Association of morbid obesity and weight change over time with cardiovascular survival in hemodialysis population.
ABSTRACT In maintenance hemodialysis (MHD) outpatients, a reverse epidemiology is described, ie, baseline obesity appears paradoxically associated with improved survival. However, the association between changes in weight over time and prospective mortality is not known.
Using time-dependent Cox models and adjusting for changes in laboratory values over time, the relation of quarterly-varying 3-month averaged body mass index (BMI) to all-cause and cardiovascular mortality was examined in a 2-year cohort of 54,535 MHD patients from virtually all DaVita dialysis clinics in the United States.
Patients, aged 61.7 +/- 15.5 (SD) years, included 54% men and 45% with diabetes. Time-dependent unadjusted and multivariate-adjusted models, based on quarterly-averaged BMI controlled for case-mix and available time-varying laboratory surrogates of nutritional status, were calculated in 11 categories of BMI. Obesity, including morbid obesity, was associated with better survival and reduced cardiovascular death, even after accounting for changes in BMI and laboratory values over time. Survival advantages of obesity were maintained for dichotomized BMI cutoff values of 25, 30, and 35 kg/m2 across almost all strata of age, race, sex, dialysis dose, protein intake, and serum albumin level. Examining the regression slope of change in weight over time, progressively worsening weight loss was associated with poor survival, whereas weight gain showed a tendency toward decreased cardiovascular death.
Weight gain and both baseline and time-varying obesity may be associated with reduced cardiovascular mortality in MHD patients independent of laboratory surrogates of nutritional status and their changes over time. Morbidly obese patients have the lowest mortality. Clinical trials need to verify these observational findings.
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ABSTRACT: Recent data suggest that the nutritional status of patients who are on the waiting list for kidney transplantation, influence outcomes after renal transplantation. Body composition (BC) analysis is rarely included in pretransplant evaluation. The aim of this study was to determine how alteration of the BC of these patients could influence pretransplant and post-transplant care. We compared the BC of French patients on a waiting list for kidney transplantation to a sex- and age-matched healthy, European control population. Patients were included when listed for kidney grafting in a prospective longitudinal study (CORPOS). Biological nutritional parameters, fat free mass (FFM) and fat mass (FM) estimated by dual-energy x-ray absorptiometry (DXA) were assessed on the day of wait-list registration. FFM and FM index (FFMi - FMi) are the ratio of FFM and FM to height squared. Results are expressed as median (range). These indexes were compared with previous study values used as a normal range in nutritional assessment and clinical practice. The study included 28 women and 70 men aged 25.3 to 65.9 y. Body mass index ranged from 16.8 kg/m² to 39.4 kg/m². Compared with controls, FMi was higher in women (10.6 kg/m² [3.7-18.6 kg/m²]) than in men (8.1 kg/m² [3.5-13.3 kg/m²] in M) and FFMi was lower in women (14.3 kg/m² [11.8-21.4 kg/m²]) than in men (17.9 kg/m² [13.9-24.2 kg/m²]) (P < 0.01), reflecting an abnormal distribution of body compartments. All biological parameters were within the normal range. BC abnormalities, which can only be detected with the use of DXA, are present in patients on a kidney transplantation waiting list. Detection of these abnormalities could influence the post-transplantation survey in order to prevent the frequent risk for developing metabolic complications after the procedure.Nutrition 02/2014; 30(2):186-91. · 2.86 Impact Factor
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ABSTRACT: Class I obesity conveys an increased risk of comorbidities, impairs physical and mental health-related quality of life, and it is associated to an increased psychosocial burden, particularly in women. The need for effective and safe therapies for class I obesity is great and not yet met by nonsurgical approaches. Eligibility to bariatric surgery has been largely based on body mass index (BMI) cut points and limited to patients with more severe obesity levels. However, obese patients belonging to the same BMI class may have very different levels of health, risk, and impact of obesity on quality of life. Individual patients in class I obesity may have a comorbidity burden similar to, or greater than, patients with more severe obesity. Therefore, the denial of bariatric surgery to a patient with class I obesity suffering from a significant obesity-related health burden and not achieving weight control with nonsurgical therapy simply on the basis of the BMI level does not appear to be clinically justified. A clinical decision should be based on a more comprehensive evaluation of the patient's current global health and on a more reliable prediction of future morbidity and mortality. After a careful review of available data about safety and efficacy of bariatric surgery in patients with class I obesity, this panel reached a consensus on ten clinical recommendations.Obesity Surgery 03/2014; · 3.10 Impact Factor
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ABSTRACT: In patients undergoing maintenance hemodialysis (MHD), increasing numbers of studies have reported a reduced mortality in patients with an increased body mass index (BMI). This article provides a meta-analysis on the assessment of the relationship between BMI and mortality in MHD patients. A systemic literature review was conducted to identify studies that examined all-cause mortality, with or without cardiovascular events, on the basis of bodyweight or obesity measures in MHD population published before October 2012. Eight observational studies with a total of 190,163 patients were included. Compared to the individuals with a normal BMI, overweight patients and obese patients were associated with lower all-cause mortality [relative risk (RR) 0.86, 95 % confidence interval (CI) 0.84-0.88; RR 0.77, 95 % CI 0.75-0.78, respectively] and cardiovascular mortality (RR 0.86; 95 % CI 0.81-0.91; RR 0.78, 95 % CI 0.73-0.83, respectively). Underweight patients had relatively higher all-cause and cardiovascular mortality (RR 1.22, 95 % CI 1.20-1.25; RR 1.19, 95 % CI 1.11-1.28, respectively). In an obesity-stratified analysis, the patients with moderate or severe obesity presented a strongly decreased all-cause mortality risk (RR 0.64, 95 % CI 0.61-0.68) and cardiovascular mortality risk (RR 0.63, 95 % CI 0.53-0.75) compared to patients with mild obesity (RR 0.74, 95 % CI 0.71-0.77; RR 0.81, 95 % CI 0.75-0.87, respectively). These findings show that overweight and obese patients have lower all-cause and cardiovascular mortality rates in patients undergoing MHD. Body weight management and optimized nutritional and metabolic support should help to reduce the high mortality rates that are prevalent in the hemodialysis population.International Urology and Nephrology 02/2014; · 1.33 Impact Factor