Stephan Bakker, Professor of Internal Medicine in the University Hospital of Groningen, and founder of the databiobank Transplantlines was quick to see the important role of nutrition: ‘’In transplant patients, health behavior such as not smoking, a healthy diet, regular exercise and muscle strength is even more important than in healthy people.”
Decreased fitness before surgery
When someone needs an organ transplant, whether it is a new lung, a hart, a kidney or a liver, he has usually been ill a long time before the transplant. Because patients become inactive, their fitness degrades. A decrease of muscles tissue, appetite and movement can result in the ´metabolic syndrome´, a combination of different metabolic complaints. These complaints aggravate the already unhealthy condition of the body due to organ failure.
New habits to prevent overweight
When the dysfunctional organ is replaced with a functioning organ, the metabolic syndrome can worsen in a short matter of time. Bakker: ‘’Patients were used to drinking energy-rich medical drinks and being inactive, on top of this, medication that is often needed after transplantation increases their appetite. Therefore, aftersurgery they need to stop drinking those, and start learning new healthy habits to prevent gaining weight.
Whipping cream for patients
‘’As a student on the dialysis department, I always had to serve whipped cream to our kidney patients. I was thinking to myself: this cannot be right’’, Bakker explains. In those years, it was unthinkable to investigate the role of nutrition in the health outcome of transplant patients. Therefore, Bakker was not able to find funding. Bakker laughs: ‘’I needed to come up with a smart move. Sometimes, we were investigating something about nutrition in the healthy population, so I addied some additional money so I could investigate it in our patient population too.”
TransplantLines: Evidence first
This way, Bakker first decided to collect evidence in order to receive follow-up grants for research into the role of nutrition in organ transplants, and so the TransplantLines database was born in 2001. The goal was to draw a picture of which factors enhance the chances of recovery, and to identify the risk factors, starting with kidney patients. Patients were questioned and examined before and multiple times after transplant surgery. By analyzing these data and publishing the scientific results, a solid basis was for future grant applications was formed. Nowadays, TransplantLines has grown into, which also includes information about health behavior and nutrition.
Examining dietary habits through urine
Bakker says he collected – due to lack of funding for nutrition questionnaires- 24h-urine samples in his first cohort. ‘’It started as an emergency solution, but it turned out to be a good idea in the end. Nowadays 24h-urine is the golden standard in nutritional research, as you can see exactly what someone has eaten in terms of protein, sodium, potassium, iodine for example.’’
Prevention: biofeedback at the outpatient clinic
Patients that participated in this study do have profited quite a bit themselves already. "Currently, at the outpatient clinic Transplant Medicine at the UMCG, we pay a lot of attention to health behavior." Bakker created a special form of biofeedback – i.e. educating patients about healthy behavior by showing signals of their own body. “It is now standard clinical practice to ask patients to collect 24 h urine samples. We will inform them about the urine test results, and we can tell them whether they have eaten healthy, how their muscle mass is growing, and things like that."
A benefit of a database is that the relationship between different predictors can be extensively investigated. Sometimes not one factor, but a combination of them, predicts the future . Or, you discover that a specific advice like ‘eat nuts’ works better than a broad advice like ‘have a varied diet’. This requires a lot of cooperation within and outside the UMCG. “You have to learn to speak each other's language, maintain good relations, and give each other room for each other's own expertise,” says Bakker.
Sometimes you start working with partners that may not seem obvious. Bakker, for example, works together with the company DSM, which is involved in animal nutrition, among other things. Reducing the use of antibiotics in chickens and pigs is an important goal for them. Animals often receive anitbiotics because they often have diarrhea.
Diarrhea is also a major problem for transplant patients. Patients often don't mention it themselves, but it is persistent and very disabling. Bakker: “So I spotted an opportunity. Normally we use lab animals to solve problems in humans, but this time we had a human model for a problem in animals. By now comparing people with and without diarrhea, we hope to be able to find nutrition to reduce the symptoms of diarrhea.”
Next to to all possible collaborations within the UMCG, international collaboration is broadly structured. A nice confirmation of the approach of TransplantLines is that scientists have now organised themselves internationally to collaborate in research into nutrition in kidney patients: Bakker is on the board of the European Renal Nutrition Working Group.
Read more about Transplantlines.