Association between BMI changes and mortality risk in children with end-stage renal disease

  • Matthew J. RobertsEmail author
  • Mark M. Mitsnefes
  • Charles E. McCulloch
  • Larry A. Greenbaum
  • Barbara A. Grimes
  • Elaine Ku
Original Article



Few studies have examined how changes in BMI [body mass index] over time associate with risk of adverse outcomes in children receiving renal replacement therapy [RRT]. The objective of this study was to examine the association between annualized changes in BMI and the risk of death in children treated with RRT.


We performed a retrospective cohort study of 1182 pediatric dialysis and transplant patients in the Pediatric Growth and Development Special Study of the United States Renal Data System. Quintiles of annualized change in BMI z-score (with cutoffs of − 0.50, − 0.13, 0.09, 0.57) were used as the primary predictor, with the middle quintile (− 0.13 to 0.09) serving as the reference category. Cox models were used to examine the association between exposure and death, with time of analysis starting from the second BMI measurement.


Median follow-up time to death or censoring was 6 years. Median age was 14.6 years, and 61% of children had a functional graft at cohort entry. There was a U-shaped association between BMI change and mortality risk: a large decline in annualized BMI z-score change (> − 0.50) was associated with an increased risk of death (adjusted hazard ratio [aHR] 1.54 (95% CI 1.17–2.03), p = 0.002). A large increase in annualized BMI z-score change (> 0.57) was also associated with an increased risk of death (aHR 1.44 (95% CI 1.07–1.92), p = 0.02). No interaction was noted between annualized BMI change and initial treatment modality (dialysis or transplant, p = 0.15).


Maintenance of a stable BMI in pediatric patients receiving RRT may be associated with improved survival.


Body mass index Malnutrition ESRD Pediatrics Obesity 



The interpretation and reporting of the data presented here are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the US government.

Author contributions

Study design: EK; data acquisition and analysis: BG, EK, MR; Data interpretation: all authors; supervision and mentorship: EK. All authors contributed intellectual content during the writing or revision of the manuscript and accept accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved.


Dr. Ku was funded by the National Kidney Foundation Satellite Dialysis Young Investigator.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

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  1. 1.
    Sabatino A, Regolisti G, Karupaiah T, Sahathevan S, Sadu Singh BK, Khor BH, Salhab N, Karavetian M, Cupisti A, Fiaccadori E (2017) Protein-energy wasting and nutritional supplementation in patients with end-stage renal disease on hemodialysis. Clin Nutr 36(3):663–671. CrossRefGoogle Scholar
  2. 2.
    Kopple JD, Greene T, Chumlea WC, Hollinger D, Maroni BJ, Merrill D, Scherch LK, Schulman G, Wang SR, Zimmer GS (2000) Relationship between nutritional status and the glomerular filtration rate: results from the MDRD study. Kidney Int 57(4):1688–1703. CrossRefGoogle Scholar
  3. 3.
    Chazot C (2009) Why are chronic kidney disease patients anorexic and what can be done about it? Semin Nephrol 29(1):15–23. CrossRefGoogle Scholar
  4. 4.
    Johansen KL, Young B, Kaysen GA, Chertow GM (2004) Association of body size with outcomes among patients beginning dialysis. Am J Clin Nutr 80(2):324–332. CrossRefGoogle Scholar
  5. 5.
    Dalrymple LS, Katz R, Kestenbaum B, Shlipak MG, Sarnak MJ, Stehman-Breen C, Seliger S, Siscovick D, Newman AB, Fried L (2011) Chronic kidney disease and the risk of end-stage renal disease versus death. J Gen Intern Med 26(4):379–385. CrossRefGoogle Scholar
  6. 6.
    Ogden CL, Carroll MD, Flegal MK (2003) Epidemiologic trends in overweight and obesity. Endocrinol Metab Clin N Am 32(4):741–760. CrossRefGoogle Scholar
  7. 7.
    Krmar RT, Barany P (2013) Obesity in children with end-stage renal disease. Nat Rev Nephrol 9(12):707–708. CrossRefGoogle Scholar
  8. 8.
    Park J, Ahmadi SF, Streja E, Molnar MZ, Flegal KM, Gillen D, Kovesdy CP, Kalantar-Zadeh K (2014) Obesity paradox in end-stage kidney disease patients. Prog Cardiovasc Dis 56(4):415–425. CrossRefGoogle Scholar
  9. 9.
    Kalantar-Zadeh K, Rhee CM, Chou J, Ahmadi SF, Park J, Chen JL, Amin AN (2017) The obesity paradox in kidney disease: how to reconcile it with obesity management. Kidney Int Rep 2(2):271–281. CrossRefGoogle Scholar
  10. 10.
    Wong CS, Gipson DS, Gillen DL, Emerson S, Koepsell T, Sherrard DJ, Watkins SL, Stehman-Breen C (2000) Anthropometric measures and risk of death in children with end-stage renal disease. Am J Kidney Dis 36:811–819. CrossRefGoogle Scholar
  11. 11.
    Ku E, Glidden V, Hsu CY, Portale AA, Grimes B, Johansen KL (2016) Association of body mass index with patient-centered outcomes in children with ESRD. J Am Soc Nephrol 27(2):551–558. CrossRefGoogle Scholar
  12. 12.
    US Renal Data System, USRDS 1994 Annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States. The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases: Bethesda, MD. June 1994Google Scholar
  13. 13.
    Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, Mei Z, Wei R, Curtin LR, Roche AF, Johnson CL (2002) 2000 CDC growth charts for the United States: methods and development. National Center for Health Statistics. Vital Health Stat 11(246):1–190Google Scholar
  14. 14.
    Chang SH, McDonald SP (2008) Post-kidney transplant weight change as marker of poor survival outcomes. Transplantation 85(10):1443–1448. CrossRefGoogle Scholar
  15. 15.
    Chang TI, Ngo V, Streja E, Chou JA, Tortorici AR, Kim TH, Kim TW, Soohoo M, Gillen D, Rhee CM, Kovesdy CP, Kalantar-Zadeh K (2017) Association of body weight changes with mortality in incident hemodialysis patients. Nephrol Dial Transplant 32:1549–1558. CrossRefGoogle Scholar
  16. 16.
    Hwang JH, Ryu J, An JN, Kim CT, Kim H, Yang J, Ha J, Chae DW, Ahn C, Jung IM, Oh YK, Lim CS, Han DJ, Park SK, Kim YS, Kim YH, Lee JP (2015) Pretransplant malnutrition, inflammation, and atherosclerosis affect cardiovascular outcomes after kidney transplantation. BMC Nephrol 16:109. CrossRefGoogle Scholar
  17. 17.
    Stenvinkel P, Gillespie IA, Tunks J, Addison J, Kronenberg F, Drueke TB, Marcelli D, Schernthaner G, Eckardt KU, Floege J, Froissart M, Anker SD (2016) Inflammation modifies the paradoxical association between body mass index and mortality in hemodialysis patients. J Am Soc Nephrol 27(5):1479–1486. CrossRefGoogle Scholar
  18. 18.
    McCausland FR, Claggett B, Burdmann EA, Eckardt KU, Kewalramani R, Levey AS, McMurray JJ, Parfrey P, Remuzzi G, Singh AK, Solomon SD, Toto RD, Pfeffer MA (2016) C-reactive protein and risk of ESRD: results FROM the trial to reduce cardiovascular events with aranesp therapy (TREAT). Am J Kidney Dis 68(6):873–881. CrossRefGoogle Scholar
  19. 19.
    Zoccali C, Mallamaci F, Benedetto FA, Tripepi G, Parlongo S, Cataliotti A, Cutrupi S, Giacone G, Bellanuova I, Cottini E, Malatino LS (2001) Cardiac natriuretic peptides are related to left ventricular mass and function and predict mortality in dialysis patients. J Am Soc Nephrol 12(7):1508–1515Google Scholar
  20. 20.
    Foster BJ, Martz K, Gowrishankar M, Stablein D, Al-Uzri A (2010) Weight and height changes and factors associated with greater weight and height gains after pediatric renal transplantation: a NAPRTCS study. Transplantation 89:1103–1112. CrossRefGoogle Scholar
  21. 21.
    Franks PW, Hanson RL, Knowler WC, Sievers ML (2010) Childhood obesity, other cardiovascular risk factors, and premature death. N Engl J Med 362:485–493. CrossRefGoogle Scholar
  22. 22.
    Twig G, Yaniv G, Levine H, Leiba A (2016) Body-mass index in 2.3 million adolescents and cardiovascular death in adulthood. N Engl J Med 374:2430–2440. CrossRefGoogle Scholar
  23. 23.
    Fulop T, Pathak MB, Schmidt DW, Lengvarszky Z, Juncos JP, Lebrun CJ, Brar H, Juncos LA (2010) Volume-related weight gain and subsequent mortality in acute renal failure patients treated with continuous renal replacement therapy. ASAIO J 56(4):333–337. Google Scholar
  24. 24.
    Kalantar-Zadeh K, Streja E, Kovesdy CP, Oreopoulos A, Noori N, Jing J, Nissenson AR, Krishnan M, Kopple JD, Mehrotra R, Anker SD (2010) The obesity paradox and mortality associated with surrogates of body size and muscle mass in patients receiving hemodialysis. Mayo Clin Proc 85(11):991–1001. CrossRefGoogle Scholar
  25. 25.
    Hricik DE, Almawi WY, Strom TB (1994) Trends in the use of glucocorticoids in renal transplantation. Transplantation 57(7):979–989CrossRefGoogle Scholar
  26. 26.
    Ferris M, Gibson K, Plattner B, Gipson DS, Kotanko P, Marcelli D, Marelli C, Etter M, Carioni P, von Gersdorff G, Xu X, Kooman JP, Xiao Q, van der Sande FM, Power A, Picoits-Filho R, Sylvestre L, Westreich K, Usvyat L (2016) Hemodialysis outcomes in a global sample of children and young adult hemodialysis patients: the PICCOLO MONDA cohort. Clin Kidney J 9(2):295–302. CrossRefGoogle Scholar

Copyright information

© IPNA 2019

Authors and Affiliations

  • Matthew J. Roberts
    • 1
    Email author
  • Mark M. Mitsnefes
    • 2
  • Charles E. McCulloch
    • 3
  • Larry A. Greenbaum
    • 4
  • Barbara A. Grimes
    • 3
  • Elaine Ku
    • 5
    • 6
  1. 1.School of MedicineUniversity of California San FranciscoSan FranciscoUSA
  2. 2.Department of Pediatrics, Division of Pediatric NephrologyCincinnati Children’s HospitalCincinnatiUSA
  3. 3.Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoUSA
  4. 4.Division of Pediatric Nephrology, Department of PediatricsEmory University and Children’s Healthcare of AtlantaAtlantaUSA
  5. 5.Department of Pediatrics, Division of Pediatric NephrologyUniversity of California San FranciscoSan FranciscoUSA
  6. 6.Department of Medicine, Division of NephrologyUniversity of California San FranciscoSan FranciscoUSA

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