VIDEO: Obesity presents obstacles to kidney care
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Key takeaways:
- ASN published guidance on managing obesity with kidney disease.
- Some kidney therapies may promote weight gain, and transplant often requires a weight cap.
- Psychosocial issues may present barriers to obesity care.
In this video exclusive, Deidra C. Crews, MD, ScM, FASN, president of the American Society of Nephrology discusses connections between kidney disease and obesity.
ASN recently published guidance on obesity management for patients living with kidney disease. Crews describes the bidirectional influence of obesity and kidney disease, including treatment effects, and psychosocial considerations for talking with patients about obesity.
Below is a transcript of the interview.
Healio: This is the first time ASN has put out guidance on managing obesity with kidney disease. Was the timing influenced by newly available treatments?
Crews: Absolutely. This is certainly the first time that ASN has put out any sort of guidance. The timing of it came at a time when we had started to reassess the fact that we had not been an organization that produced either guidelines or guidance. We had undertaken a study of what space we could fill in the kidney care space and landed on this idea that what our community broadly might benefit from is having these timely, shorter versions of information in the form of guidance, as opposed to guidelines, which tend to take years to produce and certainly are much longer documents.
We felt a space we could fill would be one, again, that would be these shorter documents that could respond to newer questions that were emerging in the clinical care of people with kidney diseases.
And then, once we’d made the decision that we would, as an organization, produce kidney health guidance, then we started to look at topics that might be the most appropriate to begin with, and that’s where we landed on the management of obesity among people with kidney diseases.
And yes, that was influenced by what we’re seeing in terms of newer therapies and emerging evidence about the role that obesity plays in so many different aspects of kidney care, as well as the numerous opportunities that we have to better support people as they try to achieve a healthy weight.
Healio: Does obesity have a direct effect on kidney disease or is it mediated through other disease, such as diabetes, for example?
Crews: This is a continuing area of study. It is thought that obesity has both direct and some indirect effects, not just on the development of kidney diseases, but also their progression, as well as obesity can influence the way that we might treat people who’ve developed kidney disease from another cause.
I’ll elaborate on that. While from a mechanistic standpoint, we’re learning more and more about how some of the same factors that may promote or be related to obesity — things like inflammation can have effects biologically on kidney health and can actually lead to kidney disease — we also know that for people who already have kidney disease, let’s say from another cause, if they also have obesity or have an unhealthy weight, that might influence the treatment choices that we may pursue. For example, a number of the different kidney diseases that we treat in nephrology might be those that would benefit from the use of corticosteroids, and we know that for many individuals that can actually lead to further weight gain or further fluid retention, and so could pose a challenge particularly for people who are already having challenges either achieving or maintaining a healthy weight. So, we know that that can be a factor there.
It really goes both ways, both as a risk factor for kidney diseases as well as having an influence over the treatment options that we have available.
I should note as well that when we think about people with kidney failure, and how kidney transplantation is the optimal therapy for those individuals, we know that most kidney transplant centers have cutoffs as far as body mass index below which they require patients to be in order to make them eligible for receiving a kidney transplant.
We know that obesity plays a role there, again, in terms of the treatment choices that are available for people with kidney failure. Similar to that, we also know that for people who may want to pursue certain types of home dialysis modalities, their weight could be a barrier, particularly for people who may want to pursue peritoneal dialysis. In some cases, the surgeries that are required for that might be a challenge for people who are at an unhealthy weight. And so again, obesity can play a role in our management choices for people with kidney diseases, as well as it can be a driver of the development of kidney disease in the first place.
Healio: Does the relationship go the other way? Can having kidney disease affect weight as well?
Crews: It can, largely via the treatments that we may have for people who have kidney diseases. I mentioned corticosteroids and medications like prednisone, which for a lot of people can tend to promote weight gain. And so, it can have that effect.
There are other medication classes as well that can also lead to weight gain. There are some medications that can actually lead to weight loss as well that we might use for kidney diseases. So, there is certainly a relationship between weight and kidney disease really that’s going in both directions.
Healio: Will you briefly talk about the first section of the guidance that addresses psychosocial considerations when talking with patients about weight? How might a conversation about weight go?
Crews: The guidance statement does emphasize that words matter when counseling patients about trying to achieve a healthy weight. We know that for a number of people, their experience, especially in the health care setting, if they are living with obesity, can be one where they may feel stigmatized, and that there’s a body of literature even showing that physicians tend to not always use the most appropriate language that is sensitive and respectful to people when they’re discussing and helping them achieve their weight goals.
We try to emphasize that in the document as well as some other factors that come into play when thinking about how a number of different social factors might influence an individual’s ability to access the types of healthy foods that might be recommended for achieving and maintaining a healthy weight, as well as being able to access places for recreation and exercise that, again, might help them achieve and maintain a healthy weight. And so, having clinicians be sensitive to that and assessing those types of needs, those potential social barriers that people may be facing to achieving a healthy weight, becomes important.
From the more psychological side of things, we know that many people who are looking to achieve a healthier weight may have some feelings of anxiety, sadness, even depression [and] depressive symptoms as well. There’s evidence showing that around one-third of people who would have a diagnosis of obesity also carry a either diagnosis or symptoms that align with mood disorders. We know that that becomes important, especially when we’re trying to support people in the steps that would be needed to help them achieve a healthy weight.
All of these things come into play, and it becomes critical that clinicians consider them as a part of that treatment plan for helping patients to achieve a healthy weight.
Healio: Anything else you’d like to add?
Crews: We’re excited about the attention that this initial guidance has gotten, and we hope that it helps support improvements in the way that we manage obesity for people who have kidney diseases.
Reference:
Ikizler TA, et al. J Am Soc Nephrol. 2024;doi:10.1681/ASN.0000000512.
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