Extreme Obesity Affects Chances Of Kidney Transplantation

[okarol]

Extreme Obesity Affects Chances Of Kidney Transplantation

ScienceDaily (Jan. 11, 2008) — For patients on the waiting list for a kidney transplant, severe and morbid obesity are associated with a lower chance of receiving an organ, reports a study in the February Journal of the American Society of Nephrology.

Led by Dr. Dorry L. Segev of the Johns Hopkins University School of Medicine, the researchers used data from the United Network for Organ Sharing (UNOS) to examine how obesity affects waiting times for kidney transplantation.

"The results identify a potential bias in organ allocation that is not consistent with the goals of our allocation system," Dr. Segev comments. "Obese patients are waiting longer for kidney transplants when compared with their non-obese counterparts, even after adjusting for all medical factors tracked through UNOS."

Dr. Segev and colleagues analyzed data on more than 132,000 patients wait-listed for kidney transplants from 1995 to 2004. As obesity increased, the likelihood of receiving a transplant decreased.

Adjusted for other factors, the chances of receiving a kidney transplant were 27 percent lower for patients classified as severely obese and 44 percent lower for morbidly obese patients, compared to normal-weight patients. (The chances of receiving a transplant were not significantly reduced for patients classified as overweight or mildly obese.)

In addition, when a kidney became available, patients in the highest categories of obesity were more likely to be "bypassed"--that is, their physician was more likely to decline the offer of a kidney. The chances of being bypassed were 11 percent higher for severely obese patients and 22 percent higher for morbidly obese patients.

The findings raise concerns that obesity may be a previously unappreciated source of bias in organ allocation. "It is possible that providers are bypassing obese patients and instead transplanting non-obese patients because they feel that kidneys are a scarce resource and they want the kidneys to go to the patients who will benefit most from them," says Dr. Segev. "However, there is strong evidence that even obese patients will benefit significantly from a kidney transplant. And more importantly, the U.S. organ allocation system is not based on such medical decisions, but instead is based on the notion that everyone who gets listed deserves a fair chance at getting transplanted."

The bias might play out in other ways as well. Obese patients tend to have worse outcomes, which may reflect badly on the results achieved by doctors or hospitals--possibly even affecting quality measurements, which are increasingly tied to reimbursement. In addition, the reimbursement for transplant surgery is the same for difficult or complicated cases as for simpler cases. "These two practices generate a strong disincentive against challenging cases, and could potentially contribute to the bias against obese patients that we saw in our study," says Dr. Segev.

Dr. Segev notes that matching an available organ with an appropriate recipient requires clinical judgment, which could not be fully captured in this study. "However," he adds, "it is unlikely that these factors could explain such dramatic observations."

This study is scheduled for publication in the February issue of the Journal of the American Society of Nephrology (JASN) and early online publication.

Adapted from materials provided by American Society of Nephrology.

http://www.sciencedaily.com/releases/2008/01/080110144806.htm

[jbeany]

". . .patients in the highest categories of obesity were more likely to be "bypassed"--that is, their physician was more likely to decline the offer of a kidney. The chances of being bypassed were 11 percent higher for severely obese patients and 22 percent higher for morbidly obese patients."

Huh?  Am I missing something in how they work the list?  I thought that most centers simply refused to put morbidly obese patients on the list at all.  And if someone is on the list, and is a match, I wasn't aware they contacted a physician to make any decision on if the kidney got offered to a particular patient.  Which physician are they consulting?  The nephrologist?  The transplant surgeon?

[KT0930]

I know that the day I went for my first meeting with the transplant team, there was a lady there in probably her early 50's, who, compared to the general population, I would call "pleasantly plump", but for her age was about average. The team we were there to see told her to lose 50 pounds and they would list her when she reached 25. There's another center in the state (much further away from where she and I live) that probably would have listed her, because they are much more lenient on certain criteria like that.

When there is an offer of a kidney, the team gets the first call, and if you're a match, they will call your neph to be sure there is no reason he is aware of that you should not be considered. Recent illness, other surgery, certain requirements (i.e. dental work, etc) that have not been met and that sort of thing. If your neph clears you, THEN they call you and make sure of the same things. At least, that's how my team did it.

My understanding is that body size matching between donor and recipient are one of the primary considerations by UNOS. If the donor had a history of high blood pressure or diabetes (more likely in severely or morbidly obese patients), then they cannot use the kidney, or it is considered an expanded criteria donor, meaning it will be offered to older patients or ones who are not doing as well on dialysis as someone who can stand to wait awhile longer.

This is the way I understand it, and I may be way off-base. Hope it clears a little confusion!

[Chicken Little]

My center won't list anyone that is above a 30 BMI.