1. Dr. Charu Kartik Senior Clinical Dietitian KFSH&RC,Riyadh Dr. Charu Kartik Senior Clinical Dietitian KFSH&RC,Riyadh NUTRITIONAL CO-MORBITIES POST RENAL TRANSPLANT: REQUIRING INTERVENTION

2. Introduction Renal transplantation is the preferred method of treatment of End Stage Renal Disease patients and is the most common solid organ transplant. Renal transplantation is the preferred method of treatment of End Stage Renal Disease patients and is the most common solid organ transplant. Successful transplantation of a kidney into a patient with renal failure restores near normal renal function and is expected to correct the nutritional abnormalities arising from renal insufficiency. Successful transplantation of a kidney into a patient with renal failure restores near normal renal function and is expected to correct the nutritional abnormalities arising from renal insufficiency. Nutrition plays a vital and often overlooked role in the care of such patients on a surgical service particularly post renal transplant. Nutrition plays a vital and often overlooked role in the care of such patients on a surgical service particularly post renal transplant. In minds of both patients and physicians, one of the major benefits of renal transplantation is an end to the dietary restrictions required for therapy during periods of progressive renal failure and dialysis. In minds of both patients and physicians, one of the major benefits of renal transplantation is an end to the dietary restrictions required for therapy during periods of progressive renal failure and dialysis.

3. Transplanted Kidney

4. Impact of Obesity on Kidney Fat cell Kidney Microalbuminuria/proteinuria Glomerulopathy Fat secretes inflammatory cytokines Increased renal plasma flow (RPF) Enhances progression of other renal diseases Diabetic nephropathy Reduced renal survival after transplant Rutkowski et al. J Ren Nutr. 2006;16:216-223

5. Obesity and Transplant Receiving a transplant with a BMI of greater than 25 is associated with a significantly higher incidence of 1.New onset diabetes mellitus 2.Wound complications post-transplant 3.Post-transplant weight gain Kent.. J Ren Nutr. 2007;17:107-113

6. Other Metabolic Abnormalities after Transplantation Diabetes Diabetes Hypertension Hypertension Hyperlipidemia Hyperlipidemia Gout Gout Kent.. J Ren Nutr. 2007;17:107-113

7. Study of renal transplant recipients at KFSH&RC, Riyadh

8. Objectives To assess the weight change post renal transplant over the period of one year To assess the weight change post renal transplant over the period of one year

9. Inclusion criteria Renal transplants done from 1 st Jan 2007 to 31 st Dec 2007 at KFSH&RC, Riyadh Renal transplants done from 1 st Jan 2007 to 31 st Dec 2007 at KFSH&RC, Riyadh Age 18 to 40 years Age 18 to 40 years Patients with functioning graft Patients with functioning graft BMI- less than 30 kg/m2 BMI- less than 30 kg/m2

10. Exclusion criteria Age less than 18 or more than 40 years Age less than 18 or more than 40 years BMI – more than 30kg/m2. BMI – more than 30kg/m2. Patients who lost their Kidney graft before one year. Patients who lost their Kidney graft before one year. Patients of multi-organ transplants Patients of multi-organ transplants

11. Material and Methods Retrospective observational study Retrospective observational study Total of 146 renal transplants were done during 2007. Total of 146 renal transplants were done during 2007. Total of 43 patients were included in the study. Total of 43 patients were included in the study. Data of renal transplant recipients including pre and post one year transplant weight & BMI collected. Data of renal transplant recipients including pre and post one year transplant weight & BMI collected. SPSS 15.0 is used for statistical analysis. SPSS 15.0 is used for statistical analysis.

12. Results Total No of Pts43 Total No of Pts43 Age 26.8 (19-39) Age 26.8 (19-39) Male 23 (53.5%) Male 23 (53.5%) Female 20 (46.5%) Female 20 (46.5%) Tx Type Tx Type LRD 37 (86%) LRD 37 (86%) DD 6 (14%) DD 6 (14%)

13. Results Tx Wt 61.6 (35-97) Tx Wt 61.6 (35-97) Tx BMI 23 (16-30) Tx BMI 23 (16-30) Post 1 yr Wt 72.4 (47-111) Post 1 yr Wt 72.4 (47-111) Post 1 yr BMI 28 (20-40) Post 1 yr BMI 28 (20-40) p value <0.05 p value <0.05

14. Results Male 23 Male 23 Tx Type Tx Type LRD 20 (87%) LRD 20 (87%) DD 3 (13%) DD 3 (13%) Age 26.3 (19-39) Age 26.3 (19-39) Tx Wt 65.15 (41-85) Tx Wt 65.15 (41-85) Tx BMI 23.3 (16-30) Tx BMI 23.3 (16-30) Post Tx Wt 77.4 (49-100) Post Tx Wt 77.4 (49-100) Post Tx BMI 27.4 (20-32) Post Tx BMI 27.4 (20-32) p value <0.05 Female 20 Tx Type LRD 17 (85%) DD 3 (15%) Age 27.4 (19-39) Tx Wt 57.6 (36-97) Tx BMI 22.5 (16-30) Post Tx Wt 66.7 (47-111) Post Tx BMI 28.2 (20-40) p value <0.05

15. Results Pts with Normal BMI Pre Tx (19-25) n-25 Pts with Normal BMI Pre Tx (19-25) n-25 Age 26.7 (20 -39) Age 26.7 (20 -39) Tx Wt 55.2 (36-78) Tx Wt 55.2 (36-78) Tx BMI 21 (19-25) Tx BMI 21 (19-25) Post Tx Wt 71 (49-100) Post Tx Wt 71 (49-100) Post Tx BMI 26.6 (20-32) Post Tx BMI 26.6 (20-32) p value <0.05 Patients with high BMI Pre Tx (>25) n-14 Age 27.8 (19-37) Tx Wt 78 (66-97) Tx BMI 28 (25.7-30) Post Tx Wt 79.5 (59-111) Post Tx BMI 31.5 (27-40) p value >0.05

16. Conclusion Renal transplant remains the treatment of choice for renal failure patients but due to the immunosuppressive medications and lack of lifestyle modifications, these patients are at increased risk of weight gain and associated complications. Renal transplant remains the treatment of choice for renal failure patients but due to the immunosuppressive medications and lack of lifestyle modifications, these patients are at increased risk of weight gain and associated complications. Pre-transplant patients with normal BMI gained more weight resulting in obesity as compared to the patients with the ones who had high BMI. Pre-transplant patients with normal BMI gained more weight resulting in obesity as compared to the patients with the ones who had high BMI.

17. Nutrition Management Nutrition Care of the renal transplant recipient is a dynamic process. Nutrition Care of the renal transplant recipient is a dynamic process. It involves integrating knowledge of the patient’s complex medical condition related to chronic renal disease and the impact of ongoing therapeutic interventions on the patient’s nutritional status. It involves integrating knowledge of the patient’s complex medical condition related to chronic renal disease and the impact of ongoing therapeutic interventions on the patient’s nutritional status.

18. Nutrition Management Three phases of care have been identified for organ transplant recipients. Three phases of care have been identified for organ transplant recipients. Pre-transplantation phase: Pre-transplantation phase: The goal is to meet current education and nutrition needs, optimize the patient’s nutritional status and assist the patient in meeting body weight criteria for transplantation. The goal is to meet current education and nutrition needs, optimize the patient’s nutritional status and assist the patient in meeting body weight criteria for transplantation. Acute post-transplantation phase: Acute post-transplantation phase: The goal is to support the increased metabolic demands of surgery and high dose immunosuppressive therapy. The goal is to support the increased metabolic demands of surgery and high dose immunosuppressive therapy. Chronic post-transplantation phase: Chronic post-transplantation phase: The goal is to provide adequate nutrition, prevent infection and manage nutritional complications. The goal is to provide adequate nutrition, prevent infection and manage nutritional complications.

19. Nutrition Management Table source:McCann L.Pocket guide to nutrition assessment of the patient with chronic kidney disease. 3 rd ed. Satellite healthcare 2002.

20. Nutrition Management

21. Proposed Research Background Renal transplantation is currently considered the treatment of choice for most patients with end-stage renal failure. Based on previous studies obesity is a significant risk factor for renal transplantation. Renal transplantation is currently considered the treatment of choice for most patients with end-stage renal failure. Based on previous studies obesity is a significant risk factor for renal transplantation. Obesity in non transplant patients has been associated with hypertension, hyperlipidemia, type II diabetes, proteinuria and glomerulopathy. Obesity in non transplant patients has been associated with hypertension, hyperlipidemia, type II diabetes, proteinuria and glomerulopathy. Given this evidence it is possible that renal transplant recipients with an elevated BMI may have worse long term graft survival. Given this evidence it is possible that renal transplant recipients with an elevated BMI may have worse long term graft survival.

22. Hypothesis Dietary intervention will reduce the incidence of Obesity in renal transplant patients thus improve survival rates. Dietary intervention will reduce the incidence of Obesity in renal transplant patients thus improve survival rates.

23. Primary Objective To evaluate the effect of dietary intervention on the incidence of obesity in patients receiving kidney transplants. To evaluate the effect of dietary intervention on the incidence of obesity in patients receiving kidney transplants. To measure the change in weight/BMI among patients receiving dietary intervention compared to control group. To measure the change in weight/BMI among patients receiving dietary intervention compared to control group.

24. Secondary Objective To measure the proportion of patients developing a new onset of Diabetes Mellitus after the renal transplantation and compare the incidence among the study group. To measure the proportion of patients developing a new onset of Diabetes Mellitus after the renal transplantation and compare the incidence among the study group.

25. Methodology: Sample Selection Inclusion criteria Non-obese patients. BMI less than 30. Age group –More than 18 years who received LRD/DD Renal Transplant over next one year Willing to participate and give consent. Exclusion criteria BMI more than 30 at the time of Renal Transplant. Multi-organ transplants. Age less than 18 years or over 40 years.

26. Tools & Techniques Develop a dietary intervention tool to reduce obesity and upcoming risk factors among the study group after the transplantation which will include: Develop a dietary intervention tool to reduce obesity and upcoming risk factors among the study group after the transplantation which will include: One to one nutrition teaching One to one nutrition teaching Group discussions Group discussions Dietary intervention booklet Dietary intervention booklet Questionnaire Questionnaire

27. Tools & Techniques Post-transplants patients are followed in the clinic twice weekly for a period of 3 months initially. Lab tests will be conducted twice a week and will include renal profile, weight and glucose levels. Post-transplants patients are followed in the clinic twice weekly for a period of 3 months initially. Lab tests will be conducted twice a week and will include renal profile, weight and glucose levels. After 3 months of transplant, monthly visits are scheduled and the above-mentioned lab tests and assessments would be performed. After 3 months of transplant, monthly visits are scheduled and the above-mentioned lab tests and assessments would be performed. After 6 months, follow up visits are scheduled every three months up-to one year post transplant. After 6 months, follow up visits are scheduled every three months up-to one year post transplant.

28. Study Design Prospective cohort study Prospective cohort study

29. Study Design Phase I : Pre transplant contact or familiarizing Phase I : Pre transplant contact or familiarizing Examine the patient physically (BMI, weight) Examine the patient physically (BMI, weight) Bio chemical investigations ( Electrolyte, Blood sugar) Bio chemical investigations ( Electrolyte, Blood sugar) Phase II : Post transplant - intervention. Phase II : Post transplant - intervention. Examine the patient physically ( BMI, weight and Blood Pressure ) Examine the patient physically ( BMI, weight and Blood Pressure ) Bio chemical investigations. Bio chemical investigations. Nutrition education, one to one basis Nutrition education, one to one basis Nutrition intervention booklet will be provided. Nutrition intervention booklet will be provided.

30. Study Design Phase III : Monthly follow-up for a period of next three months Phase III : Monthly follow-up for a period of next three months Examine the patient physically ( BMI, weight) Examine the patient physically ( BMI, weight) Bio chemical investigations. Bio chemical investigations. Nutrition education, one to one basis. Nutrition education, one to one basis.

31. Study Design Phase IV & V : Nine and twelve months post transplant follow-up Phase IV & V : Nine and twelve months post transplant follow-up Examine the patient physically ( BMI, weight) Examine the patient physically ( BMI, weight) Bio chemical investigations ( Electrolyte, Blood sugar) Bio chemical investigations ( Electrolyte, Blood sugar) Nutrition reinforcement Nutrition reinforcement Phase VI : Data compilation and statistical analysis would be done at the end of the study. Phase VI : Data compilation and statistical analysis would be done at the end of the study.

32. Recommendations Appropriate Nutrition Counseling should be provided during the transplant work-up. Appropriate nutrition protocol should be developed to ensure weight management using appropriate nutrition intervention. Regular nutrition follow ups are highly recommended for these patients to avoid obesity and associated complications.

33. Recommendations The nutrition goals post transplantation are to achieve and maintain good overall nutritional status, manage nutrition related pre-existing medical concerns, and prevent or minimize the side effects of immunosuppressive therapy (hyperlipidemia, obesity, hypertension, glucose intolerance and bone disease). The nutrition goals post transplantation are to achieve and maintain good overall nutritional status, manage nutrition related pre-existing medical concerns, and prevent or minimize the side effects of immunosuppressive therapy (hyperlipidemia, obesity, hypertension, glucose intolerance and bone disease). Specialized weight loss programs - pre and post transplantation should be developed which will improve transplant outcomes. Specialized weight loss programs - pre and post transplantation should be developed which will improve transplant outcomes.

34. Thank You