A third of UK kidney patients on dialysis are living with obesity, yet many are denied access to a transplant because of their weight. This matters because obesity is common among people with kidney failure, but weight-loss options are limited. Bariatric surgery carries extra risk for these patients, and standard NHS obesity services are often out of reach. Formula low energy diets—meal replacements that produce substantial weight loss—could offer a practical alternative, but no one has tested whether they work for people on haemodialysis who want a transplant. If the programme proves feasible and safe, it could give patients a non-surgical route to lose weight, get listed for a transplant, and leave dialysis behind. That would reduce inequity in access to transplantation and save the NHS significant costs, since dialysis is expensive to deliver year after year. The findings will also give transplant centres clearer guidance on how to manage obesity, replacing the current patchwork of inconsistent local rules.
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Background Obesity affects 25% of UK adults and is associated with chronic kidney disease (CKD) and to kidney failure (KF; previously termed end stage kidney disease), resulting, overtime, in requirement for kidney replacement therapy (dialysis/transplantation). In England, 15% of adults have CKD, of this 7% have more advanced CKD. Almost 30,000 UK adults are on dialysis, with data showing 39.2% of people with KF live with obesity. Despite guidelines stating that obesity (body mass index; BMI≥30kg/m2) should not preclude kidney transplantation, about 30% being excluded. Obesity reduces the likelihood of being listed for transplantation, while weight loss can improve access. Uncertainty remains on the impact of obesity on transplant outcomes, with pre-2003 data showing greater complications post-transplant (e.g., delayed graft function) and surgical difficulties, but recent data show no difference across BMI categories for graft survival and mortality, up to BMI≥40kg/m2. Nevertheless obesity remains a risk factor for graft failure and death. Inequitable access to kidney transplantation for those with obesity persists, with variation in UK centres' criteria, further hampered by guidelines offering little guidance on managing obesity. Therefore, effective weight-loss strategies are needed. Bariatric surgery is an effective treatment for obesity but is not available to all and has an increased risk in people with KF. Other obesity treatments in CKD (energy restriction, exercise and pharmacotherapy) may benefit weight loss and health, but effectiveness data is sparse and of low quality. This is further confounded by limited access to UK obesity services. Formula low energy diets (LED) achieve ~10kg weight loss in people with obesity, are associated with health improvements, and could be an option for people on HD. Aims/Objectives The fellowship aims to assess the feasibility, acceptability, and safety of a formula LED programme to help people with obesity and KF on haemodialysis (HD) to lose weight and be listed for kidney transplantation. The objectives are to: gain knowledge of obesity management of UK patients with KF acquire in-depth understanding from stakeholders of barriers and facilitators to establishing a LED programme in HD services work together with stakeholders to develop a LED programme conduct a feasibility study of a LED programme in patients with obesity on HD. Methods Work Package 1 (3-12months): a national survey of transplant centres will assess current management practices for people with obesity and KF, followed by focus group and individual interviews of healthcare professionals to further explore practice. Work Package 2, (9-54months): a mixed methods approach will assess facilitators and barriers to implementation of a LED programme, and will draw on principles of co-design and tailored implementation to produce implementation strategies using observations and stakeholder workshops. Work package 3, a randomised feasibility study (18-48months) will be conducted comparing using a LED programme with standard care. Impact and dissemination HD costs £32-35K/person/year, while having a transplant shows better survival compared to remaining on HD. This fellowship has important implications on healthcare resources, inequity of access and health outcomes. The findings will be disseminated via multiple channels including academic papers, conferences and public/patient engagement events.
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