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The impact of nutrition and physical activity on long‐term survival after pediatric solid organ transplantation

Patients with chronic renal failure and their relatives are accustomed to follow sometimes extreme restrictions in dietary and fluid intake. Hence, one of the most positive aspects of kidney transplantation is that such restrictions belong to the past and are not required again. However, is this the reality, or will there be other restrictions and recommendations, not only after kidney transplantation, but after all solid organ transplantations? Sport is regarded as an integral part of the treatment, for example in coronary artery disease and in other chronic diseases in adult medicine (1). Recently, publications about endurance training in chronically ill pediatric and adolescent patients have emerged, indicating the importance of routine training on endurance, quality of life and hence better social integration of the chronically ill child (2). However, sport is not routinely implemented in treatment either before or after transplantation; would it not be better if it were? What kind of situation arises after transplantation? Despite all efforts to optimize dietary (calorie) intake and to improve all secondary measures involving the underlying disease (e.g., involving either kidney, liver, or heart), nutrient status before transplantation frequently is worse, or extremely imbalanced. For example, in patients who underwent liver transplantation, a high prevalence of obesity before and after the transplantation is described in both adult and pediatric liver transplant recipients (3). In addition, endurance capacity and quality of life are often limited, due to malnutrition, the underlying disease, acute medical problems or even due to motivational/psychologic issues arising during the course of the disease (4, 5). Immediately after transplantation, at least the dietary situation changes dramatically because of positive perceptions and accumulated needs, as well as triggered by immunosuppressive medication, for example, corticosteroids. What impact do malnutrition, unbalanced nutrition and the ‘‘no-sports mentality’’ have after transplantation? Does such behavior result in worse transplant function, possibly related to non-immune-regulated chronic rejection? How can endurance capacity be increased? Will the increase in physical fitness impact positively related to long-term graft survival? Next to immunologic and anatomic issues, which are definitively a necessary part of therapeutic interventions after transplantation, a variety of other parameters can be influenced by a balanced diet and training interventions: blood pressure, anemia, diabetes mellitus, arteriosclerosis, the metabolic syndrome and others. Does this necessarily mean that dietary restrictions are (again) required? Can an unbalanced diet be compensated for by regular training? How much is the diet influenced by immunosuppressive medication? It is well known that dietary advice, for example, modified, normal protein supply will lead to more stable long-term graft function. Also, a diet less in calories and fat intake will reduce steroid-induced obesity and hypertension. Such modifications will achieve better physical fitness, improved well-being and, in long-term follow-up, better adherence to medication and thus transplant function. The negative side effects of medication on calorie intake and subsequent metabolic syndrome/obesity (steroids), as well as on hyperlipidemia and/or hyperuricemia (steroids, calcineurin inhibitors, M-TOR inhibitors) are well known. Therefore, steroid treatment is either completely avoided or usually tapered rapidly and stopped as early as possible after the Pediatr Transplantation 2012: 16: 675–677 2012 John Wiley & Sons A/S.