in the first year, but 26.6% lost weight. 37.2% increased their BMI, while 9.5% decreased it. The determinants of the different evolution of weight were age (OR for every 10 years: 0.6, P=.002), previous dialysis modality (ref. hemodialysis) (OR 0.3, P=.003), and BMI before transplantation (OR 0.9, P=.017). The different evolution of weight did not influence the final situation of the graft. The BMI at one year did influence as a continuous variable (HR 1.3, P=.003), and obesity, with a worse evolution (HR 7.0, P=.025).

CONCLUSIONS

Although not all patients gain weight after kidney transplantation, the different evolution of weight does not influence graft survival.

Nutritional Parameters in Early and Late Kidney Transplantation

BACKGROUND

Kidney transplantation (KT) has the advantage of providing a better quality of life and freedom for the patient. However, nutritional changes can occur, with clinical repercussions. The aim of the study was to compare the nutritional status in the initial and late post-KT period.

METHODS

A cross-sectional study was conducted involving 169 outpatients post-KT. Clinical, demographic, biochemical, food intake, handgrip strength (HGS), and anthropometric data were collected from medical records for the first nutritional care after KT. Statistical tests were performed to compare the groups according to the time of KT: early (≤1 year) and late (>1 year). The level of significance adopted was 5%.

RESULTS

The median age of the patients was 46 years (range, 38-57), 50.3% were men, and it was observed that 66.9% underwent KT with a deceased donor. There was a higher prevalence of diabetes mellitus (42.6% vs 23.5%; P = .011), and higher body mass index (28.80 ± 7.26 vs 26.51 ± 6.62 kg/m²; P = .046), arm muscle circumference (25.84 ± 4.63 vs 24.09 ± 3.36 cm; P = .019), and HGS (26.97 ± 10.70 vs 20.21 ± 10.83 kg; P = .010) in patients with late KT. Linear regression analysis showed that at each log of time, there was an increase of 1.90 kg in HGS (P = .045) and 0.48 cm (P = .036) in mid-arm muscle circumference.

CONCLUSION

The present study demonstrated that late kidney transplantation was associated with higher values of body mass index, mid-arm muscle circumference, and HGS.

Interventions for weight loss in people with chronic kidney disease who are overweight or obese

BACKGROUND

Obesity and chronic kidney disease (CKD) are highly prevalent worldwide and result in substantial health care costs. Obesity is a predictor of incident CKD and progression to kidney failure. Whether weight loss interventions are safe and effective to impact on disease progression and clinical outcomes, such as death remains unclear.

OBJECTIVES

This review aimed to evaluate the safety and efficacy of intentional weight loss interventions in overweight and obese adults with CKD; including those with end-stage kidney disease (ESKD) being treated with dialysis, kidney transplantation, or supportive care.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 14 December 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of more than four weeks duration, reporting on intentional weight loss interventions, in individuals with any stage of CKD, designed to promote weight loss as one of their primary stated goals, in any health care setting.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility and extracted data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess the certainty of evidence. We estimated treatment effects using random-effects meta-analysis. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardised mean difference (SMD) for continuous outcomes or in descriptive format when meta-analysis was not possible.

MAIN RESULTS

We included 17 RCTs enrolling 988 overweight or obese adults with CKD. The weight loss interventions and comparators across studies varied. We categorised comparisons into three groups: any weight loss intervention versus usual care or control; any weight loss intervention versus dietary intervention; and surgical intervention versus non-surgical intervention. Methodological quality was varied, with many studies providing insufficient information to accurately judge the risk of bias. Death (any cause), cardiovascular events, successful kidney transplantation, nutritional status, cost effectiveness and economic analysis were not measured in any of the included studies. Across all 17 studies many clinical parameters, patient-centred outcomes, and adverse events were not measured limiting comparisons for these outcomes. In studies comparing any weight loss intervention to usual care or control, weight loss interventions may lead to weight loss or reduction in body weight post intervention (6 studies, 180 participants: MD -3.69 kg, 95% CI -5.82 to -1.57; follow-up: 5 weeks to 12 months, very low-certainty evidence). In very low certainty evidence any weight loss intervention had uncertain effects on body mass index (BMI) (4 studies, 100 participants: MD -2.18 kg/m², 95% CI -4.90 to 0.54), waist circumference (2 studies, 53 participants: MD 0.68 cm, 95% CI -7.6 to 6.24), proteinuria (4 studies, 84 participants: 0.29 g/day, 95% CI -0.76 to 0.18), systolic (4 studies, 139 participants: -3.45 mmHg, 95% CI -9.99 to 3.09) and diastolic blood pressure (4 studies, 139 participants: -2.02 mmHg, 95% CI -3.79 to 0.24). Any weight loss intervention made little or no difference to total cholesterol, high density lipoprotein cholesterol, and inflammation, but may lower low density lipoprotein cholesterol. There was little or no difference between any weight loss interventions (lifestyle or pharmacological) compared to dietary-only weight loss interventions for weight loss, BMI, waist circumference, proteinuria, and systolic blood pressure, however diastolic blood pressure was probably reduced. Furthermore, studies comparing the efficacy of different types of dietary interventions failed to find a specific dietary intervention to be superior for weight loss or a reduction in BMI. Surgical interventions probably reduced body weight (1 study, 11 participants: MD -29.50 kg, 95% CI -36.4 to -23.35), BMI (2 studies, 17 participants: MD -10.43 kg/m², 95% CI -13.58 to -7.29), and waist circumference (MD -30.00 cm, 95% CI -39.93 to -20.07) when compared to non-surgical weight loss interventions after 12 months of follow-up. Proteinuria and blood pressure were not reported. All results across all comparators should be interpreted with caution due to the small number of studies, very low quality of evidence and heterogeneity across interventions and comparators.

AUTHORS' CONCLUSIONS

All types of weight loss interventions had uncertain effects on death and cardiovascular events among overweight and obese adults with CKD as no studies reported these outcome measures. Non-surgical weight loss interventions (predominately lifestyle) appear to be an effective treatment to reduce body weight, and LDL cholesterol. Surgical interventions probably reduce body weight, waist circumference, and fat mass. The current evidence is limited by the small number of included studies, as well as the significant heterogeneity and a high risk of bias in most studies.

Dietary interventions with dietitian involvement in adults with chronic kidney disease: A systematic review

BACKGROUND

A comprehensive evidence base is needed to support recommendations for the dietetic management of adults with chronic kidney disease (CKD). The present study aimed to determine the effect of dietary interventions with dietitian involvement on nutritional status, well-being, kidney risk factors and clinical outcomes in adults with CKD.

METHODS

Cochrane Central Register of Controlled Trials, CINAHL, MEDLINE, PsycINFO and EMBASE.com were searched from January 2000 to November 2019. Intentional weight loss and single nutrient studies were excluded. Risk of bias was assessed using the Cochrane risk-of-bias tool. Effectiveness was summarised using the mean difference between groups for each outcome per study.

RESULTS

Twelve controlled trials (1906 participants) were included. High fruit and vegetable intake, as well as a multidisciplinary hospital and community care programme, slowed the decline in glomerular filtration rate in adults with stage 3-4 CKD. Interventions addressing nutrition-related barriers increased protein and energy intake in haemodialysis patients. A Mediterranean diet and a diet with high n-3 polyunsaturated fatty acids improved the lipid profile in kidney transplant recipients.

CONCLUSIONS

A limited number of studies suggest benefits as a result of dietary interventions that are delivered by dietitians and focus on diet quality. We did not identify any studies that focussed on our primary outcome of nutritional status or studies that examined the timing or frequency of the nutritional assessment. This review emphasises the need for a wider body of high-quality evidence to support recommendations on what and how dietetic interventions are delivered by dietitians for adults with CKD.

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.

Comparing Glycaemic Benefits of Active Versus Passive Lifestyle Intervention in Kidney Allograft Recipients: A Randomized Controlled Trial

BACKGROUND

New-onset diabetes is common after kidney transplantation, but the benefit of lifestyle intervention to improve glucose metabolism posttransplantation is unproven.

METHODS

We conducted a single-center, randomized controlled trial involving 130 nondiabetic kidney transplant recipients with stable function between 3 and 24 months post-transplantation. Participants were randomly assigned in a 1:1 ratio to receive active intervention (lifestyle advice delivered by renal dietitians using behavior change techniques) versus passive intervention (leaflet advice alone). Primary outcome was 6-month change in insulin secretion, insulin sensitivity, and disposition index. Secondary outcomes included patient-reported outcomes, cardiometabolic parameters, clinical outcomes, and safety endpoints.

RESULTS

Between August 17, 2015 and December 18, 2017, 130 individuals were recruited, of whom 103 completed the study (drop-out rate 20.8%). Active versus passive intervention was not associated with any change in glucose metabolism: insulin secretion (mean difference, -446; 95% confidence interval [CI], -3184 to 2292; P = 0.748), insulin sensitivity (mean difference, -0.45; 95% CI, -1.34 to 0.44; P = 0.319), or disposition index (mean difference, -940; 95% CI, -5655 to 3775; P = 0.693). Clinically, active versus passive lifestyle intervention resulted in reduced incidence of posttransplantation diabetes (7.6% versus 15.6%, respectively, P = 0.123), reduction in fat mass (mean difference, -1.537 kg; 95% CI, -2.947 to -0.127; P = 0.033), and improvement in weight (mean difference, -2.47 kg; 95% CI, -4.01 to -0.92; P = 0.002). No serious adverse events were noted.

CONCLUSIONS

Active lifestyle intervention led by renal dietitians did not improve surrogate markers of glucose metabolism. Further investigation is warranted to determine if clinical outcomes can be improved using this methodology.

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.

Usability and experience testing to refine an online intervention to prevent weight gain in new kidney transplant recipients

OBJECTIVES

Weight gain in the first year following kidney transplantation increases the risk of adverse health outcomes. Currently, there is no recognized intervention available to prevent weight gain after kidney transplantation. An online kidney transplant-specific resource, entitled Exercise in Renal Transplant Online (ExeRTiOn), has been co-created by a multi-professional team, including patients, to assist with weight prevention. This study aimed to evaluate patient and health care professional usability and experience of the ExeRTiOn online resource.

DESIGN

Qualitative study utilizing 'Think-Aloud' and semi-structured interviews.

METHODS

Participants (n = 17) were purposively sampled to include new kidney transplant recipients (n = 11) and transplant health care professionals (n = 6). Kidney transplant recipient participants were from a spread of physical activity levels based on scores from the General Practice Physical Activity Questionnaire (GPPAQ). 'Think-Aloud' interviews assessed the usability of ExeRTiOn. Semi-structured interviews explored participants' experience of ExeRTiOn, weight gain, and physical activity. The data set were analysed thematically. Participant characteristics, including login data and self-reported body weight, were collected.

RESULTS

Data analyses identified valued intervention content and usability aspects which were summarized by two themes. The first theme 'You need to know how to manage yourself' included subthemes: (1) the resource filled a guidance gap, (2) expert patient content resonated, and (3) the importance of goal setting and monitoring progress. The second theme 'room for improvement' included subthemes: (2) web support and (2) content and operational change suggestions.

CONCLUSIONS

Results have allowed for identification of potential areas for resource refinement. This has facilitated iterative enhancement of ExeRTiOn in preparation for a randomized controlled feasibility trial.

Advances in exercise therapy in predialysis chronic kidney disease, hemodialysis, peritoneal dialysis, and kidney transplantation

PURPOSE OF REVIEW

Chronic kidney disease (CKD) is characterized by poor levels of physical activity which contribute to increased morbidity across the disease trajectory. The short nature, small samples, and poor methodology across most studies have failed to translate the role of exercise in CKD into its adoption as a frontline adjunct therapeutic option. This review focuses on recent advances surrounding the benefits of exercise interventions across the CKD spectrum.

RECENT FINDINGS

Key recent advances in exercise studies have focused on the efficacy of novel intervention strategies across the CKD spectrum. These include high-intensity interval training, virtual reality gaming, intradialytic yoga, electrical stimulation of muscles, blood flow restriction training, and protocols combining exercise with nutritional supplementation. Research is also beginning to explore the role of prehabilitation for patients prior to dialysis and kidney transplantation.

SUMMARY

Studies continue to demonstrate wide-ranging benefits of exercise across CKD; however, implementation of exercise remains scarce. Future research needs include evaluating the efficacy of larger and/or more comprehensive interventions on clinically important outcomes. It is hoped with increasing global evidence, high-quality clinical studies, and sustained clinician and patient engagement, exercise programs will become better prioritized in the nephrology field.

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.

Uremic Sarcopenia: Clinical Evidence and Basic Experimental Approach

Sustained physical activity extends healthy life years while a lower activity due to sarcopenia can reduce them. Sarcopenia is defined as a decrease in skeletal muscle mass and strength due not only to aging, but also from a variety of debilitating chronic illnesses such as cancer and heart failure. Patients with chronic kidney disease (CKD), who tend to be cachexic and in frail health, may develop uremic sarcopenia or uremic myopathy due to an imbalance between muscle protein synthesis and catabolism. Here, we review clinical evidence indicating reduced physical activity as renal function deteriorates and explore evidence-supported therapeutic options focusing on nutrition and physical training. In addition, although sarcopenia is a clinical concept and difficult to recapitulate in basic research, several in vivo approaches have been attempted, such as rodent subtotal nephrectomy representing both renal dysfunction and muscle weakness. This review highlights molecular mechanisms and promising interventions for uremic sarcopenia that were revealed through basic research. Extensive study is still needed to cast light on the many aspects of locomotive organ impairments in CKD and explore the ways that diet and exercise therapies can improve both outcomes and quality of life at every level.

Obesity After Kidney Transplantation-Results of a KTx360°Substudy

OBJECTIVE

There is solid evidence that kidney transplant (KTx) patients are susceptible to weight gain after transplantation. Post-transplantation obesity [body mass index (BMI) ≥ 30 kg/m2] seems to be associated with higher risks of hypertension, dyslipidemia, diabetes mellitus, and cardiovascular events, while there are contradicting findings regarding the association between obesity and mortality, graft failure after transplantation as well as other variables. We aimed to evaluate the course of weight after KTx and to assess the prevalence of post-transplant obesity in a large sample of German KTx patients. Further, we focused on potential associations between weight gain, obesity, and BMI after transplantation with sociodemographic, medical, psychological [levels of anxiety and depression measured with the Hospital Anxiety and Depression Scale (HADS)], and donation-specific variables.

METHODS

In a structured post-transplant care program 433 KTx patients were evaluated at Hannover Medical School. Information on the pre-transplant body weight/dry weight of dialysis patients was taken from the electronic patient charts. At post-transplant assessment body weight was measured in the transplant center. For statistical analyses, descriptive statistics, analyses of variance, tests for correlations, and regression analyses were used.

RESULTS

Mean age was 51.3 years, 59% were male and 26.3% had ≥12 years of school attendance. Regarding somatic conditions 6.0% were suffering from type 2 diabetes mellitus, 6.9% were affected by new-onset diabetes after transplantation (NODAT), and the mean estimated glomerular filtration rate (eGFR) was 47.7 ml/min/1.73m2. The prevalence rates of obesity before and after kidney transplantation were 14.8 and 19.9%, respectively. This represents an increase of 34%. Obesity after transplantation was associated with higher rates of type 2 diabetes mellitus and of NODAT. Additionally, there was an association between increasing pre-transplant as well as post-transplant BMI and decreasing eGFR. Higher age and female sex were associated with higher rates of post-transplant obesity.

CONCLUSIONS

Our results suggest that obesity represents a serious problem in KTx patients, especially regarding the association between increasing BMI and decreasing graft functioning (eGFR). However, this aspect is often overlooked and information on effective treatment options for these patients are scarce making further research on this topic necessary.

Weight change trajectories in Aboriginal and Torres Strait islander Australians after kidney transplantation: a cohort analysis using the Australia and New Zealand Dialysis and Transplant registry (ANZDATA)

Background

Weight change post-kidney transplantation and its associations in Aboriginal and Torres Strait Islander Australians, a group known to have poor patient and graft outcomes, are unknown. Weight change based on body mass index in Aboriginal and Torres Strait Islander Australian recipients was compared to non- indigenous recipients.

Methods

We performed a cohort analysis of data from the Australia and New Zealand Dialysis and Transplant Registry for first deceased donor kidney transplant recipients between 1995 and 2014 in Australia. Weight change post-kidney transplantation was analysed by recipient ethnicity using multivariate mixed effect linear regression analysis.

Results

There were 343 (5.24%) Aboriginal and Torres Strait Islander Australian kidney transplants recipients from a total of 6550 recipients. They had higher pre-transplant BMI (p < 0.001), higher rates of current smokers (p < 0.001), diabetes (p < 0.001), coronary artery disease (p < 0.001), cerebrovascular disease (p = 0.011) and peripheral vascular disease (p = 0.013), ≥4 HLA mismatches (p < 0.001), graft loss (p < 0.001), mortality (p < 0.001) and rejection rates (p < 0.001). Weight increased in the first 2 years post-transplantation in both Aboriginal and Torres Strait Islander Australians and non-indigenous Australians. After adjusting for the baseline differences, weight change diverged significantly at 6, 12 and 24 months. The difference was most marked between 6 and 12 months. When stratified by pre-transplantation BMI, all groups except underweight reflected this pattern. Normal weight and obese Aboriginal and Torres Strait Islander Australian recipients had substantial increase at 12 and 24 months and overweight at 6, 12 and 24 months.

The difference in BMI trajectories between Aboriginal and Torres Strait Islander Australians and non- indigenous Australian transplant recipients persisted after adjustment in multivariate mixed effect linear regression analysis.

Conclusions

Post-kidney transplantation weight gain in this high-risk population is substantial and greater than in non-indigenous Australians. Further studies should assess the effect of treatment factors and weight gain on transplant and recipient outcomes.

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

AIMS

The nutritional management of renal transplant recipients (RTR) represents a complex problem either because the recovery of renal function is not complete and for the appearance of "unavoidable" metabolic side effects of immunosuppressive drugs. Nevertheless, it remains a neglected problem, whereas an appropriate dietary intervention could favorably affect graft survival.

DATA SYNTHESIS

Renal transplantation is associated with steroids and calcineurin inhibitors administration, liberalization of diet after dialysis restrictions, and patients' better quality of life. These factors predispose, from the first months after surgery, to body weight gain, enhanced post transplant diabetes, hyperlipidemia, metabolic syndrome, with negative consequences on graft outcome. Unfortunately, specific guidelines about this topic and nutritional counseling are scarce; moreover, beyond the low adherence of patients to any dietary plan, there is a dangerous underestimation of the problem by physicians, sometimes with inadequate interventions. A prompt and specific nutritional management of RTR can help prevent or minimize these metabolic alterations, mostly when associated with careful and repeated counseling.

CONCLUSIONS

A correct nutritional management, possibly tailored to enhance patients' motivation and adherence, represents the best preventive maneuver to increase patients' life and probably improve graft survival, at no cost and with no side effects.