Fat discrimination in kidney transplants

In related news, the New York Times reports today on a study showing the higher a person’s body mass index, the less likely they are to receive a kidney transplant.

The study in question – posted online on Dec. 19 in The Journal of the American Society of Nephrology – included more than 130,000 patients registered for kidney transplantation from 1995 to 2006, and followed each as they waited for available organs. Led by lead author Dr. Dorry L. Segev, an assistant professor of medicine at Johns Hopkins assistant professor of medicine at Johns Hopkins, the team of researchers found:

After controlling for sex, ethnicity, insurance status and other variables, they found that compared with those of normal weight, the obese people were 8 percent less likely to receive a transplant, the severely obese 28 percent less likely and the morbidly obese — those with a B.M.I. over 40 — 44 percent less likely.

Article author Nicholas Bakalar suggests financial disincentives might be a play, citing that it is “known that obese patients are likely to have more complications and a worse outcome” (although he doesn’t offer up any statistics or numbers to justify this). He goes on to point out, however, “the practice is to assign organs only on the basis of how long a patient has been waiting, so such considerations should not enter into the decision.”

“There is a major organ shortage, and deciding how to allocate kidneys is difficult,” said Segev. “If the transplant community decides that patients with higher risks should have lower priority, this is something that should be formalized as public policy.”

Our commentary:

If you feel you have been denied placement on an organ transplant list or have been denied an available organ because of your weight, here are a few recourses available to you:

Get another opinion: If you feel your doctor is in error or is dispensing medical advice under bias, see another specialist.

Put on the pressure: Send written requests to your doctor, the hospital, the hospital’s administrators, its Board of Directors, the state medical board, your state and national representatives. In your letter, include detail on what was said to you, by whom and on what date. If you have written materials, include a copy. Ask the facility to provide their procedures and requirements on organ donation.

Find allies: Ask your doctor or your legislator to write a letter on your behalf. Contact your local patients rights association. Marshal your friends and family on a letter-writing campaign. You are not alone and the doctor or hospital needs to see this.

Research your condition and all known treatments for it: Not only will you understand the medical talk, but you will be more armed to recognize and combat bias in treatment plans offered.

Use the law – discrimination is illegal: Hire an attorney, or if you cannot afford one, many legal referral services offer information on how to secure free legal services or can give a referral for a non-profit association offering free legal services. Your local bar association may also provide information on free lawyer services. Don’t stop there: Contact your state medical board and even the National Department of Justice.

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  1. My partner is a renal patient on dialysis and on the waiting list for a new kidney. He’s always been a bit chubby, but the type of dialysis he does has caused him to gain a substantial amount weight as well (‘dry weight’, that is, which is one’s weight after excess fluid has been removed via dialysis ). So I have a vested interest in this.

    Medical discrimination against fat people definitely exists. And it could explain why more low BMI people got transplants. But I find myself wondering, if in this instance, there are factors other than discrimination at play as well. (Egads! What am I saying?)

    The abstract to the study states:

    Although matching an available organ with an appropriate recipient requires clinical judgment, which could not be fully captured in this study, the observed differences are dramatic and warrant further studies to understand this effect better and to design a system that is less susceptible to unintended bias.

    Clinical judgement could definitely be a factor, if you ask me.

    Firstly, from what I have seen in dialysis clinics, more weight seems to be an indicator of better residual kidney function (relatively speaking). i.e. patients not doing well on dialysis tend to be very underweight and sickly.

    Secondly, there are a couple of different types of dialysis. Hemodialysis (the traditional kind that filters the blood) and Peritoneal Dialysis (in which fluid goes into the peritoneal cavity and filters by osmosis). In the second kind, PD, the fluid contains dextrose, a kind of sugar, which draws the impurities out. PD patients often gain weight on the treatment (all that sugar) but I also understand that PD patients are likely to have better/more stable residual renal function compared to patients on Hemo.

    Obviously patients who are more critically ill and have poorer residual renal function would receive transplants first, subject to a suitable organ becoming available. But if you are on PD and/or have comparitively ‘good’ residual renal function (good for a kidney patient, I mean) your specialist would probably be less likely to prioritise you for transplant. And PD patients tend to be heavier.

    So I’m speculating that maybe, just maybe, the results of the study are skewed due to people with better dialysis outcomes having higher BMIs?

    Sigh. Maybe the above reasoning is just denial/wishful thinking, but I hope not.

  2. Oh. In case you hadn’t realised, my comment above is based solely on my decidedly non-clinical and non-scientific observations and John’s experiences. Just in case you wondered.

  3. Fatadelic, several of my relatives have been on dialysis (and I probably will at some stage too) and had transplants and that’s my understanding of how it works, at least here in Australia. Of the transplantees, one was slim and the other was a bit fatter (a size 16-18). The fatter one coped with both dialysis and transplant better, but I guess these things can vary quite a lot by individual.

    The hardest thing to deal with after a transplant is the side effects of the anti-rejection drugs, as they obviously weaken your immune system and can cause osteoporosis. Higher weight does help protect against bone loss, and provides extra reserves if you’re struck with an infection (which can be quite serious if you’ve got a weak immune system).

    I think one ‘justification’ I read from some transplant doctor in one of those articles was that the wound can heal more slowly because fat is less vascular, but frankly most people up for a transplant would be willing to take the risks of that, and there are simple precautions that can be taken to minimise risk.

    I really hate all the fuss that’s made over OMG fat people who need surgery, like it’s the end of the world if a surgeon has to see a fat roll. Many doctors just roll up their sleeves and get on with it, are educated on the different care a very large person may need, and actually take care of all of their patients properly. I find the admonishing, hand-wringing ones all a bit precious. And just plain fat-phobic.

  4. nonegiven

     /  January 13, 2008

    I don’t think I would like to be operated on by a surgeon who thought I would have a poor outcome. I would rather find another surgeon. Self-fulfilling prophecy and all that.

  5. According to a report form the Medical College of Georgia:

    “There was, however, no significant correlation between obesity and graft survival for either cadaver or living donor transplants. Although obese patients have an increased risk of delayed graft function with cadaver donor transplantation, obesity has no discernible impact on either immunologic or overall graft survival with cadaver or living donor transplantation. The impact of moderate obesity on transplant outcome is modest and should not prevent these patients from receiving a transplant.”1

    Many studies report no effect of BMI on graft survival or major outcomes, but choose to emphasize short-term negatives such as the higher risk of wound infection in fat patients2.

    Although there are reports to the contrary, the majority of studies indicate that obesity does not reduce the success of kidney transplant3-8.

    On the other hand, low BMI is a very serious risk for kidney transplantation9. Remarkably, low BMI is never given as a reason for withholding a kidney.
    1. Drafts HH, Anjum MR, Wynn JJ, Mulloy LL, Bowley JN & Humphries AL. The impact of pre-transplant obesity on renal transplant outcomes. Clin Transplant. 1997;11:493-496.

    2. Espejo B, Torres A, Valentin M, Bueno B, Andres A, Praga M & Morales JM. Obesity favors surgical and infectious complications after renal transplantation. Transplant Proc. 2003;35:1762-1763.

    3. Howard RJ, Thai VB, Patton PR, Hemming AW, Reed AI, Van der Werf WJ, Fujita S, Karlix JL & Scornik JC. Obesity does not portend a bad outcome for kidney transplant recipients. Transplantation. 2002;73:53-55.

    4. Johnson DW, Isbel NM, Brown AM, Kay TD, Franzen K, Hawley CM, Campbell SB, Wall D, Griffin A & Nicol DL. The effect of obesity on renal transplant outcomes. Transplantation. 2002;74:675-681.

    5. Marks WH, Florence LS, Chapman PH, Precht AF & Perkinson DT. Morbid obesity is not a contraindication to kidney transplantation. Am J Surg. 2004;187:635-638.

    6. Massarweh NN, Clayton JL, Mangum CA, Florman SS & Slakey DP. High body mass index and short- and long-term renal allograft survival in adults. Transplantation. 2005;80:1430-1434.

    7. Singh D, Lawen J & Alkhudair W. Does pretransplant obesity affect the outcome in kidney transplant recipients? Transplant Proc. 2005;37:717-720.

    8. Yamamoto S, Hanley E, Hahn AB, Isenberg A, Singh TP, Cohen D & Conti DJ. The impact of obesity in renal transplantation: an analysis of paired cadaver kidneys. Clin Transplant. 2002;16:252-256.

    9. Sezer S, Ozdemir FN, Elsurer R, Uyar M, Arat Z & Haberal M. Pretransplantation and posttransplantation body mass indices and prognosis in renal transplant recipients: low versus normal. Transplant Proc. 2005;37:2994-2997.


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