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Con: Weight loss prior to transplant: no.

In large registries of hemodialysis patients, higher body mass index (BMI) is known to be associated with lower mortality rates, while weight loss associates with reduced survival. This so-called 'obesity paradox' includes patients categorized as overweight and obese. Transplantation in the obese patient population has been shown to improve quality of life and reduce mortality when compared with obese recipient candidates remaining on dialysis. Most transplant centers, however, restrict access to transplant based upon predetermined BMI cutoffs. This policy effectively mandates weight loss for many obese transplant candidates. However, BMI, though easily measured, is an inadequate assessment of nutritional status and lean muscle mass in obese patients. Regimens designed to prevent protein-energy wasting may include dietary recommendations and exercise programs that result in favorable changes in body composition without significantly impacting weight. The goal of weight loss is not achievable for many if not most obese dialysis patients. The consequence to the patient is reduced access to life improving transplantation. Patients are forced to pursue dietary, behavioral and possibly surgical interventions to accomplish weight loss despite limited evidence regarding the safety and utility of these interventions. The delay in transplantation also hinders the achievement of improved exercise capacity after successful transplant, a time when weight loss regimens may be safer and more effective.