Abstracts / Clinical Nutrition ESPEN 14 (2016) 42e57

disease for a long time. Much less is known on dietary therapy in acute renal disease. due to induction of mild chronic inflammation. Catabolism is more pro-nounced in the
Here we will try to draw some parallels and differences between the nutritional acute compared to the chronic kidney failure. Kidney pa-tient nutrition must therefore be
treatments of acute and chronic renal impairment. Acute kidney disease or failure is adjusted to the requirements specific for different type and stage of kidney disease and
usually not an isolated organ damage, but only one of the several components of multi the mode of treatment.
organ failure, which occurs during the catabolic phase of critical illness. Patients with Patient's nutriton after kidney transplantation is influenced by several different factors,
acute renal disease usually relatively quickly develop protein-energy malnutrition, which such as the time after transplantation, kidney function (chronic kidney disease stages 1-
is a negative prognostic factor. The inflammatory response and pro-oxidative state that 5T), side effects of immunosuppressive and other drugs, possible food-drug interactions
develop with the protein-energy malnutrition lead to further deterioration of health. Thus, and possible immuno-modulatory effects of some food additives.
the nutritional support of patients with the acute renal failure is often needed, although
the benefits are not proven, because of its complexity. We believe that an individual In the early post-transplant period adequate nutrition has to enable wound healing,
approach is very important for treatment of acute renal failure. It is necessary to assess prevent infection and correct clinically significant elec-trolyte and metabolic
the cause and nature of the primary event that led to the acute renal failure. Specific abnormalities caused by the restoration of kidney function and immunosuppressive
indicators, such as hemodynamic monitoring, acid-base balance, liver function and lung medications. In the long run nutrition helps to stabilize and prevents deterioration of
function should be considered and this information adapted to the nutritional treatment of renal function, develop-ment of obesity, dyslipidemia, anemia, diabetes/hyperglycemia,
the acutely ill. It is essential to perform the nutritional assessment, which includes both hyper-tension and bone disease.
conventional laboratory as well as clinical indicators.
Immunosupressive drugs cause side effects, some of which can be influ-enced by
nutrition. Steroids cause osteoporosis, fluid retention and hy-pertension, dyslipidemia,
new onset diabetes after transplantation (NODAT), increased appetite and weight gain.
Salts in parenteral nutrition cannot be used to correct the acid-base dis-orders, but they Dyslipidemia is caused also by calcineurin inhibitors (tacrolimus and cyclosporine) and
can be used for the maintenance of normal acid-base metabolism. Overeating, which can mTOR in-hibitors (everolimus and sirolimus). Tacrolimus is also a possible reason for
be both enteral and parenteral, could be linked to the accumulation of carbon dioxide, NODAT. Hypomagnesemia was described with cyclosporin, everolimus and tacrolimus,
which can lead to dete-rioration of respiratory acidosis. Parenteral and enteral nutrition hyperkalemia with cyclosporine and tacrolimus. Both calci-neurin inhibitors cause higher
should not be initiated in the patients with unstable acid-base equilibrium. incidence of hyperurikemia then myco-phenolate or mTOR inhibitors.

Chronic kidney disease is usually a slowly progressive disease, in which the expected
worsening of the renal function and the expected metabolic complications can be Pre-transplant nutritional status affects outcomes after transplantation. Recipients with
improved by the suitable diet. It is known that nutritional therapy for chronic kidney BMI <18 (protein energy wasting) and those with BMI >35 (obesity) incur an excess of
disease is an equivalent therapeutic agent lowering uremic toxicity, reducing the risk of morbidity and mortality as compared to those within a normal BMI range. Wound
malnutrition and slowing the progression of chronic kidney disease. The most important healing and immune defence rely on enhanced synthesis of new proteins which is limited
measure for nutritional therapy in pre-dialysis period is thus the protein restriction with by negative energy and nitrogen balance. Presence of obesity at the time of
the equivalent energy intake. It is important that there is no protein-energy malnutrition transplantation is associated with a greater risk of delayed graft function and surgical
during this period. The role of health care workers in this period is important for the wound complications. Pre-transplant malnutrition is associated with poor graft and
patient's long term status. The progression of chronic kidney disease towards the renal patient survival. Indirect effects of abnormal nutritional status are also evident, mediated
failure is gradual, therefore a good protein-energy status is even more important . In the through nutrition-related disorders including diabetes, osteoporosis and cardiovascular
dialysis period, the protein intake can be increased, thereby avoiding the protein-energy disease. Therefore, optimal nutritional status should be maintained in all patients on the
malnutrition, which is a strong prognostic factor for morbidity in patients with chronic transplant waiting list. Required energy and nutrients after kidney transplantation are
kidney disease. 30e35 kcal/kg IBW/d in acute and chronic phases, protein ~1.4 g/kg IBW/d (acute
phase) and 0.75e1.0 g/kg IBW/d (chronic phase). Fat should contribute <30% of total
energy, with 8e10% of total energy from n-6 polyunsaturated fat; there should be n-3
In conclusion, it is necessary to stress once again that the nutritional treatment of renal polyunsaturated fats from both plant and marine sources; approx. 20% monounsaturated
disease is an important measure that can be used as a variable that can change the course fat and <10% saturated and trans fatty acids. Carbohydrates should represent approx.
of the disease, either acute or chronic. Keywords: acute renal disease, chronic kidney 50% of total energy. They should have low glycemic index and should contain high
disease, nutritional therapy, the differences dietary fi-ber. Simple sugars should be limited. The recommended daily alowance (RDA)
of calcium is 1000 - 1300 mg/d, phosphorous 1000 - 1300 mg/d, sodium 80 - 100
mmol/d (no added salt), potassium restricted if hyper-kalemia persists. Iron 10 - 15 mg/d,
References vitamin D 5 - 15 mg/d, fiber 25 - 30 g/d. Vitamins and minerals, in particular B6, B12,
1. Cano N, Aparicio M, Brunori G et all. ESPN Guidelines on parenteral nutrition: Adult magnesium and zinc ac-cording to RDA for the general population or age and gender,
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edition. Humana Press. Science+Business Media New York, 2014. Nutritional assessment should be performed soon after the trans-plantation, then monthly
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Third edition. Elsevier Inc 2013. may have optimal post-transplant course that corrects metabolic abnormaliteis or may
6. Lindic J, Kovac D, Kveder R et all. Bolezni ledvic. Tretja izdaja. Ljubljana, 2014. have delayed graft function, wound healing complications and gut disturbances that
contributes to undernutrition. Nutritional requirements change over time after
7. Knap B, Lavrinec J. Prehrana pri ledvicni bolezni. Ljubljana: drustvo ledvicnih transplantation. Individual management is required. Keywords: cronic renal failure,
bolnikov Slovenije; 2012. P. 1-38. transplantation, nutrition

NUTRITION AFTER KIDNEY TRANSPLANTATION

References
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E-mail address: gregor.mlinsek@kclj.si F. (2010). Nutritional management of dyslipidaemia in adult kidney transplant recipients.
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Progression of chronic kidney disease is accompanied by metabolic changes that result in transplant recipients. American Journal of Transplantation: Official Journal of the
catabolism. Dialysis dependance further exacerbates catabolic rate due to protein and American Society of Transplantation and the American So-ciety of Transplant Surgeons,
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3. Hwang, J. H., Ryu, J., An, J. N., Kim, C. T., Kim, H., Yang, J., … Lee, J. P. (2015). Several studies suggest that intravenous ascorbic acid in hemodialysis patients improves
Pretransplant malnutrition, inflammation, and atherosclerosis affect car-diovascular hemoglobine and iron availability in epoetin-hypores-ponsive hemodialysis patients with
outcomes after kidney transplantation. BMC Nephrology, 16, iron overload. Vitamin C helps release iron from ferritin and mobilizes it from the
7
109. reticuloendothelial system and thus increases erythropoiesis . This in turn could lead to
4. Knoll, G. a., Blydt-Hansen, T. D., Campbell, P., Cantarovich, M., Cole, E., Fairhead, a reduced need for recombinant epoetin which could reduce the cost of ESRD treatment.
T., … Prasad, G. V. R. (2010). Canadian Society of Transplantation and Canadian Oral nutritional supplements are protein rich but contain only small amounts of
Society of Nephrology commentary on the 2009 KDIGO clinical practice guideline for 8
phosphate. They do not increase phosphatemia and do not increase the treatment cost in
the care of kidney transplant recipients. American Journal of Kidney Diseases, 56(2), this regard.
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of Renal Disease (Kindle book., Chapter 34, pp 28230e29126 of 39452). in advanced CKD and ESRD patients, their optimal nutritional care should be
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1
population . Cost-effectiveness analyses in chronic kidney disease (CKD) patients are Transplant. 1998;2867e72.
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2
chronic kidney disease and the time to onset of dialysis treatment . The estimation of
cost effectiveness of low protein diet compared with no dietary treatment in patients with
CKD 4 and 5 after 2, 3, 5 and 10 years showed that treatment with a low protein diet URAEMIC SARCOPENIA
appears to be more efficient in terms of the years of good overall quality of life in all the 1 2
time intervals considered. The difference in the terms of quality adjusted life years was Martin Hren MD , Assoc. Prof.Sebastjan Bevc MD, PhD , Prof.Radovan
2 1
always in favour of the dietary treatment, starting from 0.09 after the first two years, Hojs MD, PhD , Assist.Masa Knehtl MD, PhD , Assist.Benjamin
2 1 2
before doubling and quadruplicating after 3 (0.16) and 5 years (0.36), up to the Dvorsak MD, PhD , Tina Stropnik Galuf MD , Eva Jakopin MD, PhD ,
1 1
difference of almost one year (0.93) after the first 10 years of treatment. In all cases the Assoc. Prof.Robert Ekart MD, PhD . Department of Dyalisis, University
cost was in favour of the low-protein treatment. Dominance was due to the fact that the 2
Medical Centre, Maribor, Slovenia; Department of Nephrology, University
treatment was more effective in terms of years of good quality life gained and was less Medical Centre, Maribor, Slovenia
3 E-mail address: Martin.hren@triera.net (M. Hren).
expensive .

Introduction
A nutritional program for severely malnourished patients with serum al-bumin < 3.5 g/dl The term uraemic sarcopenia is used to describe the abnormalities of skeletal muscle that
resulted in an improvement in serum albumin of 0,2 g/dl. Albumin < 3.5 g/l was develop in the uraemic milieu. They are not charac-terized by an abnormal muscle
associated with a 2 fold increase in death and hos-pitalization risk compared to albumin physiology but instead by a significant muscle wasting and selective structural changes.
4.0 g/dl. It was concluded that nutritional interventions that increase serum albumin for They present with a reduced muscle force and lead to an increased morbidity and
0.2 g/dl may lead to considerable improvements in mortality, hospitalization and mortality of uraemic patients. Mechanisms of muscle wasting in the uraemic milieu are
4 numerous: hormonal, immunologic, cellular and metabolic, where low protein intake due
treatment cost . Daily supplemental feeding is ideal but regular administration of
supplements within the dialysis unit provides an excellent method, whether in the form to loss of appetite, metabolic acidosis and physical inactivity are the most important.
of oral nutrition or intradialytic parenteral nutrition (IDPN). Overall prevalence of sarcopenia in uraemic patients is high and reaches 50% in dialysis
patients.
Metabolic acidosis, independent of uremia, accelerates protein catabolism. When
acidosis is corrected, CKD patients adapt to lower protein intake by reducing amino-acid Pathogenesis
5 Some selective structural changes of muscle tissue, that are visible on muscle biopsy, are
oxidation and protein degradation and maintain protein synthesis at normal levels .
Bicarbonate supplementation corrects acidosis and reduces net protein degradation. It typical for uraemic milieu. There is an atrophy of muscle fibers, predominantly of fast
was demonstrated that bicarbonate supplementation slows the rate of progression of renal twitch Type II fibers. Research has shown a link between a lower activity of
6 mitochondrial enzymes in muscle cells and a worsening of renal function, a link that is
failure to ESRD and improves nutritional status among patients with CKD . Low
bicarbonate cost suggests that its supplementation is cost-effective. very similar to the one described in ageing.