Obesity and Chronic Kidney Disease A Current Review

Nutritional status and its relationship with COVID-19 prognosis in hemodialysis patients

Introduction

Introduction: among the groups more affected by the COVID-19 pandemic were patients undergoing chronic hemodialysis (HD) treatment due to their comorbidities, advanced age, impaired innate and adaptive immune function, and increased nutritional risk due to their underlying inflammatory state. All of these factors contribute to a higher risk of severe complications and worse outcomes compared to the general population when infected with SARS-CoV-2. Objective: the objective of this study was to describe the nutritional characteristics of and their potential association with the prognosis of COVID-19 in patients undergoing chronic HD treatment. Method: a descriptive, retrospective, observational design. All cases of COVID-19 in patients undergoing chronic treatment at the Hemodialysis Unit of Hospital de Manises, Valencia, Spain, from the start of the pandemic to before vaccination were included. Results: for that, 189 patients were studied, who received chronic HD treatment in the hospital unit, 22 patients were diagnosed with COVID-19 (12 %) in that period. The mean age was 71 years, 10 were women, the Charlson index was 6.59 points, diabetes mellitus 10, vintage HD 51.6 months, 2 patients had previously received a currently non-functioning kidney transplant, 16 had arteriovenous fistula as vascular access, and 6 had central vascular access. The mean dialysis session time was 220.14 minutes and the initial value of the single dose of the Kt/V pool was 1.7. 16 patients had body composition measurement, a strong association (p < 0.05) was identified between mortality and BMI, as well as mortality and FTI. Furthermore, the differences between deceased and surviving groups in the serum levels of various variables related to nutritional status were analyzed, finding significant differences with p < 0.05 in the value of triglycerides and ferritin. Conclusions: higher body mass index and higher body fat content, along with lower baseline levels of triglycerides and ferritin, were significantly associated with higher COVID-19 mortality in patients on chronic hemodialysis. These findings suggest that the initial nutritional status of these patients can significantly influence the prognosis of SARS-CoV-2 infection.

Kidney function evaluation in children and adolescents with obesity: a not-negligible need

The role of obesity as risk factor for chronic kidney disease (CKD) has been well-recognized. As previously demonstrated in adults, emerging data highlighted the relevant impact of obesity on renal function since childhood. As a matter of fact, obesity also affects renal health through a complex pathogenic mechanism in which insulin resistance (IR) plays a pivotal role. Worthy of note, the vicious interplay among obesity, IR, and renal hemodynamics clinically translates into a plethora of kidney function impairments potentially leading to CKD development. Therefore, renal injury needs to be added to the well-known spectrum of cardiometabolic obesity comorbidities (e.g., type 2 diabetes, IR, metabolic syndrome, cardiovascular disease).

CONCLUSION

Taking this into account, a careful and timely monitoring of kidney function should not be neglected in the global assessment of children with obesity. We aimed to provide a comprehensive overview on the relevance of kidney evaluation in children with obesity by shedding lights on the intriguing relationship of obesity with renal health in this at-risk population.

WHAT IS KNOWN

• Obesity has been found to be a risk factor for chronic kidney disease. • Unlike adults, pediatric data supporting the association between obesity and renal function are still limited.

WHAT IS NEW

• As observed in adults, obesity might affect renal function since childhood. • Kidney function should be carefully evaluated in children with obesity.

Policy Interventions to Enhance Medical Care for People With Obesity in the United States-Challenges, Opportunities, and Future Directions

Policy Points Health policymakers have insufficiently addressed care for people with obesity (body mass index ≥ 30 kg/m2) in the United States. Current federal policies targeting obesity medications reflect this unfortunate reality. We argue for a novel policy framework to increase access to effective obesity therapeutics and care, recognizing that, though prevention is critical, the epidemic proportions of obesity in the United States warrant immediate interventions to augment care. Reducing barriers to and improving the quality of existing anti-obesity medications, intensive behavioral therapy, weight management nutrition and dietary counseling, and bariatric surgery are critical. Moreover, to ensure continuity of care and patient-clinician trust, combating physician and broader weight stigma must represent a central component of any viable obesity care agenda.

Approach to weight management in patients with advanced chronic kidney disease in a real-life clinical setting

Objective

Excess adiposity represents a risk factor for chronic kidney disease (CKD) and progression to end-stage kidney disease. Anti-Obesity Medications (AOMs) are vastly underutilized in patients with advanced CKD because of concerns related to safety and efficacy. This study was conducted to evaluate the real-world approach to weight management and the efficacy and safety of AOMs in people with advanced CKD.

Methods

This is a retrospective analysis of individuals with Body Mass Index (BMI) ≥ 27 kg/m2 and eGFR ≤ 30 mL/min/1.73 m2 referred to an academic medical weight-management program between 01/2015 and 09/2022. Evaluation of weight-management approaches, body weight change, treatment-related side effects, and reasons for treatment discontinuation were reported.

Results

Eighty-nine patients met inclusion criteria, 16 were treated with intensive lifestyle modifications (ILM) alone and 73 with AOMs (all treated with glucagon-like peptide-1 receptor agonist [GLP1-RA] +/- other AOMs) along with ILM. Patients treated with AOMs had a longer duration of on-treatment follow-up (median 924 days) compared to (93 days) the ILM group. Over 75% of patients treated with AOMs lost ≥5% body weight versus 25% of those treated with ILM. Only 15% of patients treated with AOMs discontinued therapy due to treatment-related side effects.

Conclusion

In patients with obesity and advanced CKD, GLP-1RA-based anti-obesity treatment was well-tolerated, effective, and led to durable weight reduction.

Cardiometabolic comorbidities and complications of obesity and chronic kidney disease (CKD)

Obesity and chronic kidney disease are two ongoing progressive clinical pandemics of major public health and clinical care significance. Because of their growing prevalence, chronic indolent course and consequent complications both these conditions place significant burden on the health care delivery system especially in developed countries like the United States. Beyond the chance coexistence of both of these conditions in the same patient based on high prevalence it is now apparent that obesity is associated with and likely has a direct causal role in the onset, progression and severity of chronic kidney disease. The causes and underlying pathophysiology of this are myriad, complicated and multi-faceted. In this review, continuing the theme of this special edition of the journal on " The Cross roads between Endocrinology and Nephrology" we review the epidemiology of obesity related chronic kidney disease (ORCKD), and its various underlying causes and pathophysiology. In addition, we delve into the consequent comorbidities and complications associated with ORCKD with particular emphasis on the cardio metabolic consequences and then review the current body of evidence for available strategies for chronic kidney disease modulation in ORCKD as well as the potential unique role of weight reduction and management strategies in its improvement and risk reduction.

Integrating classification and regression learners with bioimpedance methods for estimating weight status in infants and juveniles from the southern Cuba region

OBJECTIVE

The search for other indicators to assess the weight and nutritional status of individuals is important as it may provide more accurate information and assist in personalized medicine. This work is aimed to develop a machine learning predictions of weigh status derived from bioimpedance measurements and other physical parameters of healthy younger volunteers from Southern Cuba Region.

METHODS

A pilot random study at the Pediatrics Hospital was conducted. The volunteers were selected between 2002 and 2008, ranging in age between 2 and 18 years old. In total, 776 female and male volunteers are studied. Along the age and sex in the cohort, volunteers with class I obesity, overweight, underweight and with normal weight are considered. The bioimpedance parameters are obtained by measuring standard tetrapolar whole-body configuration. The bioimpedance analyser is used, collecting fundamental bioelectrical and other parameters of interest. A classification model are performed, followed by a prediction of the body mass index.

RESULTS

The results derived from the classification leaner reveal that the size, body density, phase angle, body mass index, fat-free mass, total body water volume according to Kotler, body surface area, extracellular water according to Kotler and sex largely govern the weight status of this population. In particular, the regression model shows that other bioparameters derived from impedance measurements can be associated with weight status estimation with high accuracy.

CONCLUSION

The classification and regression predictive models developed in this work are of the great importance to assist the diagnosis of weigh status with high accuracy. These models can be used for prompt weight status evaluation of younger individuals at the Pediatrics Hospital in Santiago de Cuba, Cuba.

Obesity and glomerular filtration rate

Obesity has received considerable attention in general medicine and nephrology over the last few years. This condition increases the risk of metabolic syndrome, diabetes mellitus, hypertension, and dyslipidemia, which are the main risk factors for developing chronic kidney disease (CKD). Kidney damage caused by obesity can be explained by many mechanisms, such as sympathetic nervous and renin-angiotensin-aldosterone systems activation, mechanical stress, hormonal unbalance, as well as inflammatory cytokines production. Even though creatinine-based glomerular filtration rate (GFR) equations in obese individuals have been validated (Salazar-Corcoran and CKD-MCQ), changes in body weight after bariatric surgery (BS) leads to changes in creatininemia, affecting its reliability. Thus, an average between creatine and cystatin-based GFR equations would be more appropriate in this setting. Bariatric surgery can reverse diabetes mellitus and improve hypertension, which are the main causes of CKD. Conclusion: GFR can be affected by obesity and BS, and its value should be cautiously evaluated in this setting.

Parental obesity predisposes offspring to kidney dysfunction and increased susceptibility to ischemia-reperfusion injury in a sex-dependent manner

Although obesity is recognized as a risk factor for cardiorenal and metabolic diseases, the impact of parental obesity on the susceptibility of their offspring to renal injury at adulthood is unknown. We examined the impact of parental obesity on offspring kidney function, morphology, and markers of kidney damage after acute kidney injury (AKI). Offspring from normal (N) diet-fed C57BL/6J parents were fed either N (NN) or a high-fat (H) diet (NH) from weaning until adulthood. Offspring from obese H diet-fed parents were fed N (HN) or H diet (HH) after weaning. All offspring groups were submitted to bilateral AKI by clamping the left and right renal pedicles for 30 min. Compared with male NH and NN offspring from lean parents, male HH and HN offspring from obese parents exhibited higher kidney injury markers such as urinary, renal osteopontin, plasma creatinine, urinary albumin excretion, and neutrophil gelatinase-associated lipocalin (NGAL) levels, and worse histological injury score at 22 wk of age. Only albumin excretion and NGAL were elevated in female HH offspring from obese parents compared with lean and obese offspring from lean parents. We also found an increased mortality rate and worse kidney injury scores after AKI in male offspring from obese parents, regardless of the diet consumed after weaning. Female offspring were protected from major kidney injury after AKI. These results indicate that parental obesity leads to increased kidney injury in their offspring after ischemia-reperfusion in a sex-dependent manner, even when their offspring remain lean.NEW & NOTEWORTHY Offspring from obese parents are more susceptible to kidney injury and worse outcomes following an acute ischemia-reperfusion insult. Male, but not female, offspring from obese parents exhibit increased blood pressure early in life. Female offspring are partially protected against major kidney injury induced by ischemia-reperfusion.

Chronic Kidney Disease Diets for Kidney Failure Prevention: Insights from the IL-11 Paradigm

Nearly every fifth adult in the United States and many older adults worldwide are affected by chronic kidney disease (CKD), which can progress to kidney failure requiring invasive kidney replacement therapy. In this review, we briefly examine the pathophysiology of CKD and discuss emerging mechanisms involving the physiological resolution of kidney injury by transforming growth factor beta 1 (TGFβ1) and interleukin-11 (IL-11), as well as the pathological consequences of IL-11 overproduction, which misguides repair processes, ultimately culminating in CKD. Taking these mechanisms into account, we offer an overview of the efficacy of plant-dominant dietary patterns in preventing and managing CKD, while also addressing their limitations in terms of restoring kidney function or preventing kidney failure. In conclusion, this paper outlines novel regeneration strategies aimed at developing a reno-regenerative diet to inhibit IL-11 and promote repair mechanisms in kidneys affected by CKD.

Association of Body Weight Time in Target Range With the Risk of Kidney Outcomes in Patients With Overweight/Obesity and Type 2 Diabetes Mellitus

OBJECTIVE

We assessed the relationship of body weight time in target range (TTR) with composite kidney outcome in people with overweight/obesity and type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

Included in this study were 3,601 participants with baseline estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 from the Look AHEAD (Action for Health in Diabetes) trial. Body weight TTR was defined as the proportion of time during the first 4 years that body weight was within the weight loss target (a weight loss of ≥7% from baseline). The primary outcome was composite kidney outcome, defined as eGFR decline ≥30% from baseline and to a level <60 mL/min/1.73 m2 at follow-up visit, or end-stage kidney disease.

RESULTS

During a median follow-up of 8.0 years, 435 cases of composite kidney outcome were documented. Body weight TTR during the first 4 years was inversely associated with the subsequent risk of composite kidney outcome (per SD increment; adjusted hazard ratio [HR] 0.81; 95% CI 0.70-0.93). Accordingly, the adjusted HRs (95% CI) of composite kidney outcome were 1.00 (reference), 0.73 (0.54-1.00), 0.71 (0.52-0.99), and 0.54 (0.36-0.80) for participants with body weight TTR of 0%, >0% to <29.9%, 29.9% to <69.7%, and 69.7% to <100%, respectively. Similar results were found for a doubling of the urine albumin to creatinine ratio (secondary outcome).

CONCLUSIONS

A higher body weight TTR, with a weight loss target of losing ≥7% of initial weight, was associated with a lower risk of kidney outcomes in participants with overweight/obesity and T2DM.

Mechanisms and treatment of obesity-related hypertension-Part 1: Mechanisms

The prevalence of obesity has tripled over the past five decades. Obesity, especially visceral obesity, is closely related to hypertension, increasing the risk of primary (essential) hypertension by 65%-75%. Hypertension is a major risk factor for cardiovascular disease, the leading cause of death worldwide, and its prevalence is rapidly increasing following the pandemic rise in obesity. Although the causal relationship between obesity and high blood pressure (BP) is well established, the detailed mechanisms for such association are still under research. For more than 30 years sympathetic nervous system (SNS) and kidney sodium reabsorption activation, secondary to insulin resistance and compensatory hyperinsulinemia, have been considered as primary mediators of elevated BP in obesity. However, experimental and clinical data show that severe insulin resistance and hyperinsulinemia can occur in the absence of elevated BP, challenging the causal relationship between insulin resistance and hyperinsulinemia as the key factor linking obesity to hypertension. The purpose of Part 1 of this review is to summarize the available data on recently emerging mechanisms believed to contribute to obesity-related hypertension through increased sodium reabsorption and volume expansion, such as: physical compression of the kidney by perirenal/intrarenal fat and overactivation of the systemic/renal SNS and the renin-angiotensin-aldosterone system. The role of hyperleptinemia, impaired chemoreceptor and baroreceptor reflexes, and increased perivascular fat is also discussed. Specifically targeting these mechanisms may pave the way for a new therapeutic intervention in the treatment of obesity-related hypertension in the context of 'precision medicine' principles, which will be discussed in Part 2.

Kidney damage predictors in children with metabolically healthy and metabolically unhealthy obesity phenotype

BACKGROUND

Obesity and kidney damage have been closely linked in adults, but little is still known in childhood.

OBJECTIVE

To identify predictors of kidney damage in children with metabolically healthy (MHO) and metabolically unhealthy (MUO) obesity phenotypes.

METHODS

We retrospectively examined 396 children with obesity (mean age 10.72 ± 2.71 years, body mass index-standard deviation score, BMI-SDS, 2.23 ± 0.57) stratified according to metabolic phenotypes. Kidney damage was defined as the presence of reduced estimated glomerular filtration rate (eGFR < 90 mL/min/1.73m2) and/or albuminuria (≥ 30 mg/g urinary creatinine).

RESULTS

Kidney damage was found in 20.9% of the study population. Children with kidney damage had higher BMI-SDS, homeostasis model assessment of insulin resistance (HOMA-IR), and inflammation markers levels and increased prevalence of non-alcoholic fatty liver disease (NAFLD) than those without kidney damage (all p < 0.005). MUO and MHO subjects had respectively an odds ratio (OR) to show kidney damage of of 1.92 (95%CI:1.22-3.01; p = 0.005) and 1.05 (95%CI:1.00-1.09; p = 0.028) after adjustments. Moreover, we found that only HOMA-IR was closely associated to kidney damage in MUO group (OR = 2.07;95%CI:1.20-3.57; p = 0.007), while HOMA-IR (OR = 1.15;95%CI:1.02-1.29; p = 0.011) and uric acid (OR = 1.15;95% CI:1.02-1.30; p = 0.010) were the only significant risk factors for kidney damage in MHO group.

CONCLUSION

An increased risk of kidney damage has been observed in children with obesity and in particular in those with MUO phenotype. As their role on kidney function, HOMA-IR should be monitored in MUO children and both HOMA-IR and uric acid in MHO children.

The Importance of Assessing Drug Pharmacokinetics and Pharmacodynamics in the Obese Population During Drug Development

Obesity remains a US national health crisis and a growing concern worldwide. Concerningly, individuals who are obese are at an increased risk for comorbid diseases that include, but are not limited to, hypertension, diabetes, cardiovascular disease, and cancer. Beyond the risk for developing these conditions, obesity may also impact the pharmacological activity of the therapies being used to treat them and other disease states. The pharmacokinetics (PK), pharmacodynamics (PD), safety, and efficacy of therapies, both currently marketed and under clinical development, may be directly impacted by the physiological alterations that occur secondary to the occurrence of chronic excess body weight. The increased prevalence of this disease should not be ignored. Both private and federal institutions involved in drug research and development should consider, as appropriate, a greater inclusion of individuals who are obese in clinical trials throughout the entirety of drug development, and leverage the available PK, PD, safety, and efficacy data to make more informed dosing recommendations.

Leading Causes of Chronic Kidney Disease Among Dialysis Patients in Al-Baha Region, Saudi Arabia

Introduction Chronic kidney disease (CKD) and its progression to end-stage renal disease (ESRD) represent a growing health concern globally, with hypertension and diabetes commonly identified as primary etiological factors. This study evaluates the demographic and health profiles of individuals undergoing dialysis treatment in the Al-Baha region of Saudi Arabia, aiming to identify the predominant causes of ESRD and the associated socioeconomic and healthcare-related factors. Methodology This cross-sectional study analyzed data from patients receiving dialysis in Al-Baha. We assessed variables including etiology of ESRD, demographic data, presence of comorbid conditions, initial symptoms, and pre-dialysis health care engagement. Statistical analysis focused on the prevalence and correlations between the different variables and ESRD. The study also examined patients' educational background and employment status to ascertain ESRD's socioeconomic impact. Results The study found hypertension and diabetes as the leading causes of ESRD. Unknown etiologies accounted for 10.1% of cases, highlighting an area for further research. Notably, coronavirus disease 2019 (COVID-19) and cardiogenic shock emerged as potential new contributors, each representing 1.7% of cases. Most patients resided in urban areas, with the largest age group being 46 to 55 years. Men had a higher prevalence of ESRD than women. Low educational attainment was significant among patients, and unemployment due to ESRD was prevalent, pointing towards the need for vocational support. Clinical findings revealed late referrals to nephrologists, with a substantial proportion of diagnoses occurring in emergency settings. Family history suggested a higher-than-expected genetic component of CKD in the region. Conclusion The study confirms hypertension and diabetes as principal contributors to ESRD in Al-Baha while also pointing to the emergence of COVID-19 as a potential risk factor. Socioeconomic factors, including educational and employment status, are critical to patient management and outcomes. The high percentage of unknown etiologies and familial CKD prevalence warrants additional research. Improving early detection, enhancing patient education, and fostering timely nephrology consultations could mitigate the progression to ESRD and enhance patient quality of life.

Microvascular complications of obesity and diabetes-Role of bariatric surgery

Bariatric surgery in people with obesity can lead to long-term remission of type 2 diabetes mellitus (T2DM) and a reduction in the incidence of macrovascular complications. The impact of bariatric surgery on microvascular complications is less clear. In this narrative review, we sought to evaluate the effect of bariatric surgery on microvascular complications in patients with and without diabetes. The risk of developing microvascular complications is increased in people with obesity, and this is amplified in those with T2DM. The impact of metabolic surgery on microvascular complications is limited to a subgroup analysis of studies or statistical modeling to predict the glycemia-independent effect of bariatric surgery. While bariatric surgery halts the progression of retinopathy in those with minimal retinopathy, it may worsen in those with advanced retinopathy. Bariatric surgery improves proteinuria and major renal outcomes, regardless of the severity of renal impairment. Bariatric surgery in patients with obesity with or without diabetes is associated with an improvement in neuropathic symptoms and regeneration of small nerve fibers. In conclusion, bariatric surgery is associated with an improvement in microvascular complications. Further studies are needed to elucidate the underlying mechanisms for the favorable effect of bariatric surgery on microvascular outcomes.

Gender Differences in Insulin Resistance: New Knowledge and Perspectives

Insulin resistance is the main mechanism in a whole series of pathological conditions, which are not only of metabolic interest but also of a systemic type. This phenomenon means that the body's cells become less sensitive to the hormone insulin, leading to higher levels of insulin in the blood. Insulin resistance is a phenomenon that can be found in both men and women and in particular, in the latter, it is found mainly after menopause. Premenopause, hormonal fluctuations during the menstrual cycle, and the presence of estrogen can affect insulin sensitivity. Androgens, such as testosterone, are typically higher in men and can contribute to insulin resistance. In both sexes, different human body types affect the distribution and location of body fat, also influencing the development of diabetes and cardiovascular disease. Insulin resistance is also associated with some neurological and neurogenerative disorders, polycystic ovary syndrome, atherosclerosis, and some of the main neoplastic pathologies. A healthy lifestyle, including regular physical activity, a balanced diet, and self-maintenance, can help to prevent the onset of insulin resistance, regardless of gender, although the different habits between men and women greatly affect the implementation of preventative guidelines that help in fighting the manifestations of this metabolic disorder. This review may help to shed light on gender differences in metabolic diseases by placing a necessary focus on personalized medical management and by inspiring differentiated therapeutic approaches.

Anthropometric Measures of Adiposity as Markers of Kidney Dysfunction: A Cross-Sectional Study

The present study was designed to provide information on the ability of several different anthropometric markers to reflect the renal impairment associated with body weight increase and to predict the development of renal alterations linked to overweight and obesity. In 574 subjects representative of the general population of the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study, with an age range between 57 and 73 years, we investigated the association between different anthropometric markers of body fat, as alternative to body mass index, and renal failure, to obtain information useful for determining their potential predictive value. Renal dysfunction was significantly associated with almost all anthropometric markers of adiposity related to body weight and body shape. After adjustment for confounders, such as age, sex, office blood pressure, serum glucose, antihypertensive drugs and smoking habit, association remained significant only for waist-to-hip ratio (WHR), lipid accumulation product (LAP) and visceral adiposity index (VAI). These 3 markers also displayed at the receiver operating curves (ROC) analysis the best ability to detect subjects with or without kidney dysfunction. The results of the present study provide evidence that WHR, LAP and VAI represent the best markers of renal dysfunction associated with visceral body fat accumulation.