Research shows that weight need not disqualify a candidate

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

A patient's body mass index is one of the factors surgeons consider when someone with end-stage renal disease needs a kidney transplant.

Today, we'll learn more about how weight can impact transplant surgery with my guest, Dr. Reza Saidi. Dr. Saidi is an associate professor of surgery and the chief of transplant services at Upstate.

Welcome to "The Informed Patient," Dr. Saidi.

Reza Saidi, MD: Thanks, Amber. Glad to be here.

Host Amber Smith: Why do surgeons have concerns about body mass index of patients who need kidney transplants?

Reza Saidi, MD: You know, in the past there was some concern that these patients who are obese might have a poor outcome.

That's why some programs would exclude these patients for transplantation, but as we gathered more information, we find that that's not true, and these patients actually enjoy same benefit from transplantation compared to the rest of the patient population.

Host Amber Smith: What is considered a normal BMI?

What's considered overweight or obese?

Reza Saidi, MD: I think for your general audience, they should understand that weight is not a good indicator of patients' overall health. Since the 19th century, actually, this kind of body mass test was introduced, which is a combination of weight and weight/height, and then they will predict how much fat is in the patient's body, and they consider anybody, (with a) BMI of maybe is around 18 to 20, as normal, and BMI of 25 to 29 is considered overweight, and BMI of 30 considered obese.

And we know that obese patients have some risk factors, for example, diabetes or cardiovascular disease, but this has been used for many, many years. I think it's a better indicator of the patient's overall health compared to weight itself.

Host Amber Smith: So is there a BMI cutoff for transplant patients at Upstate?

Reza Saidi, MD: No, actually we don't. Actually, we studied our own cohort of the patients that we transplanted in the last five years. And we have transplanted actually patients from BMI of normal up to 56 and find out that these patients enjoy the same outcome compared to basically non-obese patients.

Because remember, chronic kidney disease is a major risk factor for the patient's overall health, and the patients (who) have chronic kidney disease have higher incidence of dying of cardiovascular disease or dying prematurely or have a lot of quality of life issues.

And, we find out in our study that patients, even obese patients, can benefit from kidney transplantation. They have a better quality of life after kidney transplantation, and also they live longer after kidney transplantation. And on the other hand, also the cost of care for this patient after kidney transplantation is much less compared to the cost of the patients who have chronic kidney disease or end-stage renal disease.

Host Amber Smith: Is the surgery more difficult if you're working with an obese patient?

Reza Saidi, MD: Yeah, absolutely. I think that's no doubt about it. The surgery is more difficult because we have to go through many, many layers of fatty tissue. These patients, their vessels are much deeper. The surgery takes longer, but the overall outcome we found out was the same, and despite the fact that obese patients could have a little bit higher incidence of, for example, wound infection or develop a hernia post-transplantation. But overall outcome regarding their kidney outcome or kidney survival or patient survival is compatible with a non-obese patient.

That's why we also published this data and, it's in (the medical) literature, and currently, at Upstate, we have no BMI cutoff.

The other thing, because their surgery is a little bit difficult, we are also in process to open up a robotic kidney transplant program, and I think they've shown that if you do this kidney transplant robotically, especially in obese patients, maybe it's better, and maybe it's even easier, and they have less postoperative complications, such as wound infection or hernia.

Host Amber Smith: Now, let me ask you, I know some of the transplants that are done are with living donors. Does the donor's weight have any bearing, or do they have to be at a certain level before they can donate?

Reza Saidi, MD: No, actually, also living donors, we have no issue with their weight. Again, remember our BMI is indicative of overall health.

If they have cardiovascular disease or diabetes, that's a different story. But if it is only weight, that should not be a contraindication for donation or kidney transplantation itself.

We evaluate all these patients in a multidisciplinary team, and we look at different factors, but weight itself, as I said, is not a contraindication for donation for organ transplantation.

Host Amber Smith: Are there complications that are more common in obese patients or overweight patients than normal-weight patients?

Reza Saidi, MD: Absolutely. I think that's what I was trying to point out. They have more, for example, wound infection or hernia, and also they're more prone to develop, for example, deep vein thrombosis (blood clots in deep veins).

These are more complications, but their overall outcome, when we talk about outcome after kidney transplantation, we talk about kidney survival and how long that kidney lasts, and also patient survival, how long the patient is going to be alive. Those main indicators of kidney transplantation are not different comparing obese patients with non-obese.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Reza Saidi. He's the chief of transplant services at Upstate, and we're talking about research he and his colleagues have done about obesity and kidney transplant.

Are patients who need a kidney transplant ever asked to lose weight before surgery?

Reza Saidi, MD: We do. We do because, again, as I said, if they lose weight, their postoperative course can be much smoother. We encourage them to lose weight. We have a dietitian on our service to help them. And also we have different programs, for example, exercise. We have a comprehensive program to help them lose weight. But again, that's not a requirement per se because we know that patients who have kidney transplant, regardless whether obese or not obese, they have much better quality of life, and they live longer. That's why we don't think obesity should prohibit anybody to receive these life-saving transplants.

Host Amber Smith: Weight loss can be difficult for anyone. Are there additional challenges for someone who is on kidney dialysis?

Reza Saidi, MD: Yes, that's another thing because remember, somebody on dialysis is going to be on the dialysis machine a couple days a week and a couple hours a day, and that's going to be challenging.

But for those patients, we have a comprehensive program to try to help them. Sometimes I say diet is important, exercise important is important, some change in habits is important. And sometimes we refer them for bariatric surgery.

Host Amber Smith: And they do the surgery for weight loss before they are eligible for the kidney transplant?

Reza Saidi, MD: Yeah. If we are referring to a weight-loss center and if they're a candidate for surgery, we recommend that the patient have surgery and then, after that, receive organ transplantation.

Host Amber Smith: In the study that you and your colleagues published recently, you compared three measures, delayed graft function, length of hospital stay, and 30-day readmission rate between patients over and under the BMI of 30, basically obese or not.

What does delayed graft function mean, and why is that important?

Reza Saidi, MD: Delayed graft function's helpful as an indicator of the function of a kidney organ immediately after the surgery. And some of these kidneys, especially coming from deceased donors, these kidneys could be out of body for many, many hours before we transplant them.

And because of that, they might not work right away. Delayed graft function means that the patient required dialysis post-transplantation, which leads to increases in length of stay and resource utilization and increased cost, for our program and for the society.

But that's one of the major factors that we monitor after kidney transplantation. And in this study, we look at it and see that the rate of, for example, delayed graft function, readmission and early and late graft outcome are not different in obese patients compared to non-obese patients.

Host Amber Smith: And then length of stay, what does that say about a patient to a transplant surgeon?

Reza Saidi, MD: Length of stay is factor for, is indicative of, for example, complications after kidney transplantation. And we show that the more they stay in the hospital, usually they require more resources, the cost of organ transplantation goes up, and that means the organ is not working properly, for example. That's an indicator, a health indicator, we'll monitor very closely after kidney transplantation.

Host Amber Smith: And so that goes hand in hand with the 30-day readmission. Is that looking at how many of these patients had to come back after they were discharged?

Reza Saidi, MD: Yes. A few days, for example (is typical. If) they stay longer, usually there's a higher chance that these patients might need readmission after transplantation, too.

Host Amber Smith: So did your study conclude that there really was no meaningful difference between obese and non-obese in all of these categories?

Reza Saidi, MD: Yes, that's correct. Actually, we looked at all these categories -- readmission, length of stay, delayed graft function complications and overall kidney survival and patient survival, and we find that there is no difference between obesity (and non-obesity).

That's why I think obesity, per se, should not be a limiting factor for a patient to receive organ transplant.

Host Amber Smith: Are there other transplant programs where obesity does disqualify someone?

Reza Saidi, MD: Yes, different programs in the country have different thresholds, and they have different practice patterns, and some of them actually require a patient to reduce weight to get to a certain BMI before they transplant.

But in our program, when we look at our experience, we decided that that factor is unnecessary and prevents the patient to receive a lifesaving transplantation. And that's why currently at Upstate, we don't have a BMI cutoff for the patient to receive a kidney transplant.

Host Amber Smith: Is there a takeaway message you'd like for patients or potential patients to understand regarding weight and kidney transplant?

Reza Saidi, MD: Yes, absolutely. This doesn't mean that the patient should have unhealthy lifestyle practices and have (excessive) weight. No doubt that weight loss can actually help the patient to basically have a healthier life and a more productive lifestyle.

But this study basically does show that obese patients can benefit, the same advantage of kidney transplant, compared to obese patients, but that doesn't mean that we would not recommend healthy lifestyle and losing weight. That's a different story.

Host Amber Smith: So someone who's maybe on dialysis and needs a kidney transplant, once they get a kidney transplant, can they then embark to lose weight, and would you recommend that?

Reza Saidi, MD: Yes, absolutely. Absolutely. We are always recommending patients, before, even after transplant, to lose weight and to get to this, healthy lifestyle, diet, exercise. These are all things that have shown that actually can prolong life and improve quality of life. We recommend that.

But again, the point of my paper is that chronic kidney disease is a risk factor, and weight should not eliminate a patient to have access to kidney transplant just because of their weight.

Because their disease is more dangerous than obesity. That's my point.

Host Amber Smith: What percent of patients do you think this would affect? What percent do you think are obese?

Reza Saidi, MD: More than 50% of (the) U.S. population are overweight. And we see the same pattern in our patients who come for kidney transplant. More than 50% of them are basically overweight, and also about 10%-20% of them are morbidly obese. That is a major health care problem in the U.S.

Host Amber Smith: Well, Dr. Saidi, I really appreciate you sharing your paper with us. Thank you.

Reza Saidi, MD: Thank you.

Host Amber Smith: My guest has been Dr. Reza Saidi, the chief of transplant services at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.