Obesity and access to kidney transplantation in patients starting dialysis: A prospective cohort study

Abstract

BackgroundObesity has been linked to poor access to medical care. Although scientific evidence suggest that kidney transplantation improves survival and quality of life in obese patients with end-stage renal disease (ESRD), few data exist on the impact of obesity on access to kidney transplantation in this population.ObjectivesWe aimed to characterize the relationships between body mass index (BMI) at the start of dialysis, changes in BMI after the start of dialysis, and either access to kidney transplantation or overall mortality in dialysis or transplantation among ESRD patients.MethodsBetween 2002 and 2011, 19524 dialysis patients with ESRD were included in the study via the French nationwide Renal Epidemiology and Information Network. Data on sociodemographic factors, comorbidities and laboratory test results were recorded upon entry into the registry. BMI were obtained at the start of dialysis and then yearly. Cubic spline regression analyses provided a graphic evaluation of the relationships between BMI at the start of dialysis and outcomes. Joint models were used to evaluate the association between the change over time in BMI and outcomes.ResultsDuring a median follow-up of 20.3 months, 6634 patients underwent kidney transplantation. A BMI >31 kg/m2 at the start of the dialysis was associated with a lower likelihood of receiving a kidney transplant, and the likelihood decreased even further with higher BMI values. For patients with BMI ≥30kg/m2 at the start of the dialysis, a 1 kg/m2 decrease in BMI during follow-up was associated with a 9% to 11% increase in the likelihood of receiving a transplant. There was an L-shaped relationship between BMI at the start of dialysis and overall mortality. We showed that obese patients with ESRD face barriers to the receipt of a kidney transplant without valid reasons.ConclusionGreater attention to this issue would improve the fairness of the organ allocation process and might improve outcomes for obese patients with ESRD.

The obesity paradox: A further consideration in dialysis patients

“…38 An analysis from the French Renal Epidemiology and Information Network showed that a BMI ≥31 kg/m 2 at the start of dialysis was associated with a lower likelihood of receiving a KT, and the likelihood decreased as BMI increased. 39 Although obese transplant recipients had a higher likelihood of delayed graft function and a slightly higher risk of graft loss compared with their nonobese counterparts, there was no significant difference in overall mortality. 40 Furthermore, patient survival was significantly better among all BMI categories, including obese and extremely obese groups of KT recipients, compared with dialysis patients who remained on the waiting list.…”

“…Many centers have adopted strict policies with regard to patients above threshold BMI of 30‐35 kg/m 2 , thus limiting the access to transplantation for obese dialysis patients . An analysis from the French Renal Epidemiology and Information Network showed that a BMI ≥31 kg/m 2 at the start of dialysis was associated with a lower likelihood of receiving a KT, and the likelihood decreased as BMI increased …”

Obesity as a barrier to kidney transplantation: Time to eliminate the body weight bias?

“…Data from the French Renal and Epidemiology Information Network (REIN) indicate that, after adjustment for potential confounding variables, the likelihood of transplantation falls as BMI increases above 30 kg/m 2 . Patients with a BMI of > 31kg/m 2 are more likely to remain on dialysis than receive a kidney transplant (HR <1) . Beyond this, patients with a BMI ≥40 kg/m 2 were half as likely to undergo transplantation than those with a BMI between 21‐31 kg/m 2 .…”

“…Patients with a BMI of > 31kg/m 2 are more likely to remain on dialysis than receive a kidney transplant (HR <1) . Beyond this, patients with a BMI ≥40 kg/m 2 were half as likely to undergo transplantation than those with a BMI between 21‐31 kg/m 2 . Furthermore, in those with a BMI ≥30kg/m 2 each 1 kg/m 2 decrease in BMI is associated with a 9%‐11% increase in the likelihood of transplantation.…”

Weight Loss After Bariatric Surgery in Morbidly Obese End-Stage Kidney Disease Patients as Preparation for Kidney Transplantation. Matched Pair Analysis in a High-Volume Bariatric and Transplant Center

“…Nearly 60% of all kidney transplant recipients are overweight or obese with male predominance [4]. It was proven that obesity limits, or at least delays, access to kidney transplantation [5]. Bariatric surgery is considered a safe method to achieve rapid and sustainable weight loss before kidney transplantation [6].…”