Does the Obesity Survival Paradox of Dialysis Patients Differ with Age?

Calabia, Jordi; Arcos, Emma; Carrero, Juan Jesús; Comas, Jordi; Vallès, Martí

doi:10.1159/000374102

Cited by 17 publications

(18 citation statements)

References 28 publications

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“…A number of studies have attempted to evaluate the interaction between obesity, age and long-term survival in HD patients, but have reported conflicting results (32, 36, 37). Hoogeveen et al (32) prospectively followed patients from a European cohort of HD patients and examined the association of age (<65 or ≥65 years) and baseline BMI (<20, 20-24 [reference], 25-29, and ≥30 kg/m 2 ) with mortality.…”

Section: Obesity and Mortality In Esrd Treated With Hdmentioning

confidence: 99%

Obesity Paradox in Advanced Kidney Disease: From Bedside to the Bench

Naderi

Kleine

Park

et al. 2018

Progress in Cardiovascular Diseases

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While obesity is associated with a variety of complications including diabetes, hypertension, cardiovascular disease and premature death, observational studies have also found that obesity and increasing body mass index (BMI) can be linked with improved survival in certain patient populations, including those with conditions marked by protein-energy wasting and dysmetabolism that ultimately lead to cachexia. The latter observations have been reported in various clinical settings including end-stage renal disease (ESRD) and have been described as the "obesity paradox" or "reverse epidemiology", engendering controversy. While some have attributed the obesity paradox to residual confounding in an effort to "debunk" these observations, recent experimental discoveries provide biologically plausible mechanisms in which higher BMI can be linked to longevity in certain groups of patients. In addition, sophisticated epidemiologic methods that extensively adjusted for confounding have found that the obesity paradox remains robust in ESRD. Furthermore, novel hypotheses suggest that weight loss and cachexia can be linked to adverse outcomes including cardiomyopathy, arrhythmias, sudden death and poor outcomes. Therefore, the survival benefit observed in obese ESRD patients can at least partly be derived from mechanisms that protect against inefficient energy utilization, cachexia and protein-energy wasting. Given that in ESRD patients, treatment of traditional risk factors has failed to alter outcomes, detailed translational studies of the obesity paradox may help identify innovative pathways that can be targeted to improve survival. We have reviewed recent clinical evidence detailing the association of BMI with outcomes in patients with chronic kidney disease, including ESRD, and discuss potential mechanisms underlying the obesity paradox with potential for clinical applicability.

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Section: Obesity and Mortality In Esrd Treated With Hdmentioning

confidence: 99%

Obesity Paradox in Advanced Kidney Disease: From Bedside to the Bench

Naderi

Kleine

Park

et al. 2018

Progress in Cardiovascular Diseases

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“…Calabia et al . reported highest mortality risks for those with lower BMI levels (BMI < 23 kg/m 2 ) with an essentially similar risk for those aged <65 years versus ≥65 years, during a median follow-up of 3.6 years, although they did not adjust for the confounding effect of smoking 20 . Interestingly, the authors mentioned a non-proportional risk over time for BMI and used a parametric model, but the actual change in mortality risk over time was not reported.…”

Section: Discussionmentioning

confidence: 98%

Lower body mass index and mortality in older adults starting dialysis

Polinder-Bos

Diepen

Dekker

et al. 2018

Sci Rep

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Lower body mass index (BMI) has consistently been associated with mortality in elderly in the general and chronic disease populations. Remarkably, in older incident dialysis patients no association of BMI with mortality was found. We performed an in-depth analysis and explored possible time-stratified effects of BMI. 908 incident dialysis patients aged ≥65 years of the NECOSAD study were included, and divided into tertiles by baseline BMI (<23.1 (lower), 23.1–26.0 (reference), ≥26.0 (higher) kg/m2). Because the hazards changed significantly during follow-up, the effect of BMI was modeled for the short-term (<1 year) and longer-term (≥1 year after dialysis initiation). During follow-up (median 3.8 years) 567 deaths occurred. Lower BMI was associated with higher short-term mortality risk (adjusted-HR 1.63 [1.14–2.32] P = 0.007), and lower longer-term mortality risk (adjusted-HR 0.81 [0.63–1.04] P = 0.1). Patients with lower BMI who died during the first year had significantly more comorbidity, and worse self-reported physical functioning compared with those who survived the first year. Thus, lower BMI is associated with increased 1-year mortality, but conditional on surviving the first year, lower BMI yielded a similar or lower mortality risk compared with the reference. Those patients with lower BMI, who had limited comorbidity and better physical functioning, had better survival.

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“…Mortality and obesity are linked in a paradoxical relationship [ 131 , 132 , 136 , 137 , 138 , 139 , 140 , 141 , 142 , 143 , 144 , 145 ]. A high BMI is not necessarily a sign of good nutrition, and obese sarcopenia may mask significant protein malnutrition [ 139 , 140 , 144 ].…”

Section: Discrepant Measures Of Nutritional Status Clinical Condimentioning

confidence: 99%

Prescribing Hemodialysis or Hemodiafiltration: When One Size Does Not Fit All the Proposal of a Personalized Approach Based on Comorbidity and Nutritional Status

Piccoli

Nielsen

Gendrot

et al. 2018

JCM

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There is no simple way to prescribe hemodialysis. Changes in the dialysis population, improvements in dialysis techniques, and different attitudes towards the initiation of dialysis have influenced treatment goals and, consequently, dialysis prescription. However, in clinical practice prescription of dialysis still often follows a “one size fits all” rule, and there is no agreed distinction between treatment goals for the younger, lower-risk population, and for older, high comorbidity patients. In the younger dialysis population, efficiency is our main goal, as assessed by the demonstrated close relationship between depuration (tested by kinetic adequacy) and survival. In the ageing dialysis population, tolerance is probably a better objective: “good dialysis” should allow the patient to attain a stable metabolic balance with minimal dialysis-related morbidity. We would like therefore to open the discussion on a personalized approach to dialysis prescription, focused on efficiency in younger patients and on tolerance in older ones, based on life expectancy, comorbidity, residual kidney function, and nutritional status, with particular attention placed on elderly, high-comorbidity populations, such as the ones presently treated in most European centers. Prescription of dialysis includes reaching decisions on the following elements: dialysis modality (hemodialysis (HD) or hemodiafiltration (HDF)); type of membrane (permeability, surface); and the frequency and duration of sessions. Blood and dialysate flow, anticoagulation, and reinfusion (in HDF) are also briefly discussed. The approach described in this concept paper was developed considering the following items: nutritional markers and integrated scores (albumin, pre-albumin, cholesterol; body size, Body Mass Index (BMI), Malnutrition Inflammation Score (MIS), and Subjective Global Assessment (SGA)); life expectancy (age, comorbidity (Charlson Index), and dialysis vintage); kinetic goals (Kt/V, normalized protein catabolic rate (n-PCR), calcium phosphate, parathyroid hormone (PTH), beta-2 microglobulin); technical aspects including vascular access (fistula versus catheter, degree of functionality); residual kidney function and weight gain; and dialysis tolerance (intradialytic hypotension, post-dialysis fatigue, and subjective evaluation of the effect of dialysis on quality of life). In the era of personalized medicine, we hope the approach described in this concept paper, which requires validation but has the merit of providing innovation, may be a first step towards raising attention on this issue and will be of help in guiding dialysis choices that exploit the extraordinary potential of the present dialysis “menu”.

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Does the Obesity Survival Paradox of Dialysis Patients Differ with Age?

Cited by 17 publications

References 28 publications

Obesity Paradox in Advanced Kidney Disease: From Bedside to the Bench

Obesity Paradox in Advanced Kidney Disease: From Bedside to the Bench

Lower body mass index and mortality in older adults starting dialysis

Prescribing Hemodialysis or Hemodiafiltration: When One Size Does Not Fit All the Proposal of a Personalized Approach Based on Comorbidity and Nutritional Status

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