Management of obesity in kidney transplant candidates and recipients: A clinical practice guideline by the DESCARTES Working Group of ERA

Abstract

The clinical practice guideline ‘Management of obesity in kidney transplant candidates and recipients’ was developed to guide decision making in caring for people with end-stage kidney disease living with obesity. The document considers the challenges in defining obesity, weighs interventions for treating obesity in kidney transplant candidates as well as recipients and reflects on the impact of obesity on the likelihood of waitlisting as well as its effect on transplant outcomes. It was designed to inform management decisions related to this topic and provide the backdrop for shared decision making. This guideline was developed by ERA's Descartes working group on Transplantation. The group was supplemented with selected methodologists to supervise the project and provide methodological expertise in guideline development throughout the process. The guideline targets any health care professional treating or caring for people with end-stage kidney disease being considered for kidney transplantation or having received a donor kidney. This includes nephrologists, transplant physicians, transplant surgeons, general practitioners, dialysis and transplant nurses. Development of this guideline followed an explicit process of evidence review. Treatment approaches and guideline recommendations are based on systematic reviews of relevant studies, and appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Limitations of the evidence are discussed, and areas of future research are presented.

Combined Donor-Recipient Obesity and the Risk of Graft Loss After Kidney Transplantation

“…The increased prevalence of obesity has important implications for both kidney transplant recipients and transplant programmes. Although not considered a contraindication for kidney transplantation according to most clinical practice guidelines ( 5 ), recipient obesity is associated with increased risk of death-censored graft loss (DCGL) ( 6 , 7 , 8 , 9 , 10 ), delayed graft function (DGF) ( 6 , 11 , 12 , 13 , 14 ), increased peri- and post-operative complications ( 6 , 15 , 16 ) and prolonged hospitalizations ( 7 , 8 ). Meanwhile, donor obesity has been linked with increased incidence of recipient DGF and DCGL ( 11 , 17 , 18 ), though its exact influence on graft outcomes is less clear.…”

Obesity and Lifestyle Habits among Kidney Transplant Recipients

“…Most available data indicate that KT recipients with obesity are at risk of worse patient and graft outcomes, with the risk progressively increasing with increasing BMI [ 13 ]. The risk may be mediated by comorbid factors, particularly cardiovascular risk factors.…”

“…Steroid therapy may contribute to post-transplant weight gain [ 10 ], but the role of lifestyle factors such as diet and physical activity is also important [ 11 , 12 ], and it is recommended that weight-management programs for KT recipients living with obesity include lifestyle modifications [ 13 ]. Several dietary patterns may have favorable effects on health status, the Mediterranean diet being the pattern supported by the strongest evidence with regard to overall mortality, cardiovascular and metabolic diseases [ 14 , 15 , 16 ].…”

How good is a living donor? Systematic review and meta-analysis of the effect of donor demographics on post kidney transplant outcomes

“…With regard to BMI, controversy still exists, with some advocating bariatric surgery as a pre-donation procedure [ 7 ], and others excluding candidates who do not fit the center’s criteria [ 8 ]. We previously investigated the effects of the recipients’ demographic characteristics on outcomes of kidney grafts from living donors (LDs) [ 9 ]; the aim of the present study is to investigate the effects of LKD demographics on kidney graft function and survival.…”