Body Mass Index and Risk of End-Stage Renal Disease: A Systematic Review and Dose-Response Meta-Analysis

Adiposity and risk of ESRD

  • Ahmad Jayedi Mail
  • Mahdiehsadat Zargar
Body mass index, End-Stage renal disease, Kidney disease, Meta-Analysis


Objective: The association of obesity with risk of chronic kidney disease has been accepted, but considering the possible indications of the obesity paradox in patients with early-stage kidney disease, the association between baseline body mass index (BMI) and future risk of end-stage renal disease (ESRD) in the general population has not been established yet.

Methods: We performed a systematic search of PubMed and Scopus for relevant studies published from database inception to June 2018. Longitudinal cohort studies reporting risk estimates of ESRD for three or more categories of BMI in the general population were included. Pooled relative risk (RR) was calculated using a random-effects model.

Results: The analysis included eight prospective cohort studies, one nested case-control study, one nested case-referent study, and two retrospective cohort studies (2,063,895 individuals and 5874 cases of end-stage renal disease). The pooled RR of ESRD for a 5-unit increment in BMI was 1.19 (95%CI: 1.06, 1.35; I2 = 94.1%). The strength of the association might be age-related; in a way that, a significant positive association was found in those with a mean age <50 years, but not those aged ≥50 years. A nonlinear dose-response meta-analysis indicated that the risk of ESRD was similar within BMI of 15-23 kg/m2, and then increased sharply and linearly at a BMI of approximately 25 kg/m2.

Conclusion: Obesity and overweight condition are associated with a higher risk of ESRD. Being as lean as possible within the normal weight range may help to prevent ESRD.


[1] Collins AJ, Foley RN, Chavers B, Gilbertson D, Herzog C, Johansen K, et al. 'United States Renal Data System 2011 Annual Data Report: Atlas of chronic kidney disease & end-stage renal disease in the United States. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2012;59:A7, e1-420.
[2] Hunsicker LG. The consequences and costs of chronic kidney disease before ESRD. Journal of the American Society of Nephrology : JASN. 2004;15:1363-4.
[3] Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. The New England journal of medicine. 2004;351:1296-305.
[4] Shidler NR, Peterson RA, Kimmel PL. Quality of life and psychosocial relationships in patients with chronic renal insufficiency. American journal of kidney diseases : the official journal of the National Kidney Foundation. 1998;32:557-66.
[5] Tonelli M, Wiebe N, Culleton B, House A, Rabbat C, Fok M, et al. Chronic kidney disease and mortality risk: a systematic review. Journal of the American Society of Nephrology : JASN. 2006;17:2034-47.
[6] Domrongkitchaiporn S, Sritara P, Kitiyakara C, Stitchantrakul W, Krittaphol V, Lolekha P, et al. Risk factors for development of decreased kidney function in a southeast Asian population: a 12-year cohort study. Journal of the American Society of Nephrology : JASN. 2005;16:791-9.
[7] Gelber RP, Kurth T, Kausz AT, Manson JE, Buring JE, Levey AS, et al. Association between body mass index and CKD in apparently healthy men. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2005;46:871-80.
[8] Song YM, Sung J, Lee K. Longitudinal relationships of metabolic syndrome and obesity with kidney function: Healthy Twin Study. Clinical and experimental nephrology. 2015;19:887-94.
[9] Yamagata K, Ishida K, Sairenchi T, Takahashi H, Ohba S, Shiigai T, et al. Risk factors for chronic kidney disease in a community-based population: a 10-year follow-up study. Kidney international. 2007;71:159-66.
[10] Hsu CY, McCulloch CE, Darbinian J, Go AS, Iribarren C. Elevated blood pressure and risk of end-stage renal disease in subjects without baseline kidney disease. Archives of internal medicine. 2005;165:923-8.
[11] Williams ME. Diabetic CKD/ESRD 2010: a progress report? Seminars in dialysis. 2010;23:129-33.
[12] Chagnac A, Weinstein T, Korzets A, Ramadan E, Hirsch J, Gafter U. Glomerular hemodynamics in severe obesity. American journal of physiology Renal physiology. 2000;278:F817-22.
[13] Goossens GH, Blaak EE, van Baak MA. Possible involvement of the adipose tissue renin-angiotensin system in the pathophysiology of obesity and obesity-related disorders. Obesity reviews : an official journal of the International Association for the Study of Obesity. 2003;4:43-55.
[14] Henegar JR, Bigler SA, Henegar LK, Tyagi SC, Hall JE. Functional and structural changes in the kidney in the early stages of obesity. Journal of the American Society of Nephrology. 2001;12:1211-7.
[15] Wahba IM, Mak RH. Obesity and obesity-initiated metabolic syndrome: mechanistic links to chronic kidney disease. Clinical journal of the American Society of Nephrology : CJASN. 2007;2:550-62.
[16] Garofalo C, Borrelli S, Minutolo R, Chiodini P, De Nicola L, Conte G. A systematic review and meta-analysis suggests obesity predicts onset of chronic kidney disease in the general population. Kidney international. 2017;91:1224-35.
[17] Lu JL, Kalantar-Zadeh K, Ma JZ, Quarles LD, Kovesdy CP. Association of body mass index with outcomes in patients with CKD. Journal of the American Society of Nephrology : JASN. 2014;25:2088-96.
[18] Hsu CY, McCulloch CE, Iribarren C, Darbinian J, Go AS. Body mass index and risk for end-stage renal disease. Annals of internal medicine. 2006;144:21-8.
[19] Zitt E, Pscheidt C, Concin H, Kramar R, Lhotta K, Nagel G. Anthropometric and Metabolic Risk Factors for ESRD Are Disease-Specific: Results from a Large Population-Based Cohort Study in Austria. PLoS ONE. 2016;11:e0161376.
[20] Panwar B, Hanks LJ, Tanner RM, Muntner P, Kramer H, McClellan WM, et al. Obesity, metabolic health, and the risk of end-stage renal disease. Kidney international. 2015;87:1216-22.
[21] Perry HM, Jr., Miller JP, Fornoff JR, Baty JD, Sambhi MP, Rutan G, et al. Early predictors of 15-year end-stage renal disease in hypertensive patients. Hypertension (Dallas, Tex : 1979). 1995;25:587-94.
[22] Reynolds K, Gu D, Muntner P, Chen J, Wu X, Yau CL, et al. Body mass index and risk of ESRD in China. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2007;50:754-64.
[23] Franceschini N, Gouskova NA, Reiner AP, Bostom A, Howard BV, Pettinger M, et al. Adiposity patterns and the risk for ESRD in postmenopausal women. Clinical journal of the American Society of Nephrology : CJASN. 2015;10:241-50.
[24] Akwo EA, Cavanaugh KL, Ikizler TA, Blot WJ, Lipworth L. Increased body mass index may be associated with greater risk of end-stage renal disease in whites compared to blacks: A nested case-control study. BMC nutrition. 2015;1.
[25] Lu JL, Molnar MZ, Naseer A, Mikkelsen MK, Kalantar-Zadeh K, Kovesdy CP. Association of age and BMI with kidney function and mortality: a cohort study. The Lancet Diabetes & Endocrinology. 2015;3:704-14.
[26] Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. Jama. 2000;283:2008-12.
[27] Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. European journal of epidemiology. 2010;25:603-5.
[28] DerSimonian R, Laird N. Meta-analysis in clinical trials. Controlled clinical trials. 1986;7:177-88.
[29] Berlin JA, Longnecker MP, Greenland S. Meta-analysis of epidemiologic dose-response data. Epidemiology (Cambridge, Mass). 1993;4:218-28.
[30] Orsini N, Bellocco R, Greenland S. Generalized least squares for trend estimation of summarized dose-response data. Stata Journal. 2006;6:40.
[31] Hamling J, Lee P, Weitkunat R, Ambuhl M. Facilitating meta-analyses by deriving relative effect and precision estimates for alternative comparisons from a set of estimates presented by exposure level or disease category. Statistics in medicine. 2008;27:954-70.
[32] Egger M, Smith GD, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. Bmj. 1997;315:629-34.
[33] Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ: British Medical Journal. 2003;327:557.
[34] Orsini N, Li R, Wolk A, Khudyakov P, Spiegelman D. Meta-analysis for linear and nonlinear dose-response relations: examples, an evaluation of approximations, and software. American journal of epidemiology. 2011;175:66-73.
[35] Bash LD, Astor BC, Coresh J. Risk of incident ESRD: a comprehensive look at cardiovascular risk factors and 17 years of follow-up in the Atherosclerosis Risk in Communities (ARIC) Study. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2010;55:31-41.
[36] Iseki K, Ikemiya Y, Kinjo K, Inoue T, Iseki C, Takishita S. Body mass index and the risk of development of end-stage renal disease in a screened cohort. Kidney international. 2004;65:1870-6.
[37] Ishani A, Grandits GA, Grimm RH, Svendsen KH, Collins AJ, Prineas RJ, et al. Association of single measurements of dipstick proteinuria, estimated glomerular filtration rate, and hematocrit with 25-year incidence of end-stage renal disease in the multiple risk factor intervention trial. Journal of the American Society of Nephrology : JASN. 2006;17:1444-52.
[38] Lew QJ, Jafar TH, Talaei M, Jin A, Chow KY, Yuan JM, et al. Increased body mass index is a risk factor for end-stage renal disease in the Chinese Singapore population. Kidney international. 2017.
[39] Sommar JN, Svensson MK, Bjor BM, Elmstahl SI, Hallmans G, Lundh T, et al. End-stage renal disease and low level exposure to lead, cadmium and mercury; a population-based, prospective nested case-referent study in Sweden. Environmental health : a global access science source. 2013;12:9.
[40] Vivante A, Golan E, Tzur D, Leiba A, Tirosh A, Skorecki K, et al. Body mass index in 1.2 million adolescents and risk for end-stage renal disease. Archives of internal medicine. 2012;172:1644-50.
[41] The NS, Suchindran C, North KE, Popkin BM, Gordon-Larsen P. Association of adolescent obesity with risk of severe obesity in adulthood. Jama. 2010;304:2042-7.
[42] Tirosh A, Shai I, Afek A, Dubnov-Raz G, Ayalon N, Gordon B, et al. Adolescent BMI trajectory and risk of diabetes versus coronary disease. The New England journal of medicine. 2011;364:1315-25.
[43] Wang Y, Chen X, Song Y, Caballero B, Cheskin LJ. Association between obesity and kidney disease: a systematic review and meta-analysis. Kidney international. 2008;73:19-33.
[44] Adelman RD. Obesity and renal disease. Current opinion in nephrology and hypertension. 2002;11:331-5.
[45] De Jong P, Verhave J, Pinto-Sietsma S, Hillege H. Obesity and target organ damage: the kidney. International journal of obesity. 2002;26:S21.
[46] Ribstein J, du Cailar G, Mimran A. Combined renal effects of overweight and hypertension. Hypertension (Dallas, Tex : 1979). 1995;26:610-5.
How to Cite
Jayedi A, Zargar M. Body Mass Index and Risk of End-Stage Renal Disease: A Systematic Review and Dose-Response Meta-Analysis. J Nutr Sci & Diet. 4(4).
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