Obesity Paradox in End-Stage Kidney Disease Patients
Section snippets
Body size and mortality in HD patients
HD patients appear to have a lower BMI than age- and sex-matched control subjects from the general population.7 In a matched analysis comparing the lipid profiles of 285 HD patients with those of 285 non-ESRD patients matched in a one-to-one fashion on age, sex, race, and diabetes, BMI was found to be significantly lower in the HD patients than in the control subjects (26.2 ± 6.0 compared with 31.5 ± 7.8 kg/m2, P < 0.001).8 A lower BMI was consistently found to be a strong predictor of increased
Body size and mortality in PD patients
Similar inverse associations between body size and mortality have been observed in some studies with PD patients, but a survival advantage associated with large body size seemed to be less likely in PD than HD patients31 (Table 2), although comparisons are limited by methodological differences across studies, including the use of different BMI categories. In the Canada-USA (CANUSA) Peritoneal Dialysis Study Group, 1% lower lean body mass estimated from creatinine kinetics was associated with a
Body composition and mortality in ESRD patients
BMI may not be an optimal surrogate of visceral obesity when compared to waist circumference, which better reflects intra-abdominal (truncal) fat. Indeed Postorino et al.40 showed that surrogate measures of abdominal obesity and segmental fat distribution (waist circumference and waist/hip ratio) were stronger predictors of all-cause and CVD death than BMI in 537 patients with ESRD. In this study, higher BMI was protective whereas higher waist circumference was a predictor of higher mortality.40
Possible explanations for the obesity paradox
The obesity paradox has been also observed in other populations such as the elderly46 and in patients with congestive heart failure.47., 48. The obesity paradox may appear counterintuitive, because obesity is an established risk factor for CVD and poor outcomes in the general population. Indeed, it is not only lack of an association between obesity and mortality, but the opposite direction of this relation. Hence, there must be prevailing conditions that are uniquely present in ESRD patients,
Remaining questions and future studies
The obesity paradox of CVD mortality in ESRD patients may have indeed serious clinical and public health implications. Is the survival advantage of obesity in ESRD patients a clinically valid characteristic, or is it a statistical fallacy that needs to be ‘controlled away’?88 Does obesity which promotes atherosclerosis and mortality in the general population, prevent cardiovascular death in ESRD patients and, if so, how? Should ESRD patients be advised to increase their nutrient intake to gain
Statement of Conflict of Interest
The author declares there are no conflicts of interest.
Acknowledgments
KKZ and CPK are supported by the National Institute of Diabetes, Digestive and Kidney Disease grants R01-DK078106 and R01-DK096920, and KKZ is supported additionally by grant K24-DK091419 and a philanthropist grant from Mr. Harold Simmons. MZM and KKZ are supported by the National Institute on Aging of the National Institutes of Health grant R21-AG047036. Disclaimer: The findings and conclusions in this report are those of the authors and not necessarily of the Centers for Disease Control and
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Statement of Conflict of Interest: see page 422.
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Correspondence: Kamyar Kalantar-Zadeh, MD PhDMPH, Harold Simmons Center, Division of Nephrology and Hypertension, University of California Irvine Medical Center, 101 The City Drive South, City Tower, Suite 400 - ZOT: 4088, Orange, CA 92868.