Obesity and nephrology: results of a knowledge and practice pattern survey

Associations of longitudinal height and weight with clinical outcomes in pediatric kidney replacement therapy: results from the ESPN/ERA Registry

BACKGROUND

Associations between anthropometric measures and patient outcomes in children are inconsistent and mainly based on data at kidney replacement therapy (KRT) initiation. We studied associations of height and body mass index (BMI) with access to kidney transplantation, graft failure, and death during childhood KRT.

METHODS

We included patients < 20 years starting KRT in 33 European countries from 1995-2019 with height and weight data recorded to the ESPN/ERA Registry. We defined short stature as height standard deviation scores (SDS) < -1.88 and tall stature as height SDS > 1.88. Underweight, overweight and obesity were calculated using age and sex-specific BMI for height-age criteria. Associations with outcomes were assessed using multivariable Cox models with time-dependent covariates.

RESULTS

We included 11,873 patients. Likelihood of transplantation was lower for short (aHR: 0.82, 95% CI: 0.78-0.86), tall (aHR: 0.65, 95% CI: 0.56-0.75), and underweight patients (aHR: 0.79, 95%CI: 0.71-0.87). Compared with normal height, patients with short and tall statures showed higher graft failure risk. All-cause mortality risk was higher in short (aHR: 2.30, 95% CI: 1.92-2.74), but not in tall stature. Underweight (aHR: 1.76, 95% CI: 1.38-2.23) and obese (aHR: 1.49, 95% CI: 1.11-1.99) patients showed higher all-cause mortality risk than normal weight subjects.

CONCLUSIONS

Short and tall stature and being underweight were associated with a lower likelihood of receiving a kidney allograft. Mortality risk was higher among pediatric KRT patients with a short stature or those being underweight or obese. Our results highlight the need for careful nutritional management and multidisciplinary approach for these patients. A higher resolution version of the Graphical abstract is available as Supplementary information.

Obesity and Kidney Transplantation-How to Evaluate, What to Do, and Outcomes

Obesity is a growing issue that is spreading worldwide; its prevalence is ever increasing in patients with end-stage renal disease and represents a potential barrier to transplantation. The lack of unanimous guidelines exacerbates the current disparity in treatment, which can affect outcomes, leading to a significantly longer time on the waiting list. Multidisciplinary and multimodal management (encompassing several healthcare professionals such as nephrologists, transplant physicians and surgeons, primary care providers, and nurses) is of paramount importance for the optimal management of this patient population in a continuum from waitlisting to transplantation. Development of this guideline followed a standardized protocol for evidence review. In this review, we report on our clinical experience in transplantation of obese patients; strategies to manage this condition, including bariatric surgery, suitable timing for transplantation among this patient population, and clinical experience in robotic sleeve gastrectomy; and simultaneous robotic kidney transplantation to achieve optimal outcomes.

Recipient race modifies the association between obesity and long-term graft outcomes after kidney transplantation

Donor and recipient obesity (defined using body mass index [BMI]) are associated with worse outcomes after kidney transplant (KT). In adult KT recipients identified using the Scientific Registry of Transplant Recipients (2000-2017), we examined the modifying effect of recipient race on recipient obesity (BMI > 30 kg/m2) and combined donor and recipient (DR) obesity pairing, with death-censored graft loss (DCGL), all-cause graft loss (ACGL), and short-term graft outcomes using multivariable Cox proportional hazards models and logistic regression. Obesity was associated with a higher risk of DCGL in White (adjusted hazard ratio [aHR], 1.29; 95% CI, 1.25-1.35) than Black (aHR, 1.13; 95% CI, 1.08-1.19) recipients. White, but not Black, recipients with obesity were at higher risk for ACGL (aHR, 1.08; 95% CI, 1.05-1.11, for White recipients; aHR, 0.99; 95% CI, 0.95-1.02, for Black recipients). Relative to nonobese DR, White recipients with combined DR obesity experienced more DCGL (aHR, 1.38; 95% CI, 1.29-1.47 for White; aHR, 1.19; 95% CI, 1.10-1.29 for Black) and ACGL (aHR, 1.12; 95% CI, 1.07-1.17 for White; aHR, 1.00; 95% CI, 0.94-1.07 for Black) than Black recipients. Short-term obesity risk was similar irrespective of race. An elevated BMI differentially affects long-term outcomes in Black and White KT recipients; uniform BMI thresholds to define transplant eligibility are likely inappropriate.

Obesity and Post-Transplant Diabetes Mellitus in Kidney Transplantation

Worldwide, the prevalence obesity, diabetes, and chronic kidney disease is increasing apace. The relationship between obesity and chronic kidney disease is multidimensional, especially when diabetes is also considered. The optimal treatment of patients with chronic kidney disease includes the need to consider weight loss as part of the treatment. The exact relationship between obesity and kidney function before and after transplantation is not as clear as previously imagined. Historically, patients with obesity had worse outcomes following kidney transplantation and weight loss before surgery was encouraged. However, recent studies have found less of a correlation between obesity and transplant outcomes. Transplantation itself is also a risk factor for developing diabetes, a condition known as post-transplant diabetes mellitus, and is related to the use of immunosuppressive medications and weight gain following transplantation. Newer classes of anti-diabetic medications, namely SGLT-2 inhibitors and GLP-1 agonists, are increasingly being recognized, not only for their ability to control diabetes, but also for their cardio and renoprotective effects. This article reviews the current state of knowledge on the management of obesity and post-transplant diabetes mellitus for kidney transplant patients.

Obesity in Renal Transplantation

BACKGROUND

Data from the WHO show an increasing rate of overweight and obesity in general population in the last decades. This increase in obesity also affects population with end-stage renal disease (ESRD) and kidney transplant (KT) candidates.

SUMMARY

In this review, we focused on how obesity impacts on KT stages: access to KT and outcomes of KT candidates; how to reduce weight and its consequences; short and long-term outcomes in obese recipients and the impact of weight variations; and the implications of obesity in living donor KT. We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials until November 30, 2020. We selected systematic reviews and meta-analyses and randomized clinical trials. When no such reports were found for a topic, observational studies were included in the assessment. Key Messages: Although obesity is a risk factor to present worst outcomes after KT, several studies have demonstrated a survival benefit compared to patients who continue on dialysis. There is a need for a public health campaign to raise awareness in KT candidates and to highlight the importance of self-care, increasing exercise, healthy diet, and weight loss.

Conservative Management of Obesity in Kidney Transplant Candidates

OBJECTIVE

Obesity is prevalent in patients with chronic kidney disease and is associated with increased complications after kidney transplantation (KT). A body mass index limit is used in most transplant programs, though few studies have focused on conservative weight loss in KT candidates. The objective of this retrospective study is to evaluate the efficacy of a basic conservative weight management program in morbidly obese KT candidates and to perform a comprehensive nutritional evaluation.

METHODS

This retrospective study included patients with a body mass index (BMI) >35 kg/m^2, with grade IV or V chronic kidney disease. The conservative weight loss program consisted of anthropometric measurements every 3 months, consultation with a nutritionist, daily exercise, and counseling for healthier eating habits. Overall and quarterly BMI targets were defined. A subset of patients further underwent a comprehensive nutritional evaluation to measure socioeconomic characteristics, food intake behavior, motivation for change, and a 4-day food diary.

RESULTS

Eighty patients were observed for a mean of 24 months. Successful weight loss (BMI < 35 kg/m²) was achieved in 26.3%, associated with women and those already close to the limit. The mean 1-year excess body weight loss was 8.4%. No patient with a BMI >40 kg/m² was successful. The comprehensive nutritional evaluation was performed with 44 patients and found that only 14.6% had previously received nutritional counseling for weight loss. Cognitive restraint scored highest in the food-intake behavior. Most patients were motivated to lose weight with 66% in the action phase. There was little evidence of overeating with a recommended mean calculated daily caloric intake of 82.9%.

CONCLUSION

The conservative weight loss program can have limited but non-negligible, success. Future successful nutritional interventions should take into consideration this surprising comprehensive profile of morbidly obese KT candidates.

Recipient Obesity and Kidney Transplant Outcomes: A Mate-Kidney Analysis

RATIONALE & OBJECTIVE

The impact of extreme recipient obesity on long-term kidney transplant outcomes has been controversial. This study sought to evaluate the association of various levels of recipient obesity on kidney transplantation outcomes by comparing mate-kidney recipient pairs to address possible confounding effects of donor characteristics on posttransplant outcomes.

STUDY DESIGN

Nationwide observational cohort study using mate-kidney models.

SETTING & PARTICIPANTS

In analysis based on the Organ Procurement and Transplant Network/United Network of Organ Sharing database, 44,560 adult recipients of first-time deceased-donor kidney transplants from 2001 through 2016 were paired by donor.

PREDICTORS

Recipient body mass index (BMI) categorized as 18-25 (n = 12,446), >25-30 (n = 15,477), >30-35 (n = 11,144; obese), and >35 (n = 5,493; extreme obesity) kg/m².

OUTCOMES

Outcomes included patient survival, graft survival, death-censored graft survival, delayed graft function (DGF), and hospital length of stay.

ANALYTICAL APPROACH

Conditional logistic regression and stratified proportional hazards models were used to compare outcomes as odds ratios and hazard ratios (HRs), adjusted for recipient and transplant factors, using recipients with a BMI >35 kg/m² as a reference.

RESULTS

At a median follow-up of 3.9 years, adjusted odds ratios for DGF were 0.42 (95% CI, 0.36-0.48), 0.55 (95% CI, 0.48-0.62), and 0.73 (95% CI, 0.64-0.83) for BMI 18-25, >25-30, and >30-35 kg/m², respectively (P < 0.001 for all). Death-censored graft failure was less frequent for BMI ≤25 and >25-30 kg/m² (HRs of 0.66 [95% CI, 0.59-0.74] and 0.79 [95% CI, 0.70-0.88], respectively; P < 0.001 for both), but not for BMI >30-35 kg/m² (HR, 0.91 [95% CI, 0.81-1.02]; P = 0.09). Length of stay and patient survival did not differ by recipient BMI.

LIMITATIONS

Observational study with limited detail regarding potential confounders.

CONCLUSIONS

Despite an increased risk of DGF likely unrelated to donor organ quality, long-term transplant outcomes among recipients with a BMI >35 kg/m² are similar to those among recipients with a BMI >30-35 kg/m², supporting a flexible approach to kidney transplantation candidacy in candidates with extreme obesity.

Usability and experience testing to refine an online intervention to prevent weight gain in new kidney transplant recipients

OBJECTIVES

Weight gain in the first year following kidney transplantation increases the risk of adverse health outcomes. Currently, there is no recognized intervention available to prevent weight gain after kidney transplantation. An online kidney transplant-specific resource, entitled Exercise in Renal Transplant Online (ExeRTiOn), has been co-created by a multi-professional team, including patients, to assist with weight prevention. This study aimed to evaluate patient and health care professional usability and experience of the ExeRTiOn online resource.

DESIGN

Qualitative study utilizing 'Think-Aloud' and semi-structured interviews.

METHODS

Participants (n = 17) were purposively sampled to include new kidney transplant recipients (n = 11) and transplant health care professionals (n = 6). Kidney transplant recipient participants were from a spread of physical activity levels based on scores from the General Practice Physical Activity Questionnaire (GPPAQ). 'Think-Aloud' interviews assessed the usability of ExeRTiOn. Semi-structured interviews explored participants' experience of ExeRTiOn, weight gain, and physical activity. The data set were analysed thematically. Participant characteristics, including login data and self-reported body weight, were collected.

RESULTS

Data analyses identified valued intervention content and usability aspects which were summarized by two themes. The first theme 'You need to know how to manage yourself' included subthemes: (1) the resource filled a guidance gap, (2) expert patient content resonated, and (3) the importance of goal setting and monitoring progress. The second theme 'room for improvement' included subthemes: (2) web support and (2) content and operational change suggestions.

CONCLUSIONS

Results have allowed for identification of potential areas for resource refinement. This has facilitated iterative enhancement of ExeRTiOn in preparation for a randomized controlled feasibility trial.

Obesity, transplantation, and bariatric surgery: An evolving solution for a growing epidemic

The increasing obesity epidemic has major implications in the realm of transplantation. Patients with obesity face barriers in access to transplant and unique challenges in perioperative and postoperative outcomes. Because of comorbidities associated with obesity, along with the underlying end-stage organ disease leading to transplant candidacy, these patients may not even be referred for transplant evaluation, much less be waitlisted or actually undergo transplant. However, the use of bariatric surgery in this population can help optimize the transplant candidacy of patients with obesity and end-stage organ disease and improve perioperative and postoperative outcomes. We review the impact of obesity on kidney, liver, and cardiothoracic transplant candidates and recipients and explore potential interventions to address obesity in these populations.

Obesity in kidney transplantation

The prevalence of obesity among patients with chronic kidney disease continues to increase as a reflection of the trend observed in the general population. Factors affecting the access to the waiting list and the transplantability of this specific population will be analysed. From observational studies, kidney transplantation in obese patients carries an increased risk of surgical complications compared to the nonobese population; therefore, many centres have been reluctant to proceed with transplantation, despite this treatment modality confers a survival advantage over dialysis. As a consequence, obese patients continue to face decreased access to the waiting list, with a lower likelihood of being transplanted and higher waiting times when compared to the nonobese candidates. In this review will be described the current strategies for treatment of obesity in different settings (pretransplant, at transplant and post-transplant). Obesity represents a risk factor for surgical complications but not a contraindication for kidney transplantation; outcomes could be greatly improved with its multidisciplinary and multimodal treatment. The modern technology with minimally invasive techniques, mainly using robotic platform, allows a reduction in the surgical complications rate, with graft and patient survival rates comparable to the nonobese counterpart.

Obesity in Kidney Transplantation: Impact on Transplant Candidates, Recipients, and Donors

Obesity is now common among children and adults who are kidney transplant candidates and recipients. It is associated with an increased risk of cardiovascular disease and kidney failure. This also pertains to potential living kidney donors with obesity. Obese patients with end-stage renal disease benefit from transplantation as do nonobese patients, but obesity is also associated with more risk. A complicating factor is that obesity is also associated with increased survival on maintenance dialysis in adults, but not in children. The assessment of obesity and body habitus should be individualized. Body mass index is a common but imperfect indicator of obesity. The medical management of obesity in renal failure patients is often unsuccessful. Bariatric surgery, specifically laparoscopic sleeve gastrectomy, can result in significant weight loss with reduced morbidity, but many patients do not agree to undergo this treatment. The best approach to manage obese transplant candidates and recipients is yet unresolved.

Variation in Practice Patterns for Listing Patients for Renal Transplantation in the United Kingdom: A National Survey

BACKGROUND

Despite the availability of guidelines for the evaluation of candidates for renal transplantation, variation in access to transplantation exists. This national survey investigates whether center variation exists in the assessment of patients for renal transplantation in the United Kingdom.

METHODS

An online survey, informed by qualitative interviews, was distributed to all UK renal centers. This survey examined center approaches to chronic kidney disease service provision, transplant recipient assessment, education provision, and waitlisting decision making processes. Center reevaluation policies for patients already listed and priorities for future development were also examined.

RESULTS

All 71 renal centers responded. Of these, 83% reviewed predialysis patients in a low clearance clinic. In 26% of the centers, transplantation was not discussed as a treatment option with all patients. Fourteen centers reported having a dedicated transplant assessment clinic, whereas 28% did not have a formal assessment protocol. Age was an exclusion criterion for listing in 3 centers, all of which had a cutoff at 75 years. Eighty-three percent of the centers excluded patients with a high body mass index. Cardiac investigations were risk-stratified in 90% of centers. Surgical involvement varied with 11% of centers listing patients without formal surgical review. There was no formal protocol in place to reevaluate listed patients in 62% of centers.

CONCLUSIONS

There is wide variation in UK practice patterns for listing patients for renal transplantation, though its impact on access to transplantation is unclear. The extent to which center-specific and patient-specific factors affect access to transplantation requires further analysis in a prospective cohort of patients.

Assessing Consensus Between UK Renal Clinicians on Listing for Kidney Transplantation: A Modified Delphi Study

Background

It is well recognized that there is significant variation between centers in access to kidney transplantation. In the absence of high-grade evidence, it is unclear whether variation is due to patient case mix, other center factors, or individual clinician decisions. This study sought consensus between UK clinicians on factors that should influence access to kidney transplantation.

Methods

As part of the Access to Transplantation and Transplant Outcome Measures project, consultant nephrologists and transplant surgeons in 71 centers were invited to participate in a Delphi study involving 2 rounds. During rounds 1 and 2, participants rated their agreement to 29 statements covering 8 topics regarding kidney transplantation. A stakeholder meeting was used to discuss statements of interest after the 2 rounds.

Results

In total, 122 nephrologists and 16 transplant surgeons from 45 units participated in rounds 1 and 2. After 2 rounds, 12 of 29 statements reached consensus. Fifty people participated in the stakeholder meeting. After the stakeholder meeting, a further 4 statements reached agreement. Of the 8 topics covered, consensus was reached in 6: use of a transplant protocol, patient age, body mass index, patient compliance with treatment, cardiac workup, and use of multidisciplinary meetings. Consensus was not reached on screening for malignancy and use of peripheral Doppler studies.

Conclusions

The Delphi process identified factors upon which clinicians agreed and areas where consensus could not be achieved. The findings should inform national guidelines to support decision making in the absence of high quality evidence and to guide areas that warrant future research.

Influence of the recipient body mass index on the outcomes after kidney transplantation

PURPOSE

The relationship between the body mass index (BMI) of kidney transplant recipients and outcomes after kidney transplantation (KT) is not fully understood and remains controversial. We studied the influence of BMI on clinically relevant outcomes in kidney transplant recipients.

METHODS

In this retrospective single-centre study, all patients who underwent kidney transplantation at our institution between January 2007 and December 2012 were included. Demographic data and BMI were correlated with the clinical course of the disease, rejection rates, delayed graft function rates, and graft and patient survival.

RESULTS

During the study period, 384 single KTs (130 women and 254 men) were performed. Seventeen percent of the transplants were transplanted within the Eurotransplant Senior Programme (ESP). Most of the transplants were performed using organs that were obtained from donors after brain death (DBD), and living donor kidney transplants were performed in 22.4% of all transplants. The median BMI of the recipients was 25.9 kg/m². Additionally, 13.5% of the recipients had a BMI of 30-34.9 kg/m² and 3.9% had a BMI >35 kg/m². A BMI >30 kg/m² was significantly associated with primary non-function of the kidney (p = 0.047), delayed graft function (p = 0.008), and a higher rate of loss of graft function (p = 0.015). The glomerular filtration rate 12 months after KT was significantly lower in recipients with a BMI >30 kg/m². Multivariate analysis revealed that recipient BMI, among other factors, was an independent risk factor for delayed graft function and graft survival. Patients with a BMI >30 kg/m² had an almost four times higher risk for surgical site infection than did recipients with a lower BMI.

CONCLUSIONS

Increased BMI at kidney transplantation is a predictor of adverse outcomes, including delayed graft function. These findings demonstrate the importance of the careful selection of patients and pre-transplant weight reduction, although the role of weight reduction for improving graft function is not clear.

Obesity and listing for renal transplantation: weighing the evidence for a growing problem

A 56-year-old female patient was referred to the transplant assessment clinic in July 2016. She started haemodialysis in 2012 for renal failure due to urinary tract infections. She is doing very well on dialysis and has an excellent exercise tolerance without shortness of breath or angina. She has had no infections since starting dialysis and no other comorbidity, except well-controlled hypertension and hyperparathyroidism requiring treatment with cinacalcet. Clinical examination is essentially normal except for truncal obesity with height 167 cm and weight 121 kg, giving her a body mass index of 43.4. Can she be listed for a renal transplant? If not, which target weight should be given to the patient before she can be transplant listed? Which interventions, if any, should be recommended to achieve weight loss?

Survey of Canadian Kidney Transplant Specialists on the Management of Morbid Obesity and the Transplant Waiting List

Background:

Obesity is associated with increased surgical complications and long-term cardiovascular mortality. Studies of access in kidney transplantation have found a bias against obese patients on the wait-listing.

Objective:

To determine the current state of clinical practice for the management of obesity in kidney transplantation.

Design:

A survey in two versions, PDF and traditional paper, composed of categorical questions.

Setting:

A pan-Canadian survey of transplant nephrologists and surgeons.

Methods:

The survey PDF was distributed electronically to the Kidney Group of the Canadian Society of Transplantation. A shorter, hardcopy version was distributed subsequently at a national transplant meeting.

Results:

There were 47 responses, including almost every Canadian adult transplant program. Most (81%) reported the use of a body mass index limit for access to the waiting list. However, only 40% reported a strict enforcement. There were several instances of intra-hospital disagreements regarding the use of a policy, among the centers with multiple responses. The body mass index limit was most commonly 40 kg/m² (62%), followed by 35 kg/m² (36%). Despite the body mass index limit, few centers (30%) reported having a weight management program. The reported experience with bariatric surgery was small, though nearly all replied that they would refer to a bariatric specialist in the future.

Limitations:

This national survey provides a broad assessment of clinical practice. The distinction between an official policy and informal clinical tendencies is difficult. The results cannot be used to support any specific limit or policy.

Conclusions:

This survey found that the body mass index limit for access to the kidney transplant waiting list was common in Canada. Several inconsistencies suggest a lack of official policy. To achieve equity in access, clear guidelines for obesity should be established and enforced. Bariatric surgery has the promise of rapid weight loss. Resource allocation to study obesity in transplant patients will be essential.

From chronic kidney disease to kidney transplantation: The impact of obesity and its treatment modalities

Obesity is associated with worse short-term outcomes after kidney transplantation but the effect on long-term outcomes is unknown. Although some studies have reported worse outcomes for obese recipients when compared to recipients with a BMI in the normal range, obese recipients who receive a transplant have better outcomes than those who remain wait-listed. Whether transplant candidates should be advised to lose weight before or after transplant has been debated and this is mainly due to the gap in the literature linking pre-transplant weight loss with better outcomes post-transplantation. The issue is further complicated by the use of BMI as a metric of body fat, the obesity paradox in dialysis patients and the different ethical viewpoints of utility versus equity. Measures used to reduce weight loss, including orlistat and bariatric surgery (in particular those with a malabsorptive component), have been associated with enteric hyperoxaluria with consequent risk of nephrolithiasis and oxalate nephropathy. In this review, we discuss the evidence regarding the use of weight loss measures in the kidney transplant candidate and recipient with a view to recommending whether weight loss should be pursued before or after kidney transplantation.

Hidden Obesity in Dialysis Patients: Clinical Implications

While body-mass index (BMI) is used to diagnose obesity in the general population, its application in the end-stage renal disease (ESRD) population is fraught with difficulty. A major limitation is its inability to distinguish muscle mass from fat mass, thereby leading to misclassification of individuals with poor muscle mass but excess adipose tissue as non-obese (i.e. BMI <30 kg/m(2) ). As muscle wasting is common among ESRD patients, this is an important problem. A substantial proportion of ESRD patients have levels of BMI in the normal range, yet excess adiposity based on other measures. The importance of this "hidden" obesity remains to be determined, but it must be recognized in order for obesity interventions to be appropriately targeted and tested in the ESRD population.

Sleep apnea and the risk of chronic kidney disease: a nationwide population-based cohort study

STUDY OBJECTIVES

Sleep apnea (SA) is characterized by apnea during sleep and is associated with cardiovascular diseases and an increase in all-cause mortality. Chronic kidney disease (CKD) is a global health problem that has placed a substantial burden on healthcare resources. However, the relationship between SA and the incidence of CKD is not clear. This study aimed to determine whether SA is an independent risk factor for the development of CKD.

DESIGN

Retrospective cohort study.

SETTING

National Health Insurance Research Database (NHIRD) of Taiwan.

PATIENTS OR PARTICIPANTS

A total of 4,674 adult patients (age ≥ 30 y) in whom SA was newly diagnosed from 2000 to 2010 were included, together with 23,370 non-SA patients as the comparison group. The two groups were frequency-matched for sex, age, and year of receiving medical service. Each individual was followed until 2011.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

These two groups were monitored and observed for the occurrence of CKD. Patients with SA experienced a 1.94-fold increase (95% confidence interval [CI], 1.52-2.46; P < 0.001) in the incidence of CKD, which was independent of sex, age, and comorbid medical conditions. Additionally, they showed a 2.2-fold increase (95% CI, 1.31-3.69; P < 0.01) in the incidence of end-stage renal disease (ESRD).

CONCLUSIONS

Patients with sleep apnea are at increased risk for chronic kidney disease and end-stage renal disease compared with the general population. As such, screening renal function and treatment of chronic kidney disease is an important issue in patients with sleep apnea.

Emerging drugs for chronic kidney disease

INTRODUCTION

Chronic kidney disease (CKD) is a worldwide health problem. Despite remarkable headway in slowing the progression of kidney diseases, the incidence of end-stage renal disease (ESRD) is increasing in all countries with a severe impact on patients and society. The high incidence of diabetes and hypertension, along with the aging population, may partially explain this growth. Currently, the mainstay of pharmacological treatment for CKD, aiming to slow progression to ESRD are ACE inhibitors and angiotensin II receptor blockers for their hemodynamic/antihypertensive and anti-inflammatory/antifibrotic action. However, novel drugs would be highly desirable to effectively slow the progressive renal function loss.

AREAS COVERED

Through the search engines, PubMed and ClinicalTrial.gov, the scientific literature was reviewed in search of emerging drugs in Phase II or III trials, which appear to be the most promising for CKD treatment.

EXPERT OPINION

The great expectations for new drugs for the management of CKD over the last decade have unfortunately not been met. Encouraging results from preliminary studies with specific agents need to be tempered with caution, given the absence of consistent and adequate data. To date, several agents that showed great promise in animal studies have been less effective in humans.

Obesity in CKD--what should nephrologists know?

Obesity, the epidemic of the 21st century, carries a markedly increased risk for comorbid complications, such as type 2 diabetes, cancer, hypertension, dyslipidemia, cardiovascular disease, and sleep apnea. In addition, obesity increases the risk for CKD and its progression to ESRD. Paradoxically, even morbid obesity associates with better outcomes in studies of ESRD patients on maintenance dialysis. Because the number of obese CKD and maintenance dialysis patients is projected to increase markedly in developed as well as low- and middle-income countries, obesity is a rapidly emerging problem for the international renal community. Targeting the obesity epidemic represents an unprecedented opportunity for health officials to ameliorate the current worldwide increase in CKD prevalence. Nephrologists need more information about assessing and managing obesity in the setting of CKD. Specifically, more precise estimation of regional fat distribution and the amount of muscle mass should be introduced into regular clinical practice to complement more commonly used practical markers, such as body mass index. Studies examining the effects of obesity on kidney disease progression and other clinical outcomes along with weight management strategies are much needed in this orphan area of research.