The Incidence and Pathophysiology of the Obesity Paradox: Should Peritoneal Dialysis and Kidney Transplant Be Offered to Patients with Obesity and End-Stage Renal Disease?
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Purpose of Review
To educate nephrologists and primary-care physicians about the incidence, pathophysiology, and survival benefits of the obesity paradox in end-stage renal disease (ESRD). This review also discusses the future of kidney transplant and peritoneal dialysis in obese dialysis patients.
Obesity paradox in ESRD was first reported three decades ago, and since then, there have been several epidemiological studies that confirmed the phenomenon. Regardless of the anthropometric indices used to define obesity in ESRD patients, these markers serve to predict the dialysis patient’s survival. The pathophysiology of obesity paradox tends to be multifactorial. Recent cohort studies demonstrated a survival benefit in all race and ethnic groups, but Hispanics and blacks experienced increased survival rates when compared to non-Hispanic whites. Obese dialysis patients should be offered peritoneal dialysis, especially if they are new to dialysis and have an adequate renal residual function. Several studies have shown that the benefit of receiving kidney transplant in obese patients exceeds the risks. The robotic-assisted kidney transplant (RAKT) procedure is the latest innovation that could offer hope for obese dialysis patients who have been denied or are waiting for kidney transplant.
The obesity paradox phenomenon in ESRD is a unique illustration of survival benefit in a population that has a high overall annual mortality. Peritoneal dialysis should be encouraged for obese patients who have preserved residual renal function. Kidney transplant centers should encourage RAKT utilization in obese dialysis patients instead of denying them a kidney transplant.
KeywordsObesity paradox in ESRD Malnutrition-inflammation complex syndrome Peritoneal dialysis in obesity Robotic assisted kidney transplant
We thank Michelle G. Holt, managing editor, LSU School of medicine, department of medicine for assisting in editing our publication.
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Conflict of Interest
The authors declare no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
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- 1.Saran R, Li Y, Robinson B, et al. US renal data system 2015 annual data report: epidemiology of kidney disease in the United States. Am J Kidney Dis. 2016;67(3 suppl 1):S1–S305.Google Scholar
- 3.Kalantar-Zadeh K, Kovesdy CP, Streja E, et al. Transition of care from pre-dialysis prelude to renal replacement therapy: the blueprints of emerging research in advanced CKD. Nephrol Dial Transplant. 2017;32(suppl-2).Google Scholar
- 9.WHO expert consultation: Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004;363:157–63.Google Scholar
- 15.• Leavey SF, McCullough K, Hecking E, Goodkin D, Port FK, Young EW. Body mass index and mortality in healthier as compared with sicker Haemodialysis patients: results from the Dialysis Outcomes and Practice and Patterns Study (DOPPS). Nephrol Dial Transplant. 2001;16:2386–94. Original Study: major observational study showing a survival advantages to obese patients on MHD. CrossRefPubMedGoogle Scholar
- 16.•• Glanton CW, Hypolite IO, Hshieh PB, Agodoa LY, Yuan CM, Abbott KC. Factors associated with improved short term survival in obese end stage renal disease patients. Ann Epidemiol. 2003;13(2):136–43. Original Article: historical cohort study showing obese patients have slight survival benefit. CrossRefPubMedGoogle Scholar
- 20.•• Park J, Jin DC, Molnar MZ, Dukkipati R, Kim YL, Jing J, et al. Mortality—predictability of body size and muscle mass surrogates in Asian versus Caucasian and African—American hemodialysis patients. Mayo Clin Proc. 2013;88(5):479–86. Original Article: confirmed that race does not modify obesity paradox phenomenon. CrossRefPubMedPubMedCentralGoogle Scholar
- 27.Kopple JD. Nutritional status as a predictor of morbidity and mortality in maintenance dialysis patients.Google Scholar
- 39.Horwich TB, Fonarow GC, Hamilton MA, Maclellan WR, Woo MA, Tillisch JH. The relation between obesity and mortality in patients with heart failure. 2001;38:789–95.Google Scholar
- 42.Rauchhaus M, Coats AJ, Anker SD. The endotoxin-lipoprotein hypothesis. 2000;356:930–3.Google Scholar
- 53.•• Marcelli D, Usvyst LA, Kotanko P, Bayh I, Canaud B, Etter M, et al. Body composition and survival in dialysis patients: results from an international cohort study. Clin J Am Soc Nephrol. 2015;10:1192–200. Original Article: BMI could be misleading. LBM and FM could offer better prognosis in obesity paradox in ESRD. CrossRefPubMedPubMedCentralGoogle Scholar
- 54.• Kalantar-Zadeh K, Streja E, Kovesdy C, Oreopoulos A, Noori N, Jing J, et al. The obesity paradox and mortality associated with surrogates of body size and muscle mass in patients receiving hemodialysis. Mayo Clin Proc. 2010;85:991–1001. Original Article: improved survival in MHD when gained muscle mass. CrossRefPubMedPubMedCentralGoogle Scholar
- 62.Obi Y, Streja E, Mehrotra R, et al. Impact of obesity on modality longevity, residual kidney function, peritonitis, and survival among incident peritoneal dialysis patients. Am J Kidney Dis. 2017.Google Scholar
- 65.• Jin H, Shin JY, Lee SH, Song JH, Kim MJ, Lee SW. Abdominal obesity and mortality in continuous ambulatory peritoneal dialysis patients. Electrolyte Blood Press. 2015;13(1):22–9. Original Article: Abdominal circumference in PD patients have similar outcomes as those smaller abdomens.CrossRefPubMedPubMedCentralGoogle Scholar
- 78.• Oberholzer J, Giulianotti P, Danielson KK, Spaggiari M, Bejarano PL, Bianco F, et al. Minimally invasive robotic kidney transplantation for obese patients previously denied access to transplantation. Am J Transplant. 2013;13:721–8. Original Article: RAKT in morbid obese dialysis patient showing impressive and promising results. CrossRefPubMedPubMedCentralGoogle Scholar
- 79.•• Garcia-Roca R, Garcia-Aroz S, Tzvetanov I, Jeon H, Oberholzer J, Benedetti E. Single center experience with robotic kidney transplantation for recipients with BMI of 40 kg/m2 or greater: a comparison with the UNOS Registry. Transplantation. 2017;101:191–6. Review article: comparing RAKT vs open kidney transplant at 3 years. CrossRefPubMedGoogle Scholar