Nutritional strategies in kidney transplantation: optimising outcomes beyond surgery

Although kidney transplantation (KTx) remains the optimal therapy for end-stage kidney disease, long-term graft survival and patient outcomes continue to be limited by cardiometabolic complications and chronic allograft dysfunction. Nutritional management has evolved from supportive care to a core component of post-transplant follow-up. The early post-transplant phase is marked by catabolism, high-dose immunosuppression, and metabolic instability, leading to increased protein requirements but also potential susceptibility to hyperfiltration injury. In the stable post-transplant phase, a moderate protein intake similar to that recommended for chronic kidney disease (CKD) may support graft longevity, although evidence in kidney transplant recipients (KTRs) remains limited and inconsistent. Plant-forward dietary models, including Mediterranean and DASH patterns, consistently improve cardiometabolic risk, inflammation, oxidative stress, and dietary acid load, with potential benefits for graft outcomes. Predominantly plant-based diets may further reduce uremic toxin generation and improve mineral metabolism, though careful monitoring for micronutrient deficiencies is required. Low-protein approaches, such as PLADO, remain largely theoretical in transplant populations, while ketogenic or very low-carbohydrate diets raise concerns regarding acid-base balance, renal hemodynamics, and long-term tolerability. Overall, personalised nutritional strategies tailored to graft function, immunosuppression, and metabolic profile are essential to optimise long-term transplant health.