Prioritizing Transplants When Other Surgeries Are on Hold

Marcia Frellick

April 06, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Currently, living donors are urged to go ahead with the preliminary steps in the process remotely, but in-person appointments and transplants are largely on hold. Deceased-donor transplantations — deemed essential surgeries — are moving forward, but surgeons are having to use their best judgment to determine whether the kidney's donor was infected with COVID-19.

Rapidly evolving concerns about the effect that COVID-19 is having on kidney transplants was a hot topic at the virtual National Kidney Foundation 2020 Spring Clinical Meetings.

The COVID-19 concerns are being added to longstanding issues in the transplant community, such as the debate about whether patients who are obese should be required to lose weight before they can be considered for kidney transplantation.

Obesity can cause complications in kidney recipients, experts agree, but views on how much emphasis should be put on pretransplant weight loss differ.

"Kidneys are a limited resource and we can't transplant everyone," said Kenneth Woodside, MD, a transplant surgeon and associate professor of surgery at Michigan Medicine in Ann Arbor.

The implications of obesity for transplant patients were discussed in a virtual presentation by Woodside and Meera Harhay, MD, associate professor of medicine at Drexel University College of Medicine in Philadelphia.

A link between obesity and death from cardiovascular disease after kidney transplantation was seen in a previous study. The meta-analysis showed that patients who are obese are twice as likely to die from cardiovascular disease after kidney transplantation as patients with a healthier weight, Woodside explained.

Cost to the healthcare system is also higher for kidney recipients who are obese, Woodside said.

Average accumulated Medicare payments for the first 3 years after transplantation ranged in cost (in 2012 US dollars) from $109,623 for living-donor recipients who had body mass index (BMI) of less than 18.5 kg/m² to $143,529 for those with a BMI over 40 kg/m², according to an unpublished study of more than 8000 patients by Tayyab Diwan, MD, and colleagues from the University of Cincinnati.

"You really see a jump at the BMI 30 mark," Woodside pointed out.

There are practical concerns as well, he explained.

Complications

"It takes longer to sew in kidneys in obese patients, so there's more delayed graft function," he said. And "to sew vessels, you need to be able to see the vessels. Retractors are only so long."

There is no question that surgical complications are a big factor in patients who are obese, said Harhay, but there are several problems with mandated pretransplant weight loss and BMI cutoffs at transplant centers.

One is the steady increase of morbid obesity in the United States, which would limit access to an ever-rising number of patients.

Although there is no national standard BMI cutoff, 66 of 67 transplant programs in the United States use a BMI cutoff of 35 to 40 kg/m², according to a previous study.

And 21% of transplant programs did not list any candidate with a BMI of 40 kg/m² or higher from 1995 to 2006, according to a study of all waiting-list registries in the United States.

"What that means is that in the United States, if you have end-stage kidney disease and morbid obesity, your access to a kidney transplant might depend more strongly on what transplant program you live near — what they're willing to do — than your own health status," Harhay explained.

"A BMI cutoff of 35 kg/m² would exclude about one in five adult incident dialysis patients in the United States from a kidney transplant evaluation, and a cutoff of 40 kg/m² would exclude one in 10 incident dialysis patients," she said, citing data from the US Renal Data System.

In addition, BMI does not equal body composition. "A person with a high BMI could be muscular, and that could be protective," Harhay said. "BMI doesn't differentiate between where fat is stored."

Importantly, it's hard for anyone to lose weight, let alone people who are on dialysis and perhaps also working. "Dialysis is an exhausting procedure and end-stage kidney disease is an exhausting condition," she emphasized.

But tips for patients with end-stage kidney disease who want to lose weight were provided at the virtual meeting by Karen Greathouse, RD, a transplant dietitian from the University of Michigan Health System in Ann Arbor.

Dietician's Tips

"The key to successful weight loss is not just losing the weight, but being able to maintain that for 5 or more years," she said.

The big problem with many diets is the lack of programs to support people. "We're trying to give handouts and expecting people to go with it," she explained.

Diets that include unusual combinations of food or that have a particular eating sequence are not sustainable, Greathouse pointed out.

She said she recommends individualized action plans with a dietitian for people with end-stage kidney disease. Dietitians will stress lifestyle changes and the importance of combining dietary changes with exercise, she noted.

And smaller goals relieve anxiety and increase the chances of success. Some people are given instructions to lose 50 pounds, which "puts them at the bottom of a well trying to climb out," she explained.

And healthcare providers often tell people to limit fruits and vegetables because they contribute to fluid complications or high potassium levels.

"I can't tell you how many times I've heard patients say they've been told not to eat salad because it contributes to fluid," Greathouse said.

"When you're increasing fruits and vegetables, you're having better bowel movements, you're lowering your potassium deposits and fluid," she explained. "Processed foods have more potassium than the fruits and vegetables, and that's what a lot of our patients are eating."

National Kidney Foundation (NKF) 2020 Spring Clinical Meetings. Presented March 26, 2020.

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