1. Obesity in the end stage kidney disease population
Dr Maleeka Ladhani
PhD Candidate, Sydney School of Public Health
Prof Jonathan Craig, A/P Germaine Wong

2. Framework
1) Prevalence of obesity in the incident and prevalent ESKD population
2) Access to transplantation for those with obesity

3. Prevalence of obesity in ESKD

4. 27% 19% Australian Institute of Health and Welfare 2015.
Cardiovascular disease, diabetes and chronic kidney disease— Australian facts:
Risk factors. Cardiovascular, diabetes and chronic kidney disease series no. 4.
Cat. no. CDK 4. Canberra: AIHW.

5. Aims
To describe the trends of obesity in the incident and prevalent Australian and New Zealand ESKD population, over time
Specifically stratifying by:
country
sex
age
diabetes status
modality of renal replacement

6. Methods All adult Australian and New Zealand patients 1995 – 2014
49,884 patients (8,745 NZ - 32% Maori)
286,500 observations over the whole period
BMI categorised according to WHO definition

7. Obesity in incident RRT patients
ie BMI at RRT initiation for all adult patients

8. Australia and New Zealand

9. Sex differences - Australia

10. Sex differences – New Zealand

11. Age Aust

12. Age NZ

13. Diabetes -Australia

14. Diabetes – New Zealand

15. Modality – Australia

16. Modality – New Zealand

17. Obesity in prevalent patients
ie all patients on RRT each year

18. Australia and New Zealand

19. Modality – Australia

20. Modality – New Zealand

21. Access to transplantation

22. BMI association with all-cause mortality
Ladhani et al, NDT 2016

23. BMI association with all-cause mortality
Ladhani et al, NDT 2016

24. Chang et al Transplantation 2007

25. Chang et al Transplantation 2007

26. Aims
To examine access to transplantation for people with obesity in 3 ways
1) Pre-emptive transplantation
2) Time to first transplant
3) Placement on the waiting list

27. Methods 1) Pre-emptive transplantation 2) Time to first transplant
Descriptive data limited to 2014
2) Time to first transplant
Kaplan Meier curve restricted to incident patients
<70 years,
3) Placement on the waiting list
Logistic regression limited to 2014 and patients <70 years with outcome of listed or not listed
Adjusted for relevant confounders +/- centre effect

28. Pre-emptive transplantation

29. Time to transplantation

30. Baseline stats Active (n=1,073) Not active (n=7,551) p-value
Age (yrs) median (IQR)
52.0 (42.0, 61.0)
60.0 (51.0, 68.0)
<0.001
Male
661 (61.6%)
4354 (57.7%)
0.014
BMI (kg/m2)
Median (IQR)
26.0 (22.7, 29.3)
27.3 (23.1, 32.4)
Race
Caucasian
ATSI
Asian
Maori/Pacific
Other
716 (66.7%)
30 (2.8%)
198 (18.5%)
40 (3.7%)
77 (7.2%)
4728 (62.6%)
1441 (19.1%)
609 (8.1%)
395 (5.2%)
342 (4.5%)
Modality
- HD
- PD
723 (67.4%)
350 (32.6%)
6138 (81.3%)
1413 (18.7%)
Baseline stats

31. Baseline stats Active (n=1,073) Not active (n=7,551) p-value
Primary renal disease GN
Polycystic
Reflux
Hypertension DM
Other
441 (41.1%)
140 (13.0%)
72 (6.7%)
74 (6.9%)
180 (16.8%)
166 (15.5%)
1789 (23.7%)
441 (5.8%)
278 (3.7%)
684 (9.1%)
3100 (41.1%)
1259 (16.7%)
<0.001
Diabetes
268 (25.0%)
4086 (54.4%)
Coronary disease
207 (19.3%)
3707 (49.3%)
Cerebrovascular disease
75 (7.0%)
1456 (19.4%)
PVD
147 (13.7%)
2603 (34.6%)
Smoking history
458 (42.9%)
4145 (55.4%)

33. Centre effect
modeled as a
random intercept

34. Conclusions Obesity is increasingly common in the ESKD population
Despite evidence that long term patient and graft outcomes are not affected by obesity, people with obesity are:
less likely to start RRT with a transplant
less likely to receive a transplant over time
less likely to be on the waiting list for a transplant – despite adjusting for confounders

35. Implications
There appears to be a discrepancy in access to transplantation for people with obesity that is not supported by long term outcome studies
This needs to be looked at further
Thank you to all ANZDATA contributors