ASN Releases New Guidance on Obesity Management in Kidney Disease

Deidra Crews, MD, ScM

Credit: Hopkins Medicine

The American Society of Nephrology (ASN) has released its inaugural Kidney Health Guidance (KHG) on the Management of Obesity in Persons Living with Kidney Diseases, providing nephrologists and other kidney health professionals with an overview of the existing tools for obesity management and guidance on their implementation in clinical practice.¹

The guidance focuses on adults ≥ 18 years of age living with obesity and kidney disease and emphasizes the importance of individualized health and weight loss goals; the need for a multidisciplinary kidney care team to optimize outcomes; and the use of a combination of multiple interventions to achieve and sustain safe weight loss.¹

“Kidney health professionals confront the consequences of unhealthy weight for their patients on a daily basis.” Deidra Crews, MD, ScM, a professor of medicine at Johns Hopkins University School of Medicine and president of ASN, said in a press release.² “Obesity is not only a significant risk factor for kidney diseases, it can limit access to and effectiveness of kidney care. With growing interest in new advancements in obesity management, ASN’s Kidney Health Guidance integrates the latest scientific research with practical, multidisciplinary approaches to enhance the quality of life and health outcomes for persons with obesity and kidney diseases."

Lifestyle Modifications and Pharmacologic Options for Weight Loss

The guidance begins by emphasizing the importance of supporting patients by addressing health-related social needs; identifying and treating common mental health comorbidities; using shared decision-making when selecting treatment options; and acknowledging different forms of stigma patients may encounter. It then segues into the use of various lifestyle modifications for weight management, citing their safety, noninvasiveness, and sustainability for patients.¹

However, the effectiveness of lifestyle changes can vary significantly due to factors such as age, sex, comorbidities, and psychosocial circumstances, underscoring the need for individualized interventions. Additionally, ongoing support and follow-up are important to increase the likelihood of success with lifestyle modifications.¹

The guidance also describes various pharmacologic options for weight loss, including incretin mimetics (semaglutide, liraglutide, tirzepatide, and dulaglutide); opioid receptor antagonists (naltrexone/bupropion); antiobesity medications (orlistat); and stimulants (phentermine/topiramate). It additionally mentions metformin and sodium-glucose cotransporter-2 inhibitors, although neither of these medications are currently US Food and Drug Administration-approved for this indication.¹

Metabolic/Bariatric Surgery

Despite the known durability and effectiveness of metabolic/bariatric surgery for the treatment of obesity, the investigators pointed to a lack of randomized trials including individuals with kidney diseases but still recognized kidney diseases should not be considered a contraindication for these procedures. Acknowledging safety concerns in patients with more advanced kidney diseases, the guidance emphasizes the need for selection and optimization of patients by a multidisciplinary team to mitigate these risks.¹

Specifically, investigators identified patients with severe or uncontrolled psychiatric disorders, eating disorders, or active substance use disorders as poor candidates for metabolic/bariatric surgery, additionally asserting that special considerations should be given to comorbid conditions that increase operative risk, including established cardiovascular disease, uncontrolled hypertension, diabetes, and obstructive sleep apnea.¹

The guidance cites evidence suggesting the benefit of bariatric procedures for overall kidney health and reduced risk of kidney disease progression, emphasizing the need to evaluate its effect on kidney function and health by monitoring the serum creatinine level and UPCR/urine albumin-creatinine ratio over time, especially during the early postoperative period. Over the longer term, investigators noted patients should continue to be assessed for general and kidney-specific risks.¹

Clinician Considerations for Implementation

For the successful implementation of the present KHG, investigators pointed to the importance of considering potential barriers and facilitators to addressing obesity as an important adverse health risk for patients with kidney disease. Although knowledge of obesity management is important, they note that clinicians must also be willing to prescribe lifestyle modifications, and weight loss medications, and/or refer patients to metabolic and bariatric surgery centers while also considering local insurance coverage, cost, and patient support for initiation and maintenance of interventions.¹

Knowledge Gaps, Future Directions

Evidence for the appropriate management of obesity in patients with kidney diseases has vastly expanded, but gaps in knowledge and implementation remain and require attention. Although a team-based approach to weight management is preferred, it is often not feasible due to limited clinical resources and a lack of policies, payment models, and insurance coverage to encourage and prioritize comprehensive treatment.¹

Additionally, despite current coverage of medical nutrition therapy by most insurance providers, registered dietitians are rarely used in the setting of kidney diseases. Collaboration with obesity medicine specialists and/or bariatric/metabolic surgeons may also be beneficial. Investigators also outline several policy, education, and quality improvement priorities for future consideration.¹

References

1. ^{Ikizler TA, Kramer H, Beddhu S, et al. ASN Kidney Health Guidance on the Management of Obesity in Persons Living with Kidney Diseases. Journal of the American Society of Nephrology. doi:10.1681/ASN.0000000512}
2. ^{American Society of Nephrology. American Society of Nephrology Releases Kidney Health Guidance on the Management of Obesity in Persons with Kidney Diseases. NewsWise. September 18, 2024. Accessed September 18, 2024. https://www.newswise.com/articles/american-society-of-nephrology-releases-kidney-health-guidance-on-the-management-of-obesity-in-persons-with-kidney-diseases}