Nutrition/electrolyte after renal transplantation
1.Nutrition after renal transplantation#
- Within 4-6W
- 此時期目標是避免protein hypercatabolism, 促進傷口癒合, 避免dehydration/electrolyte imbalance
- Protein 1.3-1.5g/kg/d(for post-OP hypercatabolism)
- Calorie 30-35kcal/kg/d(for post-OP hypercatabolism)(fat:30-35%; Carbohydrate:50%)
- 考慮補充Zinc
- 避免生食, 加強洗手, 因為此時用高劑量immunosuppressions
- 須小心diuretic phase, tubular dysfunction, CNI/MMF/mTORi, still high iPTH導致的electrolyte imbalance
- 容易hypophosphatemia(due to DC vitamin D, still high iPTH, still high FGF 23, tubular phosphated wasting, mTORi use), hypomagnesium(CNI, MMF, diuretic phase...); 術後1W內容易hypocalcemia(tubular dysfunction? high dosage steroid? previous PTX? DC Ca片 and DC vitamin D?), 之後若仍high iPTH可能hypercalcemia；Cruzado RCT(J Am Soc Nephrol 2016; PMID 26647424)：次全副甲狀腺切除(PTX)相較 cinacalcet 控制移植後持續高血鈣更佳(12個月正常血鈣率 100% vs 67%)且增加骨密度〔PMID 26647424〕
"Subtotal parathyroidectomy was superior to cinacalcet for controlling persistent hypercalcemia in kidney transplant recipients (normocalcemia at 12 months, 100% vs. 67%; P<0.001) and was associated with significant improvement in bone mineral density." (Cruzado JM, et al. PMID 26647424)
- 容易hypophosphatemia(due to DC vitamin D, still high iPTH, still high FGF 23, tubular phosphated wasting, mTORi use), hypomagnesium(CNI, MMF, diuretic phase...); 術後1W內容易hypocalcemia(tubular dysfunction? high dosage steroid? previous PTX? DC Ca片 and DC vitamin D?), 之後若仍high iPTH可能hypercalcemia；Cruzado RCT(J Am Soc Nephrol 2016; PMID 26647424)：次全副甲狀腺切除(PTX)相較 cinacalcet 控制移植後持續高血鈣更佳(12個月正常血鈣率 100% vs 67%)且增加骨密度〔PMID 26647424〕
- For hypophosphatemia
- 大多Pts 1年內phosphate level normalized
- 除非P<1-1.5mg/dL或S/S(+)不然不太需要補
- Post-OP >4-6W
- 此時期目標是避免三高, 維持ideal BW
- 見-For PTDM(post-transplantation diabetes mellitus)
- 需routine screen DM
- 考慮low GI foods；SGLT2i(empagliflozin RCT, Diabetes Care 2019; PMID 30862658)：用於 PTDM 受者安全降糖且減重(-2.5 kg)，未改變 eGFR 或 CNI 濃度〔PMID 30862658〕
"Empagliflozin safely reduced HbA1c and body weight (-2.5 kg) in kidney transplant recipients with posttransplantation diabetes mellitus (PTDM), without adversely affecting eGFR or tacrolimus trough levels." (Halden TAS, et al. PMID 30862658)
- 見-For PTDM(post-transplantation diabetes mellitus)
- 此時期目標是避免三高, 維持ideal BW
- Protein:0.8g/kg/d(KDOQI 2020 營養指引: 穩定維持期受者建議 0.6-0.8 g/kg/d〔PMID 32829751〕)
- Calorie:25-30kcal/kg/d(fat<30%; saturated fat <10% of calorie)(可以建議fat from PUFA 10-15% of calorie and MUFA >=10% of calorie); carbohydrate:50%)
- Calorie比一般RRT Pts低?
- 註一般CKD diet如下(感覺差不多)
- Total calories from fat約25-35%; 多<1g/kg/d
- Total calories from saturated fat <7%; from monounsaturated fat ≤20%, from polyunsaturated fat ≤10%
- Cholesterol <200mg/day
- Omega-3 PUFA, DHA, EPA
- Electrolytes
- Non-AG metabolic acidosis(due to CNI, Baktar, hyperparathyroidism, rejection…)
- 小心hyperkalemia(due to PTDM, β-blockers, metabolic acidosis, poor graft function, ACEI/ARB, CNI(主因;due to ↓renin, ↑aldosterone resistance, ↑NCC), Baktar)
- 仍可hypophosphatemia(見上述；殘存 HPT、vitamin D 缺乏、sirolimus 等)
- Hypomagnesium(CNI related)
- Both
- Fiber:20-30g/d
- 其餘和CKD類似(見CKD Tx-diet), 不過Mg記得有用CNI要補充
- 食物-藥物交互作用(必考)
- 葡萄柚/柚類(pomelo、grapefruit；clementine 亦有類似作用): 抑制腸道 CYP3A4/P-gp → CNI(CsA>FK506)、sirolimus/everolimus 濃度↑(可致 over-exposure) → 移植後應避免〔PMID 27890698〕（【臺灣專科高頻考點】：中秋節文旦柚子 Pomelo 具相同強烈抑制 CYP3A4 機制，易致 CNI 嚴重過量蓄積與急性腎毒性，受者嚴格禁食）
- 聖約翰草(St. John's wort): 誘導 CYP3A4/P-gp → CNI/mTORi 濃度↓↓(排斥風險) → 禁用
- 其他 CYP3A4 抑制: azole 類抗黴菌(ketoconazole/itraconazole)、部分巨環類(erythromycin/clarithromycin)、diltiazem/verapamil → 需減量並監測 trough
- 高鉀食物注意(尤其合用 ACEI/ARB/Baktar); 酒精: 肝毒性/干擾血糖, 建議限制
- 生食/未滅菌乳酪(Listeria、Salmonella、Toxoplasma): 術後早期與加強免疫抑制期間嚴格禁止
