Impact of panniculectomy on transplant candidacy of obese patients with chronic kidney disease declined for kidney transplantation because of a high-risk abdominal panniculus: A pilot study

Management of obesity in kidney transplant candidates and recipients: A clinical practice guideline by the DESCARTES Working Group of ERA

The clinical practice guideline Management of Obesity in Kidney Transplant Candidates and Recipients was developed to guide decision-making in caring for people with end-stage kidney disease (ESKD) living with obesity. The document considers the challenges in defining obesity, weighs interventions for treating obesity in kidney transplant candidates as well as recipients and reflects on the impact of obesity on the likelihood of wait-listing as well as its effect on transplant outcomes. It was designed to inform management decisions related to this topic and provide the backdrop for shared decision-making. This guideline was developed by the European Renal Association's Developing Education Science and Care for Renal Transplantation in European States working group. The group was supplemented with selected methodologists to supervise the project and provide methodological expertise in guideline development throughout the process. The guideline targets any healthcare professional treating or caring for people with ESKD being considered for kidney transplantation or having received a donor kidney. This includes nephrologists, transplant physicians, transplant surgeons, general practitioners, dialysis and transplant nurses. Development of this guideline followed an explicit process of evidence review. Treatment approaches and guideline recommendations are based on systematic reviews of relevant studies and appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendations Assessment, Development and Evaluation approach. Limitations of the evidence are discussed and areas of future research are presented.

But Why Weight: Understanding the Implications of Obesity in Kidney Transplant

Obesity is increasing in prevalence among candidates for kidney transplant. Understanding the influence of obesity on candidate evaluation, surgical risk, peritransplant management, and post-transplant outcomes is critical to ensuring equitable access to transplant for this growing population.

Abdominal Panniculectomy Can Simplify Kidney Transplantation in Obese Patients

BACKGROUND

Obesity is frequently present in patients suffering from end-stage renal disease (ESRD). However, overweight kidney transplant candidates are a challenge for the transplant surgeon. Obese patients tend to develop a large abdominal panniculus after weight loss creating an area predisposed to wound-healing disorders. Due to concerns about graft survival and postoperative complications after kidney transplantation, obese patients are often refused in this selective patient cohort. The study aimed to analyze the effect of panniculectomies on postoperative complications and transplant candidacy in an interdisciplinary setting.

METHODS

A retrospective database review of 10 cases of abdominal panniculectomies performed in patients with ESRD prior to kidney transplantation was conducted.

RESULTS

The median body mass index was 35.2 kg/m2 (range 28.5-53.0 kg/m2) at first transplant-assessment versus 31.0 kg/m2 (range 28.0-34.4 kg/m2) at panniculectomy, and 31.6 kg/m2 (range 30.3-32.4 kg/m2) at kidney transplantation. We observed no major postoperative complications following panniculectomy and minor wound-healing complications in 2 patients. All aside from 1 patient became active transplant candidates 6 weeks after panniculectomy. No posttransplant wound complications occurred in the transplanted patients.

CONCLUSION

Abdominal panniculectomy is feasible in patients suffering ESRD with no major postoperative complications, thus converting previously ineligible patients into kidney transplant candidates. An interdisciplinary approach is advisable in this selective patient cohort.

KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation

The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.

Operating on the Edge? Body Contouring Procedures in Patients with Body Mass Index Greater 35

BACKGROUND

Body contouring surgery after massive weight loss was shown to ameliorate the patient's quality of life and to enhance physical and psychological well-being. However, numerous patients are still obese when presenting for body contouring surgery, not able to lose additional weight for various reasons. Data regarding general feasibility, outcome, and postoperative complications in obese patients is rare. The aim of this study was to investigate the outcome in body contouring procedures in obese patients.

METHODS

A retrospective chart review of 65 cases in 42 patients was performed. Patients with a body mass index (BMI) > 35 kg/m² at the time of operation were enrolled and all different types of body contouring surgery were included. Complications were classified as major (need for surgical intervention) and minor complications.

RESULTS

The median BMI of all patients was 38 kg/m² (range 35.1-65.1 kg/m²). The majority of performed types of body contouring was abdominal body contouring (panniculectomy n = 27 (42%), abdominoplasty n = 12 (18%)). Complications occurred in 27 cases (41.5%). Twenty-one cases (32.3%) were classified as minor complications, six (9.2%) as major complications. The most common major complications were hematoma and wound dehiscence; the most common minor complication was seroma.

CONCLUSION

A reasonable risk for complications is well known in body contouring surgery especially in obese patients. It is imperative to discuss related risks and expected results. Taking several points into account concerning the perioperative management, reduction of major complications is possible even in still obese patients, making body contouring surgery a discussible option.

Abdominoplasty in Hemodialysis Patients Before Transplant

Morbid obesity in patients with chronic kidney disease is a contraindication for inclusion on the kidney transplant waitlist.Despite intentional weightloss,the persistence of the abdominal adipose panniculus poses postoperative risks, such as infection of the surgical site and seromas. We describe 2 cases of patients on hemodialysis who had a body mass index greater than 35 kg/m² who underwent abdominoplasty before transplant without perioperative complications. One patient received a living-related kidney transplant (donor was the brother) without complications.

Panniculectomy at the time of living donor renal transplantation: An 8-year experience

Panniculectomy can be performed as a prophylactic procedure preceding transplantation to enable obese patients to meet criteria for renal transplantation. No literature exists on combined renal transplant and panniculectomy surgery (LRT-PAN). We describe our 8-year experience performing LRT-PAN. A retrospective chart review of all patients who had undergone LRT-PAN from 2010 to 2018 was conducted. Data were collected on patient demographics, allograft survival and function, and postoperative course. Fifty-eight patients underwent LRT-PAN. All grafts survived, with acceptable function at 1 year. Median length of stay was 4 days with a mean operative duration of 363 minutes. The wound complication rate was 24%. Ninety-day readmission rate was 52%, with medical causes as the most common reason for readmission (45%), followed by wound (32%) and graft-related complications (23%). Body mass index, diabetes status, and previous immunosuppression did not influence wound complication rate or readmission (P = .7720, P = .0818, and P = .4830, respectively). Combining living donor renal transplant and panniculectomy using a multidisciplinary team may improve access to transplantation, particularly for the obese and postobese population. This combined approach yielded shorter-than-expected hospital stays and similar wound complication rates, and thus should be considered for patients in whom transplantation might otherwise be withheld on the basis of obesity.

Abdominal Panniculectomy: Determining the Impact of Diabetes on Complications and Risk Factors for Adverse Events

BACKGROUND

The prevalence of obesity along with bariatric surgery and massive weight loss requiring panniculectomy is increasing in the United States. The effect of diabetes mellitus on outcomes following panniculectomy remains poorly defined despite its prevalence. This study aims to evaluate the impact of diabetes mellitus on complications following panniculectomy and determine risk factors for adverse events.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients undergoing panniculectomy between 2010 and 2015. Patients were stratified based on diabetes status.

RESULTS

Review of the database identified 7035 eligible patients who underwent panniculectomy, of which 770 (10.9 percent) were diabetic. Multivariate regression showed that diabetes mellitus was a significant risk factor for wound dehiscence (OR, 1.92; 95 percent CI, 1.41 to 3.15; p = 0.02). Obesity was a significant risk factor for superficial (OR, 2.78; 95 percent CI, 1.53 to 3.69; p < 0.001) and deep (OR, 1.52; 95 percent CI, 1.38 to 3.97; p = 0.01) incisional surgical-site infection. Smokers were also at an increased risk for superficial (OR, 1.42; 95 percent CI, 1.19 to 1.75; p = 0.03) and deep (OR, 1.63; 95 percent CI, 1.31 to 2.22; p = 0.02) incisional surgical-site infection.

CONCLUSIONS

Diabetes mellitus is an independent risk factor for wound dehiscence following panniculectomy. Obesity and smoking were significant risk factors for superficial and deep incisional surgical-site infection. These results underscore the importance of preoperative risk factor evaluation in patients undergoing panniculectomy for safe outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Renal Transplant in Obese Patients and Impact of Weight Loss Before Surgery on Surgical and Medical Outcomes: A Single-Center Cohort Study

OBJECTIVES

Previous studies have linked obesity to poor outcomes in renal transplant recipients, prompting many transplant centers to encourage weight loss pretransplant in obese patients. Here, we performed a single-center retrospective study to assess the effects of weight loss on graft and patient outcomes.

MATERIALS AND METHODS

Data from 893 renal transplant recipients at our center from 2007 to 2011 were analyzed. First, renal transplant recipients with a history of obesity before transplant (42%) were compared with nonobese patients. Second, in the obese group, renal transplant recipients with significant weight loss (> 10%) before transplant were compared with other obese renal transplant recipients without significant weight loss.

RESULTS

Renal transplant recipients were predominantly white, with 74% having undergone living-donor transplant. Obese patients were older (56.6 vs 46.7 y old) and had more comorbidities and more surgical complications, in particular wound complications and incisional hernias, posttransplant than nonobese patients (14.7 vs 5.5%, respectively). Patient and graft survival rates were similar to those in nonobese patients. In the obese group, patient characteristics and medical or surgical complications after transplant did not differ between those with or without significant weight loss. However, obese patient and graft survival rates were lower in patients with weight loss than in obese patients without weight loss.

CONCLUSIONS

In our study, weight loss before transplant surgery in obese patients had no influence on surgical outcomes but was associated with a higher mortality rate. A prospective assessment of the impact of weight loss before surgery is needed to establish its usefulness.

Panniculectomy Outcomes in Patients with End-Stage Renal Disease in Preparation for Renal Transplant

PURPOSE

End-stage renal disease (ESRD) is associated with increased cardiovascular risk factors, electrolyte imbalances, and iron deficiency anemia. These factors may increase the risk of adverse outcomes in patients undergoing panniculectomy. There is a paucity of data regarding outcomes in patients with ESRD undergoing panniculectomy. The purpose of this study is to investigate whether ESRD is associated with increased rate of complications following a panniculectomy.

METHOD

The Nationwide Inpatient Sample database (2006-2011) was used to identify patients who underwent a panniculectomy. Among this cohort, patients diagnosed with end-stage renal disease were identified. Patients excluded from the study were emergency admissions, pregnant women, patients less than 18 years old, and patients with concurrent nephrectomy or kidney transplants. Demographic factors, comorbidities, and postoperative complications were evaluated. Chi-squared and risk-adjusted multivariate logistic regression analyses were performed to determine whether end-stage renal disease was associated with increased rate of postoperative complications.

RESULTS

A total of 34,779 panniculectomies were performed during the study period. Of these, 613 (1.8%) were diagnosed with ESRD. Patients with ESRD were older (mean age 58.9 vs. 49.3, p < 0.01) and more likely to have Medicare (63.5 vs. 18.4%, p < 0.01). They had higher rates of comorbidities, including diabetes, hypertension, congestive heart failure, chronic lung disease, chronic anemia, liver disease, peripheral artery disease, obesity, and coagulopathies (p < 0.01). The procedure was more likely to occur at a large, teaching hospital (p < 0.01). Postoperatively, patients with ESRD had a higher rate of death (3.3 vs. 0.2%, p < 0.01), wound complications (10.6 vs. 6.2%, p < 0.01), venous thromboembolism (4.9 vs. 0.8%, p < 0.01), blood transfusions (25.3% vs. 7.0%, p < 0.01), non-renal major medical complications (40.0% vs. 8.4%), and longer hospital stay (9.2 vs. 3.8 days, p < 0.01). Multivariate logistic regression analysis controlling for age, race, sex, hospital location/teaching hospital, payer, and all comorbidities demonstrated that ESRD was independently associated with increased venous thromboembolisms (OR 2.38, 95% CI 1.48-3.83) and non-renal major medical complications (OR 1.51, 95% CI 1.19-1.91). ESRD was not independently associated with increased rate of wound complications or transfusions.

CONCLUSION

Patients with ESRD are at increased risk of VTE and non-renal major medical complications following panniculectomy. Moreover, patients with ESRD have longer hospital stays and higher rates of mortality.

LEVEL OF EVIDENCE IV

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