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April 6, 2020 Currently, living donors are urged to follow the preliminary steps of the process remotely, but in-person appointments and transplants are largely on hold. Transplants from deceased donors, considered essential surgeries, are moving forward, but surgeons have to use their best judgment to determine if the kidney donor was infected with COVID-19.The rapidly evolving concerns about the effect COVID-19 is having on kidney transplants was a hot topic at the National Kidney Foundation 2020 virtual spring clinical meetings.COVID-19 concerns are adding to long-standing issues in the transplant community, such as the debate over whether obese patients must lose weight before they can be considered for a kidney transplant.

Obesity can cause complications in kidney receptors, experts say, but opinions on how much emphasis to put on weight loss before transplantation differ."The kidneys are a limited resource and we cannot transplant everyone," said Kenneth Woodside, MD, a transplant surgeon and associate professor of surgery at Michigan Medicine in Ann Arbor.The implications of obesity for transplant patients were discussed in a virtual presentation by Woodside and Meera Harhay, MD, associate professor of medicine at Drexel University School of Medicine in Philadelphia.A previous study found a link between obesity and death from cardiovascular disease after kidney transplant. The meta-analysis showed that obese patients are twice as likely to die from cardiovascular disease after kidney transplant than patients at a healthier weight, Woodside explained.The cost to the health system is also higher for kidney recipients who are obese, Woodside said.Cumulative average Medicare payments for the first 3 years after transplant ranged in cost (in 2012 US dollars) from $ 109,623 for living donor recipients who had a body mass index (BMI) of less than 18.5 kg / m at $ 143,529 for those with a BMI greater than 40 kg / m, according to an unpublished study of more than 8,000 patients by Dr. Tayyab Diwan and colleagues at the University of Cincinnati.

Continued"You really see a jump at the BMI 30 mark," Woodside noted.There are also practical concerns, he explained.

Complications

"It takes longer to sew the kidneys in obese patients, so there is more delayed graft function," he said. And "to sew cups, you need to be able to see the cups. Retractors are so long."There is no doubt that surgical complications are a major factor in obese patients, Harhay said, but there are several problems with mandatory pre-transplant weight loss and BMI cuts at transplant centers. One is the steady increase in morbid obesity in the United States, which would limit access to an increasing number of patients.Although there is no national standard BMI limit, 66 of 67 transplant programs in the United States use a BMI limit of 35 to 40 kg / m, according to a previous study.And 21% of transplant programs did not include any candidate with a BMI of 40 kg / m or more between 1995 and 2006, according to a study of all waiting list registries in the United States."What that means is that in the United States, if you have end-stage kidney disease and morbid obesity, your access to a kidney transplant may depend more strongly on what transplant program you are living in, what you are willing to do, than your own state of health, "explained Harhay."A 35 kg / m BMI limit would exclude one in five adult incident dialysis patients in the United States from a kidney transplant evaluation, and a 40 kg / m limit would exclude one in 10 dialysis patients incident, "he said. citing data from the US Kidney Data System. USAAlso, BMI is not equal to body composition. "A person with a high BMI could be muscular and that could be protective," said Harhay. "BMI does not differentiate where fat is stored."Importantly, it is difficult for anyone to lose weight, much less people who are on dialysis and perhaps also work. "Dialysis is an exhausting procedure and end-stage kidney disease is an exhausting condition," he emphasized.

ContinuedHowever, Karen Greathouse, RD, a transplant dietitian at the University of Michigan Health System at Ann Arbor, provided advice for patients with end-stage kidney disease who want to lose weight.

Dietitian Tips

"The key to successful weight loss is not just losing it, but being able to keep it off for 5 years or more," he said.The big problem with many diets is the lack of programs to support people. "We are trying to give brochures and we hope that people will accept it," he explained.Greathouse noted that diets that include unusual food combinations or that have a particular eating sequence are not sustainable.She said she recommends individualized action plans with a dietitian for people with end-stage kidney disease. Dietitians will emphasize lifestyle changes and the importance of combining diet changes with exercise, he noted.And smaller goals alleviate anxiety and increase the chances of success. Some people are instructed to lose 50 pounds, which "places them at the bottom of a well trying to get out," he explained.And health care providers often tell people to limit fruits and vegetables because they contribute to fluid complications or high potassium levels."I can't say how many times I have heard patients say they have been told not to eat salad because it contributes to the liquid," Greathouse said."When you increase fruits and vegetables, you have better stools, you decrease potassium and fluid deposits," he explained. "Processed foods have more potassium than fruits and vegetables, and that's what many of our patients are eating."

Medscape Medical News

Sources

National Kidney Foundation (NKF) 2020 Spring Clinical Meetings. Presented on March 26, 2020.

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Home » How to lose weight safely » Prioritize transplants when other surgeries are on hold – NewsDio