PhD Defence 27.01.2017 - Liidia Kiisk

Liidia Kiisk will defend her doctoral thesis titled „Long-term nutritional study: anthropometrical and clinico-laboratory assessments in renal replacement therapy patients after intensive nutritional counselling“ on 27 January 2017 at 14:00.

Location: Ravila 19-1006

Supervisors: Associate Professor emeritus Helje Kaarma; Professor Mai Rosenberg

Opponent: Professor Inga Arūnė Bumblytė (MD, PhD), Lithuanian University of Life Sciences, Kaunas, Lithuania.

Summary: Optimal nutritional evaluation, the use of biochemistry together with anthropometry in clinical practice is of great importance in all chronic kidney disease phases, including the post-transplant period. The gain of body weight often develops after kidney transplantation and influences the long-term outcome. Much research has been carried out in the world studying the body composition of healthy people but there are limited data about the research where these methods together with other clinical parameters have been used for investigating patients with a transplanted kidney. The assessment of body composition in a complex manner, including the anthropometrical, blood biological and nutritional peculiarities of the patients with a transplanted kidney, have not been previously studied in Estonia. According to literature, the main problem after kidney transplantation is the gain of body weight, therefore, we planned to test if intensive nutritional counselling has an effect on a patient’s nutritional habits in preventing the gain of body weight. The general aim of the present study was to analyse the body build and nutritional habits of end-stage chronic kidney disease (CKD) patients. We hypothesised that intense nutritional counselling significantly improves nutritional habits, and, ultimately, the gain of body weight after kidney transplantation will be prevented. The specific aims of the present study were as follows: 1. To analyse anthropometric measurements data of the end-stage CKD patients and to compare the body composition of the dialysis and transplant patients. 2. To test if intensive nutritional counselling has an effect on body composition of kidney transplant male and female patients. 3. To evaluate the effect of intensive nutritional counselling on the changes of anthropometric, biochemical and nutritional parameters of kidney transplant patients after the follow-up and to describe gender-specific associations between the studied parameters. 4. To estimate the long-term effect of intensive nutritional counselling on anthropometrical measures of kidney transplant patients. 5. To evaluate the follow-up changes of the intake of nutrients of kidney transplant patients on the basis of a 3-day menu. Subjects of study and methods: The prospective long-term study was carried out during the years 2003–2005 and 2015 at the Department of Internal Medicine of the University of Tartu. In total, 150 chronic kidney disease patients were studied. The kidney transplant patients had their transplantation at the Transplant Center of the Tartu University Hospital. The first anthropometric study population consisted of 75 consecutive non-diabetic CKD patients (37 males and 38 females) of renal replacement therapy who had agreed to participate in the study and who were treated at the Nephrology Division of the Tartu University Hospital. The participation was voluntary and all patients signed a written informed consent. The transplanted patients’ population was formed from consecutive stable ambulatory non-diabetic kidney transplant patients (12 males at the age of 42.8 ± 16.1 years and 16 females at the age of 47.0 ± 14.9 years) who had agreed to participate in the study and who were monitored by the nephrologists at the Tartu University Hospital. The participation was voluntary and all patients signed a written informed consent. The transplanted patients’ control population was formed from 47 clinically consecutive stable ambulatory non-diabetic kidney transplant patients who had agreed to participate in the study and who were monitored by the nephrologists at the Tartu University Hospital or at the West-Tallinn Central Hospital. The participation was voluntary and all patients signed a written informed consent. All the measurements of 28 kidney transplant patients, including anthropometry, densitometry, biochemistry, the food frequency questionnaire (FFQ) and the 3-days dietary records, were analysed. The data of anthropometry, biochemistry and the 3-days dietary records analyses were performed in patients twice: one and a half years after the first cadaveric kidney transplantation and afterwards, three years after the kidney transplantation during the follow-up. Densitometry was performed in patients once after three years of the transplantation. The preventive nutritional counselling and dietary consultation by a dietitian were carried out for all the kidney transplant patients during one and a half years after the kidney transplantation. The initial data were compared with the results obtained at the end of the study. The last anthropometric measurements ten years after the kidney transplantation were carried out both in the counselled kidney transplant patients and in the control kidney transplant patients. Conclusions: 1. The anthropometrical profile in the studied dialysis and transplant patients was almost similar. No significant differences were found in the studied anthropometrical parameters of the dialysis and kidney transplant patients either in male or female patients’ groups which evidently can be explained by the fact that the transplanted patients were studied shortly after the transplantation. 2. The body composition characteristics indicated the systematic differences between the male and female patients of renal transplantation. After the intense nutritional counselling, the anthropometric measurement changes were in accordance with the increase of body weight after the follow-up which was statistically significant in the studied males but not in females. 3. The effect of intensive nutritional counselling on the changes of biochemical indices revealed the normalization of inflammatory status in most patients, and the studied lipids levels remained within normal reference values. 4. The associations between anthropometric and biochemical parameters were found to be different in male and female patients. In male patients, several anthropometrical parameters were associated with inflammatory parameters but in females with lipids. These associations deserve attention because inflammation and hyperlipidaemia are well-known cardiovascular risk factors. 5. The amount of consumed food (3-day menu indices of macro- and micronutrients) was not associated with the anthropometrical variables of the studied transplant patients which shows that there is no clinical significance of these correlations. 6. Intensive nutritional counselling was effective in the long term: ten years after the kidney transplantation, statistically significant body weight gain was not seen either in males or in females, but on the contrary, it was present in the kidney transplant patients with standard care control. 7. The increased consumption of proteins and carbohydrates after kidney transplantation was found in females but not in males. The consumption of fats was within the normal range. After intensive nutritional counselling, all the values of macronutrients remained within the normal range in accordance with the Estonian nutritional recommendations. We conclude that nutritional counselling and guidance is important and should be offered early and regularly after kidney transplantation to maintain body weight and appropriate nutritional state longitudinally. Post-transplant outcomes will be optimized by a team approach for the comprehensive management of the kidney transplantation recipient combined with vigilant surveillance to detect body weight gain in a timely fashion. However, long-term body weight gain data clearly showed that in our kidney transplant patient population, the patients who received intensive individual dietary counselling had much more educated behaviour in the long-term, thereby preventing body weight gain which is a really well-known risk factor for long-term graft failure as well as for cardiovascular complications and mortality.