Impact of obesity on dialysis and transplant and its management

Abstract

The prevalence of obesity in the United States and the world is increasing to unprecedented levels. Obesity is defined as a body mass index (BMI) ≥30 kg/m 2 , severe obesity as a BMI ≥35 kg/m 2 , and extreme obesity as ≥40 kg/m 2 . 1 In 2015-2016, approximately 93.3 million or 39.8% of the USA adult population was obese, and by 2030 this is estimated to increase to more than 50%. 2 Obesity is also increasing in the dialysis and renal transplant population; the proportion of patients undergoing kidney transplantation who are obese (BMI ≥30 kg/m 2 ) is currently 60%. 3 This increased prevalence of obesity has posed new challenges to accessing, delivering, and maintaining optimal care of patients with chronic kidney disease, including those treated with hemodialysis (HD), peritoneal dialysis (PD), and kidney transplant. [3][4][5][6] Obesity is associated with a multitude of complications in the transplant recipient including delayed graft function, acute rejection, wound complications, prolonged hospitalization, new onset diabetes mellitus, cardiovascular complications, [7][8][9] and reduced graft survival. 4-6,10-17 Recognition of these associated complications has led many centers to limit transplant candidacy at a BMI of 35-40 kg/m 2 . Singularly, obesity has become a major obstacle to life-saving kidney transplant and is the third-most common reason for patients to be inactive on the kidney transplant waitlist. 18In this review, we discuss the morbidity associated with obesity and strategies to prevent and manage these complications, as well as medical and surgical treatment of obesity in the end-stage kidney disease (ESKD) population. | THE OB E S IT Y PAR ADOXParadoxically, obesity has been associated with increased survival in the HD population, while a normal or low BMI has been associated with worse outcomes. 19,20 In a meta-analysis of over 190 000 patients, obese patients were 34% less likely to die than those of normal BMI, 21 while the lowest all-cause and cardiovascular mortality was associated with a BMI of 40-45 kg/m 2 . 22 Multiple theories have been proposed to explain the 'obesity paradox'. First and foremost, it remains unclear that this represents a true 'cause and effect' relationship. Rather, this may reflect confounding by comorbid illness and/or inflammation, or survivor bias, that obese patients reaching ESKD are a highly atypical subgroup of the general obese population, most of which has died before reaching ESKD. This may also be a result of competing risks that the dialysis patient does not survive long enough for the increase in cardiovascular and other disease processes that are directly caused by obesity to manifest. 20,[23][24][25][26][27][28][29][30]

Associação entre estado nutricional, perfil lipídico e adequação dialítica de pacientes submetidos a hemodiálise / Association between nutritional status, lipid profile and dialysis adequacy of patients undergoing hemodialysis

“…Apesar do estado de eutrofia ter prevalecido em nosso trabalho, o excesso de peso obteve destaque em 2018 e 2020 (Tabela 1). Diwan et al, aponta que a obesidade está relacionada à dificuldade no acesso para diálise além das complicações associadas que interferem na qualidade das sessões, como congestão pulmonar, hipotensão intradialítica e dificuldade em estabelecer com precisão o peso seco 21 . Lin et al em seu estudo com 322 pacientes, encontrou que os obesos (IMC > 30 kg/m²) eram mais inflamados que os eutróficos pela avaliação da proteína C-reativa e interleucina-6 22 , constatando a importância do acompanhamento do IMC para inserção de estratégias de controle de peso nessa população.…”

Impact of Obesity in Kidney Diseases

“…The increasing prevalence of obesity produces a challenge for optimal care of patients in renal replacement therapy, in both hemo-and peritoneal dialysis [80]. In the case of hemodialysis, at 3 years, adiposity of the subcutaneous tissue produced problems with vascular access and a reduction in the catheter functionality.…”

Weight Loss Challenges in Achieving Transplant Eligibility in Patients With Kidney Failure: A Qualitative Study

“…Patients with a BMI ranging from 30-34.9 have an improved graft survival rate compared to patients with a BMI  35 9 . Obesity has become both a driver for the increased incidence of kidney failure and a barrier to treatment of patients with kidney failure 10 . The prevalence of obesity worldwide has shown a marked increase from the 1980s to the 2000s 11 .…”

“… 9 Obesity has become both a driver for the increased incidence of kidney failure and a barrier to treatment of patients with kidney failure. 10 The prevalence of obesity worldwide has shown a marked increase from the 1980s to the 2000s. 11 In the United States, between 2012 and 2014, nearly 40,000 dialysis patients had obesity as the sole contraindication to wait-listing for kidney transplant.…”