Outcomes of Renal Transplantation in Obese Recipients

doi:10.1016/j.transproceed.2012.09.031

Transplantation Proceedings

Volume 44, Issue 9, November 2012, Pages 2787-2791

https://doi.org/10.1016/j.transproceed.2012.09.031 Get rights and content

Abstract

Purpose

Although obesity has been shown to paradoxically increase dialysis patient survival, its impact has not been clearly defined on renal transplantation. We assessed outcomes of obesity renal transplant patients by evaluating graft and patient survivals.

Patients and Methods

A single-institution, retrospective study was performed on 202 renal transplant recipients from January 2004 to December 2008 excluding two combined kidney and liver transplantations. Recipients were classified based on body mass index (BMI) at the time of transplantation: obese (BMI ≥ 30 kg/m²) and nonobese recipients (BMI < 30 kg/m²). The comparative analysis included surgical complications, hospital stay, onset of delayed graft function (DGF), acute rejection episodes and graft patient survivals.

Results

Twenty-one renal transplants were performed in obese recipients versus 179 in the control group. Obese patients were older (53.3 ± 11.2 versus 46.4 ± 14.4 years old; P = .035) and more often diabetic (29% ± 0.46 versus 60% ± 0.24, P = .001), but there were no differences among other combidities of high blood pressure, arteriopathy, thrombophilia, and smoking. Obesity did not appear to be a risk factor for urinary or vascular as well as parietal complications, but did tend to augment lymphatic complications (14.3% ± 0.36 versus 4.5% ± 0.21; P = .065). DGF occurred more frequently in obese patients (38% ± 0.50 versus 14% ± 0.34; P = .004) and hospital stays were therefore longer in this group (24.9 ± 23.53 days versus 15.6 ± 13.67 days; P = .008). Graft (hazard ratio [HR] 1.22; 95% confidence interval [CI] [0.25–6.0], P = .63) and patient survivals (HR:0,81; 95% CI [0.12– 5.3], P = .83) were comparable between the groups.

Conclusion

Obese patients seeking renal transplantation are usually older and more often diabetic compared with nonobese recipients. The higher rate of lymphatic complications and DGF lead to longer hospital stays among the group with BMI ≥ 30 kg/m². However, long-term results showed similar graft and patient survivals as nonobese patients. Consequently, there seemed to be no reason to avoid renal transplantation in obese recipients.

Section snippets

Patients and Methods

We performed a retrospective study of 200 of 202 kidney transplantations performed in our center from January 2004 to December 2008, excluding two combined kidney and liver cases. All transplantations were performed by one four experienced staff surgeons, using standard techniques. Kidneys were placed either in the right or left iliac fossa via an extraperitoneal approach. A U-stich ureteroneocystostomy was performed in all cases9, 10 with double-J stents removed 2 months later. Transurethral

Results

Overall, recipient mean age was 47.1 years (range, 18.4 to 75.2 years; Table 1). There was a majority of men (67% versus 33%). Twenty-one (10.5%) recipients were obese (BMI ≥ 30kg/m²); (OP group) and 179, obese (NOP group). Among the patients, 11 (52.4%) presented as type I obesity (BMI 30 to 34.9 kg/m²), eight (38%) as type II obesity (BMI 35 to 39.9 kg/m²), and two (9.6%) as type III obesity (BMI ≥ 40kg/m²). The majority of recipients showed one or several comorbidities such as hypertension

Discussion

We observed that despite significantly greater pretransplantation comorbodities, renal transplantations in obese patients were not associated with higher rates of surgical complications or inferior and graft survivals as nonobese patients. Obese patients in our cohort, were more often older and diabetic. Obesity, which is responsible for the development of insulin-resistance, is a contributing factor for the appearance of diabetes mellitus. Obesity is a risk factor for the development and

References (28)

K. Kalantar-Zadeh et al.
Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients
Kidney Int
(2003)
J.D. Kopple et al.
Body weight-for-height relationships predict mortality in maintenance hemodialysis patients
Kidney Int
(1999)
F.P. Secin et al.
Comparing Taguchi and Lich-Gregoir ureterovesical reimplantation techniques for kidney transplants
J Urol
(2002)
J.L. Veale et al.
Long-term comparative outcomes between 2 common ureteroneocystostomy techniques for renal transplantation
J Urol
(2007)
N. Kambham et al.
Obesity-related glomerulopathy: an emerging epidemic
Kidney Int
(2001)
F. Furriel et al.
Pretransplantation overweight and obesity: does it really affect kidney transplantation outcomes?
Transplant Proc
(2011)
E. Roine et al.
Targeting risk factors for impaired wound healing and wound complications after kidney transplantation
Transplant Proc
(2010)
J.L. Gore et al.
Obesity and outcome following renal transplantation
Am J Transplant
(2006)
R.A. Cacciola et al.
Effect of degree of obesity on renal transplant outcome
Transplant Proc
(2008)
K.A. Griffin et al.
Adverse renal consequences of obesity
AM J Physiol Renal Physiol
(2008)

H.J. Kramer et al.

Increasing body mass index and obesity in the incident ESRD population

J Am Soc Nephrol

(2006)

Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report

Obese Res

(1998)

S. Nguyen et al.

Excess weight as a risk factor for kidney failure

Curr Opin Nephrol Hypertens

(2007)

C.Y. Hsu et al.

Body mass index and risk for end-stage renal disease

Ann Intern Med

(2006)

Cited by (48)

Effect of Recipient Body Mass Index on Kidney Transplantation Outcomes: A Systematic Review and Meta-analysis by the Transplant Committee from the French Association of Urology
2023, European Urology Focus
The impact of recipient obesity on kidney transplantation (KT) outcomes remains unclear.
The aim of this study was to perform a systematic review and meta-analysis to appraise all available evidence on the outcomes of KT in obese patients (body mass index [BMI] ≥30 kg/m²) versus nonobese patients (BMI <30 kg/m²).
A systematic review and meta-analysis was performed. Search was conducted in the MEDLINE OvidSP, Web of Science, Google Scholar, Embase, and Cochrane databases to identify all studies reporting the outcomes of KT in obese versus nonobese recipients.
Fifty-two articles met the inclusion criteria. Delayed graft function and surgical complications were significantly higher in obese recipients (delayed graft function: relative risk [RR]: 1.44, 95% confidence interval [CI]: 1.32–1.57, p < 0.01; surgical complications: RR: 1.74, 95% CI: 1.36–2.22, p < 0.0001). Five-year patient survival (RR: 0.96, 95% CI: 0.92–1.00, p = 0.01), 10-yr patient survival (RR: 0.90, 95% CI: 0.84–0.97, p = 0.006), and 10-yr graft survival (RR: 0.87, 95% CI: 0.79–0.96, p = 0.01) were significantly inferior in the obese group.
KT in obese recipients was associated with lower patient and graft survival, and higher delayed graft function, acute rejection, and medical and surgical complications than nonobese recipients. In the current situation of organ shortage and increasing prevalence of obesity, ways to optimize KT in this setting should be investigated.
Compared with nonobese population, kidney transplantation in obese recipients has inferior patient and graft survival, and higher medical and surgical complications.
Effect of weight change after renal transplantation on outcomes of graft survival
2022, Nefrologia
Tras el trasplante renal se produce de manera global un incremento del peso pudiendo aumentar el riesgo de enfermedad renal crónica (ERC) y de pérdida del injerto. Pero no todos los pacientes ganan peso, y la repercusión sobre el injerto de esta diferente evolución, no está bien estudiado. El objetivo fue determinar las causas de esta diferente evolución y su efecto sobre el injerto.
Estudio de cohortes retrospectivo unicéntrico de 201 pacientes seguidos tras el trasplante, analizando los determinantes de la variación del peso al año mediante regresión logística, y su efecto sobre la pérdida del injerto al final del seguimiento mediante regresión de Cox.
Globalmente se produjo durante el primer año un aumento de peso de 4,5 kg de media, pero un 26,6% perdieron peso. El 37,2% aumentó su índice de masa corporal (IMC), mientras que el 9,5% lo disminuyó. Los determinantes de la diferente evolución del peso fueron la edad (OR por cada 10 años: 0,6; p = 0,002), la modalidad de diálisis previa (ref. hemodiálisis) (OR: 0,3; p = 0,003) y el IMC previo al trasplante (OR: 0,9; p = 0,003). La diferente evolución del peso no influyó en la pérdida del injerto. Sí influyeron el IMC al año como variable continua (HR: 1,3; p = 0,003) y la obesidad, con peor evolución (HR: 7,0; p = 0,025).
Aunque no todos los pacientes ganan peso tras el trasplante renal, la diferente evolución del peso no influye en la supervivencia del injerto.
After kidney transplantation, there is an overall increase in weight, which may increase the risk of chronic kidney disease (CKD) and graft loss. But, not all patients gain weight, and the impact on the graft of this different evolution has not been well studied. The objective was to determine the causes of this different evolution and its effect on the graft.
Retrospective single-center cohort study of 201 patients followed up after transplantation, analyzing the determinants of the variation in weight at one year using logistic regression, and its effect on graft survival at the end of follow-up using Cox regression.
Globally, there was an average weight gain of 4.5 kg in the first year, but 26.6% lost weight. 37.2% increased their BMI, while 9.5% decreased it. The determinants of the different evolution of weight were age (OR for every 10 years: 0.6, P=.002), previous dialysis modality (ref. hemodialysis) (OR 0.3, P=.003), and BMI before transplantation (OR 0.9, P=.017). The different evolution of weight did not influence the final situation of the graft. The BMI at one year did influence as a continuous variable (HR 1.3, P=.003), and obesity, with a worse evolution (HR 7.0, P=.025).
Although not all patients gain weight after kidney transplantation, the different evolution of weight does not influence graft survival.
Nonlinear relationship between body mass index and clinical outcomes after kidney transplantation: A dose-response meta-analysis of 50 observational studies
2022, Surgery (United States)
Citation Excerpt :
After titles and abstracts screening, 11,265 studies were excluded. After full texts screening, another 143 studies were eliminated, and 94 studies were included.5–10,34–121 Characteristics of the included studies were presented in Supplementary Table S1, and they were published between 1991 and 2019.
Exact dose-response relationship between body mass index at transplantation and clinical outcomes after kidney transplantation remained unclear, and no specific body mass index threshold and pretransplant weight loss aim were recommended for kidney transplantation candidates among transplant centers.
PubMed, Embase, Web of Science, and Cochrane Library were searched for literature published up to December 31, 2019. The two-stage, random effect meta-analysis was performed to estimate the dose-response relationship between body mass index and clinical outcomes after kidney transplantation.
Ninety-four studies were included for qualitative assessment and 50 for dose-response meta-analyses. There was a U-shaped relationship between graft loss, patient death, and body mass index. Body mass index with the lowest risk of graft loss was 25.2 kg/m², and preferred body mass index range was 22–28 kg/m². Referring to a body mass index of 22 kg/m², the risk of graft loss was 1.088, 0.981, 1.003, and 1.685 for a body mass index of 18, 24, 28, and 40 kg/m², respectively. Body mass index with the lowest risk of patient death was 24.7 kg/m², and preferred body mass index range was 22–27 kg/m². Referring to a body mass index of 22 kg/m², the patient death risk was 1.115, 0.981, 1.032, and 2.634 for a body mass index of 18, 24, 28, and 40 kg/m², respectively. J-shaped relationships were observed between body mass index and acute rejection, delayed graft function, primary graft nonfunction, and de novo diabetes. Pair-wise comparisons showed that higher body mass index was also a risk factor for cardiovascular diseases, hypertension, infection, longer length of hospital stay, and lower estimated glomerular filtration rate level.
Underweight and severe obesity at transplantation are associated with a significantly increased risk of graft loss and patient death. A target body mass index at kidney transplantation is 22–27 kg/m².
Conservative Management of Obesity in Kidney Transplant Candidates
2022, Journal of Renal Nutrition
Citation Excerpt :
Obesity is a worldwide epidemic and is prevalent in patients with end-stage renal disease (ESRD).1-4 The risks associated with obesity during kidney transplantation (KT) include increased surgical site infections, lymphoceles, and postoperative cardiovascular complications.5-9 Worsened early graft outcomes include increased delayed graft function, higher rates of graft nephrectomy, and increased risk of acute rejection.6,7,10,11
Obesity is prevalent in patients with chronic kidney disease and is associated with increased complications after kidney transplantation (KT). A body mass index limit is used in most transplant programs, though few studies have focused on conservative weight loss in KT candidates. The objective of this retrospective study is to evaluate the efficacy of a basic conservative weight management program in morbidly obese KT candidates and to perform a comprehensive nutritional evaluation.
This retrospective study included patients with a body mass index (BMI) >35 kg/m^2, with grade IV or V chronic kidney disease. The conservative weight loss program consisted of anthropometric measurements every 3 months, consultation with a nutritionist, daily exercise, and counseling for healthier eating habits. Overall and quarterly BMI targets were defined. A subset of patients further underwent a comprehensive nutritional evaluation to measure socioeconomic characteristics, food intake behavior, motivation for change, and a 4-day food diary.
Eighty patients were observed for a mean of 24 months. Successful weight loss (BMI < 35 kg/m²) was achieved in 26.3%, associated with women and those already close to the limit. The mean 1-year excess body weight loss was 8.4%. No patient with a BMI >40 kg/m² was successful. The comprehensive nutritional evaluation was performed with 44 patients and found that only 14.6% had previously received nutritional counseling for weight loss. Cognitive restraint scored highest in the food-intake behavior. Most patients were motivated to lose weight with 66% in the action phase. There was little evidence of overeating with a recommended mean calculated daily caloric intake of 82.9%.
The conservative weight loss program can have limited but non-negligible, success. Future successful nutritional interventions should take into consideration this surprising comprehensive profile of morbidly obese KT candidates.
Obesity, Chronic Kidney Disease, and Kidney Transplantation: An Evolving Relationship
2021, Seminars in Nephrology
Summary: Obesity has a fundamental role in driving the global kidney disease burden. The perplexing relationship of obesity with chronic kidney disease remains debated. However, a thorough understanding of the interplay of obesity in conjunction with chronic kidney disease and appropriate management options is lacking, leading to further increases in morbidity and mortality. Moreover, underutilization of bariatric procedures and unrealistic expectations of weight reduction based on body mass index, leading to poor access to kidney transplantation, are fueling the fire. In this review, we summarize the available data related to the obesity and chronic kidney disease association and its novel management options.
Early Postoperative Complications and Outcomes of Kidney Transplantation in Moderately Obese Patients
2020, Transplantation Proceedings
Obese renal transplant recipients (body mass index [BMI] ≥30 kg/m²) are at risk of delayed graft function and postoperative complications, such as infections or delayed wound healing. There is also a tendency to exclude extremely obese patients from transplantation (KTx). Nonetheless, no association between obesity and increased mortality has been reported. The aim of this study is to evaluate the effect of BMI on the most common surgical and infectious complications after KTx.
An observational study in 872 patients transplanted from 2010-2017 was conducted. Median BMI was 24.6 (13.9-34.3), and 8.3% of the group was obese. Patient records were searched for early postoperative complications: lymphocele or hematoma (>33 mL), urinary leakage, or urinary tract infection (UTI). Mann-Whitney U and χ² or Fisher exact tests were used. P < .05 was considered statistically significant. The study complies with the Helsinki Congress and the Istanbul Declaration.
Renal primary nonfunction was observed in 1.4% (12/872) of patients. Surgical or infectious complications occurred in 52.7% (453/860) of patients. No correlation between BMI and complication rate was noted. Complications were observed in 56.9% (41/72) of obese vs 52.3% (412/788) of nonobese patients (P = .448), including lymphocele in 15.3% vs 16.4% (P = .810), hematoma in 22.2% vs 19.2% (P = .530), urinary leakage in 1.4% vs 4.6% (P = .203), and UTI in 31.9% vs 32.9% (P = .873), respectively.
Recipient’s BMI has no significant association with the most common surgical complications after KTx. There is no need to delay KTx in moderately obese patients.

View all citing articles on Scopus

View full text

11th congress of the french speaking society of transplantationKidney transplantation: OutcomesOutcomes of Renal Transplantation in Obese Recipients

Abstract

Purpose

Patients and Methods

Results

Conclusion

Section snippets

Patients and Methods

Results

Discussion

Kidney Int

Kidney Int

J Urol

J Urol

Kidney Int

Transplant Proc

Transplant Proc

Am J Transplant

Transplant Proc

Adverse renal consequences of obesity

AM J Physiol Renal Physiol

Increasing body mass index and obesity in the incident ESRD population

J Am Soc Nephrol

Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report

Obese Res

Excess weight as a risk factor for kidney failure

Curr Opin Nephrol Hypertens

Body mass index and risk for end-stage renal disease

Ann Intern Med

11th congress of the french speaking society of transplantation
Kidney transplantation: Outcomes
Outcomes of Renal Transplantation in Obese Recipients