Issues of Obesity in Kidney Transplantation

A systematic approach to postoperative management of deceased donor kidney transplant patients with a clinical pathway

CONTEXT

Clinical pathways have been used in many acute hospital settings.

OBJECTIVES

To develop a systematic approach to postoperative care of adult recipients of deceased donor kidney transplants at the University of Mississippi Medical Center.

DESIGN AND SETTING

A pilot quality improvement project that uses implementation of a clinical pathway 24 hours after surgery for adult recipients of a deceased donor kidney transplant for 7 months. Charts from the same 7 months of the preceding year were retrospectively reviewed for comparison. The project occurred on the transplant floor in an acute care hospital and did not include any patients admitted to the intensive care unit.

MAIN OUTCOME MEASURES

To demonstrate that clinical pathways can (1) promote a method for standardizing postoperative care, (2) decrease postoperative length of stay, and (3) contain costs by minimizing hospital charges related to laboratory and room fees and promote efficient medication use in adult recipients of a deceased donor kidney transplant.

RESULTS

All 24 patients in the clinical pathway group met daily goals of the implemented clinical pathway. The clinical pathway group had statistically significant decreases in postoperative length of stay, use of laboratory tests, and use of intravenous medications compared with the comparison group. The 2 groups were similar in race, sex, age, and body mass index. Surgical readmissions did not differ significantly between the 2 groups.

A Systematic Approach to Postoperative Management of Deceased Donor Kidney Transplant Patients with a Clinical Pathway

Context

Clinical pathways have been used in many acute hospital settings.

Objectives

To develop a systematic approach to postoperative care of adult recipients of deceased donor kidney transplants at the University of Mississippi Medical Center.

Design and Setting

A pilot quality improvement project that uses implementation of a clinical pathway 24 hours after surgery for adult recipients of a deceased donor kidney transplant for 7 months. Charts from the same 7 months of the preceding year were retrospectively reviewed for comparison. The project occurred on the transplant floor in an acute care hospital and did not include any patients admitted to the intensive care unit.

Main Outcome Measures

To demonstrate that clinical pathways can (1) promote a method for standardizing postoperative care, (2) decrease postoperative length of stay, and (3) contain costs by minimizing hospital charges related to laboratory and room fees and promote efficient medication use in adult recipients of a deceased donor kidney transplant.

Results

All 24 patients in the clinical pathway group met daily goals of the implemented clinical pathway. The clinical pathway group had statistically significant decreases in postoperative length of stay, use of laboratory tests, and use of intravenous medications compared with the comparison group. The 2 groups were similar in race, sex, age, and body mass index. Surgical readmissions did not differ significantly between the 2 groups.

Defining High Risk in Adult Kidney Transplantation

Background

Because identifiable factors contribute to allograft loss, and because no consensus has been reached on the definition of high risk, an interdisciplinary group of nurses, physicians, pharmacists, and social workers was convened in May 2008.

Objective

Participants sought to reach consensus about the current state of science and best practices related to the definition and management of high-risk kidney transplant recipients.

Methods

An expert facilitator with extensive experience in leading consensus teams guided consensus-building activities, which included discussion and small-group work.

Results

This consensus group conceptualized the definition of the “high-risk” kidney transplant recipient and provided information to guide the multidisciplinary team in their assessment of these patients before and after transplant. Three key areas, which were conceptualized as independent scales, had a substantial impact on outcomes: (1) transplant recipient medical factors, (2) donor and recipient immunological factors, and (3) transplant recipient psychosocial factors. Though depicted separately, alteration of a specific risk on one scale could influence some risk factors on another scale. In addition, the kidney allograft itself must be considered in the assessment of high risk.

Conclusions

The continuum of risk described here should be useful to transplant clinicians in their assessment of high-risk adult kidney transplant patients, may aid centers in developing a more complete definition of high risk, and may lead to risk-reduction efforts.

Serum leptin, insulin resistance, and body fat after renal transplantation

OBJECTIVE

Our objective was to evaluate serum levels of leptin, body mass index (BMI), body-fat percentage (BF%), and insulin resistance in the first year after renal transplantation.

DESIGN

This study involved a prospective, observational cohort.

SETTING

The setting was a transplant unit of a university teaching hospital in Porto Alegre, Brazil.

PATIENTS

Thirty-two patients who underwent renal transplantation were prospectively followed for 1 year. A control group of 19 healthy individuals, matched by sex, age, and BMI, was included in the study.

METHODS

Body mass index and BF% were measured according to anthropometric measures, serum leptin was measured by radioimmunoassay, and the homeostasis model assessment (HOMA) was used as an index of insulin resistance. Anthropometric measures and biochemical markers were evaluated prospectively, starting at transplant time and then every 3 months for up to 1 year.

RESULTS

Leptin levels were increased before transplantation, and decreased significantly in the first year (median, 11.9 [interquartile range, 9.2 to 25.2] to 9.3 [4.9 to 16.4] ng/mL; P < .001). The HOMA values presented a similar pattern, decreasing from 2.4 +/- 1.5 (mean +/- SD) before transplantation, to 1.5 +/- 1.1 (P = .001) at 3 months after transplantation, but increasing to 2.0 +/- 1.7 at month 12 after transplantation (P = not significant). The BMI and BF% increased significantly in the first year after transplantation (23.3 +/- 2.7 kg/m(2) vs. 24.4 +/- 2.7 kg/m(2), P = .001, and 23.71% +/- 7.79% vs. 25.63% +/- 7.68%, P = .002, respectively). According to multivariate regression analysis, HOMA levels and BF% independently predicted leptin levels after transplantation.

CONCLUSIONS

We found that leptin serum levels decreased significantly over the first posttransplant year. However, the effect of transplantation on insulin resistance appears to be transitory, and BF% also increases steadily in this period. The beneficial profile of leptin levels is counterbalanced by the detrimental effects of insulin resistance and BF% that may be related to the elevated cardiovascular risk observed after transplantation.

Insulin resistance, body fat percentage, and lipid abnormalities as risk factors for cardiovascular diseases in renal transplant recipients: a 1-year analysis

The aim of this study was to evaluate changes in body mass index (BMI), body fat percentage (BF%), insulin resistance, and lipid profile in 32 patients during the first year after renal transplantation by anthropometric measures. The homeostasis model assessment index (HOMA) was calculated for insulin resistance estimation. Anthropometric measures and biochemical markers were evaluated at the time of transplantation (T(0)), and prospectively at 3 (T(3)), 6 (T(6)), 9 (T(9)), and 12 (T(12)) months posttransplantation. The HOMA index decreased significantly at 3 months after transplantation (T(3)) (2.4 +/- 1.5 vs 1.5 +/- 1.1; P < .01); however, an increment was observed at T(6) and T(9) (1.8 +/- 0.8 and 2 +/- 1.5, respectively), remaining stable at T(12) (2 +/- 1.7). BMI and BF% increased significantly over 12 months (23.3 +/- 2.7 vs 24.4 +/- 2.7 kg/m(2); P = .001 and 23.7 +/- 7.8 vs 25.6 +/- 7.7 %; P = .002). Total cholesterol, low-density lipoprotein cholesterol and triglyceride levels showed significant increases starting at T(3). In conclusion, insulin resistance decreased transitorily post-renal transplantation. BMI, BF%, and lipid profile showed unfavorable changes during the first year post-renal transplantation.

Pretransplant obesity: a weighty issue affecting transplant candidacy and outcomes

Because of the global increase in prevalence of obesity, many more overweight and obese individuals are undergoing evaluation for transplantation than in the past. Although obesity seems to provide a survival benefit in dialysis patients, obesity has traditionally been considered a contraindication for transplantation of most organs. It is theorized that obesity will contribute to worse transplant outcomes, including lower rates of graft and patient survival and higher rates of delayed graft function and infection. This review evaluates the available literature evaluating outcomes of obese patients with end-stage organ failure who undergo transplantation. Obesity seems to be associated with increased rates of wound infection after transplantation. However, other adverse transplant outcomes related to obesity seem to be dependent on the type of organ being transplanted and the degree of obesity. For example, a body mass index (BMI) of 30 kg/m(2) may reduce short-term survival in lung transplant recipients; however, obesity does not seem to confer an adverse effect on short- or long-term survival in liver transplant patients until a much higher BMI is reached (such as 35 or 40 kg/m(2)). Each transplant center must determine weight guidelines and criteria for identifying the level of obesity as a contraindication for transplantation. This must be based on organ type, each center's transplant and complication statistics, and available donor pools. Guidelines must also consider the morbidity and mortality risks of the obese patient with organ failure who does not receive a transplant.