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

Abstract

There is clear evidence that survival rates following transplantation far exceed those for remaining on dialysis, regardless of body size measured by body mass index (BMI). Studies over the past 15 years also suggest little to no difference in long‐term outcomes, including graft survival and mortality, irrespective of BMI, in contrast to earlier evidence. However, weight bias still exists, as access to kidney transplantation remains inequitable in centers using arbitrary BMI limits. Clinicians faced with the decision regarding listing based on body size are not helped by conflicting recommendations in national and international guidelines. Therefore, in clinical practice, obesity, and recommendations for weight loss, remain a controversial issue when assessing suitability for kidney transplantation. Obesity management interventions in end‐stage kidney disease (ESKD), whether for weight loss for transplantation listing or for slowing kidney disease progression, are under‐explored in trial settings. Bariatric surgery is the most successful treatment for obesity, but carries increased risk in the ESKD population, and the desired outcome of kidney transplant listing is not guaranteed. Centers that limit transplants to those meeting arbitrary levels of body mass, rather than adopting an individualized assessment approach, may be unfairly depriving many ESKD patients of the survival and quality of life benefits derived from kidney transplantation. However, robotic kidney transplantation surgery holds promise for reducing perioperative risks related to obesity, and may therefore represent an opportunity to remove listing criteria based on size.

Modest rates and wide variation in timely access to repeat kidney transplantation in the United States

“…Several of the findings suggest that comorbid conditions and clinical factors may affect differential rates of PRLT. Older age, obesity, and diabetes were associated with lower rates of listing for repeat transplantation, consistent with findings associated with access to primary transplantation . These results suggest there are a number of clinical factors, including potential noncodified factors that may render patients nonviable for a repeat transplant procedure .…”

“…Older age, obesity, and diabetes were associated with lower rates of listing for repeat transplantation, consistent with findings associated with access to primary transplantation. 11,31,44 These results suggest there are a number of clinical factors, including potential noncodified factors that may render patients nonviable for a repeat transplant procedure. [45][46][47][48] Interestingly, results demonstrated a strong association between longer graft survival and likelihood of PRLT.…”

Weighing the waitlist: Weight changes and access to kidney transplantation among obese candidates

“…The optimal approach to weight management in obese kidney transplant candidates has been debated for many decades [5][6][7][8][9]15,16,[24][25][26]. Multiple observational studies have demonstrated that obesity is associated with lower risk of mortality in dialysis patients [27][28][29][30][31][32].…”

“…Obesity has increased in prevalence among adults with end-stage kidney disease (ESKD) at a rate that has exceeded that of the general population [1][2][3]. The high prevalence of obesity among patients with ESRD is concerning because many transplant centers in the US continue to have pre-specified body mass index (BMI) criteria for candidates to be deemed eligible for transplantation [4][5][6][7]. Although some guidelines no longer recommend use of BMI cutoffs for transplant eligibility determination [8,9], many transplant centers in the US have not yet adopted these recommendations.…”

Obesity in work-up of kidney transplant candidates – review of clinical practice guidelines.

“…Due to the obesity epidemic, nearly 60% of all kidney transplant recipients are overweight or obese, with male predominance [1]. Kidney transplantation (KT) is the most effective method of ESKD treatment but it is still a debatable whether obese patients are suitable candidates for KT [2][3][4][5][6]. Clinical practice guidelines (CPGs) review current research and formulate recommendations based on available evidence and expert opinion.…”