Association of age and BMI with kidney function and mortality: a cohort study

doi:10.1016/S2213-8587(15)00128-X

The Lancet Diabetes & Endocrinology

Volume 3, Issue 9, September 2015, Pages 704-714

https://doi.org/10.1016/S2213-8587(15)00128-X Get rights and content

Summary

Background

Compared with normal weight, obesity might be associated with worse clinical outcomes, including chronic kidney disease. Whether this association is modified by age is not known. We investigated the association of BMI with progressive loss of kidney function and all-cause mortality in US veterans.

Methods

In a national cohort of 3 376 187 US veterans with an estimated glomerular filtration rate (eGFR) of more than 60 mL/min per 1·73 m², we assessed the association of BMI in patients of different ages (<40 years, 40 years to <50 years, 50 years to <60 years, 60 years to <70 years, 70 years to <80 years, and ≥80 years) with loss of kidney function and with all-cause mortality in logistic regression models and Cox proportional hazards models adjusted for ethnic origin, sex, comorbidities, medications, and baseline eGFR.

Findings

274 764 (8·1%) of 3 376 187 veterans had a rapid decline in kidney function (decrease in slope of >5 mL/min per 1·73 m²). The lowest risk for loss of kidney function was noted in patients with BMI of at least 25 kg/m² but less than 30 kg/m². A generally consistent U-shaped association was noted between BMI and rapid loss of kidney function that was more prominent with increasing age, except in the patients younger than 40 years, in whom BMI did not seem to be predictive of renal function impairment. 672 341 veterans died (28·7 per 1000 patient-years, 95% CI 28·6–28·7) over a median follow-up of 6·8 years (IQR 6·5–7·7). BMI also showed a U-shaped association with mortality, which was similar in all age groups.

Interpretation

A BMI of 30 kg/m² or more is associated with rapid loss of kidney function in patients with eGFR of at least 60 mL/min per 1·73 m², and this association is accentuated in older patients. A BMI of 35 kg/m² or more is also associated with high mortality. A BMI of at least 25 kg/m² but less than 30 kg/m² is associated with the best clinical outcomes.

Funding

National Institute of Health, Memphis VA Medical Center, Long Beach VA Healthcare System, Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development, and VA Information Resource Center.

Introduction

Obesity is associated with increased risk of incident chronic kidney disease,1, 2 end-stage renal disease,3, 4 and mortality,5, 6 according to the results of some studies. In the past, the associations of various outcomes with BMI in individuals of different ages⁷ and with clinical disorders have been assessed in observational studies.⁸ Paradoxical associations were noted in individuals with pre-existing chronic illnesses.9, 10, 11 The optimum BMI for survival has also varied between studies.5, 12 Besides obesity, very low BMIs were consistently associated with high all-cause mortality rates.6, 13 Kidney function improved after intentional weight loss in obese individuals in some studies.14, 15

Obesity is a chronic disorder that can persist for decades in most affected individuals. Older age is associated with an increasing prevalence of comorbidities and high short-term mortality rate, and therefore age might modify the association of BMI with outcomes such as kidney disease. The heterogeneity of the study populations in most previous studies, in which individuals were different not only in age but also in their comorbidities, makes it difficult to ascertain the independent effect of age on the risk imparted by obesity. To find out whether the risk of adverse clinical outcomes in relation to obesity would differ by age, we assessed the association of BMI with progressive loss of kidney function and with all-cause mortality in a large national cohort of US veterans with an estimated glomerular filtration rate (eGFR) of at least 60 mL/min per 1·73 m² grouped by age. We hypothesised that the association of BMI with clinical outcomes will be attenuated in older patients, especially in individuals with a high burden of chronic comorbidities.

Section snippets

Study design and participants

Data were extracted from a historical cohort study (Racial and Cardiovascular Risk Anomalies in Chronic Kidney Disease [RCAV] study), as previously described.16, 17 Briefly, the cohort consisted of 3 582 478 US veterans, selected from all veterans who received clinical care in any of the Veteran Affairs (VA) health-care facilities, and who had an eGFR of at least 60 mL/min per 1·73 m² recorded during Oct 1, 2004, to Sept 30, 2006, calculated with the Chronic Kidney Disease Epidemiology

Results

The mean age of the cohort was 60·0 years (SD 14·0), 2 415 726 (71·6%) of 3 376 187 veterans were white and the mean baseline eGFR was 83·8 mL/min per 1·73 m² (SD 15·6). The mean of the intraindividual mean BMI values was 29·1 kg/m² (SD 5·6), and BMI was measured a median of 18 times per patient (IQR 10–30). Baseline characteristics of patients categorised by their BMI and age are described in the table. Younger patients were more likely to be women and unmarried (table). Systolic blood

Discussion

In this large national cohort of veterans with baseline eGFR of at least 60 mL/min per 1·73 m², we noted an incrementally accentuated U-shaped association of BMI with rapid loss of kidney function in patients older than 40 years. Patients younger than 40 years showed no detrimental association between BMI and kidney function over the follow-up of about 7 years. A similar U-shaped association was present between BMI and all-cause mortality rate, with an especially high rate noted in patients

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ArticlesAssociation of age and BMI with kidney function and mortality: a cohort study

Summary

Background

Methods

Findings

Interpretation

Funding

Introduction

Section snippets

Study design and participants

Results

Discussion

Am J Kidney Dis

Kidney Int

J Card Fail

J Am Coll Cardiol

Am J Clin Nutr

J Clin Epidemiol

Atherosclerosis

Am J Clin Nutr

Kidney Int

Kidney Int

Nutr Metab Cardiovasc Dis

Am J Clin Nutr

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Predictors of new-onset kidney disease in a community-based population

JAMA

Body mass index in 1.2 million adolescents and risk for end-stage renal disease

Arch Intern Med

Body-mass index and mortality among 1.46 million white adults

N Engl J Med

Underweight and overweight in relation to mortality among men aged 40–59 and 50–69 years—the seven countries study

Am J Epidemiol

The effect of age on the association between body-mass index and mortality

N Engl J Med

Body mass index and all-cause mortality in a large prospective cohort of white and black U.S. Adults

PLoS One

Paradoxical effect of body mass index on survival in rheumatoid arthritis: role of comorbidity and systemic inflammation

Arch Intern Med

Body mass index and mortality in ‘healthier’ as compared with ‘sicker’ haemodialysis patients: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS)

Nephrol Dial Transplant

Elevated body mass index and mortality risk in the elderly

Obes Rev

The effect of middle- and old-age body mass index on short-term mortality in older people

J Am Geriatr Soc

Effects of weight loss on renal function in obese CKD patients: a systematic review

Nephrol Dial Transplant

Weight loss interventions in chronic kidney disease: a systematic review and meta-analysis

Clin J Am Soc Nephrol

Association of hepatitis C virus infection with incidence and progression of chronic kidney disease in a large cohort of US veterans

Hepatology

Association of medical treatment nonadherence with all-cause mortality in newly treated hypertensive US veterans

Hypertension

A new equation to estimate glomerular filtration rate

Ann Intern Med

Blood pressure and mortality in U.S. veterans with chronic kidney disease: a cohort study

Ann Intern Med

Articles
Association of age and BMI with kidney function and mortality: a cohort study