Treating the Obese Dialysis Patient: Challenges and Paradoxes

Abstract

Obesity is a major epidemic in the general population and has added unique challenges to renal replacement therapy as choice of access, dialysis adequacy, and preparation for kidney transplantation may all be affected. There are few clinical studies on managing obese patients with end-stage renal disease (ESRD) and no accepted strategies for the variety of problems encountered in this population. Attempts at weight loss are generally advisable to prevent obesity-related surgical complications and improve patient and graft survival after kidney transplantation. This article reviews the unique aspects of managing obese patients with ESRD.

Intensive weight loss combining flexible dialysis with a personalized, ad libitum, coach‐assisted diet program. A “pilot” case series

“…The obesity epidemic does not spare dialysis patients, yet its treatment is highly controversial. Overweight and obesity on dialysis are good examples of reverse epidemiology . The weight‐to‐survival curve is U‐shaped and malnutrition exerts a negative effect on survival, in association with inflammation and atherosclerosis (MIA syndrome).…”

“…Dialysis patients are often on potassium‐ and phosphate‐restricted diets, thus limiting access to diets that are rich in vegetables and proteins. Furthermore, delivering an adequate dialysis dose to obese patients is difficult, and the effects of obesity and underdialysis may merge …”

“…Overweight and obesity on dialysis are good examples of reverse epidemiology. [1][2][3][4][5] The weight-to-survival curve is U-shaped and malnutrition exerts a negative effect on survival, in association with inflammation and atherosclerosis (MIA syndrome). Inflammation is however also a hallmark of obesity on dialysis, thus rendering the approach to these patients particularly difficult, and suggesting a need for comprehensive individualized evaluation.…”

Bariatric surgery in patients with reduced kidney function: an analysis of short-term outcomes

“…[7] demonstrated an increase in morbidity and mortality among hemodialysis patients compared to nonhemodialysis patients undergoing major abdominal surgery. In addition to perioperative risk, concerns over what is referred to as the 'obesity paradox', in which epidemiologic evidence suggests a survival advantage in hemodialysis patients with higher BMI, have called to question whether bariatric surgery should be offered to ESRD patients [8,9]. However, obesity is also an independent predictor of poor outcomes after kidney transplantation [10][11][12] and has been shown to be a barrier to accessing transplantation [13].…”

Challenges Associated with Managing End-Stage Renal Disease in Extremely Morbid Obese Patients: Case Series and Literature Review

“…Traditionally, the adequacy of HD is assessed by urea clearance, expressed as Kt/V. Large body size and the associated increase in body water (V) suggest the need for an increase in dialysis time to achieve a higher dialysis dose [25] . Thus, extremely morbid obese individuals are less likely to receive adequate doses of dialysis with average dialysis time, which seems to cause a negative influence on their survival [26] .…”