*Purpose: The treatment of Mycophenolate mofetil (MMF) related diarrhea in kidney transplants recipients involves providing lower MMF doses more frequently to maintain the same daily dose. However, this fractionated dosing regimen is associated with reduced adherence to immunosuppression and poor outcomes. We hypothesized that dietary fiber or polyols intake post-transplantation would be associated with MMF-related diarrhea.

*Methods: The Microbiome and Immunosuppression in Kidney Transplantation (MISSION) study used Mosio, Inc (Seattle, WA) to implement a HIPPA compliant text-based survey. The survey was sent for up to 6 months post-transplant on a bi-weekly basis, to collect diarrhea information from 8 participants receiving MMF and Tacrolimus. Diarrhea events were defined using the V 5.0 definition of the National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE). The cohort was dichotomized based on development of diarrhea events of CTCAE grade 2 (increase of 4-6 stools per day compared to the previous week). Baseline 48-hour food recalls were collected one-week post-transplant for 7 of the 8 participants using the Nutrition Data System for Research.

*Results: Over 4 months of follow up, 242 diarrhea surveys were completed and 15 diarrhea events were reported (Figure 1). The median time to the first reported diarrhea event was 17.5 days post-transplant (range: 2-79 days). We did not observe a difference in dietary fiber intake based on diarrhea outcomes. However, participants who developed diarrhea appeared to have higher intake of the polyols mannitol (median: 0.45g, range: 0.43-0.47g) and sorbitol (median: 0.03g, range: 0.02-0.1g), compared to participants who did not (median: 0.04g, range:0.02-0.24g and median 0g, range: 0-0.01g for mannitol and sorbitol, respectively) (Table 1).

*Conclusions: These preliminary findings suggest an increased dietary intake of polyols may contribute to the development of MMF related diarrhea. Mannitol and sorbitol have an osmotic action in the small intestine and are readily fermented by colonic bacteria, leading to altered bowel habits. The prospective collection of diarrhea, nutrition and microbiome data will contribute to future interventions to reduce incidence of MMF-related diarrhea in kidney transplantation.

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