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The challenge of weight loss in obese people in dialysis treatment

The challenge of weight loss in obese people in dialysis treatment. Case report.

Made in collaboration with the US nephrology hospital of Orbassano (TO) and the University of Turin.

Published on "Giornale Italiano di Nefrologia" (Nephrology Italian Magazine).

Obesity is a growing problem in the population and not sparing dialysis patients who find obtaining and managing a substantial weight loss particularly difficult. However, several centers require a BMI <30-35 kg / m2 in order to submit the patients on the waiting list for kidney transplant.

Therefore, weight loss becomes a must for obese patients, otherwise they are unfit candidates for transplant.

The purpose of this case report is to suggest that a combination of intensive dialysis and nutritional coaching, with personalized diet, can be the key to success, to be tested on a larger scale.

The main concerns addressed the risk of malnutrition, which could further reduce muscle mass, already decreased in uremic patients, and hypercatabolism, potentially leading to increased potassium and phosphorus, and a worsening of metabolic acidosis.

Despite the rapid and substantial weight loss, our patients did not present any of the feared side effects; on the contrary, there was an unexpected improvement in the Ca, P, PTHi balances and better correction of acidosis. This improvement may be due to the acquisition of healthy eating habits and the elimination of canned foods, preserved foods, and snacks, containing additives rich in phosphates, whose contribution to hyperphosphataemia, in patients with chronic renal failure on dialysis, was recognized only recently, as very important.

Another interesting aspect is related to sodium and body water. At the beginning of the diet, the patient was neither oedematous nor severely hypertensive: consequently, the weight loss achieved is not only a reflection of a new balance, as often happens at the beginning of the dialysis, when patients lose mainly the overhydration quota.

Moreover, the lowering of blood pressure, recorded in the initial stages, was associated with the net sodium reduction of the diet (despite normal levels of serum sodium) and required an increase of the Na content in the dialysate to be appropriate.

However, the main effector of low-sodium diet is usually considered to be the kidney and our patient was anuric. This observation emphasizes the importance of the direct sodium effect to vascular systemic levels, as suggested by some authors, who have reconsidered the importance of  low sodium diets in dialysis patients with hypertension.

Overall, our experience suggests that intensive weight-loss programs can also be applied in hemodialysis patients, as long as under adequate clinical surveillance.

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