Stanicki B, Puntiel DA, Peticca B, Egan N, Prudencio TM, Robinson SG, Karhadkar SS. Investigating the controversial link between pediatric obesity and graft survival in kidney transplantation. World J Nephrol 2025; 14(2): 101961 [DOI: 10.5527/wjn.v14.i2.101961]
Corresponding Author of This Article
Sunil S Karhadkar, FACS, MD, Assistant Professor, Department of Surgery, Temple University Hospital, 3401 N Broad Street, Philadelphia, PA 19140, United States. sunil.karhadkar@tuhs.temple.edu
Research Domain of This Article
Transplantation
Article-Type of This Article
Retrospective Cohort Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Nephrol. Jun 25, 2025; 14(2): 101961 Published online Jun 25, 2025. doi: 10.5527/wjn.v14.i2.101961
Investigating the controversial link between pediatric obesity and graft survival in kidney transplantation
Brooke Stanicki, Dante A Puntiel, Benjamin Peticca, Nicolas Egan, Tomas M Prudencio, Samuel G Robinson, Sunil S Karhadkar
Brooke Stanicki, Dante A Puntiel, Benjamin Peticca, Nicolas Egan, Tomas M Prudencio, Samuel G Robinson, Sunil S Karhadkar, Department of Surgery, Temple University Hospital, Philadelphia, PA 19140, United States
Author contributions: Stanicki B and Puntiel DA led the study design, participated in data analysis, performed statistical analysis in conjunction with the Temple University Center for Biostatistics and Epidemiology and drafted and finalized the manuscript; Peticca B participated in design and oversight of the study and assisted with the data analysis; Egan Nicolas, Prudencio TM, and Robinson SG participated in data analysis and drafting the manuscript; Karhadkar SS participated in oversight of the study, drafted, and finalized the manuscript; all authors read and approved the final manuscript.
Institutional review board statement: This study does not involve human subjects as defined by DHHS or FDA regulations. Consequently, there is no IRB. A Declaration of IRB exemption has been submitted.
Informed consent statement: This study does not involve human subjects as defined by DHHS or FDA regulations. Consequently, there are no informed consent forms.
Conflict-of-interest statement: None of the authors have any conflicts to disclose.
STROBE statement: The authors have read the STROBE statement – checklist of items, and the manuscript was prepared and revised according to the STROBE statement – checklist of items.
Data sharing statement: No additional data are available.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Sunil S Karhadkar, FACS, MD, Assistant Professor, Department of Surgery, Temple University Hospital, 3401 N Broad Street, Philadelphia, PA 19140, United States. sunil.karhadkar@tuhs.temple.edu
Received: October 8, 2024 Revised: January 2, 2025 Accepted: February 8, 2025 Published online: June 25, 2025 Processing time: 188 Days and 15.8 Hours
Abstract
BACKGROUND
Childhood obesity is a significant public health concern, particularly amongst children with chronic kidney disease requiring kidney transplant (KT). Obesity, defined as a body mass index (BMI) of 30 kg/m² or greater, is prevalent in this population and is associated with disease progression. While BMI influences adult KT eligibility, its impact on pediatric transplant outcomes remains unclear. This study investigates the effect of BMI on graft survival and patient outcomes, addressing gaps in the literature and examining disparities across BMI classifications.
AIM
To assess the impact of BMI classifications on graft and patient survival following KT.
METHODS
A retrospective cohort study analyzed 23081 pediatric transplant recipients from the Standard Transplant Analysis and Research database (1987-2022). Patients were grouped into six BMI categories: Underweight, healthy weight, overweight, and Class 1, 2, and 3 obesity. Data were analyzed using one-way way analysis of variance, Kruskal-Wallis tests, Chi-squared tests, Kaplan-Meier survival analysis with log-rank tests, and Cox proportional hazard regressions. Statistical significance was set at P < 0.05.
RESULTS
Class 3 obese recipients had lower 1-year graft survival (88.7%) compared to healthy-weight recipients (93.1%, P = 0.012). Underweight recipients had lower 10-year patient survival (81.3%, P < 0.05) than healthy-weight recipients. Class 2 and 3 obese recipients had the lowest 5-year graft survival (67.8% and 68.3%, P = 0.013) and Class 2 obesity had the lowest 10-year graft survival (40.7%). Cox regression identified increases in BMI category as an independent predictor of graft failure [hazard ratio (HR) = 1.091, P < 0.001] and mortality (HR = 1.079, P = 0.008). Obese patients experienced longer cold ischemia times (11.6 and 13.1 hours vs 10.2 hours, P < 0.001). Class 3 obesity had the highest proportion of Black recipients (26.2% vs 17.9%, P < 0.001).
CONCLUSION
Severe obesity and underweight status are associated with poorer long-term outcomes in pediatric KT recipients, emphasizing the need for nuanced transplant eligibility criteria addressing obesity-related risks and socioeconomic disparities.
Core Tip: This study investigates the relationship between pediatric obesity and kidney transplant outcomes, addressing a gap in research by analyzing graft survival across body mass index categories. While short-term outcomes for overweight and Class 1 obese pediatric recipients are comparable to healthy-weight peers, Class 2 and 3 obese patients experience significantly reduced long-term graft survival. Underweight recipients also exhibit poorer outcomes, highlighting the dual risks of obesity and malnutrition. The findings highlight the need for individualized transplant criteria and targeted interventions for severely obese children, emphasizing the role of socioeconomic and racial disparities in pediatric kidney transplantation.
