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The Obesity Paradox and Mortality Associated With Surrogates of Body Size and Muscle Mass in Patients Receiving Hemodialysis

  • Kamyar Kalantar-Zadeh
    Correspondence
    Individual reprints of this article are not available. Please address correspondence to Kamyar Kalantar-Zadeh, MD, MPH, PhD, Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1124 West Carson Street, C1-Annex, Torrance, CA 90509-2910
    Affiliations
    Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA

    Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA

    UCLA David Geffen School of Medicine, Los Angeles, CA

    Department of Family Health and/or Epidemiology, UCLA School of Public Health, Los Angeles, CA
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  • Elani Streja
    Affiliations
    Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA

    Department of Family Health and/or Epidemiology, UCLA School of Public Health, Los Angeles, CA
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  • Csaba P. Kovesdy
    Affiliations
    Salem Veterans Affairs Medical Center, Salem, VA
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  • Antigone Oreopoulos
    Affiliations
    University of Alberta, Edmonton, Alberta, Canada
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  • Nazanin Noori
    Affiliations
    Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
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  • Jennie Jing
    Affiliations
    Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
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  • Author Footnotes
    1 Drs Nissenson and Krishnan are employees of DaVita. Dr Kalantar-Zadeh is the medical director of the DaVita Harbor-UCLA/MFI Chronic Dialysis Center in Long Beach, CA.
    Allen R. Nissenson
    Footnotes
    1 Drs Nissenson and Krishnan are employees of DaVita. Dr Kalantar-Zadeh is the medical director of the DaVita Harbor-UCLA/MFI Chronic Dialysis Center in Long Beach, CA.
    Affiliations
    UCLA David Geffen School of Medicine, Los Angeles, CA

    Davita, El Segundo, CA
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  • Author Footnotes
    1 Drs Nissenson and Krishnan are employees of DaVita. Dr Kalantar-Zadeh is the medical director of the DaVita Harbor-UCLA/MFI Chronic Dialysis Center in Long Beach, CA.
    Mahesh Krishnan
    Footnotes
    1 Drs Nissenson and Krishnan are employees of DaVita. Dr Kalantar-Zadeh is the medical director of the DaVita Harbor-UCLA/MFI Chronic Dialysis Center in Long Beach, CA.
    Affiliations
    Davita, El Segundo, CA
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  • Joel D. Kopple
    Affiliations
    Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA

    UCLA David Geffen School of Medicine, Los Angeles, CA

    Department of Family Health and/or Epidemiology, UCLA School of Public Health, Los Angeles, CA
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  • Rajnish Mehrotra
    Affiliations
    Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA

    UCLA David Geffen School of Medicine, Los Angeles, CA
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  • Stefan D. Anker
    Affiliations
    Charité University School of Medicine, Berlin, Germany and Centre for Clinical and Basic Research, IRCCS San Raffaele, Rome, Italy
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  • Author Footnotes
    1 Drs Nissenson and Krishnan are employees of DaVita. Dr Kalantar-Zadeh is the medical director of the DaVita Harbor-UCLA/MFI Chronic Dialysis Center in Long Beach, CA.

      OBJECTIVE

      To determine whether dry weight gain accompanied by an increase in muscle mass is associated with a survival benefit in patients receiving maintenance hemodialysis (HD).

      PATIENTS AND METHODS

      In a nationally representative 5-year cohort of 121,762 patients receiving HD 3 times weekly from July 1, 2001, through June 30, 2006, we examined whether body mass index (BMI) (calculated using 3-month averaged post-HD dry weight) and 3-month averaged serum creatinine levels (a likely surrogate of muscle mass) and their changes over time were predictive of mortality risk.

      RESULTS

      In the cohort, higher BMI (up to 45) and higher serum creatinine concentration were incrementally and independently associated with greater survival, even after extensive multivariate adjustment for available surrogates of nutritional status and inflammation. Dry weight loss or gain over time exhibited a graded association with higher rates of mortality or survival, respectively, as did changes in serum creatinine level over time. Among the 50,831 patients who survived the first 6 months and who had available data for changes in weight and creatinine level, those who lost weight but had an increased serum creatinine level had a greater survival rate than those who gained weight but had a decreased creatinine level. These associations appeared consistent across different demographic groups of patients receiving HD.

      CONCLUSION

      In patients receiving long-term HD, larger body size with more muscle mass appears associated with a higher survival rate. A discordant muscle gain with weight loss over time may confer more survival benefit than weight gain while losing muscle. Controlled trials of muscle-gaining interventions in patients receiving HD are warranted.
      BMI (body mass index), CKD (chronic kidney disease), DEXA (dual-energy X-ray absorptiometry), HD (hemodialysis), Kt/V (dialysis dose), LBM (lean body mass), PEW (protein-energy wasting), UKM (urea kinetic modeling)
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