A Narrative Review of Dietary Approaches for Kidney Transplant Patients

Laura Goldfarb Cyrino, Jennie Galpern, Lori Moore, Lea Borgi, Leonardo V Riella, Laura Goldfarb Cyrino, Jennie Galpern, Lori Moore, Lea Borgi, Leonardo V Riella

Abstract

A healthy eating pattern has proven to lower the risk of metabolic and cardiovascular diseases. However, there are sparse dietary recommendations for kidney transplant recipients, and the ones available focus only on single nutrients intake, such as sodium, potassium, and proteins, and not on the overall eating pattern. Considering that individuals do not typically consume nutrients in isolation, but as part of a complete dietary pattern, it is challenging for the average transplanted patient to understand and implement specific dietary recommendations. Also, single-nutrient interventions demonstrate largely inconclusive effects, and it seems improbable that they could have a strong enough impact on transplant outcomes. Dietary trends such as plant-based diets, intermittent fasting, low-carb diet/keto-diet, and juicing, have gained major attention from the media. Herein, we review the potential risks and benefits of these diets in kidney transplant recipients and provide an updated dietary recommendation for this population with consideration of current nutritional trends. Overall, the Mediterranean and DASH diets have demonstrated to be the most beneficial dietary patterns to the post kidney transplant population by focusing on less meat and processed foods, while increasing the intake of fresh foods and plant-based choices. We believe that to maintain a healthy lifestyle posttransplant, patients should be educated about the scientific evidence of different diets and choose a dietary pattern that is sustainable long-term.

Keywords: dietary patterns; intermittent fasting; ketogenic diets; kidney transplantation; nutrition trends; plant-based diets.

© 2021 International Society of Nephrology. Published by Elsevier Inc.

Figures

Figure 1
Figure 1
Kidney recipient’s balanced plate. Illustration depicting recommendations and balanced plate visuals for kidney transplant recipients.

References

    1. Orlich M.J., Singh P.N., Sabaté J. Vegetarian dietary patterns and mortality in Adventist Health Study 2. JAMA Intern Med. 2013;173:1230–1238.
    1. What is a plant-based diet , and is it good for your kidneys ? National Kidney Foundation Web site. Updated August 18, 2018. Available at:
    1. van Westing A.C., Küpers L.K., Geleijnse J.M. Diet and kidney function: a literature review. Curr Hypertens Rep. 2020;22:1–9.
    1. Clegg D.J., Gallant K.M.H. Plant-based diets in CKD. Clin J Am Soc Nephrol. 2019;14:141–143.
    1. Wai S.N., Kelly J.T., Johnson D.W., Campbell K.L. Dietary patterns and clinical outcomes in chronic kidney disease: The CKD.QLD Nutrition Study. J Ren Nutr. 2017;27:175–182.
    1. Nettleton J.A., Steffen L.M., Palmas W. Associations between microalbuminuria and animal foods, plant foods, and dietary patterns in the Multiethnic Study of Atherosclerosis. Am J Clin Nutr. 2008;87:1825–1836.
    1. Banerjee T., Crews D.C., Wesson D.E. High dietary acid load predicts ESRD among adults with CKD. J Am Soc Nephrol. 2015;26:1693–1700.
    1. Gutiérrez O.M., Muntner P., Rizk D.V. Dietary patterns and risk of death and progression to ESRD in individuals with CKD: a cohort study. Am J Kidney Dis. 2014;64:204–213.
    1. Kim H., Caulfield L.E., Garcia-Larsen V. Plant-based diets and incident CKD and kidney function. Clin J Am Soc Nephrol. 2019;14:682–691.
    1. Stamler J. Toward a modern Mediterranean diet for the 21st century. Nutr Metab Cardiovasc Dis. 2013;23:1159–1162.
    1. Sofi F., Abbate R., Gensini G.F., Casini A. Accruing evidence on benefits of adherence to the Mediterranean diet on health : an updated systematic review and meta-analysis. Am J Clin Nutr. 2010;92:1189–1196.
    1. Gomes-Neto A.W., Osté M.C.J., Sotomayor C.G. Mediterranean style diet and kidney function loss in kidney transplant recipients. Clin J Am Soc Nephrol. 2020;15:238–246.
    1. Bach K.E., Kelly J.T., Campbell K.L. Healthy dietary patterns and incidence of CKD: A meta-analysis of cohort studies. Clin J Am Soc Nephrol. 2019;14:1441–1449.
    1. Chauveau P., Aparicio M., Bellizzi V. Mediterranean diet as the diet of choice for patients with chronic kidney disease. Nephrol Dial Transplant. 2018;33:725–735.
    1. Khatri M., Moon Y.P., Scarmeas N. The association between a mediterranean-style diet and kidney function in the northern manhattan study cohort. Clin J Am Soc Nephrol. 2014;9:1868–1875.
    1. Stachowska E., Wesołowska T., Olszewska M. Elements of Mediterranean diet improve oxidative status in blood of kidney graft recipients. Br J Nutr. 2005;93:345–352.
    1. Schwingshackl L., Hoffmann G. Mediterranean dietary pattern, inflammation and endothelial function: a systematic review and meta-analysis of intervention trials. Nutr Metab Cardiovasc Dis. 2014;24:929–939.
    1. Minelli P., Montinari M.R. The Mediterranean diet and cardioprotection: historical overview and current research. J Multidiscip Healthc. 2019;12:805–815.
    1. Martínez-González M.A., Gea A., Ruiz-Canela M. The Mediterranean diet and cardiovascular health. Circ Res. 2019;124:779–798.
    1. U.S. Department of Agriculture. Agricultural Research Service Nutrient intakes from food and beverages: mean amounts consumed per individual, by gender and age, what we eat in America, NHANES 2013–2014. Available at:
    1. Slavin J. Dietary guidelines. Nutr Today. 2012;47:245–251.
    1. U.S. Department of Health and Human Services and U.S. Department of Agriculture 2015–2020 Dietary Guidelines for Americans. 8th Edition. Published December 2015. Available at:
    1. Safa K., Ohori S., Borges T.J. Salt accelerates allograft rejection through serum- and glucocorticoid-regulated kinase-1-dependent inhibition of regulatory T cells. J Am Soc Nephrol. 2015;26:2341–2347.
    1. Siervo M., Lara J., Chowdhury S. Effects of the Dietary Approach to Stop Hypertension (DASH) diet on cardiovascular risk factors: a systematic review and meta-analysis. Br J Nutr. 2015;113:1–15.
    1. Appel L.J., Moore T.J., Obarzanek E. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med. 1997;336:1117–1124.
    1. Hollenberg N.K. Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (DASH) diet: Editor’s comments. Curr Hypertens Rep. 2001;3:373.
    1. Weir M.R., Burgess E.D., Cooper J.E. Assessment and management of hypertension in transplant patients. J Am Soc Nephrol. 2015;26:1248–1260.
    1. Osté M.C.J., Gomes-Neto A.W., Corpeleijn E. Dietary Approach to Stop Hypertension (DASH) diet and risk of renal function decline and all-cause mortality in renal transplant recipients. Am J Transplant. 2018;18:2523–2533.
    1. Lew Q.L.J., Jafar T.H., Koh H.W.L. Red meat intake and risk of ESRD. J Am Soc Nephrol. 2017;28:304–312.
    1. Haring B., Selvin E., Liang M. Dietary protein sources and risk for incident chronic kidney disease: results from the Atherosclerosis Risk in Communities (ARIC) Study. J Ren Nutr. 2017;27:233–242.
    1. Brunori G., Viola B.F., Parrinello G. Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly: a prospective randomized multicenter controlled study. Am J Kidney Dis. 2007;49:569–580.
    1. Chen X., Wei G., Jalili T. The associations of plant protein intake with all-cause mortality in CKD. Am J Kidney Dis. 2016;67:423–430.
    1. Wiwanitkit V. Renal function parameters of Thai vegans compared with non-vegans. Ren Fail. 2007;29:219–220.
    1. Plant-Based Diet or Vegetarian Diet – What is the Difference? | National Kidney Foundation Web site. Available at:
    1. Kalantar-Zadeh K., Moore L.W. Does kidney longevity mean healthy vegan food and less meat or is any low-protein diet good enough? J Ren Nutr. 2019;29:79–81.
    1. Kalantar-Zadeh K., Fouque D. Nutritional management of chronic kidney disease. N Engl J Med. 2017;377:1765–1776.
    1. Baragetti I., De Simone I., Biazzi C. The low-protein diet for chronic kidney disease: 8 years of clinical experience in a nephrology ward. Clin Kidney J. 2019;13:253–260.
    1. Hahn D., Hodson E.M., Fouque D. Low protein diets for non-diabetic adults with chronic kidney disease. Cochrane Database Syst Rev. 2018;10:CD001892.
    1. Jhee J.H., Kee Y.K., Park S. High-protein diet with renal hyperfiltration is associated with rapid decline rate of renal function: a community-based prospective cohort study. Nephrol Dial Transplant. 2020;35:98–106.
    1. Lin J., Hu F.B., Curhan G.C. Associations of diet with albuminuria and kidney function decline. Clin J Am Soc Nephrol. 2010;5:836–843.
    1. Rodrigues Neto Angéloco L., Arces de Souza G.C., Almeida Romão E., Garcia Chiarello P. Alkaline diet and metabolic acidosis: practical approaches to the nutritional management of chronic kidney disease. J Ren Nutr. 2018;28:215–220.
    1. Parpia A.S., L'Abbé M., Goldstein M. The impact of additives on the phosphorus, potassium, and sodium content of commonly consumed meat, poultry, and fish products among patients with chronic kidney disease. J Ren Nutr. 2018;28:83–90.
    1. Jeon H.J., Kim Y.C., Park S. Association of serum phosphorus concentration with mortality and graft failure among kidney transplant recipients. Clin J Am Soc Nephrol. 2017;12:653–662.
    1. Van Londen M., Aarts B.M., Deetman P.E. Post-transplant hypophosphatemia and the risk of death-censored graft failure and mortality after kidney transplantation. Clin J Am Soc Nephrol. 2017;12:1301–1310.
    1. Connolly G.M., Cunningham R., McNamee P.T. Elevated serum phosphate predicts mortality in renal transplant recipients. Transplantation. 2009;87:1040–1044.
    1. Stevens K.K., Morgan I.R., Patel R.K. Serum phosphate and outcome at one year after deceased donor renal transplantation. Clin Transplant. 2011;25:E199–E204.
    1. Moe S.M., Zidehsarai M.P., Chambers M.A. Vegetarian compared with meat dietary protein source and phosphorus homeostasis in chronic kidney disease. Clin J Am Soc Nephrol. 2011;6:257–264.
    1. St-Jules D.E., Goldfarb D.S., Sevick M.A. Nutrient non-equivalence: does restricting high-potassium plant foods help to prevent hyperkalemia in hemodialysis patients? J Ren Nutr. 2016;26:282–287. [published correction appears in J Ren Nutr. 2016 Nov;26(6):416]
    1. Noori N., Kalantar-Zadeh K., Kovesdy C.P. Dietary potassium intake and mortality in long-term hemodialysis patients. Am J Kidney Dis. 2010;56:338–347.
    1. Black A.P., Anjos J.S., Cardozo L. Does low-protein diet influence the uremic toxin serum levels from the gut microbiota in nondialysis chronic kidney disease patients? J Ren Nutr. 2018;28:208–214.
    1. Recommended Daily Intake Fiber Web site. Updated January 23, 2017. Available at:
    1. Camerotto C., Cupisti A., D’Alessandro C. Dietary fiber and gut microbiota in renal diets. Nutrients. 2019;11:1–15.
    1. Demirci B.G., Tutal E., Eminsoy I.O. Dietary fiber intake: its relation with glycation end products and arterial stiffness in end-stage renal disease patients. J Ren Nutr. 2019;29:136–142.
    1. Chauveau P., Combe C., Fouque D., Aparicio M. Vegetarianism: advantages and drawbacks in patients with chronic kidney diseases. J Ren Nutr. 2013;23:399–405.
    1. Joshi S., Shah S., Kalantar-Zadeh K. Adequacy of plant-based proteins in chronic kidney disease. J Ren Nutr. 2019;29:112–117.
    1. Nolte Fong J.V., Moore L.W. Nutrition trends in kidney transplant recipients: the importance of dietary monitoring and need for evidence-based recommendations. Front Med. 2018;5:302.
    1. De Cabo R., Mattson M.P. Effects of intermittent fasting on health, aging, and disease. N Engl J Med. 2019;381:2541–2551.
    1. Harvie M., Howell A. Potential benefits and harms of intermittent energy restriction and intermittent fasting amongst obese, overweight and normal weight subjects-A narrative review of human and animal evidence. Behav Sci (Basel) 2017;7:4.
    1. Hatori M., Vollmers C., Zarrinpar A. Time-restricted feeding without reducing caloric intake prevents metabolic diseases in mice fed a high-fat diet. Cell Metab. 2012;15:848–860.
    1. Chaix A., Zarrinpar A., Miu P., Panda S. Time-restricted feeding is a preventative and therapeutic intervention against diverse nutritional challenges. Cell Metab. 2014;20:991–1005.
    1. Chaix A., Lin T., Le H.D. Time-restricted feeding prevents obesity and metabolic syndrome in mice lacking a circadian clock. Cell Metab. 2019;29:303–319.e4.
    1. Willcox D.C., Willcox B.J., Todoriki H. Caloric restriction and human longevity: What can we learn from the Okinawans? Biogerontology. 2006;7:173–177.
    1. Furmli S., Elmasry R., Ramos M., Fung J. Therapeutic use of intermittent fasting for people with type 2 diabetes as an alternative to insulin. BMJ Case Rep. 2018;2018:2017221854.
    1. Kossoff E.H., Zupec-Kania B.A., Auvin S. Optimal clinical management of children receiving dietary therapies for epilepsy: updated recommendations of the International Ketogenic Diet Study Group. Epilepsia Open. 2018;3:175–192.
    1. Qurashi S., Tamimi A., Jaradat M., Al Sayyari A. Effect of fasting for Ramadan on kidney graft function during the hottest month of the year (August) in Riyadh, Saudi Arabia. Exp Clin Transplant. 2012;10:551–553.
    1. Ghalib M., Qureshi J., Tamim H. Does repeated Ramadan fasting adversely affect kidney function in renal transplant patients? Transplantation. 2008;85:141–144.
    1. Ketogenic diet. Epilepsy Society Web site. Updated April 2019. Available at:
    1. Kosinski C., Jornayvaz F.R. Effects of ketogenic diets on cardiovascular risk factors: evidence from animal and human studies. Nutrients. 2017;9:1–16.
    1. Torres J.A., Kruger S.L., Broderick C. Ketosis ameliorates renal cyst growth in polycystic kidney disease. Cell Metab. 2019;30:1007–1023.e5.
    1. Oyabu C., Hashimoto Y., Fukuda T. Impact of low-carbohydrate diet on renal function: a meta-analysis of over 1000 individuals from nine randomised controlled trials. Br J Nutr. 2016;116:632–638.
    1. Juraschek S.P., Chang A.R., Appel L.J. Effect of glycemic index and carbohydrate intake on kidney function in healthy adults. BMC Nephrol. 2016;17:70.
    1. Tay J., Thompson C.H., Luscombe-Marsh N.D. Long-term effects of a very low carbohydrate compared with a high carbohydrate diet on renal function in individuals with type 2 diabetes: a randomized trial. Medicine (Baltimore) 2015;94
    1. Ellenbroek J.H., van Dijck L., Töns H.A. Long-term ketogenic diet causes glucose intolerance and reduced β- and α-cell mass but no weight loss in mice. Am J Physiol Endocrinol Metab. 2014;306:E552–E558.
    1. Seidelmann S.B., Claggett B., Cheng S. Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis. Lancet Public Health. 2018;3:e419–e428.
    1. Bravata D.M., Sanders L., Huang J. Efficacy and safety of low-carbohydrate diets: a systematic review. JAMA. 2003;289:1837–1850.
    1. Ludwig D.S., Hu F.B., Tappy L., Brand-Miller J. Dietary carbohydrates: role of quality and quantity in chronic disease. BMJ. 2018;361:k2340.
    1. Reynolds A., Mann J., Cummings J. Carbohydrate quality and human health: a series of systematic reviews and meta-analyses. Lancet. 2019;393:434–445. [published correction appears in Lancet. 2019 Feb 2;393(10170):406]
    1. Giugliano D., Maiorino M.I., Bellastella G., Esposito K. More sugar? No, thank you! The elusive nature of low carbohydrate diets. Endocrine. 2018;61:383–387.
    1. Sharif A., Moore R., Baboolal K. Influence of lifestyle modification in renal transplant recipients with postprandial hyperglycemia. Transplantation. 2008;85:353–358.
    1. Wissing K.M., Pipeleers L. Obesity, metabolic syndrome and diabetes mellitus after renal transplantation: prevention and treatment. Transplant Rev. 2014;28:37–46.
    1. What is a juice diet? BBC Good Food Web site. Available at:
    1. U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. MyPlate Dairy Group. Nutrients and health benefits. . Published 2015. Available at:
    1. Abuajah C.I., Ogbonna A.C., Osuji C.M. Functional components and medicinal properties of food: a review. J Food Sci Technol. 2015;52:2522–2529.
    1. Yahfoufi N., Alsadi N., Jambi M., Matar C. The immunomodulatory and anti-inflammatory role of polyphenols. Nutrients. 2018;10:1–23.
    1. Hussain T., Tan B., Yin Y. Oxidative stress and inflammation: what polyphenols can do for us? Oxid Med Cell Longev. 2016;2016:7432797.
    1. Simpson H.L., Campbell B.J. Review article: Dietary fibre-microbiota interactions. Aliment Pharmacol Ther. 2015;42:158–179.
    1. Henning S.M., Yang J., Shao P. Health benefit of vegetable/fruit juice-based diet: Role of microbiome. Sci Rep. 2017;7:2167.
    1. Tomé-Carneiro J., Visioli F. Polyphenol-based nutraceuticals for the prevention and treatment of cardiovascular disease: Review of human evidence. Phytomedicine. 2016;23:1145–1174.
    1. Paul B., Barnes S., Demark-Wahnefried W. Influences of diet and the gut microbiome on epigenetic modulation in cancer and other diseases. Clin Epigenetics. 2015;7:112.
    1. Muscogiuri G., Cantone E., Cassarano S. Gut microbiota: a new path to treat obesity. Int J Obes Suppl. 2019;9:10–19.
    1. Castaner O., Goday A., Park Y.M. The gut microbiome profile in obesity: a systematic review. Int J Endocrinol. 2018;2018:4095789.
    1. Kvit K.B., Kharchenko N.V. Gut microbiota changes as a risk factor for obesity. Wiad Lek. 2017;70:231–235.
    1. Wu H., Singer J., Kwan T.K. Gut microbial metabolites induce donor-specific tolerance of kidney allografts through induction of T regulatory cells by short-chain fatty acids. J Am Soc Nephrol. 2020;31:1445–1461.
    1. Alegre M.-L. Can diet induce transplantation tolerance? J Am Soc Nephrol. 2020;31:1417–1418.
    1. Centers for Disease Control and Prevention Only 1 in 10 adults get enough fruits or vegetables. . Updated November 16, 2017. Available at:
    1. Lee-Kwan S.H., Moore L.V., Blanck H.M. Disparities in state-specific adult fruit and vegetable consumption — United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66:1241–1247.
    1. U.S. Department of Agriculture, Center for Nutrition Policy and Promotion All about the fruit group. . Published 2015. Available at:
    1. U.S. Department of Agriculture, Center for Nutrition Policy and Promotion All about the vegetable group. . Published 2015. Available at:
    1. Sepulveda M., Pirozzolo I., Alegre M.L. Impact of the microbiota on solid organ transplant rejection. Curr Opin Organ Transplant. 2019;24:679–686.
    1. A-344 - Influence of the Gut Microbiota on Acute Rejection of Vascular Allografts (ID 291) - 2020 American Transplant Congress. Available at:
    1. The gut microbiota stimulates dendritic cells for immune modulation - ATC Abstracts. Available at:
    1. Changes in gut microbiota and acute rejection after kidney transplantation - ATC Abstracts. Available at:
    1. Specific gut microbiota community suppresses acute rejection by reducing natural killer cell population - ATC Abstracts. Available at:
    1. Microbiota modulates ischemia-reperfusion injury in mouse liver transplantation - ATC Abstracts. Available at:
    1. Ulerich L. To juice or not to juice? National Kidney Foundation Web site. Published October 12, 2018. Available at:
    1. Lien Y.H.H. Juicing is not all juicy. Am J Med. 2013;126:755–756.
    1. Getting J.E., Gregoire J.R., Phul A., Kasten M.J. Oxalate nephropathy due to “juicing”: case report and review. Am J Med. 2013;126:768–772.
    1. Auten A.A., Beauchamp L.N., Taylor J. Hidden sources of grapefruit in beverages: potential interactions with immunosuppressant medications. Hosp Pharm. 2013;48:489–493.

Source: PubMed

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