Obesity in CKD and Renal Transplantation 2017

Sheffield Kidney Institute
Obesity and CKD
Professor Meguid El Nahas, PhD, FRCP
Chairman, Global Kidney Academy
Sheffield, UK

I can think
for
myself….

5Whats
• What is this intervention FOR?
• What is the Evidence: VALIDITY ?
• What is the Relevance: UTILITY ?
• What is the RISK:BENEFIT?
• What is the COST:BENEFIT?

LOOSE WEIGHT GAIN WEIGHT

Tx
LOOSE WEIGHT LOOSE WEIGHT
GAIN WEIGHT

Tx
LOOSE WEIGHT
CKD

Eckell et al, 2005
US ~ 47 million (23.7%)

Tozawa et al, 2002
Okinawa Screening Program
Obesity

Chen et al, 2004
NHANESIII 1988-1994

MS and Incident CKD
Rashidi et al, 2007

Obesity and FSGS (ORG)

Does Obesity
accelerate
CKD
Progression?

BMI and CKD Progression
Lu et al, 2014

Herrigton et al, 2017

Okinawa Study

Now that you are Starting Dialysis…

Tx
LOOSE WEIGHT
GAIN WEIGHT
ESRD

Lu et al, 2014
BMI and Mortality in CKD

Kalantar-Zadeh et al, 2005
Obesity: Survival Advantage on HD

HD: All Cause Mortality and BMI
Park et al, 2014

and Maori/
ficant rela-
e mortality
cluded that
r death and
tive cohort
ty Wave II
nd that 5-y
0 compared
by log-rank
30 was not
ry recently,
and MHD
he USRDS
odels eval-
ity over 2 y
reas time-
odality for
FIGURE 3. Risk-adjusted survival curves for the 4 BMI (in kg/m2
)
categories at 5 y. The variables entered into the equation were age, sex,
hypertension, diabetes mellitus, left ventricular ejection fraction, hemody-
VANTAGES OF OBESITY IN DIALYSIS 547
Older Population with CHF

Obesity Paradox in ESRD

Stenvinkel et al, 2013

Clinical scenario
• Mrs A on ESRD with a BMI of 35kg/m² feels unwell since
trying to lose weight. Transplant surgeon tells her she
has to achieve a BMI of 30kg/m² before being listed for a
transplant.
• She asks why she is being denied a transplant when her
friend with a pre-transplant BMI of 43kg/m² was
successfully transplanted 10 years ago and has excellent
graft function

Now that you are on TxWL…
Restart

Tx
LOOSE WEIGHT
GAIN WEIGHT
Pre-Tx

Talk outline
• How does recipient obesity impact on post-
transplant outcomes?
• Is weight loss on dialysis safe?
• Transplantation or dialysis for the obese?
KEY POINTS

Recipient obesity associated with delayed
graft function
• 11,386 HD patients
underwent transplant
• 2001-2006
• High BMI associated
with a higher risk of
DGF
Molnar MZ et al. Kidney Int. 2011; 80(2) 218-24.

Relationship between graft loss and BMI at
transplant
• ANZDATA Registry data 1991-
2004
• Univariate analysis of 5684
patients
Chang, SH et al Transplantation. 2007. 84(8):981-987.

Relationship between Graft loss and BMI
at Transplantation
Chang, SH et al Transplantation. 2007. 84(8):981-987.
Obesity NOT associated with increased risk of graft loss or death

Risk factors for Graft Failure
Following Transplantation
Gore et al. American Journal of Transplantation. 2006;6:357-63

Obesity and Outcome Following Transplantation
• UNOS data. 1997-1999
• 27,377 recipients
Gore et al. American Journal of Transplantation. 2006;6:357-63

Pre-transplant BMI and mortality
transplanted 2001-
2007 in USA
• 5 year follow up
Obesity NOT associated with increased risk of graft loss
or death

Obesity NOT associated with
Graft Loss
or
Patient Death

High BMI does not associate with mortality in
Hemodialysis patients waitlisted for transplant
Molnar MZ et al. American Journal of Transplantation. 2011; 11(4) 725-736.
• 6 year registry data
• High BMI associated
with a lower risk of
mortality

Weight loss in Transplant Waitlisted Maintenance‐
Hemodialysis Patients associates with mortality
• 6 year registry data
• Case-mix adjusted
• Weight loss prior to
transplantation associated with
higher risk of mortality
Molnar MZ et al. American Journal of Transplantation. 2011; 11(4) 725-736.

Pre-transplant muscle mass and outcomes
post transplant
transplanted 2001-
2007 in USA
• 5 year follow up
Preserved muscle mass associates with improved
outcomes

Pretransplant Serum Albumin with Post Transplant‐
Outcomes in Kidney Transplant Recipients
Molnar MZ et al. American Journal of Transplantation. 2011;11(5) 1006-1015
• 2001-2006
• Case mix adjusted
• Low pre-transplant albumin
associated with higher risk o
DGF, mortality, graft-failure

Conclusions
• Obesity is associated with increased risk of DGF and
wound infections
• No evidence that weight loss prior to transplantation
positively impacts on post- transplant outcomes and may
be harmful.
• Transplantation in obese patients associated with
survival advantage compared to haemodialysis.
• Impact of obesity on graft and patient survival
comparable to other recipient comorbidities such as
diabetes

Death Rate Tx Obese v HD Obese
Gill et al, 2013

Obesity in CKD and Renal Transplantation 2017

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Editor's Notes