Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA.
Division of Bioethics and Palliative Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA.
Pediatr Nephrol. 2023 Feb;38(2):345-356. doi: 10.1007/s00467-022-05572-8. Epub 2022 Apr 29.
The inclusion of body mass index (BMI) as a criterion for determining kidney transplant candidacy in children raises clinical and ethical challenges. Childhood obesity is on the rise and common among children with kidney failure. In addition, obesity is reported as an independent risk factor for the development of CKD and kidney failure. Resultantly, more children with obesity are anticipated to need kidney transplants. Most transplant centers around the world use high BMI as a relative or absolute contraindication for kidney transplant. However, use of obesity as a relative or absolute contraindication for pediatric kidney transplant is controversial. Empirical data demonstrating poorer outcomes following kidney transplant in obese pediatric patients are limited. In addition, pediatric obesity is distributed inequitably among groups. Unlike adults, most children lack independent agency to choose their food sources and exercise opportunities; they are dependent on their families for these choices. In this paper, we define childhood obesity and review (1) the association and impact of obesity on kidney disease and kidney transplant, (2) existing adult guidelines and rationale for using high BMI as a criterion for kidney transplant, (3) the prevalence of childhood obesity among children with kidney failure, and (4) the existing literature on obesity and pediatric kidney transplant outcomes. We then discuss ethical considerations related to the use of obesity as a criterion for kidney transplant.
将体重指数 (BMI) 纳入儿童肾移植候选标准引发了临床和伦理挑战。儿童肥胖症呈上升趋势，在肾衰竭儿童中很常见。此外，肥胖被报道为 CKD 和肾衰竭发展的独立危险因素。因此，预计需要接受肾移植的肥胖儿童会越来越多。世界上大多数移植中心将高 BMI 用作肾移植的相对或绝对禁忌症。然而，将肥胖用作儿童肾移植的相对或绝对禁忌症存在争议。证明肥胖儿童肾移植后预后较差的经验数据有限。此外，儿科肥胖在人群中分布不均。与成年人不同，大多数儿童缺乏选择食物来源和锻炼机会的独立机构；他们依赖家庭做出这些选择。在本文中，我们定义了儿童肥胖症，并回顾了（1）肥胖与肾脏疾病和肾移植的关联和影响，（2）现有成人指南和将高 BMI 用作肾移植标准的理由，（3）肾衰竭儿童中儿童肥胖的流行情况，以及（4）肥胖与儿科肾移植结果相关的现有文献。然后，我们讨论了将肥胖用作肾移植标准的伦理考虑。
