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Obesity in kidney transplantation….
Dan Ridgway, Consultant Surgeon, Royal Liverpool University Hospital
Audience question.
What would be your main concern about a pre-dialysis patient with BMI of 35 having a live donor kidney transplant?
A Surgical complications (SSI)
B Risk of acute rejectionC Risk of delayed graft functionD Risk of graft loss (within 5 years)E Risk of mortality compared to dialysisF All of the above
Why worry?
• Success of transplantation• Epidemiology of obesity• Individual patient outcomes• Regulatory scrutiny• Stewardship
D. L. Segev, et al. (2008). `Obesity impacts access to kidney transplantation.'. Journal of the American Society of Nephrology : JASN 19(2):349-355.
What is the evidence?
• Low quality evidence.• Registry data.• Outcomes – perioperative complications
-short term complications (3-6 months)-medium term graft and pt survival (upto 5 years)
• BMI centric.• Wrong comparator.• Pre vs post transplant obesity.• No interventional RCTs for pre-Tx obesity.
Up to now……………
H. U. Meier-Kriesche, et al. (1999). `The effect of body mass index on long-term renal allograft survival.'. Transplantation 68(9):1294-1297.
Not simply ‘obesity’….
• More likely to be elderly• More likely to be diabetic• More likely to be from ethnic minority
background
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• Obesity (BMI) at listing has no consistent effect on DGF, AR and graft or pt survival in individual observational studies.
• Meta-analysis implies 40% increased risk of DGF.
• Slightly increased risk of AR.
• No increased risk of mortality upto 5 years under ‘new’ immunosuppression.
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S. P. Curran, et al. (2014). `Increased recipient body mass index is associated with acute rejection and other adverse outcomes after kidney transplantation.'.
Transplantation 97(1):64-70.
S. P. Curran, et al. (2014). `Increased recipient body mass index is associated with acute rejection and other adverse outcomes after kidney transplantation.'.
Transplantation 97(1):64-70.
J. D. Schold, et al. (2007). `A "weight-listing" paradox for candidates of renal transplantation?'. American Journal of Transplantation 7(3):550-559.
M. Z. Molnar, et al. (2011). `Associations of body mass index and weight loss with mortality in transplant-waitlisted maintenance hemodialysis patients.'. American Journal of
Transplantation 11(4):725-736.
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C. P. Kovesdy, et al. (2010). `Body mass index, waist circumference and mortality in kidney transplant recipients.'. American Journal of Transplantation
10(12):2644-2651.
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K. Kalantar-Zadeh, et al. (2012). `Mortality prediction by surrogates of body composition: an examination of the obesity paradox in hemodialysis patients using composite ranking score analysis.'. American Journal of Epidemiology
175(8):793-803.
J. H. Kuo, et al. (2012). `Renal transplant wound complications in the modern era of obesity.'. The Journal of Surgical Research 173(2):216-223
• BMI is a poor measure of ‘fatness’ and CV risk in CKD
• More discerning anthropometrics needed
• Avoid sarcopenic obesity
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Abdominal obesity Visceral obesity
Surgical injury
Donor factors
Immune injury
activation
Fat is immunologically active tissue
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P. M. Moraes-Vieira, et al. (2014). `Leptin deficiency impairs maturation of dendritic cells and enhances induction of regulatory T and Th17 cells.'. European
Journal of Immunology 44(3):794-806.
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J. S. Gill, et al. (2013). `The survival benefit of kidney transplantation in obese patients.'. American Journal of Transplantation 13(8):2083-2090.
J. Oberholzer, et al. (2013). `Minimally invasive robotic kidney transplantation for obese patients previously denied access to transplantation.'. American Journal of Transplantation 13(3):721-728.
Robotic (n=28) Conventional (n= 28)
BMI 42.6 38.1 P=0.02
Surgical site infection
0 8 p=0.004
6 month Cr (mg/dl)
1.5 1.6 P=0.47
6 month graft survival
28 28
6 month pt survival
28 28
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• Viseral obesity and sarcopenia is a pro-inflammatory milieu.
• Graft factors can adjust Tx risks.• SCD, ECD and LD transplants reduce
mortality at 1 year compared to equivalent wait-listed patients.
P.-T. T. Pham, et al. (2013). `Kidney transplantation in the obese transplant candidates: to transplant or not to transplant?'. Seminars in Dialysis 26(5):568-577.
Audience question.
What would be your main concern about a pre-dialysis patient with BMI of 35 having a live donor kidney transplant?
A Surgical complications (SSI)
B Risk of acute rejectionC Risk of delayed graft functionD Risk of graft loss (within 5 years)E Risk of mortality compared to dialysisF All of the above