Kidney transplantation is the most preferred treatment for end-stage kidney disease, and a successful transplantation generally leads to improvement in nutritional status and fewer dietary restrictions as compared to before transplantation. However, you may still need to make some dietary adjustments to keep your new kidney healthy and functioning well.

Early phase after transplantation

During the early phase after transplantation, your diet plan will focus mainly on recovery:

• It is important to consume adequate calories and protein intake to promote wound healing and prevent muscle wasting.

• Conditions such as low blood phosphorus, either high or low blood potassium and high blood sugar, are common during the early phase of transplantation. Your dietitian will recommend some oral nutrition supplementations to support your recovery.

• It is advisable to avoid foods that may interact with the transplant medications.

• It is also advisable to adopt good food hygiene practices to reduce risk of foodborne illnesses.

Maintenance phase after transplantation

During the maintenance phase after transplantation, you should be able to adopt a normal, balanced and health diet provided there are no other underlying issues or complications. Nevertheless, each patient may face different nutritional challenges depending on medical background, medications taken, eating habits and lifestyle choices.

Aim to adopt healthy eating habits and a healthy lifestyle to prevent nutrition-related side effects from transplant medications, such as high blood sugar, high blood pressure and high blood cholesterol levels. At the same time, consult your transplant team and/or dietitian to develop an individualised diet plan to improve your overall health and quality of life.

References

Immunosuppressants are medicines you will be taking after your transplantation to prevent your body from rejecting your new kidney, and to allow the new kidney to function. Common immunosuppressants include cyclosporine, tacrolimus, steroids and others. However, many of these medications come with side effects, and may affect nutrient utilisation and absorption in your body.

Some common side effects include:

• Increase in blood sugar level

• Increase in blood pressure

• Increase in body cholesterol and triglyceride levels

• Increase in blood potassium level

• Decrease in blood magnesium

• Change of appetite (increased appetite or loss of appetite) that may lead to weight gain, weight fluctuation or weight loss (depending on which medications you are taking)

• Increase in risk of osteoporosis, anemia, sodium and fluid retention, and low immunity.

Hence, it is important to recognise your side effects and adjust your diet and medications to prevent any undesired health outcomes. Consult your transplant team and dietitian for an individualised diet plan.

In addition, here are some tips for achieving a healthy post-transplant diet:

Consume appropriate amounts of carbohydrates, protein and fat.

• A balanced and nutritious diet helps to support a healthy weight and prevent other comorbidities such as high blood pressure, diabetes and high cholesterol level. It can also keep your immunity strong, as well as prevent osteoporosis and body muscle breakdown.

Ensure good food hygiene and avoid raw or undercooked foods

• Transplant medications can affect your immune system and your body’s ability to fight off infections. To reduce the risk of food-borne infections, it is important to practise good food hygiene during food preparation, avoid cross-contamination of raw meat with fresh produce, and ensure that all foods are well-cooked.

Avoid foods that may interact with your transplant medications

• Food and drug interactions may increase the risk of side effects, or reduce the function or effectiveness of your medications. Hence, consult your transplant team and/or dietitian for more information on what food to avoid. Avoid taking any herbal supplements or tonics without first discussing it with your doctor.

References

After a kidney transplant, it is not uncommon for weight gain to occur. This can be attributed to post-transplant immunosuppressant medications that are prescribed to prevent rejection of the newly transplanted kidney, or due to improved appetite and changes in dietary intake since kidney transplant recipients can now eat a wider variety of foods.

It is still important to maintain a healthy weight post-kidney transplant, as being overweight or obese can still put you at risk of chronic diseases such as heart diseases, diabetes mellitus and hypertension, which are known risk factors for kidney disease.

Generally, you should aim to maintain a healthy weight with a BMI of between 18.5 and 24.9kg/m2. Some ways that you can keep your weight in check includes:

• Practicing portion control by following national healthy eating guidelines in your country (e.g. USDA MyPlate, UK’s Eatwell Guide, Singapore’s My Healthy Plate)

• Limiting your intake of refined sugar, especially from drinks and snacks

• Increasing your intake of dietary fibre from fruits, vegetables and wholegrains to promote satiety and prevent overeating

• Limiting your intake of calorie-dense and high-fat foods, such as animal fats and skin, butter, lard, full-fat dairy, deep-fried foods, baked goods (e.g. cakes and pastries), and high-fat or high-sugar snacks (e.g. potato chips, cookies)

• Keeping active through regular exercise

References

Abnormal cholesterol results or dyslipidaemia, is common in post-transplant patients and is a risk factor for cardiovascular disease. There are many factors that can contribute to the development of dyslipidaemia after kidney transplantation, such as:

• Age and gender

• Genetic predispositions

• Liver disease

• Renal insufficiency

• Liberalization of dietary restrictions, including high-cholesterol and fructose diets

• Weight gain and obesity

• Reduced physical activity

• Diabetes

• Hypothyroidism

• Hypertensive medications (e.g beta-blockers, diuretics)

• Smoking

• Lipid levels before transplantation

• Post-transplant medications (immunosuppressive agents)

Lifestyle factors such as diet, physical activity and smoking are modifiable factors, in the sense that you can make positive changes to better manage your cholesterol levels post-transplantation.

You can manage your blood cholesterol levels through diet by keeping the calories contributed by fats to less than 30% of your total daily calorie intake. Limit your intake of saturated fats, which can be found in animal fats and skin, butter, lard, full-fat dairy, palm oil, coconut oil or milk/cream. Also, limit your intake of trans fats, which are found mainly in baked goods and deep-fried foods, prepared with oils that are solid at room temperature.

Where possible, replace saturated fats with healthier unsaturated fats instead, such as oily fish (e.g. salmon, tuna, mackerel), nuts, seeds, avocadoes, plant oils (e.g. olive, soybean, sunflower or canola oil). Nutrition guidelines for managing chronic kidney disease also suggest that a Mediterranean Diet in post-transplanted patients (with or without dyslipidemia) may improve lipid profiles.

References

Bones are living tissues, and they are continuously being broken down while new bone cells are produced to replace the old ones. After kidney transplantation, mineral and bone disorders are common. This happens when bone breaks down faster than it can be replaced, causing the bones to become weak and brittle, and hence increase the risk of fracture.

There are many possible reasons for bone loss after kidney transplantation, including:

• Persistently high parathyroid hormone (PTH) – a hormone that helps to maintain the right balanced of calcium in your body

• Low blood phosphorus after kidney transplantation

• Vitamin D deficiency

• Increased calcium in the blood

• Side effects of transplant medications such as steroids

• Impaired physical activity

There are many nutrients that can work together to build and strengthen bones. It is important to consume a healthy diet with sufficient calcium and other nutrients such as protein, phosphorus, magnesium, vitamin K, vitamin C and vitamin D to keep your bones healthy. You are encouraged to include sufficient calcium-rich foods in your diet, including:

• Milk and dairy products

• Soy products, especially fortified soy products such as soy bean, soy milk and tofu

• Fish with edible bones (e.g sardines, salmon)

• Dark and green leady vegetables such as spinach and broccoli

Other ways to maintain healthy bones and prevent bone loss include adequate sun exposure to boost your vitamin D level; regular physical activity to improve muscle strength and agility, helping to reduce the risk of falls and fracture.

References

Manage your weight

Aim to maintain a healthy weight with a BMI of between 18.5 and 24.9kg/m2.

Tips to manage your weight:

• Have balanced meals that include the important food groups such as carbohydrates, protein, vegetables and fruits

• Consider using national guidelines and visual concepts to get an idea of portion control (i.e USDA MyPlate, UK’s Eatwell Guide, Singapore’s My Healthy Plate)

• Choose skinless poultry and lean cuts of meats. Fish can also a be a lower-fat protein source. Depending on your blood potassium/phosphorus levels, your dietitian may advise you on how to include plant-based proteins such as legumes and tofu in your diet

• Use healthier cooking methods that require little to no oil such as blanching, steaming, boiling, baking, roasting or grilling

• Limit deep-frying or consuming deep-fried foods to not more than twice a week

• Skim off oil or fat from stews, soups, gravies or curries

• Use oils and spreads sparingly

• Substitute high-calorie, high-fat and high-sugar snacks with fresh fruits, vegetables, low-fat dairy products (e.g. low-fat yoghurt), wholegrain breads or crackers

• If you are consuming freshly-made desserts when eating out, request for no added or less sugar or syrup

• Reduce the consumption of sugar-sweetened beverages, and replace with unsweetened or low/less-sugar added options (e.g. water, fruit-flavoured water, hot and cold teas)

• Choose low-fat and low-sugar products over regular fat and sugar versions

• Read the Nutrition Information Panel of products to compare the fat and sugar content provided per 100g or 100ml. Always compare between products of the same type of food/drink, to choose the lower-fat and lower-sugar options

Besides managing weight gain, excessive weight loss can also be a concern. If you have unintentional weight loss and/or reduced appetite, speak with your dietitian to ensure you are consuming enough calories to maintain your weight and prevent further weight loss.

• Small, frequent meals may help if you struggle to finish 3 large, main meals

• Fortifying foods can help to increase the calorie and/or protein content of the food, for example adding adding extra amounts of spreads to crackers and sandwiches or eggs to increase the protein content of dishes.

• Oral nutritional supplements may be prescribed by your dietitian to increase your calorie and protein intake

Manage your blood sugar levels if you have diabetes

Tips to manage your blood sugar levels:

• Speak to your dietitian about including wholegrains instead of refined carbohydrates in your diet, especially if you have to be cautious about your dietary potassium/phosphorus intake

• While carbohydrates are an important source of energy for our bodies, excessive amounts can lead to increases in blood sugar levels and weight gain. Hence, it is also important to manage the portions of your carbohydrate foods.

• Aim to include dietary fibre in all your main meals, which can be found in vegetables, fruits, legumes, nuts and seeds. Speak to your dietitian to learn how to incorporate these foods if you are concerned about your potassium and/or phosphorus intake

• Limit your intake of refined sugar, particularly from beverages, snacks and desserts

• Substitute sugar-sweetened beverages with options of less or no sugar added (i.e water, fruit-flavoured water, hot and cold teas)

• Limit the amount of sugar or syrup that you add to your drinks

• Choose unsweetened or low/less-sugar products over regular versions

• If you are going for sugar-free products, it is important to read the ingredient list on the packaging. Look out for potassium-based sweeteners that may be used instead and which might not be suitable if you have been advised potassium restrictions

• Take your medications as prescribed by your doctor

Manage your blood cholesterol levels

Tips to manage your blood cholesterol levels

• Limit your intake of saturated fats which can be found in animal fats and skin, butter, lard, full-fat dairy, palm oil, coconut oil or milk/cream

• Limit your intake of trans fats which can be found in baked goods such as cakes, pastries, biscuits and cookies, deep-fried food prepared with shortening or partially hydrogenated oils

• Replace saturated fats with healthier unsaturated fats such as oily fish (i.e salmon, tuna, mackerel), nuts, seeds, avocadoes, plant oils (i.e olive, soybean, sunflower or canola oil)

• Include dietary fibre from wholegrains, legumes, nuts, seeds, vegetables and fruits in all your meals

• Ask for no or less gravies to be served with your foods

• Choose lower-fat options when eating out, such as clear soups or plain/aglio olio-style instead of cream-based soups or pastas

• Substitute products that are higher in saturated fats with lower-fat alternatives, such as replacing butter with margarine, low-fat/skim or plant-based instead of full cream dairy

• Look out for reduced-fat or lower-fat labels on products

• Read the Nutrition Information Panel to compare the saturated fat and trans fat content per 100g/100ml between products of the same type of food/drink to choose the lower saturated/trans fats option

• Avoid or limit refined sugar and alcohol consumption as these can raise your blood triglyceride levels

• If you have been prescribed cholesterol-lowering medications, take them as prescribed by your doctor

Manage your blood pressure

Tips to manage your sodium intake:

• Limit your sodium intake to less than 2300mg per day

• Plan to have most of your meals home-cooked instead of eating out too frequently

• Use fresh ingredients such as fresh fish, poultry, meat, vegetables, and fruits

• Choose plain frozen fish, meats, poultry or vegetables that are not crumbed or breaded

• Use vegetables, herbs and spices such as pepper, cilantro, mint leaves, turmeric to enhance the aroma and flavours of dishes instead of adding excessive salt

• Make your own soup stocks, broths and gravies using fresh ingredients instead of using commercial stock, canned soups, or instant gravies

• When grocery shopping, look out for labels such as “unsalted”, “no added salt”, “reduced sodium”, “low-sodium”

• Read the Nutrition Information Panel and compare the sodium content between different products (per 100g/100ml) to choose the lower sodium option

• Avoid finishing large portions of soup as these tend to be high in sodium

• Opt to leave out the gravy and sauces or ask for them to be served separately

• Avoid dipping your foods in additional sauces (e.g. soy sauce, Hoisin sauce, ketchup, chilli sauce etc) that are high in sodium

• Have a taste of your food before you add more salt or sauces, as the dish may already be tasty without the need to add more

• When having curries or stews, choose to consume ingredients such as the proteins and/or vegetables and leave the gravy behind

• Opt for dishes prepared with mostly fresh ingredients instead of processed foods such as fish balls, luncheon meat, sausages or preserved items (e.g salted eggs, preserved vegetables, fish etc.)

• If you smoke, quit smoking and aim to keep active and manage stress well

• Take your hypertension medications as prescribed

References

After kidney transplantation, you will be taking medications, known as immunosuppressants, to prevent your immune system from rejecting your new kidney and to allow your new kidney to function. These medications may weaken your body’s immunity, and increase the risk of infections. Hence, you will need to protect yourself from food-borne illnesses by avoiding raw or undercooked foods, and practising good food hygiene during food preparation.

Foods to avoid after a kidney transplant:

• Raw seafood such as clams, oysters, sashimi or sushi

• Raw, rare or undercooked meat, fish and poultry

• Raw or undercooked eggs, or any foods containing raw eggs such as cookie dough

• Unpasteurised milk, cheese and yogurt

• Unwashed raw fruits or vegetables

• Any foods that may be spoiled, mouldy or expired

• Foods from salad bars, fruit bars and buffets as the food may have been exposed for long periods and may thus have been contaminated

It is important to note that some foods may interact with your transplant medications, which could increase the risk of side effects or reduce the effectiveness of your transplant medications. As a result, you will need to avoid some foods and herbal supplements after transplantation. These include:

• Grapefruit and grapefruit juice

• Pomegranate and pomegranate juice

• Other citrus fruit such as pomelo and Seville oranges

• Herbal supplements or tonics (such as ginseng, St.John’s Wort etc)

It is important to talk to your transplant team or dietitian to know more about food to avoid, and never take any herbal supplements or tonic without first discussing with your doctor

Some tips for practising good food hygiene:

• Wash your hands thoroughly with soap before handling food

• Wash all surfaces, cutting boards and cutting utensils thoroughly, with hot soapy water before and after use

• Food should be kept or stored at the correct temperatures to prevent food poisoning. Bacteria in food multiply quickly when the temperature of the food is between 5°C and 60°C, doubling in number in as little as 20 minutes. This is known as the Temperature Danger Zone, and food kept within this temperature range for more than 2 hours is at risk of spoilage, leading to potential food poisoning. To reduce the risk of food poisoning, hot food should be kept hot until ready to be served/eaten, and cold food should be kept cold/chilled until ready to be served/eaten.

• Always cook food, especially protein foods, thoroughly to kill any harmful bacteria

• When cooking meat, including chicken and other poultry, ensure that the meat is cooked thoroughly. Use a food thermometer to check the internal temperature of large cuts of meat, poultry and other dishes when cooking or reheating. Do ensure that the internal temperature of meat reaches at least 75°C.

• When cooking liquid foods such as soup, gravies and sauces, make sure it is brought to a complete boil and thoroughly cooked before serving.

References

After kidney transplantation, your protein requirement will change over time, depending on the time that has passed since your kidney transplantation, and the function of your new kidney.

Early phase after transplantation

In the first 4 to 6 weeks after transplantation, body tissue recovery combined with surgical stress will lead to body protein breakdown. Hence, an adequate protein intake is necessary for quick recovery, wound healing, and to protect against susceptibility to infections. Your target daily protein intake should range from 1.3 to 2 g/kg of body weight. If your appetite is fair and you are not able to meet your protein target through food intake alone, high-protein oral nutrition supplements may be prescribed.

Maintenance phase after transplantation

During the maintenance phase after transplantation, adequate protein intake is still important to maintain good kidney function and overall wellbeing. Your daily protein intake should not differ vastly from that of generally healthy adults. A moderate amount of protein, which consists of 0.6-0.8g protein per kilogram body weight, is often recommended. You are encouraged to include both animal-based and plant-based proteins as part of your well-balanced diet.

Protein can be found in both animal and plant-based sources. Protein content and completeness differ across various foods – foods from animal sources such as meat, poultry, fish and eggs are good sources of complete protein (comprises all essential amino acids), whereas plant-based foods such as vegetables, nuts and seeds are incomplete protein sources (lacking one or more essential amino acids).

Some examples of protein content in commonly consumed foods:

• 1 matchbox-sized portion of chicken, fish, or meat provides 7-10g of protein

• 1 whole egg provides about 8g of protein

• ½ cup of cooked beans or lentils provides 10g of protein

Usually, it is said that 1 matchbox-sized portion of meat (7-10g protein) provides 1 protein exchange. Hence, if your protein requirement is 50g per day, you will require approximately 5-6 protein exchanges per day.

Do consume a variety of protein foods from different sources, to ensure you get a complimentary intake of the different amino acids, especially if you are a vegetarian or prefer to opt for plant-based protein foods.

References

After kidney transplantation, your potassium may go up and down depending on your new kidney function and transplant medications.

Early phase after transplantation

In the early phase after transplantation, high blood potassium (hyperkalemia) is a common problem due to the higher dosage of transplant medications. If this occurs, it will be important to limit your potassium intake until your new kidney is able to filter out the excess potassium and you are on a stable dose of transplant medications. You are encouraged to avoid high potassium foods such as dried fruits, herbal products, banana and potatoes for the first 4 – 6 weeks post-transplantation. If you are unsure which foods may be higher in potassium, refer to these tables. [Link to Table showing potassium content of certain foods]

Maintenance phase after transplantation

During the maintenance phase after transplantation, you should be able to have a normal amount of potassium intake from foods, if your new kidney is functioning well. Your transplant team or dietitian would advise you on how to gradually re-introduce potassium-containing foods into your diet. However, it is important to bear in mind that some transplant medications may affect your blood potassium levels, and that dietary control of potassium may be needed if your blood potassium levels go up or down.

Figuring out potassium

References

After kidney transplantation, low blood phosphorus (hypophosphatemia) is a common problem, especially during the immediate post-transplantation period. Many factors could contribute to the low blood phosphorus level, such as increased level of parathyroid hormone (PTH) activity, hyperabsorption of phosphorus from bones, reduced intestinal absorption of phosphorus, and side effects of transplant medications.

If your blood phosphorus levels are low, you are advised to consume more phosphorus-rich foods such as dairy products; protein-rich foods; nuts, seeds and whole grains to replenish your phosphorus levels. Your transplant team or dietitian may also recommend phosphate supplementation if needed, to prevent complications such as bone and cardiovascular problems.

However, if your blood phosphorus levels fall within the recommended range, dietary control of phosphorus may not be necessary. You are encouraged to eat a healthy and balanced diet, in the recommended amounts or portion sizes.

References

After kidney transplantation, it is still important to control your sodium intake to prevent hypertension and protect your newly transplanted kidney. Excessive sodium intake can increase blood pressure, which in turn may cause damage to the kidneys. Studies have shown that increased blood pressure is associated with increased risk of kidney transplant failure.

On the other hand, well-controlled blood pressure can be beneficial in preventing cardiovascular and renal complications. The recommended amount of sodium intake for post-transplantation should be limited to less than 2300mg per day, to reduce blood pressure and improve volume control.

Furthermore, certain medications that are prescribed post-transplantation can also affect blood pressure. For example, steroid medications impair water and salt excretion through urine, causing your body to retain fluids and thereby increasing blood pressure. Another type of transplant medication known as calcineurin inhibitors (CNI) can cause constriction of blood vessels that increases the resistance in your blood circulatory system and can cause expansion of blood volume

References

Generally, there is no definite recommendation for fluid intake post-kidney transplantation, with different sources suggesting fluid intake of up to 2 to 4 litres per day. Your doctor will be able to advise you on whether you need to restrict fluid intake, and how much fluids you should be consuming per day. Your daily fluid intake would depend on factors such as your fluid requirements for your weight/size, fluid retention and urine output.

Do remember that consuming adequate fluids is also important for preventing dehydration. Water is a practical and reliable way to keep yourself hydrated. It is naturally low in calories, sugar and fats compared to other beverages that are higher in sugar and/or fat. Some ways to help you meet your fluid requirements include:

• Adding fruits (such as strawberries, blueberries, a slice of orange or lemon etc), a squeeze of lime, or mint leaves to plain water to add some flavour

• Choosing water to quench your thirst while having your meals and snacks

• Bringing a water bottle around with you or keeping a cup of water at your desk, to increase your water intake as compared to other types of beverages

• Adding frozen fruit cubes to plain water

• Drinking tea (e.g. green tea, Oolong tea, red tea etc) or fruit teas, prepared from tea bags or loose leaves without adding sugar

References