Abstract
Background
Exact dose-response relationship between body mass index at transplantation and clinical
outcomes after kidney transplantation remained unclear, and no specific body mass
index threshold and pretransplant weight loss aim were recommended for kidney transplantation
candidates among transplant centers.
Methods
PubMed, Embase, Web of Science, and Cochrane Library were searched for literature
published up to December 31, 2019. The two-stage, random effect meta-analysis was
performed to estimate the dose-response relationship between body mass index and clinical
outcomes after kidney transplantation.
Results
Ninety-four studies were included for qualitative assessment and 50 for dose-response
meta-analyses. There was a U-shaped relationship between graft loss, patient death,
and body mass index. Body mass index with the lowest risk of graft loss was 25.2 kg/m2, and preferred body mass index range was 22–28 kg/m2. Referring to a body mass index of 22 kg/m2, the risk of graft loss was 1.088, 0.981, 1.003, and 1.685 for a body mass index
of 18, 24, 28, and 40 kg/m2, respectively. Body mass index with the lowest risk of patient death was 24.7 kg/m2, and preferred body mass index range was 22–27 kg/m2. Referring to a body mass index of 22 kg/m2, the patient death risk was 1.115, 0.981, 1.032, and 2.634 for a body mass index
of 18, 24, 28, and 40 kg/m2, respectively. J-shaped relationships were observed between body mass index and acute
rejection, delayed graft function, primary graft nonfunction, and de novo diabetes.
Pair-wise comparisons showed that higher body mass index was also a risk factor for
cardiovascular diseases, hypertension, infection, longer length of hospital stay,
and lower estimated glomerular filtration rate level.
Conclusion
Underweight and severe obesity at transplantation are associated with a significantly
increased risk of graft loss and patient death. A target body mass index at kidney
transplantation is 22–27 kg/m2.
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References
- Mortality by dialysis modality among patients who have end-stage renal disease and are awaiting renal transplantation.Clin J Am Soc Nephrol. 2006; 1: 774-779
- Peritoneal dialysis patient survival: a comparison between a Swedish and a Korean centre.Nephrol Dial Transplant. 2005; 20: 1207-1213
- Expanding the donor pool: living donor nephrectomy in the elderly and the overweight.Transplantation. 2012; 93: 1158-1165
- Recipient outcomes for expanded criteria living kidney donors: the disconnect between current evidence and practice.Am J Transplant. 2009; 9: 1558-1573
- UK renal transplant outcomes in low and high BMI recipients: the need for a national policy.J Nephrol. 2020; 33: 371-381
- Outcomes of underweight, overweight, and obese pediatric kidney transplant recipients.Pediatr Nephrol. 2018; 33: 2353-2362
- The impact of obesity on allograft failure after kidney transplantation: a competing risks analysis.Transplantation. 2016; 100: 1963-1969
- Kidney transplantation significantly improves patient and graft survival irrespective of BMI: a cohort study.Am J Transplant. 2015; 15: 2378-2386
- Incidences of-and risk factor for new onset diabetes after transplantation in live donor kidney transplantation: a prospective single centre study.Int J Pharm Pharm Sci. 2016; 8: 230-233
- Is big bad or bearable? Long-term renal transplant outcomes in obese recipients.QJM. 2018; 111: 365-371
- Obesity, metabolic syndrome and diabetes mellitus after renal transplantation: prevention and treatment.Transplant Rev (Orlando). 2014; 28: 37-46
- Effects of obesity on kidney transplantation outcomes: a systematic review and meta-analysis.Transplantation. 2014; 98: 167-176
- Body mass index and outcome in renal transplant recipients: a systematic review and meta-analysis.BMC Med. 2015; 13: 111
- KDIGO clinical practice guideline on the evaluation and management of candidates for kidney transplantation.Transplantation. 2020; 104: S11-S103
- Obesity impacts access to kidney transplantation.J Am Soc Nephrol. 2008; 19: 349-355
- Con: weight loss prior to transplant: no.Nephrol Dial Transplant. 2015; 30: 1805-1809
- Weight loss in advanced chronic kidney disease: should we consider individualised, qualitative, ad libitum diets? A narrative review and case study.Nutrients. 2017; 9: 1109
- Associations of body mass index and weight loss with mortality in transplant-waitlisted maintenance hemodialysis patients.Am J Transplant. 2011; 11: 725-736
- Association between weight loss before deceased donor kidney transplantation and posttransplantation outcomes.Am J Kidney Dis. 2019; 74: 361-372
- Body mass index and risk of inflammatory bowel disease: a systematic review and dose-response meta-analysis of cohort studies of over a million participants.Obes Rev. 2019; 20: 1312-1320
- Body mass index, abdominal fatness, weight gain and the risk of urinary incontinence: a systematic review and dose-response meta-analysis of prospective studies.BJOG. 2019; 126: 1424-1433
- Higgins J.P.T. Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011 (Available from:) (Accessed February 1, 2020)
- Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.BMJ. 2009; 339: b2535
- Pro: pretransplant weight loss: yes.Nephrol Dial Transplant. 2015; 30: 1798-1803
- Obesity in kidney transplantation.Transpl Int. 2020; 33: 581-589
- Recipient obesity and outcomes after kidney transplantation: a systematic review and meta-analysis.Nephrol Dial Transplant. 2015; 30: 1403-1411
- Body mass index and mortality in kidney transplant recipients: a systematic review and meta-analysis.Am J Nephrol. 2014; 40: 315-324
- Adherence to the Mediterranean diet in relation to all-cause mortality: a systematic review and dose-response meta-analysis of prospective cohort studies.Adv Nutr. 2019; 10: 1029-1039
- Glycemic index, glycemic load, and risk of type 2 diabetes: results from 3 large US cohorts and an updated meta-analysis.Am J Clin Nutr. 2014; 100: 218-232
- Meat consumption and risk of lung cancer: evidence from observational studies.Ann Oncol. 2012; 23: 3163-3170
- Whole grain consumption and risk of cardiovascular disease, cancer, and all cause and cause specific mortality: systematic review and dose-response meta-analysis of prospective studies.BMJ. 2016; 353: i2716
- Dietary intake of total, animal, and plant proteins and risk of all cause, cardiovascular, and cancer mortality: systematic review and dose-response meta-analysis of prospective cohort studies.BMJ. 2020; 370: m2412
- Central fatness and risk of all cause mortality: systematic review and dose-response meta-analysis of 72 prospective cohort studies.BMJ. 2020; 370: m3324
- Recipient comorbidity and survival outcomes after kidney transplantation: a UK-wide prospective cohort study.Transplantation. 2020; 104: 1246-1255
- Hospital admissions and emergency department visits among kidney transplant recipients.Clin Transplant. 2019; 33e13522
- HDL cholesterol efflux predicts incident new-onset diabetes after transplantation (NODAT) in renal transplant recipients independent of HDL cholesterol levels.Diabetes. 2019; 68: 1915-1923
- Beyond death and graft survival-variation in outcomes after kidney transplantation. Results from the NSQIP transplant beta phase.Am J Transplant. 2019; 19: 2622-2630
- Incidence of post-transplantation diabetes mellitus within 1 year after kidney transplantation and related factors in Korean cohort study.Transplant Proc. 2019; 51: 2714-2717
- Where to draw the line in surgical obesity for renal transplant recipients: an outcome analysis based on body mass index.Exp Clin Transplant. 2019; 17: 37-41
- Renal transplant in obese patients and impact of weight loss before surgery on surgical and medical outcomes: a single-center cohort study.Exp Clin Transplant. 2019; 17: 604-612
- Body mass index, weight-adjusted immunosuppression and the risk of acute rejection and infection after kidney transplantation: a cohort study.Nephrol Dial Transplant. 2019; 34: 2132-2143
- Effect of Obesity on clinical outcomes of kidney transplant patients.Transplant Proc. 2019; 51: 1093-1095
- The associations of muscle strength, muscle mass, and adiposity with clinical outcomes and quality of life in prevalent kidney transplant recipients.J Ren Nutr. 2019; 29: 536-547
- Morbid obesity and functional status as predictors of surgical complication after renal transplantation.Am J Surg. 2018; 215: 663-668
- Being overweight is related to faster decline in annual glomerular filtration rate in kidney transplant.Transplant Proc. 2018; 50: 3392-3396
- Influence of the recipient body mass index on the outcomes after kidney transplantation.Langenbecks Arch Surg. 2018; 403: 73-82
- Impact of obesity in kidney transplantation: monocentric cohort study and review of the literature.Nephrol Ther. 2018; 14: 454-461
- Tell me your weight before kidney transplant and I’ll tell you your risks.Port J Nephrol Hypert. 2018; 32: 22-28
- Diabetes mellitus after kidney transplantation in Japanese patients: the Japan Academic Consortium of Kidney Transplantation study.Int J Urol. 2017; 24: 197-204
- Effect of changes in body mass index on cardiovascular outcomes in kidney transplant recipients.Transplant Proc. 2017; 49: 1038-1042
- The effect of body mass index on patient and graft survival rate in kidney transplanted patients in Iran.Nephrourol Mon. 2017; 9e14386
- Body mass index and metabolic syndrome impact differently on major clinical events in renal transplant patients.Eur Rev Med Pharmacol Sci. 2017; 21: 4654-4660
- One-year outcomes of a cohort of renal transplant patients related to BMI in a steroid-sparing regimen.Transplant Direct. 2017; 3e330
- Pretransplantation risk factors associated with new-onset diabetes after living-donor kidney transplantation.Transplant Proc. 2016; 48: 3299-3302
- Impact of obesity on renal graft function-analysis of kidney grafts from the same donor.Transplant Proc. 2016; 48: 1482-1488
- Absence of the effect of pretransplant body mass index on post kidney transplant outcomes.Prog Transplant. 2016; 26: 183-190
- Association between body mass index and outcomes in Japanese living kidney transplant recipients: the role of sex differences.Int J Urol. 2016; 23: 776-784
- Recipient criteria predictive of graft failure in kidney transplantation.Int J Angiolol. 2016; 25: 29-38
- Effect of the obesity epidemic on kidney transplantation: obesity is independent of diabetes as a risk factor for adverse renal transplant outcomes.PLoS One. 2016; 11e0165712
- Long-term effect of body mass index changes on graft damage markers in patients after kidney transplantation.Ann Transplant. 2016; 21: 626-631
- The impact of morbid obesity on resource utilization after renal transplantation.Surgery. 2016; 160: 1544-1550
- Kidney transplant outcomes in the super obese: a national study from the UNOS dataset.World J Surg. 2016; 40: 2808-2815
- New-onset diabetes after transplantation: results from a double-blind early corticosteroid withdrawal trial.Am J Transplant. 2015; 15: 1982-1990
- Body mass index: short- and long-term impact on kidney transplantation.Int J Clin Pract. 2015; 69: 1357-1365
- New onset diabetes mellitus after living donor renal transplantation: a unique pattern in the Egyptian population.J Diab Metab. 2015; 6: 1-5
- Pre-transplant weight loss and survival after kidney transplantation.Am J Nephrol. 2015; 41: 448-455
- Prevalence and predictors of early cardiovascular events after kidney transplantation: evaluation of pre-transplant cardiovascular work-up.PLoS One. 2015; 10e0131237
- Twelve-month and five-year analyses of risk factors for new-onset diabetes after transplantation in a group of patients homogeneous for immunosuppression.Transplant Proc. 2015; 47: 1831-1839
- Multivariable risk of developing new onset diabetes after transplant-results from a single-center study of 481 adult, primary kidney transplant recipients.Clin Transplant. 2015; 29: 301-310
- Renal transplantation: tetter fat than thin.J Surg Res. 2015; 194: 644-652
- The impact of morbid obesity on hospital length of stay in kidney transplant recipients.J Ren Nutr. 2014; 24: 411-416
- Morbid obesity is not an independent predictor of graft failure or patient mortality after kidney transplantation.J Ren Nutr. 2014; 24: 50-57
- Renal transplantation in obese patients: experience in an Argentine center.Transplant Proc. 2014; 46: 2981-2983
- Impact of pretransplant body mass index on early kidney graft function.Transplant Proc. 2014; 46: 2689-2691
- Increased recipient body mass index is associated with acute rejection and other adverse outcomes after kidney transplantation.Transplantation. 2014; 97: 64-70
- Body mass index and the development of new-onset diabetes mellitus or the worsening of pre-existing diabetes mellitus in adult kidney transplant patients.J Ren Nutr. 2014; 24: 116-122
- Obesity and urologic complications after renal transplantation.Saudi J Kidney Dis Transpl. 2014; 25: 303-308
- Obesity in kidney transplant recipients: association with decline in glomerular filtration rate.Ren Fail. 2013; 35: 1199-1203
- Recipient-related predictors of kidney transplantation outcomes in the elderly.Clin Transplant. 2013; 27: 436-443
- The impact of recipient obesity on outcomes after renal transplantation.Ann Surg. 2013; 257: 978-984
- Body mass index and postoperative complications in kidney transplant recipients.Nephrology (Carlton). 2012; 17: 582-587
- Recipient and donor body mass index as important risk factors for delayed kidney graft function.Transplantation. 2012; 93: 524-529
- The role of obesity in kidney transplantation outcome.Transplant Proc. 2012; 44: 1864-1868
- Outcomes of renal transplantation in obese recipients.Transplant Proc. 2012; 44: 2787-2791
- Associations of pretransplant weight and muscle mass with mortality in renal transplant recipients.Clin J Am Soc Neprhol. 2011; 6: 1463-1473
- Obesity in renal transplantation: the role of induction therapy on long-term outcomes.Transplant Proc. 2011; 43: 469-471
- Higher recipient body mass index is associated with post-transplant delayed kidney graft function.Kidney Int. 2011; 80: 218-224
- Long-term kidney transplant outcome in obese patients in a predominantly African American population.Clin Transplant. 2011; 25: E264-270
- Effect of obesity on the outcome of kidney transplantation: a 20-year follow-up.Transplantation. 2011; 91: 869-874
- Pretransplantation overweight and obesity: does it really affect kidney transplantation outcomes?.Transplant Proc. 2011; 43: 95-99
- Recipient risk factors associated with delayed graft function: a paired kidney analysis.Transplantation. 2011; 91: 666-671
- Obesity in kidney transplantation affects renal function but not graft and patient survival.Transplant Proc. 2011; 43: 367-372
- Kidney transplantation in the morbidly obese: complicated but still better than dialysis.Clin Transplant. 2011; 25: 401-405
- Pre-transplant overweight and obesity do not affect physical quality of life after kidney transplantation.J Am Coll Surg. 2010; 210: 336-344
- Impact of continuous value of body mass index on graft loss in overweight patients.Transplant Proc. 2010; 42: 1074-1076
- Impact of obesity on urologic complications among unrelated living donor kidney transplants.Indian J Surg. 2010; 72: 211-214
- Effect of pretransplantation body mass index on allograft function and patient survival after renal transplantation.Transplant Proc. 2010; 42: 785-788
- Obesity, surgical site infection, and outcome following renal transplantation.Ann Surg. 2009; 250: 1014-1020
- Outcome of living donor renal transplantation in obese recipients.Transplant Proc. 2008; 40: 921-922
- Depressive disorder in renal transplantation: an analysis of Medicare claims.Am J Kidney Dis. 2008; 51: 819-828
- Associations between pre-kidney-transplant risk factors and post-transplant cardiovascular events and death.Transpl Int. 2008; 21: 985-991
- Impact of recipient obesity on living donor kidney transplant outcomes: a single-center experience.Transplant Proc. 2007; 39: 1421-1423
- High body mass index and posttransplant weight gain are not risk factors for kidney graft and patient outcome.Transplant Proc. 2007; 39: 2205-2207
- Effects of body mass index at transplant on outcomes of kidney transplantation.Transplantation. 2007; 84: 981-987
- Obesity and outcome following renal transplantation.Am J Transplant. 2006; 6: 357-363
- Body mass index as a predictive factor for long-term renal transplant outcomes in Asians.Clin Transplant. 2006; 20: 582-589
- The influence of obesity on short- and long-term graft and patient survival after renal transplantation.Transpl Int. 2006; 19: 901-907
- Does pretransplant obesity affect the outcome in kidney transplant recipients?.Transplant Proc. 2005; 37: 717-720
- Effect of body mass index at time of transplantation and weight gain after transplantation on allograft function in kidney transplant recipients in Shiraz.Transplant Proc. 2005; 37: 2998-3000
- High body mass index and short- and long-term renal allograft survival in adults.Transplantation. 2005; 80: 1430-1434
- Morbid obesity is not a contraindication to kidney transplantation.Am J Surg. 2004; 187: 635-638
- Obesity favors surgical and infectious complications after renal transplantation.Transplant Proc. 2003; 35: 1762-1763
- The impact of obesity in renal transplantation: an analysis of paired cadaver kidneys.Clin Transplant. 2002; 16: 252-256
- The effect of obesity on renal transplant outcomes.Transplantation. 2002; 74: 675-681
- Obesity does not portend a bad outcome for kidney transplant recipients.Transplantation. 2002; 73: 53-55
- Obesity as a risk factor following cadaveric renal transplantation.Transplantation. 1990; 49: 387-389
- The impact of body mass index on renal transplant outcomes: a significant independent risk factor for graft failure and patient death.Transplantation. 2002; 73: 70-74
- The effect of body mass index on long-term renal allograft survival.Transplantation. 1999; 68: 1294-1297
- Should obese patients lose weight before receiving a kidney transplant?.Transplantation. 1997; 64: 599-604
- Is obesity still a risk factor in renal transplantation?.Transpl Int. 1997; 10: 284-288
- The impact of pre-transplant obesity on renal transplant outcomes.Clin Transplant. 1997; 11: 493-496
- The causes of kidney allograft failure: more than alloimmunity. A viewpoint article.Transplantation. 2020; 104: e46-e56
- Assessing the complex causes of kidney allograft loss.Transplantation. 2020; 104: 2557-2566
- Early failure of kidney transplants in the current era-a national cohort study.Transpl Int. 2018; 31: 880-886
- Nephron underdosing: a programmed cause of chronic renal allograft failure.Am J Kidney Dis. 1993; 21: 66-72
- Association of BMI with overall and cause-specific mortality: a population-based cohort study of 3.6 million adults in the UK.Lancet Diabetes Endocrinol. 2018; 6: 944-953
- Body mass index and the risk of infection - from underweight to obesity.Clin Microbiol Infect. 2018; 24: 24-28
Article info
Publication history
Published online: November 24, 2021
Accepted:
October 11,
2021
Footnotes
Saifu Yin and Linyan Wu contributed equally to the study and share co-first authorship.
Identification
Copyright
© 2021 Elsevier Inc. All rights reserved.
