Understanding common nutritional concerns with immunosuppressants after transplant

According to the United Network for Organ Sharing (UNOS), there are over 105,000 individuals waiting for an organ transplant. The list of organs that can be transplanted has grown since the original successful kidney transplant and now also includes the heart, lungs, liver, intestine, and pancreas. To promote and optimize transplant function for the long term, immunosuppressant medications and a healthy diet play a significant role in the treatment of these individuals.

What are immunosuppressant medications?

After transplant, individuals need immunosuppressive medications to prevent organ rejection. Since the transplanted organ is considered “foreign” by the body, the initial response of the individual’s immune system is to attack the unrecognized organ. Immunosuppressive medications help to minimize this response and allow for the new organ to function.  

Often, two forms of immunosuppressives are needed and these include induction and maintenance medications. Maintenance medications are used indefinitely to prevent organ rejection, while induction medications are used with the initial transplant before being tapered in most individuals. Due to the many different types of medications and impact on the body, immunosuppressant medications may trigger unwanted side effects that range in severity and can influence a transplant recipient’s nutritional status.  

Immunosuppressant medications: Common types and side effects

Calcineurin inhibitors 

How the medication works: Inhibit normal calcineurin enzyme activity that promotes immune response 

• tacrolimus (Prograf®, FK 506®). Side effects: Gastrointestinal (GI) symptoms, mouth sores, increased potassium, hyperglycemia, hypomagnesemia
• cyclosporine (Neoral®, Gengraf®, Sandimmune®). Side effects: GI symptoms, oral candida, gingival hyperplasia, weight changes, altered electrolytes, hypertension (HTN), or dyslipidemia 

Mammalian target of Rapamycin (mTOR) inhibitor 

How the medication works: Limits the immune system by blocking mTOR, a protein kinase, used for energy by T-cells 

• sirolimus (Rapamune®, Rapamycin®). Side effects: Altered blood lipids, GI symptoms, mouth ulcerations, low potassium 
• everolimus (Zortress®). Side effects: GI symptoms, headache, loss of appetite, fatigue, anemia, weight loss, hypophosphatemia, hyperglycemia 

Fusion protein 

How the medication works:  Decreases immune function to prevent organ rejection 

• belatacept (Nulojix®). Side effects: GI symptoms, hyperglycemia, HTN, hyperlipidemia 

Anti-Proliferative 

How the medication works: Limits pathways that promote T- and B-cell production to prevent rejection  

• mycophenolate (Myfortic®, CellCept®). Side effects: GI pain, bleeding of gums, fruity breath, appetite changes, weight fluctuation 
• azathioprine (Imuran®). Side effects: GI symptoms, appetite change, weight loss 

Steroid 

How the medication works: Reduces organ rejection by inhibiting granulocyte function and offers an anti-inflammatory effect 

• prednisone (Deltasone®). Side effects: Hyperglycemia, GI symptoms, HTN, increased potassium, sodium & fluid retention 

Induction/Acute rejection 

How the medication works: Used with other immunosuppressants to decrease T-cell action or interleukin-2 receptor blocking antibodies to prevent organ rejection 

• anti-T cell globulin, (Thymoglobulin®). Side effects:  GI symptoms, rash, increased potassium, high or low blood pressure 
• basiliximab, (Simulect®). Side effects:  GI symptoms, headache 

Health concerns after transplant

Many individuals awaiting an organ transplant are considered a higher risk for malnutrition. Contributors to malnutrition can vary with each chronic disease and include an altered metabolic rate, insufficient oral intake, and in some cases, impaired nutrient absorption. Improving nutritional status after transplant is possible and a registered dietitian should be involved in this process to guide the patient as they navigate dietary changes.  

Other complications can also occur because of the need for chronic immunosuppression after transplant. While diabetes, dyslipidemia, and HTN are more commonly recognized in some individuals because of medications, changes with normal GI function and gout are also potential side effects. Recognizing concerns or new complications and adjusting the treatment plan with diet and medications is helpful in managing any of these undesired health changes.  

Nutrition considerations after transplant

With immunosuppression after transplant, certain dietary recommendations should be encouraged to maintain a healthy transplant function. Consider the following tips when providing diet education with these patients.  

Macronutrient distribution: Individual needs may vary after transplant, and this can determine the appropriate amounts of carbohydrate, protein, and fat. A nutritious diet is recommended to support a healthy weight and other comorbidities such as HTN or diabetes should be considered when determining the best diet approach.  

Food safety: Preventing foodborne illness after transplant is necessary because of the individual’s compromised immune function. Caution should be taken to ensure all fresh foods are washed (as needed) and stored properly. When preparing a meal, avoid cross contamination of raw meat with fresh produce and ensure that items needing cooked are well done.  

Herbal supplementation: Use of herbal supplements after transplant is typically contraindicated. The primary concern is that the herbal supplement will interfere with immunosuppressant action causing an increased risk for organ rejection or medication toxicity. Individuals interested in taking herbals after transplant should discuss any supplements with their physician.  

Drug-nutrient interactions: Certain foods should be avoided when taking immunosuppressive medications to prevent a drug-nutrient interaction. Experts recommend eliminating grapefruit and grapefruit juice, Seville oranges, pomegranate juice or fruit, and black licorice. These foods in particular can increase the effectiveness and levels of certain immunosuppressants in the body, which can be harmful in the transplant patient.  

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References:

Collins M, Tomic R, Myers C, et al. Malnutrition in lung transplant recipients: weighing the outcomes. J Heart Lung Transplant. 2022;41(4):S405. 

Fortier L. Malnutrition, frailty, sarcopenia, obesity- optimizing nutrition care in liver transplantation. AME Med J. 2018;3(22):1-11. 

McCann L. Pocket Guide to Nutrition Assessment of the Patient with Kidney Disease. 6th ed. National Kidney Foundation;2021. 

Nutrition Care Manual. General Guidance for Organ Transplant. Available at: https://www.nutritioncaremanual.org/adult-nutrition-care. Accessed July 29, 2022. 

Phillips S, Gonyea J. Clinical Guide to Nutrition Care in Chronic Kidney Disease. 3rd edition. Chicago, IL: Academy of Nutrition and Dietetics;2022. (Publication pending) 

United Network for Organ Sharing: Organ Transplant. Available at: https://unos.org/transplant/. Accessed July 28, 2022. 

WebMD. Common Health Problems After an Organ Transplant. Available at: https://www.webmd.com/a-to-z-guides/organ-transplant-staying-healthy. Accessed July 29, 2022.