Obesity in kidney transplantation…. Dan Ridgway, Consultant Surgeon, Royal Liverpool University Hospital.

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Presentation transcript:

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? ASurgical complications (SSI) BRisk of acute rejection CRisk of delayed graft function DRisk of graft loss (within 5 years) ERisk of mortality compared to dialysis FAll 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):

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):

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. 14

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):

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):

19 C. P. Kovesdy, et al. (2010). `Body mass index, waist circumference and mortality in kidney transplant recipients.'. American Journal of Transplantation 10(12):

20 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):

J. H. Kuo, et al. (2012). `Renal transplant wound complications in the modern era of obesity.'. The Journal of Surgical Research 173(2):

BMI is a poor measure of ‘fatness’ and CV risk in CKD More discerning anthropometrics needed Avoid sarcopenic obesity 23

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Abdominal obesity Visceral obesity Surgical injury Donor factors Immune injury activation Fat is immunologically active tissue

2626

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):

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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):

J. Oberholzer, et al. (2013). `Minimally invasive robotic kidney transplantation for obese patients previously denied access to transplantation.'. American Journal of Transplantation 13(3): Robotic (n=28)Conventional (n= 28) BMI P=0.02 Surgical site infection08p= month Cr (mg/dl)1.51.6P= month graft survival 28 6 month pt survival28

32 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):

Audience question. What would be your main concern about a pre-dialysis patient with BMI of 35 having a live donor kidney transplant? ASurgical complications (SSI) BRisk of acute rejection CRisk of delayed graft function DRisk of graft loss (within 5 years) ERisk of mortality compared to dialysis FAll of the above