A new research paper that was recently published in The Lancet Healthy Longevity alongside an accompanying comment article suggest that postoperative diet and exercise guidance can be beneficial for health-related quality of life (HRQoL) in patients who have received a kidney transplant, but that maintaining these improvements can prove to be challenging for some patients.
The research, conducted by Eva Corpeleijn (University Medical Center Groningen, Groningen, The Netherlands) et al, was a multicentre, open-label, parallel-group, randomised controlled trial (RCT) among patients who have received a kidney transplant between October 2010 to November 2016. Participants from six hospitals across The Netherlands were randomly assigned 1:1:1 by an independent company into: usual care, exercise, and exercise plus diet. The exercise intervention encompassed a three-month supervised exercise programme (twice weekly) combined with 15 months of lifestyle coaching, with 15 months of additional dietary counselling (12 sessions) for the exercise plus diet group. The primary outcome measure was HRQoL-domain physical functioning, assessed using the 36-item Short Form Survey (SF-36) at 15 months.
The study cohort included 221 participants who had received a kidney transplant, 138 (62%) who were male and 83 (38%) who were female, who were included and randomly assigned to usual care (n=74), exercise intervention (n=77), and exercise plus diet intervention (n=70). In the intention-to-treat analyses, at 15 months post-baseline, no significant differences in HRQoL-domain physical functioning were found for the exercise group (5.3 arbitrary units, 95% confidence interval (CI) –4.2 to 14·9; p=0.27), and the exercise plus diet group (5.9 arbitrary units, -4.1 to 16.0; p=0.25) compared with the control. The authors stated that the safety outcomes showed no concerns. After three months of supervised exercise intervention, HRQoL-domain physical functioning improved in the exercise group (7.3 arbitrary units, 95% CI 1.2 to 13.3; p=0.018) but not in the exercise plus diet group (5.8 arbitrary units, -0.5 to 12.1; p=0.072).
Speaking to Renal Interventions, Corpeleijn expanded on some of the challenges that the research team encountered when attempting to improve the HRQoL for patients who have received a kidney transplant.
“What you really see quite clearly,” she stated, “is that after the three-month period of intense exercise support, patients improve in quality of life physical functioning. But if you look at 15 months, at the end of the whole programme, [the improvement] is no longer significant. This is not because the whole group went back to baseline in their values, but rather that there’s huge heterogeneity in what happens to these patients in the long term. You see that, in general, most people actually still do well, but there’s also a fair group that doesn’t do well after such a period.”
Further, Corpeleijn et al identify that the most effective of the three tracks was the exercise programme, and Corpeleijn did highlight to Renal Interventions that it was difficult to distinguish between the effectiveness of the exercise group versus the combination of exercise and diet.
“For the diet component, separately, we are not sure [how effective it was]. With diet and exercise, we saw a significant reduction in serious adverse events. So something is happening there, but we’re not sure if it’s because of diet, or because of more intense follow-up after transplantation; [patients] see the care professionals more, they’re more aware, and maybe they’re even more compliant to medication use because they’re seen more by someone on the clinical team. So we have to [identify whether exercise or diet is more effective] first.”
Implementation of diet/exercise measures could also present an additional roadblock for improving HRQoL for kidney transplant patients. According to Corpeleijn, dietary care is already quite well organised in The Netherlands, so it was “relatively easy to implement”, but the exercise programme was a challenge to start with. “[The exercise programme] looks like an ordinary rehabilitation programme for people who have cancer or cardiovascular problems, but it’s more specialised. It’s also a little bit different because it’s a long-term programme. We developed it so that the lifestyle changes would be more sustainable, so that patients were directed to stay active when they are back in their home environment.” This was the issue that the team encountered, because, as they found out, a more extensive infrastructure is needed in order to offer this lifestyle programme.
The final obstacle that the research highlighted as an impediment to improving HRQoL for kidney transplant patients is a lack of awareness of the support that is already available. “What is so interesting,” Corpeleijn averred, “is that there are options for patients to undergo rehabilitation or receive support for their recovery, but it’s not being used. It’s not being discussed with the patients on what they could do to benefit their recovery.” Their main message, for both the professionals and patients alike, was to start talking about post-operative recovery and look for opportunities that are there. “We are giving people new organs,” Corpeleijn concluded, “but we also have to give them a new start. If your doctor doesn’t start talking about recovery, as a patient, you should start talking about it yourself; ask them “what can I do? How can you help me recover?”
