Predictors of weight gain and cardiovascular risk in a cohort of racially diverse kidney transplant recipients

doi:10.1016/S0899-9007(01)00723-7

Nutrition

Volume 18, Issue 2, February 2002, Pages 139-146

https://doi.org/10.1016/S0899-9007(01)00723-7 Get rights and content

Abstract

OBJECTIVE: Renal transplantation is associated with an increased risk of atherosclerotic cardiovascular disease and marked racial and ethnic disparities in graft and patient survival. We characterized differences in racial and ethnic susceptibility to weight gain, diabetes, and alterations in circulating lipid levels and isolated independent predictors of those changes in a diverse population of kidney transplant recipients.

METHODS: The data for this analysis were drawn from a prospectively collected database of 506 renal transplant recipients obtained between 1983 and 1998. Univariate and multivariate analyses characterized differences in outcomes and predictors of cardiovascular risk by race and ethnicity.

RESULTS: In all recipients, coronary artery disease was the most common cause of death, and African-American recipients had the shortest graft survival and the highest percentage of deaths. At 1 y post-transplantation, 39% of African-American recipients were obese (body mass index > 30), and the odds ratios for post-transplant diabetes were 3.5 and 5 times greater in non-white and obese recipients, respectively.

CONCLUSIONS: Multiple regression analysis confirmed the predominant independent effect of African American race or ethnicity on weight gain; however, hypercholesterolemia was independent of race or ethnicity and predicted by cyclosporine treatment and post-transplant diabetes. Therefore, kidney transplantation represents a state of accelerated atherogenic risk induced in part by the metabolic effects of immunosuppressive medications and compounded by marked racial and ethnic disparities in weight gain and diabetes risk.

Introduction

Renal transplantation (RT) is the most common solid organ transplantation procedure, with more than 12 000 performed in 1999 in the United States.1 The growing success of organ transplantation is due in large part to dramatic improvements in immunosuppressive therapy resulting in greater than 90% 1-y graft and patient survival.1, 2 Patient survival has improved in large part because of a reduction in immunosuppression-related infectious mortality. In place of infectious causes of death, a number of reports have noted a growing incidence of cardiovascular complications, and cardiovascular disease (CVD) is now believed to be the leading cause of death in RT recipients.3 Estimates of the frequency of ischemic heart disease range from 25% to 58%, with significant numbers of recipients also suffering from peripheral vascular disease and carotid atherosclerosis.3, 4 Estimates of the relative incidence indicate that CVD is four times as great as in the general population, suggesting that transplantation accelerates the atherogenic process.5 To a small degree the increased incidence of CVD reflects the increase in length of survival and the inclusion of a greater number of diabetic and older patients with pre-existent CVD. In addition, the presence of a renal allograft initiates a host immune reaction that may generalize and directly affect vasculature outside of the transplanted graft.5, 6

A growing number of studies have documented striking racial disparities in RT outcomes. Recent data indicates that African Americans (AA) are 1.7 times as likely as European Americans (W) and others (O; Hispanics, Asians and Native Americans) to suffer graft failure in living related donor recipients in whom the impact of differences in graft preservation and human leukocyte antigens are minimized.7 A similar trend was noted in patient survival with the risk of death among AAs at 1.37 times that of W recipients adjusted for age and sex.7 The mechanisms responsible for the racial disparities in transplant outcomes are poorly understood; however, the increased incidence of obesity, diabetes, and cardiovascular risk in AAs in the general public led us to postulate that similar racial differences in CVD risk affect post-transplant mortality. A growing body of data also suggests that CVD risk factors may adversely affect the development of allograft vasculopathy, suggesting another possible mechanism for racial and ethnic disparities in graft survival.5 Therefore, we evaluated the relative importance of race, ethnicity, immunosuppressive medication, and other demographic variables on the risk of developing intermediate risk factors for cardiovascular disease in a large RT database.

Section snippets

Subjects

Between 1983 and 1998, data on 780 RT recipients were collected prospectively as part of a clinical database at the University of Illinois at Chicago Medical Center. After approval from the university institutional review board, we retrospectively analyzed data on 506 adult RT recipients provided they had complete demographic and medical information as well as height and weight data at the time of transplant and weight at 1 y post-transplant. Subjects were assigned to three groups based on race

Baseline characteristics and transplant outcomes

At baseline there were no differences in BMI and the percentage of overweight (BMI > 25) or obesity (BMI > 30; Table I). The AA group tended to be older, taller, and heavier, with higher baseline creatinine concentrations and a higher percentage of hypertensive nephropathy. The W group had the highest baseline triacylglycerol level, and the AA and W groups had higher baseline cholesterol levels than the O group.

Immunosuppressive therapy, renal function, rejection episodes, graft survival, and

Discussion

Retrospective studies of transplant databases have indicated that the primary cause of death for RT recipients has shifted from infection to CVD8; our studies support this conclusion, with CVD accounting for 40% of deaths. Aker et al. demonstrated that PTDM, male sex, older age, cigarette smoking, hypercholesterolemia, hyperuricemia, and overweight (BMI > 25kg/m²) were statistically significant independent predictors of CVD, whereas post-transplant hypertension was not.8 A major deficiency in

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A Randomized Controlled Trial of an Intensive Nutrition Intervention Versus Standard Nutrition Care to Avoid Excess Weight Gain After Kidney Transplantation: The INTENT Trial
2018, Journal of Renal Nutrition
Excessive weight gain is common after kidney transplantation and increases cardiovascular risk. The aim of this randomized controlled trial was to determine whether an intensive nutrition and exercise intervention delivered alongside routine post-transplant care would reduce post-transplant weight gain.
Single-blind, randomized controlled trial.
Adult kidney transplant recipients at a regional transplant center were recruited during routine outpatient clinic visits in the first month after transplant. Patients with a body mass index >40 kg/m² or <18.5 kg/m², severe malnutrition, or ongoing medical complications were excluded.
Participants were randomized to intensive nutrition intervention (individualized nutrition and exercise counselling; 12 dietitian visits; 3 exercise physiologist visits over 12 months) or to standard nutrition care (guideline based; 4 dietitian visits).
The primary outcome was weight at 6 months after transplant adjusted for baseline weight, obesity, and gender, analyzed using analysis of covariance. The secondary outcomes included body composition, biochemistry, quality of life, and physical function.
Thirty-seven participants were randomized to the intensive intervention (n = 19) or to standard care (n = 18); one intensive group participant withdrew before baseline. Weight increased between baseline, 6 and 12 months (78.0 ± 13.7 [standard deviation], 79.6 ± 13.0 kg, 81.6 ± 12.9 kg; mean change 4.6% P < .001) but at 6 months did not differ significantly between the groups: 77.0 ± 12.4 kg (intensive); 82.2 ± 13.4 kg (standard); difference in adjusted means 0.4 kg (95% confidence interval: −2.2 to 3.0 kg); analysis of covariance P = .7. No between-group differences in secondary outcomes were observed. Across the whole cohort, total body protein and physical function (gait speed, sit to stand, grip strength, physical activity, and quality of life [all but 2 domains]) improved. However, adverse changes were seen for total body fat, HbA1c, and fasting glucose across the cohort.
Kidney transplant recipients in the first year after transplant did not benefit from an intensive nutrition intervention compared with standard nutrition care, although weight gain was relatively modest in both groups.
Effect of kidney transplantation on sleep-disordered breathing in patients with End Stage Renal Disease: a polysomnographic study
2018, Sleep Medicine
Citation Excerpt :
This finding could be due to the corticosteroids that these patients were receiving as part of the immunosuppressive therapy. Long-term follow-up is required to comment on the sustained decrease in these traditional risk factors because there are studies [25,26] that have shown that there is a progressive weight gain as years pass by after the transplant, which could worsen SDB. Both AHI and desaturation index, as well as baseline SaO2, were significantly associated with the mentioned parameters.
Sleep-disordered breathing (SDB) is common in patients with end-stage renal disease (ESRD). SDB is associated with comorbidities such as hypertension, diabetes mellitus, and obesity, interplaying with metabolic derangements in the form of uremia, acidosis, and hypervolemia. Renal transplant has been observed to correct most of these metabolic derangements and to control progression of comorbidities. While SDB is highly prevalent among patients in the pretransplant stage, it remains to be seen whether the beneficial aspects of transplant are extended to improvement in SDB in patients with ESRD.
Eighteen patients undergoing thrice-weekly hemodialysis (HD) for ESRD at the transplant clinic of All India Institute of Medical Sciences (AIIMS), New Delhi, underwent detailed clinical, laboratory, and polysomnographic evaluation. The average number of apneas and hypopneas per hour of sleep, ie, Apnea–Hypopnea Index (AHI), was used to define the severity of sleep apnea. All patients underwent polysomnography (PSG) within 24 h of the last HD and after three months of living-donor transplant.
Of 18 patients, there were 14 males and four females. The median age was 28 years (range 19–50 years). They had already spent a median period of six months (range 3–31 months) on HD before inclusion. The prevalence of SDB (AHI ≥ 5/h) was 44.4% (8/18) before transplant, which decreased to 5.6% (1/18) after transplant (p = 0.016). The oxygen desaturation index had a median value of 5.8 events/h (range 0.1–35.4) in the pretransplant stage, which decreased to 0 events/h (range 0–6.6) in the post-transplant stage (p = 0.035).
There was a significant improvement in the prevalence and severity of SDB after transplant. Whether improvement in SDB is sustained on a long-term follow-up remains to be seen.
Cardiovascular Disease and Renal Transplantation
2017, Kidney Transplantation, Bioengineering, and Regeneration: Kidney Transplantation in the Regenerative Medicine Era
Cardiovascular and renal diseases frequently coexist, not surprisingly since several of the factors that predispose someone to cardiovascular disease (CVD) also may lead to chronic kidney disease (CKD). Multiple clinical studies have documented that CVD is responsible for significant morbidity and mortality during and after renal transplantation. The process of identifying those patients at high risk for CVD complications during renal transplantation has also been a subject of intense study, and at times controversy. Once transplanted, the transplant recipient receives an array of immunosuppressants designed to impede rejection. Interestingly, in addition to their beneficial effects, these drugs may also aggravate hypertension, and accelerate atherosclerosis. In the posttransplant patient, aggressive risk factor modification and optimal therapy for all comorbidities and for coronary artery disease should be pursued in all patients. CVD including myocardial ischemia, congestive heart failure, cerebrovascular disease, and atrial fibrillation are common and should be treated per standard guidelines, recognizing the need for immunosuppression therapy. With appropriate evaluation and management the renal transplant patient can live a healthy and productive life with a modest risk of a serious CVD complication.
Energy expenditure, spontaneous physical activity and with weight gain in kidney transplant recipients
2015, Clinical Nutrition
Alterations in energy metabolism could trigger weight gain after renal transplantation.
Nineteen transplanted non-diabetic men, 53 ± 1.6 years old, receiving calcineurin inhibitors but no corticosteroids were studied. They were compared with nine healthy men matched for height, age and lean body mass. Daily energy expenditure and its components (sleeping, basal and absorptive metabolic rates) were analyzed for 24 h in calorimetric chambers and for 4 days in free living conditions using calibrated accelerometry. Other variables known to influence energy expenditure were assessed: body composition, physical activity, 4-day food intake, drug consumption, serum C-reactive protein, interleukin-6, thyroid and parathyroid hormones, and epinephrine. Transplant recipients who gained more than 5% body weight after transplantation (n = 11, +11.0 ± 1.5 kg) were compared with those who did not (n = 8) and with the controls.
Weight gain compared with non-weight gain patients and controls exhibited higher fat mass without change in lean body mass. Daily, sleeping and resting energy expenditure adjusted for lean body mass was significantly higher in non-weight gain (167.1 ± 4.2 kJ/kg/lean body mass/24 h, P < 0.05) compared with weight gain patients (147.4 ± 3.6) and controls (146.1 ± 4.6). Weight gain compared with controls and non-weight gain subjects had lower free living physical activity and a higher consumption of antihypertensive drugs and β-blockers.
After kidney transplantation, weight gain patients were characterized by lower adjusted energy expenditure, reduced spontaneous physical activity but a more sedentary life style and a trend toward a higher energy intake explaining the reason they gained weight. The nWG KTR had increased resting and sleeping EE which protected them from weight gain. Such hypermetabolism was also observed in 24-h EE measurements. By comparison with the nWG patients, the WG transplant recipients were characterized by higher β-blocker consumption. These data could be helpful in the prevention of weight gain in kidney transplant recipients.
Post-transplantation weight gain: Prevalence and the impact of steroid-free therapy
2014, Transplantation Proceedings
Weight gain after renal transplantation has a multifactorial etiology, which can be associated with complications such as hypertension, dyslipidemia and diabetes, with a probable impact on cardiovascular morbidity and mortality post-transplantation.
The objectives of this study were to investigate the prevalence of weight gain and obesity post-transplantation among renal recipients of a hospital and to evaluate the impact of immunosuppressive therapy without steroids.
We have evaluated all patients who had kidney transplantations performed between January 2005 and December 2009 at General Hospital of Fortaleza, who were older than 18 years of age and had at least 12 months of follow-up post-transplantation. Overweight was defined as body mass index (BMI) between 25 and 30 kg/m² and obesity >30 kg/m². The association between weight gain and the following variables was investigated: age and gender of the recipient and the donor, donor type, steroid use, presence of systemic arterial hypertension (SAH) and diabetes mellitus, creatinine, glucose, cholesterol, and triglycerides.
The study population included 203 recipients; 59.5% were males, their mean age systemic arterial hypertension (SAH) was 37 years, and 64.2% had deceased donors. In regard to immunosuppression, 41.3% made use of steroids. After 36 months of follow-up, the average weight gain was 6.6 kg in relation to the first month post-transplantation. Among the variables studied, the recipient's younger age and female gender, the younger donor, and the creatinine level were associated with greater weight gain after 36 months of transplantation.
The percentage of weight gain was on average 9% after 36 months post-transplantation, although the prevalence of overweight and obesity increased significantly in the same period. The use of steroid therapy had no impact on the percentage of weight gain post-transplantation, and association was observed only between the younger age and the female gender of the recipient, the younger donor age, and the creatinine level with the highest weight gain post-transplantation.

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Applied nutritional investigationPredictors of weight gain and cardiovascular risk in a cohort of racially diverse kidney transplant recipients

Abstract

Introduction

Section snippets

Subjects

Baseline characteristics and transplant outcomes

Discussion

Transplant Proc

Am J Kidney Dis

Transplant Proc

Am J Kidney Dis

Kidney Int

J Ren Nutr

Nutrition

Lancet

Unos Scientific Registry Data

Improved graft survival after renal transplantation in the United States, 1988 to 1996

N Engl J Med

Applied nutritional investigation
Predictors of weight gain and cardiovascular risk in a cohort of racially diverse kidney transplant recipients