ROCKVILLE, Md.—A step towards improved collaboration between the nephrology and obesity medicine communities in managing persons with concurrent obesity and chronic kidney disease (CKD) has been initiated thanks to a workshop sponsored by the National Kidney Foundation (NKF) and The Obesity Society (TOS). The results of that workshop are described in a special report published in Obesity, The Obesity Society’s (TOS) flagship journal.
This multi-specialty, international, scientific workshop was held in 2021 by NKF and TOS to advance the understanding and management of obesity in adults with CKD. Attendees included top experts in the areas of kidney disease, obesity medicine, endocrinology, diabetes, bariatric/metabolic surgery, endoscopy, transplant surgery, nutrition, as well as patients with obesity and CKD.
“Obesity is arguably the most important risk factor in the 21st century for the development and progression of CKD. It is also a major cause in people with pre-existing CKD of worse health outcomes and lower quality of life. The rationale for the workshop was for nephrologists to learn more about obesity from physicians who specialize in treating obesity, and for obesity experts to better understand how kidney disease could affect people with obesity. The workshop offered the opportunity for clinicians and scientists from a variety of fields to work together and begin to identify challenges and opportunities in improving care for patients with obesity and CKD,” said Allon N. Friedman, MD, Division of Nephrology, School of Medicine, Indiana University in Indianapolis. Friedman is the corresponding author of the report.
Experts note that It is becoming increasingly clear that obesity, which affects more than 650 million people globally, is not only highly prevalent in persons with CKD but is also a prime inducer of CKD and other kidney-related and unrelated adverse outcomes. Despite the unabated growth in obesity among adults and children, the utility of managing co-existing obesity as a strategy to improve health outcomes in persons with CKD is just beginning to be recognized and pursued in earnest.
According to the report’s authors, strategies for engaging nephrologists and obesity medicine experts are more likely to be successful if they bridge common ground. An initial step to facilitating engagement would be to recognize that, similar to treating CKD, obesity management includes recognition of obesity as a chronic disease with a specific pathophysiology that can be targeted utilizing available pharmacologic and bariatric surgery treatments. The benefits of weight management extend beyond just total pounds lost to include improvements in metabolic, blood pressure and cardiac health that help mitigate progression of kidney damage.
Nephrologists and obesity medicine experts must also appreciate that different strategies may be required depending on the stage of CKD and the severity of obesity. For example, in patients with CKD stages 3-4, the goal of obesity management could be to slow down or perhaps even reverse existing disease, whereas a more appropriate focus in persons with CKD stage 5 might be to facilitate successful kidney transplantation.
Another suggestion for collaboration is in the expanded use of dietitians, clinical pharmacists, nurse educators and advanced practice providers as clinical extenders. These affiliated providers could be trained to help promote effective obesity care by educating patients and referring them when indicated to obesity medicine specialists, multi-disciplinary obesity treatment centers or other qualified practitioners. This suggestion stems from the challenge that work required by nephrologists to manage obesity is often viewed as too time consuming or ineffective, according to the report’s authors. Nephrologists may also have limited knowledge on the effects of obesity on the kidney and how to best manage it.
The two organizations also developed strategies to improve patient engagement. Patients with CKD and obesity are generally ill-informed about the potential contribution of obesity to their kidney disease and the kidney-related benefits of effective obesity management. Improving self-recognition of CKD, particularly in earlier CKD stages, is a necessary initial step to correcting this problem, the study’s authors noted. Obesity as a risk factor for CKD progression is rarely raised by nephrologists to their patients. Likewise, obesity specialists, who are more likely than nephrologists to see patients in earlier stages of CKD when weight management could have disproportionate long-term benefits on kidney health, may not be aware of the degree to which obesity is linked to CKD and related medical problems. “Changing these patterns will require concerted and long-term efforts to educate patients and clinicians alike, “ said Jonathan Q. Purnell, MD, Oregon Health & Science University, Portland, Ore., a co-author of the report.
Patients who participated in the workshop that generated the report felt that information on the biological control of appetite (i.e., hunger, satiety) and body weight would be an important aid in helping them understand that obesity in most instances cannot be optimally controlled merely by adjusting the type and amount of food consumed (lifestyle alone). Expanding support groups for patients undergoing medical or surgical treatment of obesity to include persons with CKD could be a helpful tool, according to patient participants.
A final suggestion to increase patient engagement is to have practitioners recognize the social stigma of obesity and make special efforts to use non-stigmatizing and non-prejudicial language and actions when addressing obesity with their patients. The report’s authors noted that care also needs to consider widely different cultural, gender and societal norms about body size, weight, and obesity and these issues all need to be factored into how best to communicate with and treat individual patients.
Research discussions focused on defining the best clinical end points for future clinical trials. End points endorsed by workshop participants included the impact of obesity treatment on body weight and metabolic parameters such as blood pressure, sleep apnea, and markers of glycemic control; development of CKD in at-risk individuals; progression to kidney failure; major cardiovascular events, hospitalization, and mortality; and changes in quality-of-life measures.
Several additional clinical outcomes specifically relevant to post-transplant patients included studying weight gain after kidney transplantation and the effects of obesity and anti-obesity therapies on graft function and survival. The report’s authors felt that clinical trial end points should address questions that are relevant to a wide range of stakeholders, including patients, clinicians, payors and healthcare systems. They added that flexible study designs, including adaptive and platform trials, allow incorporation and evaluation of emerging treatment options to keep the results as clinically relevant as possible.
The report’s authors conclude that wide dissemination of study results will be critical to capturing the greatest benefit from this research investment for patients, providers and payors alike.
Other authors of the study include Philip R. Schauer, Pennington Biomedical Research Institute, Louisiana State University, Baton Rouge; Srinivasan Beddhu,, Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City; Holly Kramer,, Department of Public Health Sciences and Medicine, Loyola University Chicago, Maywood, Ill.; Carel W. le Roux, Diabetes Complications Research Centre, Conway Institute, University College Dublin, Ireland; Duane Sunwold, Culinary Program, Spokane Community College, Spokane, Wash.; Katherine R. Tuttle, Providence Health Care and School of Medicine, University of Washington, Spokane and Seattle, Wash.; Ania M. Jastreboff, Endocrinology & Metabolism, Department of Medicine and Pediatric Endocrinology, Department of Pediatrics, School of Medicine, Yale University, New Haven, Conn.; and Lee M. Kaplan, Obesity, Metabolism and Nutrition Institute and Gastroenterology Division, Massachusetts General Hospital, and Medical School, Harvard University, Boston, Mass.
The study, titled "Obstacles and Opportunities in Managing Coexisting Obesity and CKD: Report of a Scientific Workshop Cosponsored by the National Kidney Foundation and The Obesity Society," will be published in Obesity.
Friedman serves as a scientific advisory board member or a consultant for GI Dynamics, Gila Therapeutics, AstraZeneca, and Goldfinch Bio, and has ownership of Eli Lilly stock. Schauer has consultancy agreements with GI Dynamics, Keyron, Persona, Mediflix; has an ownership interest in SE Healthcare LLC and Mediflix; has received research funding from Ethicon, Medtronic, Pacira, and Persona; has received honoraria from Ethicon, Medtronic, BD Surgical, and Gore; and is serving as scientific advisor for or a member of SE Healthcare Board of Directors, GI Dynamics, Keyron, Persona, and Mediflix. Beddhu has received research support from Boehringer Ingelheim, Novo Nordisk, and Bayer, has received royalties from UpToDate, and has received grant funding from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK; R01DK11821 and R01DK128640), National Institute on Aging (R01AG074592), and Veterans Affairs (ORH-14398). Kramer has served as a consultant to Bayer Pharmaceuticals and AstraZeneca. Le Roux has received grants from the Irish Research Council, Science Foundation Ireland, Anabio, and the Health Research Board; serves on the advisory boards of Novo Nordisk, Herbalife, GI Dynamics, Eli Lilly, Johnson & Johnson, Sanofi Aventis, AstraZeneca, Janssen, Bristol-Myers Squibb, Glia, and Boehringer Ingelheim; is a member of the Irish Society for Nutrition and Metabolism outside the area of work commented on here; has served in an unremunerated capacity as chief medical officer and director of the Medical Device Division of Keyron since January 2011; received gifted stock holdings from Keyron in September 2021, which he divested in full in that same month; and provides ongoing scientific advice to Keyron for no remuneration. Purnell serves as an advisory board member for Novo Nordisk, Boehringer Ingelheim, and Luciole Pharmaceuticals. Tuttle has received research and other support from Eli Lilly, Boehringer Ingelheim, Gilead, AstraZeneca, Goldfinch Bio, Novo Nordisk, Bayer, and Travere; and research support from seven National Institutes of Health grants across institutes (NIDDK; National Center for Advancing Translational Sciences; National Institute on Minority Health and Health Disparities; National Heart, Lung, and Blood Institute) and a Centers for Disease Control and Prevention contract. Jastreboff serves as a scientific advisory board member or consultant for Novo Nordisk, Eli Lilly, Boehringer Ingelheim, Intellihealth, Scholar Rock, and Pfizer; and has received research support from the American Diabetes Association, Eli Lilly, Novo Nordisk, and NIDDK (R01DK099039 and R01DK117651). Kaplan serves as a scientific and medical consultant to Amgen, Gelesis, Gilead, Johnson & Johnson, Eli Lilly, Novo Nordisk, Pfizer, and Rhythm Pharmaceuticals. The remaining authors declare no relevant financial interests.
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The Obesity Society (TOS) is the leading organization of scientists and health professionals devoted to understanding and reversing the epidemic of obesity and its adverse health, economic and societal effects. Combining the perspective of researchers, clinicians, policymakers and patients, TOS promotes innovative research, education and evidence-based clinical care to improve the health and well-being of all people with obesity. For more information, visit www.obesity.org.