Nutritional status and quality of life in HIV positive pre- and post- kidney transplant recipients, from HIV positive donors.
Martin, Claire Juliet.
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Background: Kidney transplantation from a HIV-positive donor to a HIV-positive recipient is now a treatment option available for patients with ESRD. Impairments in nutritional status are common, and increase the risk of adverse clinical and health-related quality of life (HRQOL) outcomes. Therefore Optimising nutritional status is therefore an important adjunct of medical care that begins with a nutritional status assessment. Aim: To describe the nutritional status and HRQOL of HIV-positive kidney transplant recipients from a HIV-positive donor and candidates on the waiting list to receive one. Objectives: To determine nutritional status through the assessment of body composition, bone mineral density (BMD), dietary intake, biochemical indicators and gastrointestinal symptoms (GIS). To determine HRQOL based on the patient’s perception of their health. Methods: The frequency and severity of GIS was determined using a previously validated questionnaire; the gastrointestinal symptom rating scale (GSRS). BMD and body composition were measured by dual-energy x-ray absorptiometry (DEXA). Dietary intake was evaluated using a 24-hour recall. Biochemical indicators of albumin, prealbumin fasting glucose, lipids and serum 25-hydroxyvitamin D [25(OH)D] were analysed. Adiposity and musculature were determined through anthropometric indices of weight, body mass index (BMI), waist circumference (WC) and mid-arm muscle circumference (MAMC). HRQOL was assessed using a validated questionnaire; the Short form-36 (SF-36) and semi-structured interviews. With the exception of DEXA, all other assessments were done at baseline and at six months. Results: The study sample consisted of 76 participants (n=22 transplant recipients, n=54 transplant candidates), who were predominantly black (93.4 %) and male (60.5%), with a mean age of 43.6 ± 8.1 years. The frequency of GIS was high for both groups. Indigestion was a frequent and severe GIS. Amongst transplant candidates, females had significantly higher GSRS severity scores for selected subscales and the overall global mean score (p=0.030) compared to males. Age and duration of treatment correlated with selected subscales in transplant candidates. WC correlated positively with constipation amongst transplant recipients. BMD was assessed in 56 participants. Osteoporosis was more prevalent amongst transplant recipients (20.0%), while osteopenia was more prevalent amongst transplant candidates (27.8%). T-scores strongly correlated with lean mass at the BMD of the spine (r = 0.707, p = 0.007), and moderately with each side of the total hip (r = 0.455, p = 0.007 and r = 0.420, p = 0.007). Serum 25(OH)D vitamin D levels was low for the group as a whole, with a mean of 22.04 ±12.74 ng/ml, and was not related to BMD. There was a significant positive association between dietary calcium and all BMD sites for transplant recipients. In a subset of participants (n = 34), there was a significant positive association between anthropometry and DEXA derived indices of adiposity. These were BMI and percent body fat (%BF) (r = 0.773, p < 0.001), WC and truncal fat (TF) (r = 0.799, p = 0.00) and visceral adipose tissue (VAT) (r = 0.885, p < 0.001). The indicator of muscularity (MAMC) correlated with appendicular lean mass index (ALMI) (r = 0.511, p = 0.011), establishing these anthropometric indices as suitable proxy measures of overall and regional adiposity (including visceral adipose tissue) as well as musculature. The majority of transplant candidates were overweight (38.5%), or had normal BMI (36.5%) At six months, 62.7% had a statistically significant weight loss t (50) = 2.072, p = 0.043). Metabolic syndrome (MetS) was present in 47.5% and 51.0% of candidates at baseline and six months respectively. The mean daily energy and protein intake were below recommendations for dialysis. The majority of transplant recipients had a normal BMI (71.4%). At six months, 52.4% showed a weight gain trend and a significant increase in WC (t (14) = -2.861, p 0.013). MetS was present in about 35% of transplant recipients. At baseline, weight correlated with total protein (r = 0.609, p = 0.003), animal (r = 0.513, p = 0.017) and plant protein (r = 0.534, p = 0.013) intake. At six months, WC correlated with animal protein (r = 0.517, p = 0.028) intake. 68 patients completed the SF-36 at baseline and 6 months. Transplant candidates had lower HRQOL than recipients. The main mental stressors were income, employment and waiting for a donor. Physical health complaints were body pain and fatigue. In transplant recipients, the composite physical and mental scores were above the average for the general population. Prealbumin, BMI, albumin and MAMC showed positive correlations with selected SF-36 domains. Conclusion: A series of studies showed altered nutritional status and HRQOL in a substantial proportion of transplant candidates and some transplant recipients. These results can be used to improve nutritional status and hence optimise graft and patient outcomes.