Ghildayal Nidhi, Hong Jingyao, Liu Yi, Li Yiting, Cockey Samuel G, Ali Nicole M, Mathur Aarti, Orandi Babak, Segev Dorry L, McAdams-DeMarco Mara
Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York.
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Clin J Am Soc Nephrol. 2025 Jan 3;20(2):197-205. doi: 10.2215/CJN.0000000604.
In frail kidney transplant (KT) candidates with obesity, unintentional weight loss preceding KT evaluation is associated with lower chance of listing. In frail candidates with obesity, both unintentional and intentional weight loss is associated with higher waitlist mortality. Results suggest that in frail candidates with obesity, careful supervision of weight loss prior to KT should be considered, emphasizing strategies to preserve muscle mass and function.
Unintentional weight loss, a hallmark of frailty, predicts worse post–kidney transplantation (KT) outcomes. However, weight loss in candidates with obesity is often recommended to enhance transplant eligibility. We tested whether pre-evaluation weight change is associated with listing/waitlist mortality, considering intentionality and frailty.
We leveraged data on body mass index, weight loss intentionality (1 year before evaluation and at evaluation), and frailty (four-component Physical Frailty Phenotype at evaluation) for 1361 candidates (895 listed) with obesity (body mass index ≥30 kg/m) enrolled in a prospective multicenter cohort study. We estimated the association between pre-evaluation weight change (stable, gain, unintentional/intentional loss) with chance of listing/waitlist mortality using Cox proportional hazards/competing-risks models.
Among candidates with obesity, 48% had stable weight, 17% had weight gain, 16% had unintentional weight loss, and 20% had intentional weight loss over the year before evaluation. Among frail candidates with obesity, stable weight was associated with a 27% lower chance of listing (adjusted hazard ratio [aHR], 0.73; 95% confidence intervals [CI], 0.55 to 0.96), weight gain with a 47% lower chance of listing (aHR, 0.53; 95% CI, 0.34 to 0.80), and unintentional weight loss with a 48% lower chance of listing (aHR, 0.52; 95% CI, 0.32 to 0.84) compared with nonfrail candidates with stable weight. However, in frail candidates with obesity, intentional weight loss was not associated with a significantly lower chance of listing compared with nonfrail candidates with stable weight. In addition, among frail candidates with obesity, stable weight (adjusted subhazard ratio [aSHR], 1.72; 95% CI, 1.01 to 2.90), unintentional weight loss (aSHR, 2.78; 95% CI, 1.23 to 6.27), and intentional weight loss (aSHR, 2.26; 95% CI, 1.05 to 4.85) were associated with higher waitlist mortality compared with nonfrail candidates with stable weight. Among nonfrail candidates, no associations were observed for weight change and frailty status with either chance of listing or waitlist mortality.
Among frail candidates with obesity, unintentional pre-KT weight loss is associated with a lower chance of listing; however, any weight loss is associated with higher waitlist mortality. Our findings suggest that frail candidates with obesity may benefit from clinician supervision of pre-KT weight loss.
在肥胖的体弱肾移植（KT）候选者中，KT评估前的非故意体重减轻与列入等待名单的可能性较低有关。在肥胖的体弱候选者中，非故意和故意体重减轻均与等待名单死亡率较高有关。结果表明，对于肥胖的体弱候选者，应考虑在KT前对体重减轻进行仔细监督，强调保留肌肉质量和功能的策略。
非故意体重减轻是体弱的一个标志，预示着肾移植（KT）后更差的结果。然而，肥胖候选者的体重减轻通常被推荐以提高移植资格。我们测试了评估前体重变化是否与列入等待名单/等待名单死亡率相关，同时考虑了意向性和体弱情况。
我们利用了一项前瞻性多中心队列研究中1361名肥胖（体重指数≥30kg/m）候选者（895名已列入等待名单）的体重指数、体重减轻意向性（评估前1年和评估时）以及体弱情况（评估时的四成分身体虚弱表型）的数据。我们使用Cox比例风险/竞争风险模型估计评估前体重变化（稳定、增加、非故意/故意减轻）与列入等待名单/等待名单死亡率之间的关联。
在肥胖候选者中，48%的人体重稳定，17%的人体重增加，16%的人非故意体重减轻，20%的人故意体重减轻。在肥胖的体弱候选者中，与体重稳定的非体弱候选者相比，体重稳定与列入等待名单的可能性降低27%相关（调整后风险比[aHR]，0.73；95%置信区间[CI]，0.55至0.96），体重增加与列入等待名单的可能性降低47%相关（aHR，0.53；95%CI，0.34至0.80），非故意体重减轻与列入等待名单的可能性降低48%相关（aHR，0.52；95%CI，0.32至0.84）。然而，在肥胖的体弱候选者中，与体重稳定的非体弱候选者相比，故意体重减轻与列入等待名单的可能性显著降低无关。此外，在肥胖的体弱候选者中，与体重稳定的非体弱候选者相比，体重稳定（调整后亚风险比[aSHR]，1.72；95%CI，1.01至2.90）、非故意体重减轻（aSHR，2.78；95%CI，1.23至6.27）和故意体重减轻（aSHR，2.26；95%CI，1.05至4.85）与等待名单死亡率较高相关。在非体弱候选者中，未观察到体重变化和体弱状态与列入等待名单或等待名单死亡率之间的关联。
在肥胖的体弱候选者中，KT前的非故意体重减轻与列入等待名单的可能性较低有关；然而，任何体重减轻都与等待名单死亡率较高有关。我们的研究结果表明，肥胖的体弱候选者可能受益于临床医生对KT前体重减轻的监督。
