NEPHROLOGY 2010; 15, S52–S55 doi:10.1111/j.1440-1797.2010.01235.

Nutritional management of overweight and obesity in adult

kidney transplant recipients
Date written: June 2008 nep_1235 52..55

Final submission: June 2009

Author: Steven Chadban, Maria Chan, Karen Fry, Aditi Patwardhan, Catherine Ryan, Paul Trevillian, Fidye Westgarth

GUIDELINES

No recommendations possible based on Level I or II evidence.

SUGGESTIONS FOR CLINICAL CARE BACKGROUND

(Suggestions are based on Level III and IV evidence) Weight gain after kidney transplantation is common and
the resulting overweight and obesity is associated with
To prevent excessive weight gain
serious health complications. Post-transplant weight gain
• Kidney transplant recipients should be referred to a
has been reported at between 10 and 35 per cent, with the
dietitian as soon as practicable after transplantation, for
majority of the weight gain occurring in the first 12 months
written and verbal advice for preventing weight gain.
post-transplant.1–4 Much of the weight gained is abdominal
(Level III)
fat.2,5 Steroids are known to enhance appetite and to have
• Regular follow-up should be arranged to prevent exces-
an adverse effect on body fat distribution and lipid metabo-
sive weight gain. (Level III)
lism thus contributing to the pattern of weight gain seen
• As obesity is associated with an increased risk of steroid
after transplantation. However, other factors, including an
induced diabetes and cardiovascular disease risk factors as
improved sense of wellbeing, may play an equally important
well as long-term graft function and poor graft survival:
role.1,5–9
– all members of the health care team should monitor
Among kidney transplant recipients, there is evidence
the weight of individual transplant recipients and
that weight gains of more than 10 per cent increase the
arrange review by a dietitian if weight gain is a problem.
chances of steroid-induced diabetes and dyslipidaemia.1 In
• Evidence from studies in the general population indi-
addition, obese kidney transplant recipients have a higher
cates that dietary advice should be individualized and
prevalence of hypertension, coronary artery disease, chronic
include meal plans, exercise plans and specific goals.
obstructive pulmonary disease and peripheral vascular
To reduce body weight in overweight or obese kidney disease, hyperlipidaemia, stroke, diabetes, coronary artery
transplant recipients: disease and mortality.10–12
• A diet that is individually planned with a moderate There is strong evidence that obesity adversely impacts
energy restriction of about 30% of energy expenditure upon long-term graft function and is an independent risk
should be applied. (Level IV) factor for poor graft survival.10,13–16
• Overweight and obese kidney transplant recipients are In the general population, dietary interventions play a
more likely to make dietary changes and lose weight with central role in the management of overweight and obesity.
monthly follow-up with a dietitian. (Level IV) This review set out to explore and collate the evidence to
• As obesity is associated with an increased risk of steroid support the use of particular nutrition interventions for the
induced diabetes and cardiovascular disease risk factors as prevention and management of weight gain in kidney trans-
well as long-term graft function and poor graft survival: plant recipients, based on the best evidence up to and
– The dietitian should arrange regular follow-up for including September 2006.
the overweight kidney transplant recipient as appropri-
ate until the desired weight loss is achieved.
– Referral to community-based weight management SEARCH STRATEGY
programmes may be appropriate.
• Based on studies in the general population, the initial Relevant reviews and studies were obtained from the sources
goal of weight loss therapy should be to reduce body weight below and reference lists of nephrology textbooks, review
by approximately 10% from baseline, with weight loss of articles and relevant trials were also used to locate studies.
1-2 kg per month. With success, further weight loss can be Searches were limited to studies on humans; adult kidney
attempted if indicated through further assessment. transplant recipients; single organ transplants and to

© 2010 Asian Pacific Society of Nephrology

No claim to original government works
Transplantation Nutrition S53

studies published in English. Unpublished studies were not vent excessive weight gain post-transplant and regular
reviewed. follow-up with a dietitian assists with compliance to dietary
Databases searched: MeSH terms and text words for kidney modifications.
transplantation; MeSH terms and text words for weight, Lopes et al.18 recruited 23 adult kidney transplant recipi-
overweight and obesity; and MeSH terms and text words for ents with a body mass index of greater than 27 and stable
nutrition interventions MEDLINE – 1966 to week 4, Sep- kidney function. All patients were advised to follow the
tember 2006; EMBASE – 1980 to week 4, September 2006; American Heart Association (AHA) Step One Diet and
the Cochrane Renal Group Specialised Register of Ran- received monthly, individualized dietary instruction from a
domised Controlled Trials. clinical nutritionist (dietitian) with a 30% energy restric-
Date of searches: 22 September 2006. tion with respect to estimated energy expenditure.
There were significant differences between mean base-
line and final intakes of energy (decreased by 632 kcal,
WHAT IS THE EVIDENCE? P < 0.001), cholesterol (decreased by 131 mg, P < 0.01),
carbohydrate (increased by 8.4%, P < 0.001), and fat
Few studies on the nutritional management of overweight (decreased by 9.2%, P < 0.001) with the final intakes con-
and obesity in kidney transplant recipients have been pub- sistent with the AHA Step One Diet guidelines. Over
lished. 6 months, the mean weight loss was 3 kg (P < 0.001) with a
Level I and II: There are no randomized, controlled trials significant reduction in % fat mass.
on this topic. The main limitations of this study were:
Level III: There is one comparative study supporting the – small numbers in the cohort;
use of intensive, individualized dietary and weight control – no control group; and
advice among kidney transplant recipients.17 – no information regarding levels of physical activity
Level IV: There is one prospective study of satisfactory achieved.
methodological quality,18 supporting the use of intensive, However, the study provides level IV evidence that
individualized dietary instruction to reduce body weight in intensive dietary intervention can lead to significant
overweight kidney transplant recipients. changes in dietary intake and significant reductions in body
Patel studied 33 kidney transplant recipients with stable weight and body fat mass among kidney transplant recipi-
functioning grafts over a period of 1 year post-transplant.17 ents.
Patients in Group A (n = 11) received intensive dietary
counselling weekly for the first month then monthly until
4 months post-transplant. The advice was individualized EVIDENCE FROM STUDIES IN THE
and provided by a dietitian and each patient received GENERAL POPULATION
information on protein, carbohydrates, fats, fibre, sodium,
calcium, iron and detailed advice on weight control, Dietary therapy for obesity is usually effective during the
including behavioural advice and exercise. They were given period of active supervised treatment, but is then followed
individualized meal and exercise plans. After 4 months by a pattern of gradual weight regain during the subsequent
they did not see the dietitian again until 12 months. unsupervised follow-up period.19 (Level I evidence)
The historical control group of 22 patients (Group B) In the general population, weight loss of 10% from base-
had received no nutrition advice or dietetic follow-up line has significant favourable effects on health.20,21 (Level I
post-transplant. evidence)
There was significantly less weight gained by patients in In the general population, a program of combined diet
Group A than those in Group B in the first 4 months after and exercise is more effective in maintaining weight loss
transplant – 1.4 kg versus 7.1 kg, respectively (P = 0.01). In than either diet alone or exercise alone.20,21 (Level II evi-
the 12-month follow-up period there was significantly less dence)
weight gained overall by patients in Group A than Group B
– 5.5 kg and 11.8 kg, respectively (P = 0.01). After inten-
sive dietary intervention was completed and up until SUMMARY OF THE EVIDENCE
12 months, patients in Group A experienced significant
weight gain (and BMI increase) from 4 months to 1 year Excessive post-transplant weight gain and obesity are asso-
(P = 0.02). ciated with a number of adverse health outcomes, including
The limitations of this study were: delayed graft function, chronic allograft nephropathy, dys-
– small numbers of patients in each group; lipidaemia, hypertension, prolonged hospitalization, acute
– different number in intervention versus control group; rejection and decreased graft and patient survival.10–16
– non-randomized; and There is level III evidence that early intervention with
– while there was no significant difference between groups regular follow-up is effective in preventing excessive weight
with respect to sex, age and baseline weight, there was no gain17 and level IV evidence that regular dietetic interven-
adjustment for other confounders. tion among overweight and obese kidney transplant recipi-
Despite the limitations, this study provides level III-3 ents can lead to significant dietary changes and weight
evidence that intensive dietary interventions can pre- loss.18
S54 The CARI Guidelines

Unfortunately, while evidence for particular dietary REFERENCES

interventions in the general population is strong,19–21 the
1. Johnson CP, Gallagher-Lepak S, Zhu YR et al. Factors influencing
current literature does not permit definitive recommenda-
weight gain after renal transplantation. Transplantation. 1993; 56:
tions in this population.
822–7.
2. Moore LW, Gaber AO. Patterns of early weight change after renal
transplantation. J. Ren. Nutr. 1996; 6: 21–5.
WHAT DO THE OTHER GUIDELINES SAY? 3. Teplan V, Poledne R, Scuck O et al. Hyperlipidemia and obesity
after renal transplantation. Ann. Transplant. 2001; 6: 21–3.
Kidney Disease Outcomes Quality Initiative: No recom- 4. Jaggers HJ, Allman MA, Chan M. Changes in clinical profile and
mendation. dietary considerations after renal transplantation. J. Ren. Nutr.
UK Renal Association: No recommendation. 1996; 6: 12–20.
Canadian Society of Nephrology: No recommendation. 5. Steiger U, Lippuner K, Jensen EX et al. Body composition and fuel
European Best Practice Guidelines:22 Obesity (BMI > 30) metabolism after kidney grafting. Eur. J. Clin. Invest. 1995; 25:
and weight gain are associated with increased prevalence of 809–16.
cardiovascular disease after transplantation. Appropriate 6. Verran D, Munn S, Collins J et al. Impact of renal allograft
implantation and immunosuppression on body composition using
dietary and lifestyle measures should be recommended to
in vivo neutron activation analysis. Transplant. Proc. 1992; 24:
these patients. 173–4.
International Guidelines: No recommendation. 7. Isiklar I, Akin O, Niron EA. Effects of renal transplantation on
body composition. Transplant. Proc. 1998; 30: 831–2.
8. Hart PD, Wilkie ME, Edwards A et al. Dual energy X-ray absorp-
Relevant guidelines for non-transplant populations tiometry versus skinfold measurements in the assessment of total
body fat in renal transplant recipients. Eur. J. Clin. Nutr. 1993; 47:
1 National Health and Medical Research Council. Clinical 347–52.
Practice Guidelines for the Management of Overweight and 9. Van den Ham ECH, Kooman JP, Christiaans MH et al. Posttrans-
Obesity in Adults. Canberra: National Health and Medical plantation weight gain is predominantly due to an increase in body
fat mass. Transplantation. 2000; 70: 241–2.
Research Council; 2003.
10. Gore JL, Pham PT, Danovitch GM et al. Obesity and outcome
2 Dietitians Association of Australia. Best Practice Guide-
following renal transplantation. Am. J. Transplant. 2006; 6: 357–
lines for the Treatment of Overweight and Obesity in 63.
Adults. Canberra: Dietitians Association of Australia; 2005. 11. Clunk JM, Lin CY, Curtis JJ. Variables affecting weight gain
in renal transplant recipients. Am. J. Kidney. Dis. 2001; 38: 349–
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IMPLEMENTATION AND AUDIT 12. Gonyea JE, Anderson CF. Weight change and serum lipoproteins
in recipients of renal allografts. Mayo. Clin. Proc. 1992; 67: 653–7.
No recommendations. 13. Ojo AO, Hanson JA, Wolfe RA et al. Long-term survival in renal
transplant recipients with graft function. Kidney. Int. 2000; 57:
307–13.
SUGGESTIONS FOR FUTURE RESEARCH 14. Micozkadioglu H, Ozdemir FN, Sezer S et al. Weight gain after
living-related renal transplantation affects long-term graft func-
Long-term follow-up studies examining the effects of differ- tion. Transplant. Proc. 2005; 37: 1029–32.
15. Meier-Kriesche HU, Vaghela M, Thambuganipalle R et al. The
ent dietary interventions among the adult kidney transplant
effect of body mass index on long-term renal allograft survival.
population are needed to confirm the most effective
Transplantation. 1999; 68: 1294–7.
methods for preventing and/or managing weight gain post- 16. Pirsch JD, Ambrust MJ, Knechtle SJ et al. Obesity as a risk factor
transplant. Such research would determine whether or not following renal transplantation. Transplantation. 1995; 59: 631–3.
current guidelines for the management of overweight and 17. Patel MG. The effect of dietary intervention on weight gains after
obesity in the general population are appropriate for kidney renal transplantation. J. Ren. Nutr. 1998; 8: 137–41.
transplant recipients. 18. Lopes IM, Martin M, Errasti P et al. Benefits of a dietary interven-
tion on weight loss, body composition, and lipid profile after renal
transplantation. Nutrition. 1999; 15: 7–10.
CONFLICT OF INTEREST 19. Douketis JD, Feightner JW, Attia J et al. Periodic health exami-
nation, 1999 update: 1. Detection, prevention and treatment of
All the above authors have no relevant financial affiliations obesity. Canadian Task Force on Preventive Health Care. CMAJ.
1999; 160: 513–25.
that would cause a conflict of interest according to the
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conflict of interest statement set down by CARI.
Guidelines for the Management of Overweight and Obesity in Adults.
Canberra: National Health and Medical Research Council, 2003.
21. Dietitians Association of Australia. Best Practice Guidelines for the
ACKNOWLEDGEMENTS Treatment of Overweight and Obesity in Adults. Canberra: Dietitians
Association of Australia, 2005.
These guidelines were developed under a project funded by 22. European Renal Association. European Best Practice Guidelines
the Greater Metropolitan Clinical Taskforce, New South for Renal Transplantation (Part 2). Nephrol. Dial. Transplant.
Wales. 2002; 17 (Suppl 4): 29–30.
APPENDIX

Table A1 Characteristics of included studies

Study design
Study ID n and setting Participants Intervention Follow up Comments and results
Patel (1998)17 Intervention Non-randomized Adult kidney transplant Intensive, individualized 1 year Both groups had similar
Transplantation Nutrition

(Group A) comparative study. recipients with stable verbal and written dietary immunosuppressive regimen; no
11 (9 male) Single US hospital functioning grafts, advice including detailed difference between baseline
Historical transplant unit. immediately post-transplant. weight control advice. weight, BMI, age, sex. There
control No record of exclusions. Weekly follow-up weekly was significantly less weight
(Group B) for the first month then gained by patients in Group A
22 (14 male) monthly to 4 months. than those in Group B in the
vs first 4 months after transplant –
Historic control that had 1.4 kg versus 7.1 kg respectively
received no dietary advice (P = 0.01). In the 12-month
or follow-up. follow-up period there was
significantly less weight gained
overall by patients in Group A
than Group B – 5.5 kg and
11.8 kg respectively, (P = 0.01).
After intensive dietary
intervention was completed and
up until 12 months, patients
in Group A experienced
significant weight gain (and
BMI increase) from 4 months to
1 year (P = 0.02).
Lopes et al. 23 (7 male) Before and after Kidney transplant recipients AHA Step One Diet (<30% 6 months There were significant
(1999)18 Age study. with stable kidney function cals from fat; <10% saturated differences between mean
42 1 14 years Single centre and BMI > 27. fat, <300 mg cholesterol/day) baseline and final intakes of
(Spain). Exclusions: Diabetes, with an energy restriction of energy (decreased by 632 kcal,
myxedema, nephrotic ~30% of TEE. P < 0.001), cholesterol
syndrome, hyperlipidemia Monthly individualized dietary (decreased by 131 mg, P < 0.01),
due to thyroid or liver instruction provided by a carbohydrate (increased by
disease, cholesterol or clinical nutritionist. 8.4%, P < 0.001), and fat
weight-lowering agents. (decreased by 9.2%, P < 0.001)
with the final intakes consistent
with the AHA Step One Diet
guidelines.
S55