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Introduction

Dietary Advice after a Kidney Transplant

Now that you have had a kidney transplant you can enjoy a much wider choice of food and drinks. This is because your new kidney is clearing any excess potassium, phosphate, salt and fluid that the body does not need.

What you eat and your lifestyle is still important because after your transplant you may have:

• A larger appetite which can lead to unwanted weight gain

• Increased levels of cholesterol in your blood

• Increased levels of sugar in the blood which may lead to post transplant diabetes

• Risk of bone problems

• Increased risk of heart disease

A healthy diet and regular exercise can help you manage these problems and will help you reduce your risk.

You also need to be careful about food hygiene because your immune system (which normally fights infections) is being suppressed by the new drugs you are taking.

Food safety

Following your transplant you will be started on medication to prevent your immune system rejecting your new kidney. This medication suppresses your immune system, increasing your risk of food poisoning, therefore, it is a good idea to follow food hygiene and safety practices.

The following food hygiene practices will minimise your risk of food poisoning and should continue for the lifetime of the transplant as the immune system will remain suppressed:

 

Food hygiene practices

Cleaning Wash your hands before preparing, handling and eating food. Keep worktops, chopping boards and utensils clean at all times using hot soapy water, especially after contact with raw food. Change dish clothes and tea towels regularly and wash at 60ºC. Use a separate towel for drying hands. Never handle food if you are ill with diarrhoea and vomiting, and do not allow others with these symptoms to handle your food.

Cooking Always ensure that food is cooked thoroughly and as per the manufacturer’s instructions. When reheating food always check that it is piping hot. Do not reheat more than once. Eat cooked foods within an hour of cooking. Always follow the cooking instructions on the label. Do not eat food past its ‘Use-by’ date.

Chilling   Maintain your fridge and freezer at the correct temperatures.   Fridge:      between 0-5°C Freezer:    -18°C or lower A cool bag maybe useful when shopping to keep things cold until getting home. Do not overload your fridge or freezer and avoid buying foods from freezers and fridges which are overloaded. Cool cooked food as quickly as possible and then put in the fridge or freezer. Keep chilled food out of the fridge for the shortest time possible during preparation.

Cross contamination Cross contamination is when bacteria spread between food, surfaces and equipment. It is most likely to happen when raw food touches or drips onto ready to eat food, equipment or surfaces. Clean and disinfect work surfaces, chopping boards and equipment prior to preparing food and after you have prepared raw food.   Always cover raw meat/fish/ poultry and store at the bottom of the fridge.

 

Food safety: High risk foods to avoid and safe alternatives

Following food safety guidance is important for all those with a transplant, but is particularly important when high doses of immunosuppressive medication are recommended or when dose adjustments are being made.  This is likely to be the case within the first six months after transplantation but this will vary for each person.

You may want to discuss your level of immunity with your doctor and whether it is possible to reintroduce some of the higher risk foods. There is little evidence to guide when this is safe and you may or may not decide to do this.

This table should help you quickly identify which foods you should avoid and safe alternatives you can enjoy:

 

Food to avoid and safe alternatives

Foods	High risk, should be avoided	Have instead:
Milk	All unpasteurised milks.	All pasteurised milk or ultra-heat treated (UHT).    This includes cow’s milk, goats, sheep milk, soya, rice, oat and nut-based milks.
Yoghurts	Yoghurt which is described on the label as ‘bio’ or ‘probiotic’.	Any plain/natural, sour cream, Greek, fruit yogurt or lassi which does not describe itself as bio or probiotic.
	Large sharing pots of yoghurt.	Small single serving pots.
	Homemade yoghurts and cultured milks such as Kefir.
Probiotics and prebiotics	Probiotic drinking yogurts such as Yakult®, Actimel®, Supermaket own versions.	Prebiotic yoghurt/product (these contain substances which promote the growth of healthy bacteria.  They do not contain any live bacteria themselves).
Foods	High risk, should be avoided	Have instead:
Cheese	Cheese from the deli counter	Best to buy pre-wrapped cheese
		All pasteurised hard cheese Cheddar Red Leicester Edam Gouda Stilton (white) Pecorino Parmesan Hard goats’ cheese
	All unpasteurised soft cheese unless cooked until piping hot	Pasteurised soft cheese (check the label) Cottage cheese Mozzarella Feta Cream cheese Paneer, labnah Ricotta Halloumi Processed cheese such as cheese spreads (eg Dairylea®)
	Soft cheese – mould-ripened (white rind) Brie, Camembert and certain goats cheese eg Chevre.   Blue-veined cheese eg Stilton, Danish Blue, Gorgonzola Roquefort and Dolcelatte.   Homemade cheeses eg labnah/paneer.	Mould-ripened (white rind) and blue-veined cheese if cooked until piping hot.
Fish and Shellfish	* Fresh fish and shellfish from fishmongers or deli counters	* Pre-packaged fish, shellfish and smoked fish.  Eat within 24 hours of opening if eaten cold or cooked until piping hot.
	Raw fish and shellfish eg sashimi, oysters and caviar.	Raw fish and shellfish should be cooked until piping hot
* There is no evidence to support this advice. This has been recommended as the safest possible option.  If you prefer to buy fish from a fishmonger, then to reduce the risk of food borne illness it is best eaten at the earliest opportunity.
Meat and poultry	Raw, rare and undercooked meat and poultry.	Cooked meat and poultry served piping hot.
	Under-cooked BBQ meat.	Ensure BBQ meat is thoroughly cooked and served piping hot
	Deli counter meat and poultry.	Sealed pre-packed meat and poultry.
	Rotisserie chickens.	Cooked and sealed chicken from the chilled cabinet.
	Cured meat*.	Safe to use in cooking if cooked thoroughly and piping hot.   Purchase in sealed packets only.
* To reduce the risk of food borne bacteria cured meat can be eaten if frozen after purchasing (ideally pre-packaged), for four day before consumption.  The meat should be defrosted thoroughly in the fridge for 24 hours before eating and leftovers discarded.
Please note: There have recently been a few cases where people who are immunosuppressed after a transplant have been infected with Hepatitis E Virus (HEV).  This was possibly due to eating under-cooked pork or pork products (such as sausages, bacon, cured meats and offal).  Cook all meat thoroughly and take particular care with barbequed meat as this can sometimes be undercooked. Try baking it first, then finish cooking it on the barbeque for added flavour.
Foods	High risk, should be avoided	Have instead:
Eggs	Uncooked eggs or partially cooked egg.	Thoroughly cooked lion-stamped eggs.   Store in the fridge.
	Sauces or desserts that may contain raw or undercooked eggs eg mayonnaise or chewy meringue.   Raw cookie dough or cake batter.	Mayonnaise or salad cream made with pasteurised egg.
Pate	Meat and vegetable pate.	Pasteurised pate and paste in tins and jars that do not need to be refrigerated.   Homemade vegetarian pate
Rice	Rice from a take-away.	Cook your own rice at home when ordering a take-away
	Reheated rice.	Rice should be served hot and eaten immediately after it is first cooked
Sushi	Homemade sushi   Ask your dietitian for further advice if you wish to eat home-made sushi.	Shop bought sushi   Check the use by date Buy from the chiller cabinet and ensure packaging intact. Store in fridge until eaten.
Fruit, vegetables and salad	Unwashed fruit, vegetables and salad.	All other fruit, vegetables and salad providing they are washed thoroughly to remove all traces of soil and visible dirt.
	Raw sprouted seeds e.g. beansprouts.	Cooked sprouted seeds and beansprouts
Drinks	Unpasteurised fruit juice or smoothies.	Pasteurised fruit juice and smoothies.
	Slush puppies.	Homemade juices and smoothies if all fruit and vegetables thoroughly washed before use.
Foods	High risk, should be avoided	Have instead
Pre-packed sandwiches or take away freshly made sandwiches	Avoid high risk fillings eg unpasteurised cheese and cured meats.	Pre-packaged sandwiches. Eat within the use by date. Toasted sandwiches must be served piping hot.
Ice cream	Whipped ice-cream from an ice cream van.	All other purchased ice cream. Caution should be taken to ensure ice-cream is not thawed and re-frozen.
	Homemade ice-cream with raw egg.	Homemade ice cream with a pasteurised egg substitute.
Miscellaneous	Unpasteurised or ‘farm fresh’ honey and honeycomb.	Pasteurised or heat-treated honey, and ideally use individual sachets or portions

Food safety: Eating out and takeaways

Eating out or consuming takeaways within the first 6-8 weeks after transplantation should be avoided. After this period, eating out can be enjoyed when following these basic principles:

• Check the eating area is clean and tidy.

• Avoid all high risk foods on the menu.

• Try to order a plated meal that is cooked fresh to order rather than a carvery, salad bars or buffet.

• Ensure your meal is piping hot and thoroughly cooked when it arrives.

• Avoid rice that has already been cooked; ask for it to be cooked fresh or choose another option such as potato, pasta, chips, chapatti or noodles.

• Beef burgers should be well done, even if they are freshly made.

• If you need to eat from a buffet it is recommended you try to be the first in the queue and not to go back for further servings as there is a risk the food may have been contaminated by other diners.

• Caution should be taken when eating food from a street vendor. The food may have been stored at incorrect temperatures allowing the perfect environment for the growth of food borne bacteria.

• Consider the previous advice about raw egg in sauces, desserts and other foods as previously listed

The Food Standards Agency website (http://ratings.food.gov.uk) provides information with regard to the overall cleanliness of a business and whether it is a suitable place to eat at.  You can also look up the hygiene rating for all restaurants.  Where possible, try to go for 5 star establishments.

Food safety: Eating and drinking abroad/foreign countries

It is especially important to be very vigilant with food safety when eating abroad. The following tips will help reduce risk of food poisoning:

Drinks

• Avoid drinking tap water outside the UK, ice and beverages made from tap water and fresh fruit juice.

• Drink bottled or canned beverages.

• Boil tap water if it is to be used.

• Some people may prefer to brush their teeth with bottled or cooled boiled water to prevent any risk of contamination.

Food

• Hot food should be served piping hot.

• Avoid any foods that may have been washed in tap water such as salads and fruit.

• Select vegetables and fruit that can be peeled.

• Caution should be taken with hotels offering buffet style restaurants as described in the ‘Eating out and Takeaways’ section.

Dietary restrictions

Before your transplant you may have been advised to cut down on foods and drinks high in potassium and phosphate as well as limit your fluid. Once your new kidney is working well many of these restrictions may be relaxed.

High potassium and phosphate levels:

Although unlikely, it is important to be aware that some people may need to continue a potassium or phosphate restriction after their transplant. This would normally be in the first few days or weeks post-transplant. Speak to your dietitian, consultant or specialist nurse if you are unsure.

Low phosphate levels:

Occasionally, after a transplant people may experience low phosphate levels. It is unclear whether this can be alleviated with higher phosphate foods and often this has to be replaced with medication. However, if you wish to try to increase your levels in your diet ask to speak to your dietitian.

Salt :

It’s still really important to continue following a low salt diet, eating no more than 6g of salt a day, which is about a teaspoon. Much of the salt in our diet comes from processed foods. It’s not just in ready meals, soups and sauces, though – keep an eye on everyday foods such as breads and cereals, as well as sweet foods.  Read food labels to make sure that you are making low-salt choices, or use the free health app, FoodSwitch, which tells you which foods are less salty.

Fluid:

It is important to keep your new kidney healthy, the doctors will tell you how much to drink each day.

• Water, tea, coffee and herbal teas without added sugar are the best options.

• It’s advisable you limit your intake of sugary drinks or high fat drink e.g. milk shakes.

Foods that interact with your new medications

Some foods and herbal remedies can interact with immunosuppressive medications and reduce their ability to function. It is not recommended to take any ‘alternative’ medicines (e.g. herbal or homeopathic) or high dose vitamins without first discussing it with the transplant team.

Grapefruit and grapefruit juice, pomelo, pomelo juice and star fruit can affect the level of medication in your blood and therefore these should be avoided.

Bone health

Following your renal transplant you may be at increased risk of diseases which affect your bones. Steroid therapy and some immunosuppression can also weaken bones. It is therefore important to minimise the risk of your bones thinning and of fractures by ensuring that you have an adequate intake of calcium and vitamin D. The list below contains foods that are rich in calcium. Aim to have a minimum of 3 - 4 portions of calcium rich foods each day.

High sources of Calcium

High sources of Calcium

Milk: if choosing non-dairy milk such as soya or rice milk check the labels to make sure that they are fortified with calcium. Cheese Yoghurt and yoghurt drinks Tofu Tinned fish especially sardines, pilchards and salmon (if the bones are eaten) Sesame seeds and tahini (sesame seed based paste) Ready Brek® or own brand hot oat cereal fortified with calcium

Moderate sources of Calcium

Cottage cheese Pulses especially baked beans, soya beans, broad beans, red kidney beans and chick peas Nuts, almonds, brazil nuts, hazel nuts Dried figs White bread and white flour products Fortified breakfast cereals

If you are struggling to meet the recommended amount of calcium through diet alone, a calcium supplement may be appropriate , your dietitian will advise.

Vitamin D

Vitamin D helps you to absorb calcium from your food. The main dietary sources of vitamin D are:

Skimmed milk powder (with added vitamin D)

Margarine and low fat spread

Oily fish such as mackerel

Fortified breakfast cereals

Eggs

The best source of vitamin D is safe sun exposure. However, transplant patients need to be careful as the immunosuppression medication you take can increase the risk of skin cancer. If you are concerned then your vitamin D level can be measured and a supplement can be prescribed by your doctor if required.

Lifestyle and bone health

Incorporating the following healthy lifestyle habits can also have a positive effect on your bone health:

• Maintaining a healthy body weight (BMI 20-25kg/m²).

• Weight bearing, high impact and strengthening exercises (eg walking, tennis, dancing, weight training).

• Not smoking.

• Drinking less alcohol. Current guidance is no more than 14 units of alcohol per week for both men and women.  

Example of units in alcoholic drinks:

Alcoholic drinks

1 unit	1 single shot (25ml) of spirit Or ½ pint low-strength (3.6%) lager, beer or cider
2 units	1 pint of low-strength (3.6%) lager, beer or cider Or 1 glass (175ml) of 12% wine
3 units	1 pint higher-strength (5.2%) lager, beer or cider Oor 1 large glass (250ml) of 12% wine

Healthy eating after a transplant

Once your kidney transplant is working well, looking after your diet and lifestyle are important. This is because some people develop side effects from their medication, such as:

• Increased appetite

• Weight gain

• Increased blood cholesterol

• Increased blood sugars

• These can all increase your risk of heart disease or developing diabetes known as Post Transplant Diabetes Mellitus (PTDM)

If you would like further dietary advice regarding healthy eating, weight reduction or diabetes, please speak to your dietitian or ask your doctor to refer to a dietitian.

Reducing your risk of heart disease and developing post-transplant diabetes

Dietary and lifestyle changes can help reduce your risk of heart disease and diabetes, these include:

• Achieving and maintaining a healthy weight (BMI within 20-25kg/m²).

• Performing physical activity within the NHS guidance.

• Stop smoking.

• Healthy eating, following the ‘Eat Well Guide’.