Obesity and the risk of cardiovascular and all-cause mortality in chronic kidney disease: a systematic review and meta-analysis

Ladhani, Maleeka; Craig, Jonathan C.; Irving, Michelle; Clayton, Philip; Wong, Germaine

doi:10.1093/ndt/gfw075

Cited by 103 publications

(115 citation statements)

References 93 publications

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“…Since some authors [6, 36] considered the association of a high BMI with morbidity and mortality controversial, we additionally divided the variable BMI in quartiles, calculated a cox regression, and found a nearly linear negative correlation between mortality and BMI (data not shown). This is in line with a publication of Ladhani et al [33], who summarized data from 165 studies and came to the conclusion, that obesity may be protective in pre- and hemodialysis patients, not however in transplant recipients. Similarly, serum levels of albumin have been described to be inversely related to all-cause mortality with significantly greater effects in studies of shorter duration, with larger sample sizes and in patients of younger compared to patients of older age [37].…”

Section: Discussionsupporting

confidence: 90%

Long-Term Survivor Characteristics in Hemodialysis Patients with Type 2 Diabetes

et al. 2018

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Background: Data concerning long-term mortality predictors among large, purely diabetic hemodialysis collectives are scarce. Methods: We used data from a multicenter, prospective, randomized trial among 1,255 hemodialysis patients with type 2 diabetes mellitus (T2DM) and its observational follow-up study. The association of 10 baseline candidate variables with mortality was assessed by Cox proportional hazards regression. Results: Overall, 103 participants survived the median follow-up of 11.5 years. Significant predictors of mortality were age (hazard ratio [HR] 1.03, 95% CI 1.02–1.04), cardiovascular (HR 1.42, 95% CI 1.25–1.62) and peripheral vascular disease (HR 1.55, 95% CI 1.36–1.76), higher hemoglobin A1c (HbA1c; HR 1.08, 95% CI 1.03–1.14), and loss of self-dependency (HR 1.20, 95% CI 1.03–1.39). Higher albumin (HR 0.72, 95% CI 0.59–0.89) and body mass index (BMI; HR 0.98, 95% CI 0.96–0.99) had protective associations. There was no significant association with sex, diabetes duration, and cerebrovascular diseases. Subgroup analyses by age and diabetes duration showed stronger associations of cardiovascular disease, HbA1c, albumin, BMI, and loss of self-dependency in younger patients and/or shorter diabetes duration. Loss of self-dependency and energy resources (albumin, BMI) increased mortality more severely in women, whilst the impact of cardiovascular and peripheral vascular diseases was more pronounced in men. Conclusion: Long-term mortality risk in patients with T2DM on hemodialysis was associated with higher age, vascular diseases, HbA1c, loss of self-dependency, and low energy resources. Interestingly, it does not vary between sexes. Further individualized prognosis estimation and therapy should strongly depend on age, diabetes duration, and gender.

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Section: Discussionsupporting

confidence: 90%

Long-Term Survivor Characteristics in Hemodialysis Patients with Type 2 Diabetes

et al. 2018

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“…The association of a lower BMI and higher mortality is well described in numerous studies . The ISRNM suggested it as a marker of body mass and includes the BMI <23 kg/m 2 in their criteria for the diagnosis of PEW …”

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confidence: 99%

Evaluating haemodialysis patient's nutritional status: Body mass index or body cell mass index?

Valente¹,

Caetano²,

Oliveira³

et al. 2019

Nephrology

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Objective Evaluate which of two combinations of parameters based on International Society of Renal Nutrition and Metabolism recommendations could better identify patients with protein‐energy wasting (PEW) and to compare the relationship of these two combinations with other clinical and body composition parameters. Methods This was a multicentre longitudinal study with 24 months of follow‐up. The PEW patients were characterized by: Group A (GA) – normalized protein catabolic rate (nPCR) < 1.0 g/kg per day, albumin <3.8 g/dL and body cell mass index (BCMI) < 6.4 kg/m2 (n = 203); Group B (GB) – nPCR <1.0 g/kg per day, albumin <3.8 g/dL and body mass index (BMI) <23 kg/m2 (n = 109). All the patients who did not meet these requirements were considered “well‐nourished” (GA: n = 1818; GB: n = 3292). Results When compared to the well‐nourished patients, PEW patients in the GA presented higher age, Kt/V, C‐reactive protein, relative overhydration, fat tissue index (FTI); lower creatinine, albumin, nPCR, PTH, haemoglobin, phosphorus, calcium X phosphorus product, potassium, dry weight, BMI, BCMI, lean tissue index, %IDWG . In the GB, well‐nourished patients FTI was significantly higher. In Cox analysis, the combination with BCMI was a strong independent predictor of mortality in these patients (hazard ratio: 1.48; confidence interval: 1.00–2.19; P = 0.048), even after adjustment. Although GB combination seemed to be also a predictor of death (hazard ratio: 2.67; confidence interval: 1.92–3.71; P < 0.001), when adjusted, the association remained no longer significant. Conclusion A new combination of parameters including protein intake, albumin and BCMI demonstrated significant associations with other nutrition and inflammation parameters as well as with mortality.

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“…It is possible that our finding is explained by physician bias; it may be easier to believe that an overweight patient, rather than a lean patient, should have reduced dry weight. Thus, obesity seems to offer some protection from overhydration in hemodialysis patients, which may then be one explanation to the obesity paradox; obesity being protective for all‐cause mortality in hemodialysis patients …”

Section: Discussionmentioning

confidence: 99%

Brain natriuretic peptide reflects individual variation in hydration status in hemodialysis patients

Stenberg

Melin

Lindberg

et al. 2019

Hemodialysis International

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Introduction: Fluid management in hemodialysis patients is a controversial topic. Brain natriuretic peptide (BNP) is secreted from the heart in response to volume overload, and may be a marker of overhydration in hemodialysis patients. Our aim was to investigate the correlation between BNP and overhydration in a cohort of hemodialysis patients, and to find out whether BNP and overhydration correlate in repeated measurements within individuals with elevated BNP. Methods: The study was prospective, observational, and had a cross‐sectional part and a longitudinal follow‐up. The distribution of BNP was investigated in a cohort of 64 hemodialysis patients. Blood samples and bioimpedance spectroscopy measurements were performed before midweek dialysis. Subsequently, 11 study participants with elevated BNP concentrations (>500 pg/mL) were assessed in another nine dialysis sessions each. These individuals also had their cardiac function and heart rate variability (HRV) examined. Findings: BNP was above 500 pg/mL in 38% of the participants, and correlated positively with overhydration (rs = 0.381), inflammation and malnutrition, but not with systolic blood pressure. In comparison to participants with BNP below 500 pg/mL, participants with elevated BNP were older, had lower muscle strength, lower bodyweight and lower levels of hemoglobin and albumin. Echocardiography revealed cardiac anomalies in all 11 participants in the longitudinal follow‐up, and HRV, as measured by SDNN, was pathologically low. In repeated measurements, the between‐individuals variation of BNP in relation to overhydration was greater (SD = 0.581) than the within‐person variation (SD = 0.285). Discussion: BNP correlates positively to overhydration, malnutrition, and inflammation. In a subgroup of patients with elevated BNP, who are mainly elderly and frail, BNP reflects individual variation in hydration status, and hence seems to be a modifiable marker of overhydration. These data suggest that BNP is best applied for measuring changes in hydration status within an individual over time.

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Obesity and the risk of cardiovascular and all-cause mortality in chronic kidney disease: a systematic review and meta-analysis

Abstract: Being obese may be protective for all-cause mortality in the predialysis and hemodialysis populations, while being underweight suggests increased risk, but not in transplant recipients.

Cited by 103 publications

References 93 publications

Long-Term Survivor Characteristics in Hemodialysis Patients with Type 2 Diabetes

Long-Term Survivor Characteristics in Hemodialysis Patients with Type 2 Diabetes

Evaluating haemodialysis patient's nutritional status: Body mass index or body cell mass index?

Brain natriuretic peptide reflects individual variation in hydration status in hemodialysis patients

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