Effect of Body Mass Index at Time of Transplantation and Weight

Gain After Transplantation on Allograft Function in Kidney Transplant

Recipients in Shiraz
G. A. Raiss-Jalali, A. R. Mehdizadeh, A. Razmkon, J. Rouzbeh, S. Behzadi, H. Memari, and S. A.
Malek-Hosseini

ABSTRACT
Chronic renal allograft dysfunction is the most common cause of graft loss, for which there
are multiple risk factors, including obesity before transplantation, which is believed to
lower long-term renal allograft survival. One hundred eighty-two kidney transplant
recipients were studied. Body mass index (BMI) at the date of transplantation was
calculated. BMI values were classified into 4 categories: (1) patients with BMI ⬍20, (2)
BMI between 20 and ⬍25, (3) BMI between 25 and ⬍30, and (4) BMI ⱖ30. The minimum
follow-up period in this study was 3 years after transplantation. The link between
categorized BMI and the presence of renal allograft dysfunction and mortality within 3
years posttransplantation was investigated using independent sample t test. BMI at the
date of transplantation showed statistically significant association with presence of renal
allograft dysfunction and mortality within 3 years posttransplantation (P ⫽ .008, P ⫽ .01,
respectively). BMI at the date of transplantation has a strong association with outcomes
after renal transplantation. The extremes of very high and very low BMI are important risk
factors for chronic renal allograft dysfunction; therefore, weight adjustment before kidney
transplantation can be useful in improving the function of a transplanted kidney and
increasing patient’s survival.

A DVANCEMENTS in renal transplantation (Tx) have

dramatically improved outcome, especially 1-year graft
survival rates for recipients with end-stage renal disease
(ESRD).1,2 Recent studies indicate that pre-Tx obesity and
increased body mass index (BMI) in adults are associated with
decreased long-term renal allograft survival.3–5
Increased BMI is an important risk factor for death in the
general population and has also been linked to specific
causes of mortality, such as cardiovascular death.6,7 Simi-
larly, in patients with ESRD who have undergone renal Tx,
higher BMI has been associated with a significantly in-
creased patient mortality.3,8 However, available data sug-
gest that being overweight or obese at the time of kidney
transplantation has a detrimental effect on both the patient
and allograft outcomes.5,7 Furthermore, kidney transplant
recipients are at risk for even further significant weight gain
(WG) post-Tx.9,10 Thus, the impact of the obesity epidemic
may have far-reaching consequences in this high-risk
group.9
Because of the reported poorer outcomes of renal trans-
plantation in obese patients, some investigators suggested
that obese patients should be excluded as candidates for
transplantation.5,11,12 The purpose of this study was to
assess the relationship between BMI and between WG after
Tx and renal allograft function in recipients of renal grafts
in a single center.
MATERIALS AND METHODS
This is a retrospective review of medical records from 182 renal
allograft recipients at Shiraz Transplant Center between 1987 and
1999. Patients’ files in addition to Persian Network for Organ
Transplant (PNOT) were used to collect data such as age, gender,
BMI at the time of operation, source of organ, amount of WG after
3 years, and cause of ESRD in recipients. Regular follow-up was
performed at the time of operation, every 3 months in the first year
after the operation, and every 6 months in the following years. The
normal levels of creatinine and blood urea nitrogen (BUN) were
defined as ⬍1.8 mg/dL and 15– 45 mg/dL, respectively.
From the Southern Organ Transplant Center, Shiraz, Iran
Address reprint requests to Ghanbar Ali Raiss-Jalali, MD, PO
Box 71455-166, Shiraz, Iran. E-mail: ali_ra@yahoo.com

0041-1345/05/$–see front matter © 2005 by Elsevier Inc. All rights reserved.

doi:10.1016/j.transproceed.2005.08.036 360 Park Avenue South, New York, NY 10010-1710

2998 Transplantation Proceedings, 37, 2998 –3000 (2005)

EFFECT OF BMI AND WEIGHT GAIN
Table 1. Demographic and Risk Factors Among 4 Groups
Group 1
No. (%) 56 (31%)
Age (mean ⫾ SD) 33.9 ⫾ 11.2
Male/female 3 (42/14)
Source of organ
Cadaveric 3 (5.3%)
Living 53 (94.7%)
Primary cause of ESRD
GN 16 (28.6%)
DM 14 (25%)
HTN 8 (14.3%)
AI 4 (7.1%)
Abbreviations: GN, glumeronephritis; DM, diabetes mellitus; HTN, hypertension; AI, autoimmune disease.
BMI was calculated based on the formula: BMI ⫽ weight
(kg)/[height (m)2] at the time of operation and was documented by
the transplant coordinator. Patients were divided into 4 groups: (1)
patients who had BMI ⬍20; (2) BMI between 20 and ⬍25; (3) BMI
between 25 and ⬍30; and (4) BMI ⱖ30.
WG was calculated based on the formula: WG ⫽ [weight at third
year after Tx (kg)]-[weight at the time of Tx]. Patients were divided
into 4 groups: (A) patients with WG ⬍5; (B) WG between 5 and
⬍15; (C) WG between 15 and ⬍25; and (D) WG ⱖ25.
Allograft dysfunction was defined as the following: serum creat-
inine level ⬎1.8 mg/dL, pathological diagnosis of renal allograft
rejection, need to administer steroid pulse therapy, and need for
admission due to allograft dysfunction.
The chi-square test and independent samples t test were used to
evaluate the relationship between the groups. P ⬍ .05 was defined
as statistical significance.
RESULTS
Of 182 patients, 50 were female and 132 were male
(male/female ratio ⫽ 2.64). The mean age of recipients was
34.0 ⫾ 9.9 (14 –58) years. Ten patients received organs from
cadavers, 76 from live-related donors (LRD), 24 from
live-unrelated donors (LURD), and 22 from spouses. De-
mographics and major risk factors among 4 groups are
shown in Table 1. Mean patient BMI was 22.2 ⫾ 4.6 kg/m2
(12.3–50.7) and mean patient WG was 11.3 ⫾ 7.4 (0 –35) kg.
The mean average BUN during the first 3 years after Tx
was 21.6 ⫾ 6.2 mg/dL (12– 62). BUN was significantly
higher in patients with higher BMIs (P ⫽ .03).
The mean average serum creatinine level during the first
3 years after Tx was 1.4 ⫾ 0.5 mg/dL (0.7– 4). There was no
significant difference between groups 1 and 2, but in
patients with BMI ⱖ 25 kg/m, the creatinine level increased
with increasing BMI (P ⫽ .01).
Mean BMI in patients with allograft dysfunction was 21.6
⫾ 3.8 kg/m2 and in patients without allograft dysfunction
was 25.6 ⫾ 7.1 kg/m2 (P ⫽ .004).
Frequency of allograft dysfunction in group A was a little
more than groups B and C, and in group D, it was
significantly higher than others (P ⫽ .02).
There was statistical significance between BMI at the
time of Tx and serum BUN (P ⫽ .011), serum Cr (P ⫽
2999
BMI
Group 2 Group 3 Group 4
86 (47%) 28 (15%) 12 (7%)
34.3 ⫾ 10.3 33.0 ⫾ 12.4 34.7 ⫾ 14.7
2.44 (61/25) 3 (21/7) 2 (8/4)
4 (4.6%) 2 (7.1%) 1 (8.3%)
82 (95.4%) 26 (92.9%) 11 (91.7%)
30 (34.9%) 9 (32.1%) 4 (33.3%)
22 (25.6%) 9 (32.1%) 5 (41.7%)
14 (16.3%) 4 (14.3%) 1 (8.3%)
6 (6.9%) 3 (10.7%) 2 (16.7%)
.007), allograft dysfunction (P ⫽ .008), and mortality rate
during the 3 years after Tx (P ⫽ .01); however, there was no
statistical significant relationship between WG and BMI at
the time of Tx (P ⫽ .645), serum BUN (P ⫽ .28), serum
creatinine (P ⫽ .612), allograft dysfunction (P ⫽ .993), and
mortality rate after Tx (P ⫽ .361).
The distribution of patients and also the mean BUN,
creatinine, mortality rate, and frequency of allograft dys-
function in different groups are shown in Table 2.
DISCUSSION
BMI is a strong independent risk factor for patient mortal-
ity and graft failure independent of patient death after renal
transplantation.7 Evidence is emerging demonstrating a
negative role of obesity on outcome of renal Tx in adults.
Most reports agree that renal Tx in obese adult patients is
associated with increased patient mortality, diminished
short-term and long-term graft survival, and increased
surgical and medical complications. Moreso et al4 showed
that obese kidney transplant recipients had a reduced
short-term graft function. Modlin et al5 and Halme et al8
showed that BMI ⬎30 was associated with increased patient
mortality. Recently, Meier-Kriesche et al3 demonstrated
that even mild obesity (BMI ⬎25) was an independent risk
factor for both decreased graft survival and patient survival.
In contrast, Drafts et al13 showed no correlation between
mild obesity and graft survival for either cadaveric or
live-donor Tx. In addition, no difference in graft survival
between obese and age-matched non-obese patients was
reported by Merion et al.14 In our study, the rate of
allograft dysfunction and the mortality rate were higher in
patients with obesity (BMI ⱖ30). Also, in underweight
patients, these rates were higher compared with patients
with normal weight. Therefore, we can conclude that being
underweight is also a risk factor for renal Tx.
A number of potential factors may account for the
increasing prevalence of overweight and obesity in ESRD
patients undergoing transplantation. First, demographic
groups at greatest risk for chronic kidney disease (ie,
diabetics and minorities) are also those with an increased
3000 RAISS-JALALI, MEHDIZADEH, RAZMKON ET AL

Table 2. Relationship Between Mean BUN, Creatinine, Patient Allograft Dysfunction, and Mortality, with BMI and WG
BMI WG

Group 1 Group 2 Group 3 Group 4 Group A Group B Group C Group D

No. (%) 56 (31%) 86 (47%) 28 (15%) 12 (7%) 38 (21%) 97 (53%) 39 (22%) 8 (4%)
Mean BUN (mg/dL) 20.4 21.1 24.3 27 22.5 21.4 21 21.7
Mean creatinine (mg/dL) 1.4 1.4 1.5 1.9 1.5 1.4 1.4 1.4
Frequency of allograft 12.5 10.5 17.9 50 17.9 12.5 12.8 33.3
dysfunction (%)
Mortality rate (%) 3.9 0 14.3 25 5.1 5.2 5.1 0

prevalence of overweight and obesity.15 Second, more
patient subgroups at increased risk of obesity (eg, older
patients and blacks) are undergoing transplantation.16
Third, better management of uremia during ESRD over
recent years, as reflected by increasing Kt/V,16 could theo-
retically improve dietary intake. Fourth, general behavioral
and cultural influences that have encouraged excess caloric
consumption or inadequate physical activity also may be
manifest in patients with ESRD.17
The reason for worse outcome in obese patients has not
been clearly defined. In adults, obesity is considered a
significant comorbidity after renal Tx leading to increased
cardiac, pulmonary, surgical, and urological complica-
tions.18 Pirsch et al19 proposed that increased BMI could
have an independent effect on the allograft due to immu-
nological causes.
We recommend decreasing weight before and after Tx
for every potential recipient. Change in behavioral habits of
eating, consultation with a nutritionist, and exercise are
perhaps the best ways in this regard. Finally, it is important
to note that obesity should not be a barrier for transplan-
tation.12
REFERENCES
1. Mitsnefes MM, Khoury P, McEnery PT: Body mass index and
allograft function in pediatric renal transplantation. Pediatr Neph-
rol. 17:535, 2002
2. Offner G, Latta K, Hoyer PF, et al: Kidney transplanted
children come of age. Kidney Int 55:1509, 1999
3. Meier-Kriesche HU, Vaghela M, Thambuganipalle R, et al:
The effect of body mass index on long-term renal allograft survival.
Transplantation. 68:1294, 1999
4. Moreso F, Seron D, Anunciada AI, et al: Recipient body
surface area as a predictor of post transplant renal allograft
evolution. Transplantation. 65:671, 1998
5. Modlin CS, Flechner SM, Goormastic M, et al: Should obese
patients lose weight before receiving a kidney transplant? Trans-
plantation 64:599, 1997
6. Calle EE, Thun MJ, Petrelli JM, et al: Body-mass index and
mortality in a prospective cohort of U.S. adults. N Engl J Med
341:1097, 1999
7. Meier-Kriesche HU, Arndorfer JA, Kaplan B, et al: The
impact of body mass index on renal transplant outcomes: a
significant independent risk factor for graft failure and patient
death. Transplantation. 73:70, 2002
8. Halme L, Eklund B, Kyllonen L, et al: Is obesity still a risk in
renal transplantation? Transpl Int 10:284, 1997
9. Friedman AN, Miskulin DC, Rosenberg IH, et al: Demo-
graphics and trends in overweight and obesity in patients at time of
kidney transplantation. Am J Kidney Dis 41:480, 2003
10. Clunk J, Lin CY, Curtis J: Variables affecting weight gain in
renal transplant recipients. Am J Kidney Dis 38:349, 2001
11. Howard RJ, Thai VB, Patton PR, et al: Obesity does not
portend a bad outcome for kidney transplant recipients. Transplan-
tation 73:53, 2002
12. Hall JE, Brands MW, Henegar JR: Mechanisms of hyper-
tension and kidney disease in obesity. Ann N Y Acad Sci 892:91,
1999
13. Drafts HH, Anjum MR, Wynn JJ, et al: The impact of
pre-transplant obesity on renal transplant outcomes. Clin Trans-
plant 11:493, 1997
14. Merion RM, Twork AM, Rosenberg L, et al: Obesity and
renal transplantation. Surg Gynecol Obstet 172:367, 1991
15. Mokdad AH, Serdula MK, Dietz WH, et al: The spread of
the obesity epidemic in the United States, 1991–1998. JAMA
282:1519, 1999
16. Excerpts from the United States Renal Data System’s 2001
Annual data report: Atlas of end-stage renal disease in the United
States. Am J Kidney Dis. 38:S117, 2001
17. French SA, Story M, Jeffery RW: Environmental influences
on eating and physical activity. Annu Rev Public Health 22:309,
2001
18. Gill IS, Hodge EE, Novick AC, et al: Impact of obesity on
renal transplantation. Transplant Proc 25:1047, 1993
19. Pirsch JD, Armbrust MJ, Knechtle SJ, et al: Obesity as a risk
factor following renal transplantation. Transplantation. 59:631,
1995