Outcome Of Dietary Intervention On Kidney Transplant Recipients With Proteinuria/ Chronic Metabolic Acidosis – A Single Cohort Prospective Study

Outcome Of Dietary Intervention On Kidney Transplant Recipients With Proteinuria/ Chronic Metabolic Acidosis – A Single Cohort Prospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Outcome Of Dietary Intervention On Kidney Transplant Recipients With Proteinuria/ Chronic Metabolic Acidosis – A Single Cohort Prospective Study Wai Pooi Lau, Kok Peng Ng, Shubash Shander Ganapathy, Pei Chien Tah, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6266091/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Proteinuria and chronic metabolic acidosis may negatively impact renal allograft survival. This study aims to evaluate dietary intervention in reducing proteinuria and correcting metabolic acidosis among kidney transplant recipients (KTRs). Methods This is a prospective dietary intervention study. KTRs have proteinuria ≥ 0.5g/day or chronic metabolic acidosis with serum bicarbonate ≤ 22 mmol/L for at least 2 readings in past 6 months were recruited. All recruited subjects were given 1-to-1 diet counselling for moderate dietary protein restriction at 0.8 g/ kg of ideal body weight (IBW) and high vegetable and fruit intake by a research Dietitian. All subjects were encouraged to replace animal protein with plant protein. The duration of the study was 3 months. Changes in proteinuria and serum bicarbonate levels pre and post dietary interventions were analyzed. Result 30 KTRs (26 with proteinuria and 4 with chronic metabolic acidosis) were enrolled and completed the intervention phase. Proteinuria reduced significantly post-1-month after the intervention (z=-2.643, p = 0.008) in alignment with a significant reduction in dietary protein (z=-2.376, p = 0.018) and dietary acid load (z=-2.149, p = 0.032). However, this effect was not sustainable when the dietary protein intake increased at 3 months. Significant weight reduction was observed post-1-month (z=-3.379, p = 0.001) and 3-months (z=-3.503, p < 0.001) after dietary intervention. There were no statistically significant changes in serum bicarbonate post intervention. Conclusion Our study shows that dietary intervention can induce a change in dietary pattern thus inducing reduction in proteinuria and body weight. Hence, dietary counseling should be part of the multi-prong approach in managing KTRs. proteinuria chronic metabolic acidosis dietary intervention protein restriction dietary acid load Figures Figure 1 Figure 2 Introduction Medical nutrition therapy is an essential part of managing chronic kidney disease (CKD) patients (Ikizler et al., 2020 ). There are well-established specific dietary guidelines for CKD stage 1 to CKD stage 5 requiring dialysis. However, no precise dietary guidelines were found in managing kidney transplant recipients (KTRs) due to lack of validated data in this cohort. Metabolic complications such as diabetes and obesity are highly prevalent among KTRs, which are well known to be detrimental to renal allograft and patient survival (Cohen, Korah, Callender, Belfort de Aguiar, & Haakinson, 2020), thus indicating that medical nutrition therapy in adjunct to pharmacological therapy should play a crucial role in reducing the risk of metabolic related complication. However, this approach is not commonly implemented. The occurrence and course of CKD may be multifactorial, and nutritional factor is known to play a major contributing role in it. It was estimated that more than 24% of CKD cases could be linked to nutritional disorders in developed countries (Wang, Chen, Song, Caballero, & Cheskin, 2008 ). The shift in modern dietary patterns, that is characterized by a high intake of processed food and meat coupled with low vegetable and fruit consumption, has resulted to a higher risk of CKD (H. Kramer, 2017 ). In contrast, diet composition with high vegetable and low meat intake, such as the Mediterranean diet, is shown to be renoprotective (Podadera-Herreros et al., 2022 ) and associated with better kidney function. (Gomes-Neto et al., 2020 ). After successful renal transplantation, most KTRs would need fewer dietary restrictions due to improved renal function (Bavanandan et al., 2015 ). However, KTRs are still considered a subset of CKD with multiple risk factors for progression to dialysis and mortality (Levey et al., 2005 ), and this is supported by data showing that at the first year post-transplantation, many KTRs had an eGFR < 60 ml/min per 1.73 m², which classified them in stage 3 CKD or worse (Huang et al., 2017 ). Thus, KTRs may still benefit from medical nutrition therapy as per CKD dietary management that emphasizes a protein-restriction diet. Moreover, a recent study reported that high dietary protein intake with > 1.2 g/kg ideal body weight (IBW) was significantly associated with proteinuria among KTRs, (Lau et al., 2022 ), which negatively affects renal allograft outcome. In addition, high consumption of animal proteins may lead to hemodynamic glomerular capillary destruction, which might result in further glomeruli loss in individuals with fewer functioning nephrons (Holly Kramer, 2019 ), such as KTRs. Meanwhile, the plant-dominant diet has been shown to retard CKD by detrimental factors such as uremic toxins, chronic inflammatory state, oxidative stress, metabolic acidosis, phosphate load and insulin resistance (Chauveau et al., 2019 ). The aforementioned favorable effect may be due to high fiber content, phytochemicals, vitamins, alkaline minerals and antioxidants as well as improvement in the growth of probiotics (Joshi, McMacken, & Kalantar-Zadeh, 2021). Proteinuria and metabolic acidosis (Ambuhl, 2007 ) are common among KTRs and can be associated with poor prognosis and more rapid deterioration of renal function (Amer et al., 2007 ). A subsequent study showed that low serum bicarbonate concentration (< 22 mmol/L) was reported to be associated with an increased risk for mortality and graft loss (Park et al., 2017). The current recommended approach for the above-mentioned disorders involves a pharmacological approach. However, studies have shown that nutritional therapy via dietary protein restriction (Salahudeen, Hostetter, Raatz, & Rosenberg, 1992 ) and dietary acid load control (van den Berg et al., 2012 ) may reduce the incidence of these disorders. Thus, adopting medical nutrition therapy may be more cost-effective due to the avoidance of drugs or medications. Despite the perceived favorable impact of nutritional therapy on proteinuria and metabolic acidosis, the effects of protein-restricted and plant-dominant diets have not been thoroughly investigated (Tantisattamo & Kalantar-Zadeh, 2023 ). This study aims to evaluate the effectiveness of dietary intervention by adopting a more realistic approach, involving dietary counselling at out-patient clinic, with the objective of reducing proteinuria and improving metabolic acidosis among KTRs. Methods This is a prospective dietary intervention study in design that aims to recruit KTRs who fulfill the criteria of either having proteinuria ≥ 0.5g/day, chronic metabolic acidosis with serum bicarbonate ≤ 22 mmol/L for at least 2 readings in the past 6 months, or both. The objective is to study the changes in proteinuria and serum bicarbonate by comparing pre and post-dietary intervention. The study period was from February 2020 to March 2021. KTRs who were post kidney transplantation of at least 3 months, on regular follow up in University Malaya Medical Centre, Malaysia, were screened for proteinuria and metabolic acidosis. The convenience sampling method was adopted for this study. Consented KTRs’ demographics, anthropometry, medical and transplant history, and concomitant medications were extracted from the medical records. The most recent 6-month laboratory results of renal function test, lipid profile, liver function tests and full blood count were captured from electronic medical records. All consented KTRs were subjected to a 24-hour urine test for protein, urea, creatinine, sodium and potassium. The pattern of dietary intake was done by means of charting a 3-day food record by the KTRs themselves, which comprised of 2 weekdays and 1 weekend days’ food intake. To reduce sampling error, KTRs were trained by our research Dietitian on proper 24-hour urine sample collection and recording of the food portion size which were reinforced with guidance information sheets. The exclusion criteria were: 1. KTRs with active acute rejection, 2. refusal to attend the follow-up session, 3. eGFR 5.5 mmol/L or recent hyperkalemia reported (past 3 months), 5. Ongoing pregnancy, 6. active malignancy, 7. active ongoing infection, 8. on medication that can alter urine output (e.g. Frusemide), or 9. ongoing protein-restricted diet with dietary protein intake 3 servings/day) and fruit diet (2 servings/day). Dietary intervention was 3 months in duration. All recruited subjects were given 1-to-1 diet motivational interviewing and counselling for moderate dietary protein restriction at 0.8 g/ kg of IBW and high vegetable (at least 3 servings of cooked vegetable per day) and fruit intake (2 servings of fruit per day). The clinical benefit of plant protein was emphasized and all subjects were encouraged to switch from animal protein to plant protein. A diet information sheet, with the preferred language (Bahasa Malaysia, Chinese and English) was given as a reference. 24-hour urine samples and 3-day food records were collected at baseline, post-1-month and 3-month after dietary intervention. Reminding call or text message (according to the subjects’ preference) was sent 1 week before each date of the subjects’ visit to improve compliance and to reduce the errors in 24-hour urine collection and food record charting. During the first 1-month follow-up session, 1-to-1 diet reinforcement was given by the research dietitian. Regular and constant reminders and reinforcement of the diet prescribed were sent via phone calls or phone messages (according to the subjects’ preference) during the dietary intervention period. Renal function test was performed post 1-month and 3-month visits to the hospital. The digital column scales SECA 701 were used to measure all subjects’ weight and height during each visit. The changes in dietary pattern as per 3-day food records collected from subjects, proteinuria, serum bicarbonate and body weight were compared pre, post-1-month and 3-month dietary intervention. This study obtained approval from Medical Research Ethics Committee (MREC), University Malaya Medical Centre with MREC ID NO: 2019930-7877 and National Medical Research Register Malaysia (NMRR) with NMRR ID: NMRR-19-3494-52159. Statistical Analysis Statistical analysis was performed using SPSS software version 26.0 (IBM SPSS Statistic, Chicago, 1II, United States). Inaccurate 3-day food record, either due to under-reporting [as defined by energy intake: basal metabolic rate (EI: BMR) 2 (Black, 2000 )], were excluded from data analysis. Invalid urine samples with volume < 1L per day(JE, 2011 ), urine collection time < 24 hours, or incomplete urine collection with missing urine collection more than once per day were also excluded from data analysis. All parametric continuous variables were reported as mean and standard deviation while non-parametric continuous variables were reported as median and interquartile range (IQR). To test for normality, the Shapiro-Wilk test of normality was performed to determine the distribution of the outcome variable. Wilcoxon signed-rank test was applied to determine if there were any significant changes to the outcome variable of pre and post-intervention. The level of significance was set at a p value of less than 0.05 with 2-tailed test. Result Demographic and Clinical Characteristic 46 eligible subjects were identified from the screening of 204 KTRs. 33 consented to participate in this intervention trial but only 30 subjects managed to complete the study: 26 had proteinuria and 4 had chronic metabolic acidosis, but none of the subjects had concurrent proteinuria and chronic metabolic acidosis. The recruitment flow chart is shown in Fig. 1 . The mean age was 49.9 ± 10.8 years old with male to female ratio of 53: 47. There were more living renal recipients in this study compared to cadaveric renal recipients, with a ratio of 4:1. Hypertension was the leading cause of end stage kidney disease in this cohort (30.0%, n = 9). The majority of KTRs had concurrent medical conditions post-transplantation, such as hypertension (86.7%, n = 26), dyslipidemia (43.3%, n = 13) and diabetes mellitus (36.7%, n = 11). 70% of the subjects were either overweight or obese with BMI ≥ 23 kg/m². The mean time after transplantation was 143.07 ± 102.04 months, in the range from 3 months to 342 months. The mean eGFR was 55.47 ± 19.21 mL/min/1.73m². All subjects were on different combinations of immunosuppression therapy. Table 1 shows the details of the socio-demographic and clinical characteristics of the subjects. Table 1 Socio-demographic and clinical characteristics of subjects (n = 30) Socio-demographic / Clinical Characteristics Number (n) % Age 19–29 y 1 3.3 30–59 y 23 76.7 60 + 6 20.0 Ethnicity Malay 4 13.3 Chinese 21 70.0 India 5 16.7 Education Primary 3 10 Secondary 11 36.7 Tertiary 16 53.3 Employment Employed 20 66.7 Unemployed 4 13.3 Retired 6 20.0 Cause of Renal Failure Diabetes Mellitus 6 20.0 Hypertension 9 30.0 Glomerulonephritis 4 13.3 Unknown 6 20.0 Others 5 16.7 Time after Transplantation 3–12 months 2 6.7 13–36 months 5 16.7 37–120 months 6 20.0 121–240 months 12 40.0 > 240 months 5 16.7 estimated Glomerular Filtration Rate, mL/min/1.73m² > 90 3 10.0 60–89 10 33.3 30–59 15 56.7 15–29 2 6.7 Body Mass Index, kg/m² < 18.5 1 3.3 18.5–22.9 8 26.7 23–27.4 5 16.7 ≥ 27.5 16 53.3 Dietary intake pre and post intervention Analysis from 24-hour urine sample Dietary outcomes were measured based on dietary protein, dietary acid load and sodium intake as derived from estimated 24-hour urine sample calculation, taken at baseline, post-1-month and post-3-month. Our study showed that the median of dietary protein intake was 1.17 g/kg IBW (IQR, 0.39 g/kg IBW) at baseline, 1.01 g/kg IBW (IQR, 0.59 g/kg IBW) at post-1-month and 1.00 g/kg IBW (IQR, 0.41 g/kg IBW) at post-3-month intervention while the median dietary acid load was 93.3 mEq (IQR, 37.6 mEq), 72.6 mEq (IQR, 37.2 mEq), 73.3 mEq (IQR, 38.4 mEq) respectively. The median of salt intake at baseline, post-1- month and 3-month was 8.06 g/day (IQR, 4.63 g/day), 7.71 g/day (IQR, 3.71 g/day) and 7.65 g/day (IQR, 5.10 g/day) respectively. There was a significant reduction of protein intake (z = -2.376, p = 0.018) and dietary acid load (z = -2.149, p = 0.032) at 1-month post intervention. The percentage of KTRs on reduced protein diet ( ≤ 0.8 g dietary protein per kg of IBW) at baseline was only 13.3% (n = 4). The number of KTRs adhering to the prescribed protein restricted diet had improved to 9 (30.0%) post 1-month intervention. In addition, the KTRs who consumed high protein diet (protein intake > 1.2g per kg IBW) had reduced from 40.0% (n = 12) to 30.0% (n = 9) at 1-month post intervention. However, the effect of dietary intervention had waned off after 3 months as no statistically significant changes were noted for both protein intake (z = -1.717, p = 0.086) and dietary acid load (z = -1.903, p = 0.057) at 3rd month. There was a non-statistically increase in adherence to low salt diet ( ≤ 5g per day) with only 3.3% (n = 1) at baseline increased to 20.0% (n = 6) post-1-month and 13.3% (n = 4) post-3-month. Analysis from 3-day food record Data collection on 3-day food records was almost complete with only 1 missing data post 1-month after intervention. Energy The median energy intake during baseline, post-1-month and 3-month were 1753 kcal/day (IQR, 584 kcal/day), 1573 kcal/day (IQR, 446 kcal/day) and 1562 kcal/day (IQR, 431 kcal/day) respectively. Our study revealed a significant reduction of estimated energy intake for both 1-month (z =-3.125, p = 0.002) and 3-months (z = -2.417, p = 0.016) post intervention. Vegetables There was a noticeable increase in KTRs consuming a minimum of 3 servings of vegetables per day after dietary counseling, from 5 KTRs at baseline to 11 at post-1-month and 3-month respectively. The overall vegetable consumption increased significantly 3-month post-intervention (z = -2.119, p = 0.034). However, it was not statistically significant at 1-month post-intervention (z = -1.913, p = 0.056). Fruits There was a significant improvement in fruit consumption throughout the intervention period [post-1-month (z = -2.896, p = 0.004), and post-3-month (z = -3.423, p = 0.001)]. The number of KTRs who did not consume fruit had reduced from 10 (33.3%) at baseline to 4 (13.3%) at 1 month and remained the same at 3-month post-intervention. Moreover, the number of KTRs consuming at least 2 servings of fruit per day increased from 1 (3.3%) at baseline, to 8 (26.7%) and 7 (23.3%) post-1-month and 3-month respectively. Protein source The majority source of protein intake among KTRs was still animal based despite the benefit of plant protein had been highlighted throughout the dietary counselling sessions. Only 3 subjects switched to plant protein food as the main source of protein intake during the 1-month post intervention but this was not sustainable as they reverted to animal protein at 3-month post intervention. Outcome Post Intervention The median proteinuria during baseline, post-1-month and 3-month were 0.80g/day (IQR, 1.21 g/kg IBW), 0.67g/day (IQR, 1.47 g/kg IBW) and 0.94g/day (IQR, 1.44 g/kg IBW) respectively. Our study showed that post-1-month intervention resulted in a significant reduction in proteinuria (z = -2.643, p = 0.008), however, the described effect was not seen at 3-month post-intervention (z = -0.946, p = 0.344). In addition, the intervention did not result in any changes of serum bicarbonate level, at post-1-month (z = -0.097, p = 0.922) and 3-months (z = -0.550, p = 0.582) with median serum bicarbonate of 24 mmol/L (IQR, 4 mmol/L) at baseline, with no differences at 1-month and 3-month post intervention. The median body weight during baseline, post-1-month and 3-month were 74.4 kg (IQR, 33.5 kg), 73.7 kg (IQR, 31.3 kg) and 72.8 kg (IQR, 32.7 kg) respectively. These results showed a consistent reduction of body weight throughout the study period [post-1-month (z = -3.379, p = 0.001) and post-3-month (z = -3.503, p < 0.001)]. A significant proportion (70%, n = 21) of KTRs had weight reduction which ranged from 0.4–7.8% at 1 month. The number increased to 80.0% (n = 24) with weight reduction ranging from 0.4–9.1% at the end of the study. Despite having lower calorie and protein intake post-dietary counseling, there were no significant changes of the serum albumin at 1-month (z = -1.098, p = 0.272) and 3-month (z = − 1.1000, p = 0.271) post-intervention. Figure 2 shows the changes in dietary protein, dietary acid load, proteinuria and body weight at baseline, post-1-month and 3-month of dietary intervention. Discussion Our study showed that switching to a lower protein diet had a desirable effect of reducing proteinuria, however, dietary adherence was not sustainable in majority of the participants. Despite the perceived improvement in both vegetable and fruit intake among the subjects, most of them still source their protein intake from animals rather than plants. Poor dietary compliance rate is well reported in most literature, (Ichimaru et al., 2016 ; Lin et al., 2019 ), not surprisingly, our study had a similar finding. Furthermore, the majority of Malaysians prefer to eat out or eat at home with commercial packed food (Poulain et al., 2020 ). In addition, a plant-dominant diet is less popular in Malaysia with an estimated only 4.9% of our population being vegetarian (Institute for Public Health (IPH), 2020) and this has restricted the food option of KTRs when they are eating out, thus resulting poor compliance rate. Dietary adherence and food preferences among renal patients are highly variable due to multiple factors. Dietary adherence was reported to be associated with psychosocial factors, including patients’ knowledge, attitude, support, satisfaction, and self-perception of success (Milas et al., 1995 ) while food preferences are greatly influenced by immediate family members and closest social circles (Tuorila, 2007 ). It is a worldwide challenge to promote patients’ compliance with the tailored regime of dietary management, irrespective of the study population. Perhaps, a more frequent review by a dietitian physically or implementing a digital health literacy plan may improve the consistency of dietary adherence. Interestingly, all the 4 KTRs in our study with chronic metabolic acidosis showed improvement with increased serum bicarbonate levels at the end of the study. Despite the positive effect, this was not significant based on statistical analysis due to low number of chronic metabolic acidosis in our cohort and poor recruitment rate (33.3% or 4 out of 12). Further study with a larger sample size should be pursued to investigate the effect of dietary intervention on chronic metabolic acidosis among KTRs. Weight gain with increased body fat composition is common post-renal transplantation (van den Ham, Kooman, Christiaans, Leunissen, & van Hooff, 2000 ). This phenomenon may be attributed to immunosuppression medications such as corticosteroids. In spite of this, lifestyle modification and behavior intervention seem to be able to negate the negative metabolic impact of immunosuppressive therapy (Patel, 1998 ). Our study showed a significant decrease in energy intake at 1 month and 3-months post-intervention, which is in keeping with the principle of energy balance, that resulted a significant weight reduction. This finding confirmed that dietary intervention plays an important role in weight management post-transplantation and highlights the benefit of personalized dietary advice. With the significantly high prevalence rate of overweight and obesity in the transplant cohort, a dedicated dietary counselling program would be beneficial. Our study showed significant improvement in vegetable, fruit and dietary protein intake post intervention, however, dietary sodium intake remained high among KTRs with the median salt intake of 7.7 g per day which did not differ much from baseline readings. Dietary sodium monitoring remains a challenging practice if eating out frequently. Eating out habit is common among working Malaysian (Ashari et al., 2022 ) and may be one of the contributing factors of excessive salt intake. According to Malaysian Community Salt Survey, 79% of Malaysians consumed an excessive amount of salt with average salt intake of 7.9 g per day, which is much higher than the WHO recommendation of 5.0 g of salt per day (Ambak et al., 2021 ). In keeping with most Malaysians’ eating habits, majority of KTRs in this cohort consumed > 5.0 g of salt per day. This may be due to 70% of the subjects are working, and eating out may be unavoidable, thus resulting in high salt intake despite proper diet advice. Studies on the role of dietary intervention in improving KTRs’ outcomes are scarce. Most of the published data using dietary approaches are observational studies. To our best knowledge, there were only 2 dietary interventional studies performed (Biesenbach, Zazgornik, Janko, Hubmann, & Syre, 1996 ; Salahudeen et al., 1992 ) for KTRs. Our study adopted a real-world approach where dietary counseling was conducted in the outpatient setting. The study design did not offer food or monetary incentives as each subject was encouraged to imbibe to dietary modification and put it into daily practice. The feasibility of this being incorporated into the clinical management of KTRs is highly promising as no extra human resources and costs are incurred. The limitation of this study is a very low number of KTRs with chronic metabolic acidosis, thus leading to an insufficient sample size to ascertain the impact of dietary intervention on serum bicarbonate. In addition, this study was conducted during the COVID-19 pandemic leading to a poor recruitment rate. Conclusion Our study showed that dietary counselling emphasizing protein restriction has resulted in a reduction of dietary protein intake and proteinuria. This finding highlights the importance of dietary intervention in complementing the pharmacological approach in treating proteinuria. However, the desired dietary pattern was not sustainable and further study is needed to analyze factors that may be associated with the sustainability of dietary adherence. The significant weight reduction observed in this study has surprised us but may potentially benefit those overweight and obese KTRs. We believe dietary intervention should be part of the multi-prong approach in managing KTRs for optimization of outcome. Standardized dietary guidelines would be crucial for the management of KTRs, however further studies are required to determine the optimal approach. Declarations Acknowledgments We thank all the nurses in renal clinic and daycare for the co-operation during data collection and subject recruitment. This work was supported by Dietetic Department and Renal Unit of University Malaya Medical Centre. Consent to Participate declaration All KTRs provided informed consent prior to their inclusion in the study. They were informed about the purpose, procedures, potential risks, and benefits of the research. Participation was entirely voluntary with no incentive provided, and all participants were informed of their right to terminate the intervention at any stage without any consequences. Confidentiality and anonymity were assured throughout the study. Ethical Approval This study obtained approval from Medical Research Ethics Committee (MREC), University Malaya Medical Centre with MREC ID NO: 2019930-7877 and National Medical Research Register Malaysia (NMRR) with NMRR ID: NMRR-19-3494-52159. Clinical trial number Not applicable. Competing interests There is no conflict of interest that might be perceived to influence the results and/or discussion reported in this paper. Funding This is a self-funded research. Availability of data and materials The raw data collected for this research was kept fully confidential as stipulated in the consent agreement signed by the subjects, hence the datasets created and/or analyzed during the current investigation are not publically available. However, they are available from the corresponding author upon reasonable request. References Ambak R, He FJ, Othman F, Michael V, Mohd Yusoff MF, Aris T. Salt intake was higher among males and those with high BMI and waist circumference: introduction to the Malaysian Community Salt Survey (MyCoSS), a population-based salt intake survey in Malaysia. J Health Popul Nutr. 2021;40(Suppl 1):23. 10.1186/s41043-021-00229-y . Ambuhl PM. Posttransplant metabolic acidosis: a neglected factor in renal transplantation? Curr Opin Nephrol Hypertens. 2007;16(4):379–87. 10.1097/MNH.0b013e3281bd8860 . Amer H, Fidler ME, Myslak M, Morales P, Kremers WK, Larson TS, Cosio FG. Proteinuria after kidney transplantation, relationship to allograft histology and survival. Am J Transpl. 2007;7(12):2748–56. 10.1111/j.1600-6143.2007.02006.x . Ashari L, Rashid A, Shahril MR, Lee YY, Kueh YC, Hakim BN, Mohamed J. Exploring the norms of eating-out practice among adults in Malaysia. Malaysian J Nutr. 2022;28. 10.31246/mjn-2021-0008 . Bavanandan S, Yap YC, Ahmad G, Wong HS, Azmi S, Goh A. The Cost and Utility of Renal Transplantation in Malaysia. Transpl Direct. 2015;1(10):e45. 10.1097/txd.0000000000000553 . Biesenbach G, Zazgornik J, Janko O, Hubmann R, Syre G. Effect of mild dietary protein restriction on urinary protein excretion in patients with renal transplant fibrosis. Wien Med Wochenschr. 1996;146(4):75–8. Black AE. Critical evaluation of energy intake using the Goldberg cut-off for energy intake:basal metabolic rate. A practical guide to its calculation, use and limitations. Int J Obes. 2000;24(9):1119–30. 10.1038/sj.ijo.0801376 . Chauveau P, Koppe L, Combe C, Lasseur C, Trolonge S, Aparicio M. Vegetarian diets and chronic kidney disease. Nephrol Dial Transpl. 2019;34(2):199–207. 10.1093/ndt/gfy164 . Cohen E, Korah M, Callender G, de Aguiar B, R., Haakinson D. Metabolic Disorders with Kidney Transplant. Clin J Am Soc Nephrol. 2020;15(5):732–42. 10.2215/cjn.09310819 . Gomes-Neto AW, Osté MCJ, Sotomayor CG, van den Berg E, Geleijnse JM, Berger SP, Navis GJ. Mediterranean Style Diet and Kidney Function Loss in Kidney Transplant Recipients. Clin J Am Soc Nephrol. 2020;15(2):238–46. 10.2215/cjn.06710619 . Huang Y, Tilea A, Gillespie B, Shahinian V, Banerjee T, Grubbs V, Saran R. Understanding Trends in Kidney Function 1 Year after Kidney Transplant in the United States. J Am Soc Nephrol. 2017;28(8):2498–510. 10.1681/asn.2016050543 . Ichimaru N, Nakazawa S, Yamanaka K, Kakuta Y, Abe T, Kaimori J-Y, Takahara S. (2016). Adherence to Dietary Recommendations in Maintenance Phase Kidney Transplant Patients. Paper presented at the Transplant Proc. Ikizler TA, Burrowes JD, Byham-Gray LD, Campbell KL, Carrero JJ, Chan W, Cuppari L. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update. Am J Kidney Dis. 2020;76(3 Suppl 1):S1–107. 10.1053/j.ajkd.2020.05.006 . Institute for Public Health (IPH), N. I. o. H., Ministry of Health Malaysia. (2020). National Health and Morbidity Survey (NHMS) 2019 . JE H. Urine Concentration and Dilution: Regulation of Extracellular Fluid Osmolarity and Sodium Concentration. 12Vol. th ed. Canada: Saunders Elsevier; 2011. Joshi, S., McMacken, M., & Kalantar-Zadeh, K. (2021). Plant-Based Diets for Kidney Disease: A Guide for Clinicians. American Journal of Kidney Diseases, 77 (2), 287–296. doi:10.1053/j.ajkd.2020.10.003. Kramer H. Kidney Disease and the Westernization and Industrialization of Food. Am J Kidney Dis. 2017;70(1):111–21. 10.1053/j.ajkd.2016.11.012 . Kramer H. Diet and Chronic Kidney Disease. Adv Nutr. 2019;10:S367–79. https://doi.org/10.1093/advances/nmz011 . Lau WP, Ng KP, Ganapathy SS, Tah PC, Ismail R, Jalalonmuhali M, Lim SK. Prevalence Rate of Proteinuria and Metabolic Acidosis Among Kidney Transplant Recipients in a Tertiary Teaching Hospital and Its Relationship to Dietary Intake. Transpl Proc. 2022;54(2):355–61. 10.1016/j.transproceed.2021.12.019 . Levey AS, Eckardt KU, Tsukamoto Y, Levin A, Coresh J, Rossert J, Eknoyan G. Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2005;67(6):2089–100. 10.1111/j.1523-1755.2005.00365.x . Lin IH, Wong TC, Nien SW, Chou YT, Chiang YJ, Wang HH, Yang SH. Dietary Compliance Among Renal Transplant Recipients: A Single-Center Study in Taiwan. Transpl Proc. 2019;51(5):1325–30. 10.1016/j.transproceed.2019.02.026 . Milas NC, Nowalk MP, Akpele L, Castaldo L, Coyne T, Doroshenko L, Snetselaar L. Factors Associated with Adherence to the Dietary Protein Intervention in the Modification of Diet in Renal Disease Study. J Am Diet Assoc. 1995;95(11):1295–300. https://doi.org/10.1016/S0002-8223(95)00340-1 . Patel MG. The effect of dietary intervention on weight gains after renal transplantation. J Ren Nutr. 1998;8(3):137–41. 10.1016/s1051-2276(98)90005-x . Podadera-Herreros A, Alcala-Diaz JF, Gutierrez-Mariscal FM, Jimenez-Torres J, Cruz-Ares S, Arenas-de Larriva AP, Yubero-Serrano EM. Long-term consumption of a mediterranean diet or a low-fat diet on kidney function in coronary heart disease patients: The CORDIOPREV randomized controlled trial. Clin Nutr. 2022;41(2):552–9. 10.1016/j.clnu.2021.12.041 . Poulain JP, Laporte C, Tibere L, Mognard E, Ari Ragavan N, Zadeh A, Ismail M. Malaysian Food Barometer (MFB): a study of the impact of compressed modernisation on food habits. Malaysian J Nutr. 2020;26:001–17. 10.31246/mjn-2019-0042 . Salahudeen AK, Hostetter TH, Raatz SK, Rosenberg ME. Effects of dietary protein in patients with chronic renal transplant rejection. Kidney Int. 1992;41(1):183–90. Tantisattamo E, Kalantar-Zadeh K. Dietary protein intake and plant-dominant diets to mitigate risk of allograft dysfunction progression in kidney transplant recipients. Curr Opin Nephrol Hypertens. 2023. 10.1097/mnh.0000000000000944 . Tuorila H. (2007). Sensory perception as a basis of food acceptance and consumption. In (pp. 34–65). van den Berg E, Engberink MF, Brink EJ, van Baak MA, Joosten MM, Gans RO, Bakker SJ. Dietary acid load and metabolic acidosis in renal transplant recipients. Clin J Am Soc Nephrol. 2012;7(11):1811–8. 10.2215/cjn.04590512 . van den Ham EC, Kooman JP, Christiaans MH, Leunissen KM, van Hooff JP. Posttransplantation weight gain is predominantly due to an increase in body fat mass. Transplantation. 2000;70(1):241–2. Wang Y, Chen X, Song Y, Caballero B, Cheskin LJ. Association between obesity and kidney disease: A systematic review and meta-analysis. Kidney Int. 2008;73(1):19–33. https://doi.org/10.1038/sj.ki.5002586 . Zainuddin AA, Nor NM, Yusof SM, Irawati A, Ibrahim N, Aris T, Huat FL. Under-reporting of energy and nutrient intake is a persistent issue in the Malaysian Adult Nutrition Surveys. Malaysian J Nutr. 2019;25(2):261–71. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6266091","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":451765769,"identity":"fd137f6e-8e68-43cc-8320-d5775d29f8b2","order_by":0,"name":"Wai Pooi Lau","email":"","orcid":"","institution":"University Malaya Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Wai","middleName":"Pooi","lastName":"Lau","suffix":""},{"id":451765770,"identity":"0a5ac7ef-9544-44ea-91d4-aab6030c8a56","order_by":1,"name":"Kok Peng Ng","email":"","orcid":"","institution":"University of Malaya","correspondingAuthor":false,"prefix":"","firstName":"Kok","middleName":"Peng","lastName":"Ng","suffix":""},{"id":451765771,"identity":"89b4f426-e942-4b26-ac3c-a060240bb458","order_by":2,"name":"Shubash Shander Ganapathy","email":"","orcid":"","institution":"Insitute for Public Health, National Institutes of Health","correspondingAuthor":false,"prefix":"","firstName":"Shubash","middleName":"Shander","lastName":"Ganapathy","suffix":""},{"id":451765772,"identity":"e0b79954-edf3-49bd-972b-45e27c7788b3","order_by":3,"name":"Pei Chien Tah","email":"","orcid":"","institution":"University Malaya Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Pei","middleName":"Chien","lastName":"Tah","suffix":""},{"id":451765773,"identity":"47bfe187-5cf4-430c-b141-67dd5c40b751","order_by":4,"name":"Rokiah Ismail","email":"","orcid":"","institution":"University Malaya Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Rokiah","middleName":"","lastName":"Ismail","suffix":""},{"id":451765774,"identity":"14c74ea8-07cb-44ab-bccf-889a3481789e","order_by":5,"name":"Soo Kun Lim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtklEQVRIiWNgGAWjYBACPmYGBsaGCiiPhxgtbGAtZ0jSAsSMjW0kaWHnTv44c97haN32A4wP3rYxRBscIOgw3m2SG7cdzt12JoHZcG4bQ+4GYrQwPgRpucHAJs1LpJbNHx/OAWth/02slg2SGxsgtjATq2Wb5Ixj6UC/JDZLzjknkTuTkBZ+/rObP/bUWOduO3744Ic3ZTa5fYS0IAHGBiAhwaBAghYokG8gWcsoGAWjYBQMcwAA+RhD2WETdZYAAAAASUVORK5CYII=","orcid":"","institution":"University of Malaya","correspondingAuthor":true,"prefix":"","firstName":"Soo","middleName":"Kun","lastName":"Lim","suffix":""}],"badges":[],"createdAt":"2025-03-20 04:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6266091/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6266091/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82103073,"identity":"cb05c49c-98ac-4a45-a62a-3c561c7033e9","added_by":"auto","created_at":"2025-05-06 19:35:25","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":312271,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of recruitment process\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6266091/v1/e22fc626211459b6a0c72e3c.jpg"},{"id":82103071,"identity":"c1d4f743-ca8e-415f-9994-fa7535eb0086","added_by":"auto","created_at":"2025-05-06 19:35:25","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":48574,"visible":true,"origin":"","legend":"\u003cp\u003eThe changes in dietary protein, dietary acid load, proteinuria, and body weight from baseline to post-intervention of 1 month and 3 months.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6266091/v1/32b67a3e293cf75a064e20a9.jpg"},{"id":83754276,"identity":"1ababbdd-82ba-41c9-95df-8c1c74e7a7ef","added_by":"auto","created_at":"2025-06-02 07:54:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1093777,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6266091/v1/cf9db742-01cd-4d8d-a6cc-ba8568a9007d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outcome Of Dietary Intervention On Kidney Transplant Recipients With Proteinuria/ Chronic Metabolic Acidosis – A Single Cohort Prospective Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMedical nutrition therapy is an essential part of managing chronic kidney disease (CKD) patients (Ikizler et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). There are well-established specific dietary guidelines for CKD stage 1 to CKD stage 5 requiring dialysis. However, no precise dietary guidelines were found in managing kidney transplant recipients (KTRs) due to lack of validated data in this cohort. Metabolic complications such as diabetes and obesity are highly prevalent among KTRs, which are well known to be detrimental to renal allograft and patient survival (Cohen, Korah, Callender, Belfort de Aguiar, \u0026amp; Haakinson, 2020), thus indicating that medical nutrition therapy in adjunct to pharmacological therapy should play a crucial role in reducing the risk of metabolic related complication. However, this approach is not commonly implemented.\u003c/p\u003e \u003cp\u003eThe occurrence and course of CKD may be multifactorial, and nutritional factor is known to play a major contributing role in it. It was estimated that more than 24% of CKD cases could be linked to nutritional disorders in developed countries (Wang, Chen, Song, Caballero, \u0026amp; Cheskin, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). The shift in modern dietary patterns, that is characterized by a high intake of processed food and meat coupled with low vegetable and fruit consumption, has resulted to a higher risk of CKD (H. Kramer, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). In contrast, diet composition with high vegetable and low meat intake, such as the Mediterranean diet, is shown to be renoprotective (Podadera-Herreros et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and associated with better kidney function. (Gomes-Neto et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAfter successful renal transplantation, most KTRs would need fewer dietary restrictions due to improved renal function (Bavanandan et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). However, KTRs are still considered a subset of CKD with multiple risk factors for progression to dialysis and mortality (Levey et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2005\u003c/span\u003e), and this is supported by data showing that at the first year post-transplantation, many KTRs had an eGFR\u0026thinsp;\u0026lt;\u0026thinsp;60 ml/min per 1.73 m\u0026sup2;, which classified them in stage 3 CKD or worse (Huang et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Thus, KTRs may still benefit from medical nutrition therapy as per CKD dietary management that emphasizes a protein-restriction diet. Moreover, a recent study reported that high dietary protein intake with \u0026gt;\u0026thinsp;1.2 g/kg ideal body weight (IBW) was significantly associated with proteinuria among KTRs, (Lau et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), which negatively affects renal allograft outcome. In addition, high consumption of animal proteins may lead to hemodynamic glomerular capillary destruction, which might result in further glomeruli loss in individuals with fewer functioning nephrons (Holly Kramer, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), such as KTRs. Meanwhile, the plant-dominant diet has been shown to retard CKD by detrimental factors such as uremic toxins, chronic inflammatory state, oxidative stress, metabolic acidosis, phosphate load and insulin resistance (Chauveau et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The aforementioned favorable effect may be due to high fiber content, phytochemicals, vitamins, alkaline minerals and antioxidants as well as improvement in the growth of probiotics (Joshi, McMacken, \u0026amp; Kalantar-Zadeh, 2021).\u003c/p\u003e \u003cp\u003eProteinuria and metabolic acidosis (Ambuhl, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2007\u003c/span\u003e) are common among KTRs and can be associated with poor prognosis and more rapid deterioration of renal function (Amer et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). A subsequent study showed that low serum bicarbonate concentration (\u0026lt;\u0026thinsp;22 mmol/L) was reported to be associated with an increased risk for mortality and graft loss (Park et al., 2017). The current recommended approach for the above-mentioned disorders involves a pharmacological approach. However, studies have shown that nutritional therapy via dietary protein restriction (Salahudeen, Hostetter, Raatz, \u0026amp; Rosenberg, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e1992\u003c/span\u003e) and dietary acid load control (van den Berg et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) may reduce the incidence of these disorders. Thus, adopting medical nutrition therapy may be more cost-effective due to the avoidance of drugs or medications.\u003c/p\u003e \u003cp\u003eDespite the perceived favorable impact of nutritional therapy on proteinuria and metabolic acidosis, the effects of protein-restricted and plant-dominant diets have not been thoroughly investigated (Tantisattamo \u0026amp; Kalantar-Zadeh, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This study aims to evaluate the effectiveness of dietary intervention by adopting a more realistic approach, involving dietary counselling at out-patient clinic, with the objective of reducing proteinuria and improving metabolic acidosis among KTRs.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a prospective dietary intervention study in design that aims to recruit KTRs who fulfill the criteria of either having proteinuria\u0026thinsp;\u0026ge;\u0026thinsp;0.5g/day, chronic metabolic acidosis with serum bicarbonate\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;22 mmol/L for at least 2 readings in the past 6 months, or both. The objective is to study the changes in proteinuria and serum bicarbonate by comparing pre and post-dietary intervention. The study period was from February 2020 to March 2021. KTRs who were post kidney transplantation of at least 3 months, on regular follow up in University Malaya Medical Centre, Malaysia, were screened for proteinuria and metabolic acidosis. The convenience sampling method was adopted for this study. Consented KTRs\u0026rsquo; demographics, anthropometry, medical and transplant history, and concomitant medications were extracted from the medical records. The most recent 6-month laboratory results of renal function test, lipid profile, liver function tests and full blood count were captured from electronic medical records. All consented KTRs were subjected to a 24-hour urine test for protein, urea, creatinine, sodium and potassium. The pattern of dietary intake was done by means of charting a 3-day food record by the KTRs themselves, which comprised of 2 weekdays and 1 weekend days\u0026rsquo; food intake. To reduce sampling error, KTRs were trained by our research Dietitian on proper 24-hour urine sample collection and recording of the food portion size which were reinforced with guidance information sheets.\u003c/p\u003e \u003cp\u003eThe exclusion criteria were: 1. KTRs with active acute rejection, 2. refusal to attend the follow-up session, 3. eGFR\u0026thinsp;\u0026lt;\u0026thinsp;15 mL/min/1.73m\u0026sup2; or already on dialysis, 4. hyperkalemia with serum potassium\u0026thinsp;\u0026gt;\u0026thinsp;5.5 mmol/L or recent hyperkalemia reported (past 3 months), 5. Ongoing pregnancy, 6. active malignancy, 7. active ongoing infection, 8. on medication that can alter urine output (e.g. Frusemide), or 9. ongoing protein-restricted diet with dietary protein intake\u0026thinsp;\u0026lt;\u0026thinsp;0.8 g/kg/day based on calculation from urine urea nitrogen and practicing high vegetable (\u0026gt;\u0026thinsp;3 servings/day) and fruit diet (2 servings/day). Dietary intervention was 3 months in duration. All recruited subjects were given 1-to-1 diet motivational interviewing and counselling for moderate dietary protein restriction at 0.8 g/ kg of IBW and high vegetable (at least 3 servings of cooked vegetable per day) and fruit intake (2 servings of fruit per day). The clinical benefit of plant protein was emphasized and all subjects were encouraged to switch from animal protein to plant protein. A diet information sheet, with the preferred language (Bahasa Malaysia, Chinese and English) was given as a reference.\u003c/p\u003e \u003cp\u003e24-hour urine samples and 3-day food records were collected at baseline, post-1-month and 3-month after dietary intervention. Reminding call or text message (according to the subjects\u0026rsquo; preference) was sent 1 week before each date of the subjects\u0026rsquo; visit to improve compliance and to reduce the errors in 24-hour urine collection and food record charting. During the first 1-month follow-up session, 1-to-1 diet reinforcement was given by the research dietitian. Regular and constant reminders and reinforcement of the diet prescribed were sent via phone calls or phone messages (according to the subjects\u0026rsquo; preference) during the dietary intervention period. Renal function test was performed post 1-month and 3-month visits to the hospital. The digital column scales SECA 701 were used to measure all subjects\u0026rsquo; weight and height during each visit. The changes in dietary pattern as per 3-day food records collected from subjects, proteinuria, serum bicarbonate and body weight were compared pre, post-1-month and 3-month dietary intervention. This study obtained approval from Medical Research Ethics Committee (MREC), University Malaya Medical Centre with MREC ID NO: 2019930-7877 and National Medical Research Register Malaysia (NMRR) with NMRR ID: NMRR-19-3494-52159.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eStatistical analysis was performed using SPSS software version 26.0 (IBM SPSS Statistic, Chicago, 1II, United States). Inaccurate 3-day food record, either due to under-reporting [as defined by energy intake: basal metabolic rate (EI: BMR)\u0026thinsp;\u0026lt;\u0026thinsp;1.2 (Zainuddin et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2019\u003c/span\u003e)], or over-reporting [EI: BMR\u0026thinsp;\u0026gt;\u0026thinsp;2 (Black, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2000\u003c/span\u003e)], were excluded from data analysis. Invalid urine samples with volume\u0026thinsp;\u0026lt;\u0026thinsp;1L per day(JE, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), urine collection time\u0026thinsp;\u0026lt;\u0026thinsp;24 hours, or incomplete urine collection with missing urine collection more than once per day were also excluded from data analysis. All parametric continuous variables were reported as mean and standard deviation while non-parametric continuous variables were reported as median and interquartile range (IQR). To test for normality, the Shapiro-Wilk test of normality was performed to determine the distribution of the outcome variable. Wilcoxon signed-rank test was applied to determine if there were any significant changes to the outcome variable of pre and post-intervention. The level of significance was set at a \u003cem\u003ep\u003c/em\u003e value of less than 0.05 with 2-tailed test.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Result","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDemographic and Clinical Characteristic\u003c/h2\u003e \u003cp\u003e46 eligible subjects were identified from the screening of 204 KTRs. 33 consented to participate in this intervention trial but only 30 subjects managed to complete the study: 26 had proteinuria and 4 had chronic metabolic acidosis, but none of the subjects had concurrent proteinuria and chronic metabolic acidosis. The recruitment flow chart is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe mean age was 49.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8 years old with male to female ratio of 53: 47. There were more living renal recipients in this study compared to cadaveric renal recipients, with a ratio of 4:1. Hypertension was the leading cause of end stage kidney disease in this cohort (30.0%, n\u0026thinsp;=\u0026thinsp;9). The majority of KTRs had concurrent medical conditions post-transplantation, such as hypertension (86.7%, n\u0026thinsp;=\u0026thinsp;26), dyslipidemia (43.3%, n\u0026thinsp;=\u0026thinsp;13) and diabetes mellitus (36.7%, n\u0026thinsp;=\u0026thinsp;11). 70% of the subjects were either overweight or obese with BMI\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;23 kg/m\u0026sup2;. The mean time after transplantation was 143.07\u0026thinsp;\u0026plusmn;\u0026thinsp;102.04 months, in the range from 3 months to 342 months. The mean eGFR was 55.47\u0026thinsp;\u0026plusmn;\u0026thinsp;19.21 mL/min/1.73m\u0026sup2;. All subjects were on different combinations of immunosuppression therapy. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the details of the socio-demographic and clinical characteristics of the subjects.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic and clinical characteristics of subjects (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eSocio-demographic / Clinical Characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u0026ndash;29 y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u0026ndash;59 y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e76.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 +\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMalay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChinese\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCause of Renal Failure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eDiabetes Mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eGlomerulonephritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime after Transplantation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e3\u0026ndash;12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e13\u0026ndash;36 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e37\u0026ndash;120 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e121\u0026ndash;240 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;240 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eestimated Glomerular Filtration Rate, mL/min/1.73m\u0026sup2;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u0026gt; 90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e60\u0026ndash;89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e30\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e56.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e15\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody Mass Index, kg/m\u0026sup2;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e18.5\u0026ndash;22.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e23\u0026ndash;27.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e 27.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDietary intake pre and post intervention\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis from 24-hour urine sample\u003c/h2\u003e \u003cp\u003eDietary outcomes were measured based on dietary protein, dietary acid load and sodium intake as derived from estimated 24-hour urine sample calculation, taken at baseline, post-1-month and post-3-month. Our study showed that the median of dietary protein intake was 1.17 g/kg IBW (IQR, 0.39 g/kg IBW) at baseline, 1.01 g/kg IBW (IQR, 0.59 g/kg IBW) at post-1-month and 1.00 g/kg IBW (IQR, 0.41 g/kg IBW) at post-3-month intervention while the median dietary acid load was 93.3 mEq (IQR, 37.6 mEq), 72.6 mEq (IQR, 37.2 mEq), 73.3 mEq (IQR, 38.4 mEq) respectively. The median of salt intake at baseline, post-1- month and 3-month was 8.06 g/day (IQR, 4.63 g/day), 7.71 g/day (IQR, 3.71 g/day) and 7.65 g/day (IQR, 5.10 g/day) respectively. There was a significant reduction of protein intake (z = -2.376, p\u0026thinsp;=\u0026thinsp;0.018) and dietary acid load (z = -2.149, p\u0026thinsp;=\u0026thinsp;0.032) at 1-month post intervention. The percentage of KTRs on reduced protein diet (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;0.8 g dietary protein per kg of IBW) at baseline was only 13.3% (n\u0026thinsp;=\u0026thinsp;4). The number of KTRs adhering to the prescribed protein restricted diet had improved to 9 (30.0%) post 1-month intervention. In addition, the KTRs who consumed high protein diet (protein intake\u0026thinsp;\u0026gt;\u0026thinsp;1.2g per kg IBW) had reduced from 40.0% (n\u0026thinsp;=\u0026thinsp;12) to 30.0% (n\u0026thinsp;=\u0026thinsp;9) at 1-month post intervention. However, the effect of dietary intervention had waned off after 3 months as no statistically significant changes were noted for both protein intake (z = -1.717, p\u0026thinsp;=\u0026thinsp;0.086) and dietary acid load (z = -1.903, p\u0026thinsp;=\u0026thinsp;0.057) at 3rd month. There was a non-statistically increase in adherence to low salt diet (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;5g per day) with only 3.3% (n\u0026thinsp;=\u0026thinsp;1) at baseline increased to 20.0% (n\u0026thinsp;=\u0026thinsp;6) post-1-month and 13.3% (n\u0026thinsp;=\u0026thinsp;4) post-3-month.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis from 3-day food record\u003c/h2\u003e \u003cp\u003eData collection on 3-day food records was almost complete with only 1 missing data post 1-month after intervention.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEnergy\u003c/h3\u003e\n\u003cp\u003eThe median energy intake during baseline, post-1-month and 3-month were 1753 kcal/day (IQR, 584 kcal/day), 1573 kcal/day (IQR, 446 kcal/day) and 1562 kcal/day (IQR, 431 kcal/day) respectively. Our study revealed a significant reduction of estimated energy intake for both 1-month (z =-3.125, p\u0026thinsp;=\u0026thinsp;0.002) and 3-months (z = -2.417, p\u0026thinsp;=\u0026thinsp;0.016) post intervention.\u003c/p\u003e\n\u003ch3\u003eVegetables\u003c/h3\u003e\n\u003cp\u003eThere was a noticeable increase in KTRs consuming a minimum of 3 servings of vegetables per day after dietary counseling, from 5 KTRs at baseline to 11 at post-1-month and 3-month respectively. The overall vegetable consumption increased significantly 3-month post-intervention (z = -2.119, p\u0026thinsp;=\u0026thinsp;0.034). However, it was not statistically significant at 1-month post-intervention (z = -1.913, p\u0026thinsp;=\u0026thinsp;0.056).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFruits\u003c/h2\u003e \u003cp\u003eThere was a significant improvement in fruit consumption throughout the intervention period [post-1-month (z = -2.896, p\u0026thinsp;=\u0026thinsp;0.004), and post-3-month (z = -3.423, p\u0026thinsp;=\u0026thinsp;0.001)]. The number of KTRs who did not consume fruit had reduced from 10 (33.3%) at baseline to 4 (13.3%) at 1 month and remained the same at 3-month post-intervention. Moreover, the number of KTRs consuming at least 2 servings of fruit per day increased from 1 (3.3%) at baseline, to 8 (26.7%) and 7 (23.3%) post-1-month and 3-month respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eProtein source\u003c/h2\u003e \u003cp\u003eThe majority source of protein intake among KTRs was still animal based despite the benefit of plant protein had been highlighted throughout the dietary counselling sessions. Only 3 subjects switched to plant protein food as the main source of protein intake during the 1-month post intervention but this was not sustainable as they reverted to animal protein at 3-month post intervention.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eOutcome Post Intervention\u003c/h2\u003e \u003cp\u003eThe median proteinuria during baseline, post-1-month and 3-month were 0.80g/day (IQR, 1.21 g/kg IBW), 0.67g/day (IQR, 1.47 g/kg IBW) and 0.94g/day (IQR, 1.44 g/kg IBW) respectively. Our study showed that post-1-month intervention resulted in a significant reduction in proteinuria (z = -2.643, p\u0026thinsp;=\u0026thinsp;0.008), however, the described effect was not seen at 3-month post-intervention (z = -0.946, p\u0026thinsp;=\u0026thinsp;0.344). In addition, the intervention did not result in any changes of serum bicarbonate level, at post-1-month (z = -0.097, p\u0026thinsp;=\u0026thinsp;0.922) and 3-months (z = -0.550, p\u0026thinsp;=\u0026thinsp;0.582) with median serum bicarbonate of 24 mmol/L (IQR, 4 mmol/L) at baseline, with no differences at 1-month and 3-month post intervention. The median body weight during baseline, post-1-month and 3-month were 74.4 kg (IQR, 33.5 kg), 73.7 kg (IQR, 31.3 kg) and 72.8 kg (IQR, 32.7 kg) respectively. These results showed a consistent reduction of body weight throughout the study period [post-1-month (z = -3.379, p\u0026thinsp;=\u0026thinsp;0.001) and post-3-month (z = -3.503, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)]. A significant proportion (70%, n\u0026thinsp;=\u0026thinsp;21) of KTRs had weight reduction which ranged from 0.4\u0026ndash;7.8% at 1 month. The number increased to 80.0% (n\u0026thinsp;=\u0026thinsp;24) with weight reduction ranging from 0.4\u0026ndash;9.1% at the end of the study. Despite having lower calorie and protein intake post-dietary counseling, there were no significant changes of the serum albumin at 1-month (z = -1.098, p\u0026thinsp;=\u0026thinsp;0.272) and 3-month (z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.1000, p\u0026thinsp;=\u0026thinsp;0.271) post-intervention.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the changes in dietary protein, dietary acid load, proteinuria and body weight at baseline, post-1-month and 3-month of dietary intervention.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study showed that switching to a lower protein diet had a desirable effect of reducing proteinuria, however, dietary adherence was not sustainable in majority of the participants. Despite the perceived improvement in both vegetable and fruit intake among the subjects, most of them still source their protein intake from animals rather than plants.\u003c/p\u003e \u003cp\u003ePoor dietary compliance rate is well reported in most literature, (Ichimaru et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Lin et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), not surprisingly, our study had a similar finding. Furthermore, the majority of Malaysians prefer to eat out or eat at home with commercial packed food (Poulain et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In addition, a plant-dominant diet is less popular in Malaysia with an estimated only 4.9% of our population being vegetarian (Institute for Public Health (IPH), 2020) and this has restricted the food option of KTRs when they are eating out, thus resulting poor compliance rate. Dietary adherence and food preferences among renal patients are highly variable due to multiple factors. Dietary adherence was reported to be associated with psychosocial factors, including patients\u0026rsquo; knowledge, attitude, support, satisfaction, and self-perception of success (Milas et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e1995\u003c/span\u003e) while food preferences are greatly influenced by immediate family members and closest social circles (Tuorila, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). It is a worldwide challenge to promote patients\u0026rsquo; compliance with the tailored regime of dietary management, irrespective of the study population. Perhaps, a more frequent review by a dietitian physically or implementing a digital health literacy plan may improve the consistency of dietary adherence.\u003c/p\u003e \u003cp\u003eInterestingly, all the 4 KTRs in our study with chronic metabolic acidosis showed improvement with increased serum bicarbonate levels at the end of the study. Despite the positive effect, this was not significant based on statistical analysis due to low number of chronic metabolic acidosis in our cohort and poor recruitment rate (33.3% or 4 out of 12). Further study with a larger sample size should be pursued to investigate the effect of dietary intervention on chronic metabolic acidosis among KTRs.\u003c/p\u003e \u003cp\u003eWeight gain with increased body fat composition is common post-renal transplantation (van den Ham, Kooman, Christiaans, Leunissen, \u0026amp; van Hooff, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). This phenomenon may be attributed to immunosuppression medications such as corticosteroids. In spite of this, lifestyle modification and behavior intervention seem to be able to negate the negative metabolic impact of immunosuppressive therapy (Patel, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1998\u003c/span\u003e). Our study showed a significant decrease in energy intake at 1 month and 3-months post-intervention, which is in keeping with the principle of energy balance, that resulted a significant weight reduction. This finding confirmed that dietary intervention plays an important role in weight management post-transplantation and highlights the benefit of personalized dietary advice. With the significantly high prevalence rate of overweight and obesity in the transplant cohort, a dedicated dietary counselling program would be beneficial.\u003c/p\u003e \u003cp\u003eOur study showed significant improvement in vegetable, fruit and dietary protein intake post intervention, however, dietary sodium intake remained high among KTRs with the median salt intake of 7.7 g per day which did not differ much from baseline readings. Dietary sodium monitoring remains a challenging practice if eating out frequently. Eating out habit is common among working Malaysian (Ashari et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and may be one of the contributing factors of excessive salt intake. According to Malaysian Community Salt Survey, 79% of Malaysians consumed an excessive amount of salt with average salt intake of 7.9 g per day, which is much higher than the WHO recommendation of 5.0 g of salt per day (Ambak et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In keeping with most Malaysians\u0026rsquo; eating habits, majority of KTRs in this cohort consumed\u0026thinsp;\u0026gt;\u0026thinsp;5.0 g of salt per day. This may be due to 70% of the subjects are working, and eating out may be unavoidable, thus resulting in high salt intake despite proper diet advice.\u003c/p\u003e \u003cp\u003eStudies on the role of dietary intervention in improving KTRs\u0026rsquo; outcomes are scarce. Most of the published data using dietary approaches are observational studies. To our best knowledge, there were only 2 dietary interventional studies performed (Biesenbach, Zazgornik, Janko, Hubmann, \u0026amp; Syre, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e1996\u003c/span\u003e; Salahudeen et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e1992\u003c/span\u003e) for KTRs. Our study adopted a real-world approach where dietary counseling was conducted in the outpatient setting. The study design did not offer food or monetary incentives as each subject was encouraged to imbibe to dietary modification and put it into daily practice. The feasibility of this being incorporated into the clinical management of KTRs is highly promising as no extra human resources and costs are incurred.\u003c/p\u003e \u003cp\u003eThe limitation of this study is a very low number of KTRs with chronic metabolic acidosis, thus leading to an insufficient sample size to ascertain the impact of dietary intervention on serum bicarbonate. In addition, this study was conducted during the COVID-19 pandemic leading to a poor recruitment rate.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study showed that dietary counselling emphasizing protein restriction has resulted in a reduction of dietary protein intake and proteinuria. This finding highlights the importance of dietary intervention in complementing the pharmacological approach in treating proteinuria. However, the desired dietary pattern was not sustainable and further study is needed to analyze factors that may be associated with the sustainability of dietary adherence. The significant weight reduction observed in this study has surprised us but may potentially benefit those overweight and obese KTRs. We believe dietary intervention should be part of the multi-prong approach in managing KTRs for optimization of outcome. Standardized dietary guidelines would be crucial for the management of KTRs, however further studies are required to determine the optimal approach.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all the nurses in renal clinic and daycare for the co-operation during data collection and subject recruitment. This work was supported by Dietetic Department and Renal Unit of University Malaya Medical Centre.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate declaration\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll KTRs provided informed consent prior to their inclusion in the study. They were informed about the purpose, procedures, potential risks, and benefits of the research. Participation was entirely voluntary with no incentive provided, and all participants were informed of their right to terminate the intervention at any stage without any consequences. Confidentiality and anonymity were assured throughout the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study obtained approval from Medical Research Ethics Committee (MREC), University Malaya Medical Centre with MREC ID NO: 2019930-7877 and National Medical Research Register Malaysia (NMRR) with NMRR ID: NMRR-19-3494-52159.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no conflict of interest that might be perceived to influence the results and/or discussion reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a self-funded research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe raw data collected for this research was kept fully confidential as stipulated in the consent agreement signed by the subjects, hence the datasets created and/or analyzed during the current investigation are not publically available. However, they are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmbak R, He FJ, Othman F, Michael V, Mohd Yusoff MF, Aris T. Salt intake was higher among males and those with high BMI and waist circumference: introduction to the Malaysian Community Salt Survey (MyCoSS), a population-based salt intake survey in Malaysia. J Health Popul Nutr. 2021;40(Suppl 1):23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s41043-021-00229-y\u003c/span\u003e\u003cspan address=\"10.1186/s41043-021-00229-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmbuhl PM. Posttransplant metabolic acidosis: a neglected factor in renal transplantation? Curr Opin Nephrol Hypertens. 2007;16(4):379\u0026ndash;87. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MNH.0b013e3281bd8860\u003c/span\u003e\u003cspan address=\"10.1097/MNH.0b013e3281bd8860\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmer H, Fidler ME, Myslak M, Morales P, Kremers WK, Larson TS, Cosio FG. Proteinuria after kidney transplantation, relationship to allograft histology and survival. Am J Transpl. 2007;7(12):2748\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1600-6143.2007.02006.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1600-6143.2007.02006.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAshari L, Rashid A, Shahril MR, Lee YY, Kueh YC, Hakim BN, Mohamed J. Exploring the norms of eating-out practice among adults in Malaysia. Malaysian J Nutr. 2022;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.31246/mjn-2021-0008\u003c/span\u003e\u003cspan address=\"10.31246/mjn-2021-0008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBavanandan S, Yap YC, Ahmad G, Wong HS, Azmi S, Goh A. The Cost and Utility of Renal Transplantation in Malaysia. Transpl Direct. 2015;1(10):e45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/txd.0000000000000553\u003c/span\u003e\u003cspan address=\"10.1097/txd.0000000000000553\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBiesenbach G, Zazgornik J, Janko O, Hubmann R, Syre G. Effect of mild dietary protein restriction on urinary protein excretion in patients with renal transplant fibrosis. Wien Med Wochenschr. 1996;146(4):75\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlack AE. Critical evaluation of energy intake using the Goldberg cut-off for energy intake:basal metabolic rate. A practical guide to its calculation, use and limitations. Int J Obes. 2000;24(9):1119\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/sj.ijo.0801376\u003c/span\u003e\u003cspan address=\"10.1038/sj.ijo.0801376\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChauveau P, Koppe L, Combe C, Lasseur C, Trolonge S, Aparicio M. Vegetarian diets and chronic kidney disease. Nephrol Dial Transpl. 2019;34(2):199\u0026ndash;207. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ndt/gfy164\u003c/span\u003e\u003cspan address=\"10.1093/ndt/gfy164\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen E, Korah M, Callender G, de Aguiar B, R., Haakinson D. Metabolic Disorders with Kidney Transplant. Clin J Am Soc Nephrol. 2020;15(5):732\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2215/cjn.09310819\u003c/span\u003e\u003cspan address=\"10.2215/cjn.09310819\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGomes-Neto AW, Ost\u0026eacute; MCJ, Sotomayor CG, van den Berg E, Geleijnse JM, Berger SP, Navis GJ. Mediterranean Style Diet and Kidney Function Loss in Kidney Transplant Recipients. Clin J Am Soc Nephrol. 2020;15(2):238\u0026ndash;46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2215/cjn.06710619\u003c/span\u003e\u003cspan address=\"10.2215/cjn.06710619\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang Y, Tilea A, Gillespie B, Shahinian V, Banerjee T, Grubbs V, Saran R. Understanding Trends in Kidney Function 1 Year after Kidney Transplant in the United States. J Am Soc Nephrol. 2017;28(8):2498\u0026ndash;510. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1681/asn.2016050543\u003c/span\u003e\u003cspan address=\"10.1681/asn.2016050543\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIchimaru N, Nakazawa S, Yamanaka K, Kakuta Y, Abe T, Kaimori J-Y, Takahara S. (2016). \u003cem\u003eAdherence to Dietary Recommendations in Maintenance Phase Kidney Transplant Patients.\u003c/em\u003e Paper presented at the Transplant Proc.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIkizler TA, Burrowes JD, Byham-Gray LD, Campbell KL, Carrero JJ, Chan W, Cuppari L. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update. Am J Kidney Dis. 2020;76(3 Suppl 1):S1\u0026ndash;107. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/j.ajkd.2020.05.006\u003c/span\u003e\u003cspan address=\"10.1053/j.ajkd.2020.05.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInstitute for Public Health (IPH), N. I. o. H., Ministry of Health Malaysia. (2020). \u003cem\u003eNational Health and Morbidity Survey (NHMS) 2019\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJE H. Urine Concentration and Dilution: Regulation of Extracellular Fluid Osmolarity and Sodium Concentration. 12Vol. th ed. Canada: Saunders Elsevier; 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoshi, S., McMacken, M., \u0026amp; Kalantar-Zadeh, K. (2021). Plant-Based Diets for Kidney Disease: A\u0026nbsp;Guide for Clinicians. \u003cem\u003eAmerican Journal of Kidney Diseases, 77\u003c/em\u003e(2), 287\u0026ndash;296. doi:10.1053/j.ajkd.2020.10.003.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKramer H. Kidney Disease and the Westernization and Industrialization of Food. Am J Kidney Dis. 2017;70(1):111\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/j.ajkd.2016.11.012\u003c/span\u003e\u003cspan address=\"10.1053/j.ajkd.2016.11.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKramer H. Diet and Chronic Kidney Disease. Adv Nutr. 2019;10:S367\u0026ndash;79. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/advances/nmz011\u003c/span\u003e\u003cspan address=\"10.1093/advances/nmz011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLau WP, Ng KP, Ganapathy SS, Tah PC, Ismail R, Jalalonmuhali M, Lim SK. Prevalence Rate of Proteinuria and Metabolic Acidosis Among Kidney Transplant Recipients in a Tertiary Teaching Hospital and Its Relationship to Dietary Intake. Transpl Proc. 2022;54(2):355\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.transproceed.2021.12.019\u003c/span\u003e\u003cspan address=\"10.1016/j.transproceed.2021.12.019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevey AS, Eckardt KU, Tsukamoto Y, Levin A, Coresh J, Rossert J, Eknoyan G. Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2005;67(6):2089\u0026ndash;100. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1523-1755.2005.00365.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1523-1755.2005.00365.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin IH, Wong TC, Nien SW, Chou YT, Chiang YJ, Wang HH, Yang SH. Dietary Compliance Among Renal Transplant Recipients: A Single-Center Study in Taiwan. Transpl Proc. 2019;51(5):1325\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.transproceed.2019.02.026\u003c/span\u003e\u003cspan address=\"10.1016/j.transproceed.2019.02.026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMilas NC, Nowalk MP, Akpele L, Castaldo L, Coyne T, Doroshenko L, Snetselaar L. Factors Associated with Adherence to the Dietary Protein Intervention in the Modification of Diet in Renal Disease Study. J Am Diet Assoc. 1995;95(11):1295\u0026ndash;300. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0002-8223(95)00340-1\u003c/span\u003e\u003cspan address=\"10.1016/S0002-8223(95)00340-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel MG. The effect of dietary intervention on weight gains after renal transplantation. J Ren Nutr. 1998;8(3):137\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s1051-2276(98)90005-x\u003c/span\u003e\u003cspan address=\"10.1016/s1051-2276(98)90005-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePodadera-Herreros A, Alcala-Diaz JF, Gutierrez-Mariscal FM, Jimenez-Torres J, Cruz-Ares S, Arenas-de Larriva AP, Yubero-Serrano EM. Long-term consumption of a mediterranean diet or a low-fat diet on kidney function in coronary heart disease patients: The CORDIOPREV randomized controlled trial. Clin Nutr. 2022;41(2):552\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.clnu.2021.12.041\u003c/span\u003e\u003cspan address=\"10.1016/j.clnu.2021.12.041\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePoulain JP, Laporte C, Tibere L, Mognard E, Ari Ragavan N, Zadeh A, Ismail M. Malaysian Food Barometer (MFB): a study of the impact of compressed modernisation on food habits. Malaysian J Nutr. 2020;26:001\u0026ndash;17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.31246/mjn-2019-0042\u003c/span\u003e\u003cspan address=\"10.31246/mjn-2019-0042\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalahudeen AK, Hostetter TH, Raatz SK, Rosenberg ME. Effects of dietary protein in patients with chronic renal transplant rejection. Kidney Int. 1992;41(1):183\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTantisattamo E, Kalantar-Zadeh K. Dietary protein intake and plant-dominant diets to mitigate risk of allograft dysfunction progression in kidney transplant recipients. Curr Opin Nephrol Hypertens. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/mnh.0000000000000944\u003c/span\u003e\u003cspan address=\"10.1097/mnh.0000000000000944\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTuorila H. (2007). Sensory perception as a basis of food acceptance and consumption. In (pp. 34\u0026ndash;65).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan den Berg E, Engberink MF, Brink EJ, van Baak MA, Joosten MM, Gans RO, Bakker SJ. Dietary acid load and metabolic acidosis in renal transplant recipients. Clin J Am Soc Nephrol. 2012;7(11):1811\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2215/cjn.04590512\u003c/span\u003e\u003cspan address=\"10.2215/cjn.04590512\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan den Ham EC, Kooman JP, Christiaans MH, Leunissen KM, van Hooff JP. Posttransplantation weight gain is predominantly due to an increase in body fat mass. Transplantation. 2000;70(1):241\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Chen X, Song Y, Caballero B, Cheskin LJ. Association between obesity and kidney disease: A systematic review and meta-analysis. Kidney Int. 2008;73(1):19\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/sj.ki.5002586\u003c/span\u003e\u003cspan address=\"10.1038/sj.ki.5002586\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZainuddin AA, Nor NM, Yusof SM, Irawati A, Ibrahim N, Aris T, Huat FL. Under-reporting of energy and nutrient intake is a persistent issue in the Malaysian Adult Nutrition Surveys. Malaysian J Nutr. 2019;25(2):261\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"proteinuria, chronic metabolic acidosis, dietary intervention, protein restriction, dietary acid load","lastPublishedDoi":"10.21203/rs.3.rs-6266091/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6266091/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eProteinuria and chronic metabolic acidosis may negatively impact renal allograft survival. This study aims to evaluate dietary intervention in reducing proteinuria and correcting metabolic acidosis among kidney transplant recipients (KTRs).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis is a prospective dietary intervention study. KTRs have proteinuria\u0026thinsp;\u0026ge;\u0026thinsp;0.5g/day or chronic metabolic acidosis with serum bicarbonate\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;22 mmol/L for at least 2 readings in past 6 months were recruited. All recruited subjects were given 1-to-1 diet counselling for moderate dietary protein restriction at 0.8 g/ kg of ideal body weight (IBW) and high vegetable and fruit intake by a research Dietitian. All subjects were encouraged to replace animal protein with plant protein. The duration of the study was 3 months. Changes in proteinuria and serum bicarbonate levels pre and post dietary interventions were analyzed.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003e30 KTRs (26 with proteinuria and 4 with chronic metabolic acidosis) were enrolled and completed the intervention phase. Proteinuria reduced significantly post-1-month after the intervention (z=-2.643, p\u0026thinsp;=\u0026thinsp;0.008) in alignment with a significant reduction in dietary protein (z=-2.376, p\u0026thinsp;=\u0026thinsp;0.018) and dietary acid load (z=-2.149, p\u0026thinsp;=\u0026thinsp;0.032). However, this effect was not sustainable when the dietary protein intake increased at 3 months. Significant weight reduction was observed post-1-month (z=-3.379, p\u0026thinsp;=\u0026thinsp;0.001) and 3-months (z=-3.503, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) after dietary intervention. There were no statistically significant changes in serum bicarbonate post intervention.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur study shows that dietary intervention can induce a change in dietary pattern thus inducing reduction in proteinuria and body weight. Hence, dietary counseling should be part of the multi-prong approach in managing KTRs.\u003c/p\u003e","manuscriptTitle":"Outcome Of Dietary Intervention On Kidney Transplant Recipients With Proteinuria/ Chronic Metabolic Acidosis – A Single Cohort Prospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 19:35:21","doi":"10.21203/rs.3.rs-6266091/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"94ee24b7-fa78-4156-bc00-7650e9bd57d3","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-02T07:54:25+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-06 19:35:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6266091","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6266091","identity":"rs-6266091","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}