Adiposity and risk of decline in glomerular filtration rate: meta-analysis of individual participant data in a global consortium [肥胖与肾小球滤过率下降的风险：对一个全球联合会中个体参与者数据的meta分析]

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BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.k5301 (Published 10 January 2019)
Cite this as: BMJ 2019;364:k5301

Authors
Alex R Chang, Morgan E Grams, Shoshana H Ballew, Henk Bilo, Adolfo Correa, Marie Evans, Orlando M Gutierrez, Farhad Hosseinpanah, Kunitoshi Iseki, Timothy Kenealy, Barbara Klein, Florian Kronenberg, Brian J Lee, Yuanying Li, Katsuyuki Miura, Sankar D Navaneethan, Paul J Roderick, Jose M Valdivielso, Frank L J Visseren, Luxia Zhang, Ron T Gansevoort, Stein I Hallan, Andrew S Levey, Kunihiro Matsushita, Varda Shalev, Mark Woodward

Abstract
Objective To evaluate the associations between adiposity measures (body mass index, waist circumference, and waist-to-height ratio) with decline in glomerular filtration rate (GFR) and with all cause mortality.

Design Individual participant data meta-analysis.

Setting Cohorts from 40 countries with data collected between 1970 and 2017.

Participants Adults in 39 general population cohorts (n=5 459 014), of which 21 (n=594 496) had data on waist circumference; six cohorts with high cardiovascular risk (n=84 417); and 18 cohorts with chronic kidney disease (n=91 607).

Main outcome measures GFR decline (estimated GFR decline ≥40%, initiation of kidney replacement therapy or estimated GFR <10 mL/min/1.73 m2) and all cause mortality.

Results Over a mean follow-up of eight years, 246 607 (5.6%) individuals in the general population cohorts had GFR decline (18 118 (0.4%) end stage kidney disease events) and 782 329 (14.7%) died. Adjusting for age, sex, race, and current smoking, the hazard ratios for GFR decline comparing body mass indices 30, 35, and 40 with body mass index 25 were 1.18 (95% confidence interval 1.09 to 1.27), 1.69 (1.51 to 1.89), and 2.02 (1.80 to 2.27), respectively. Results were similar in all subgroups of estimated GFR. Associations weakened after adjustment for additional comorbidities, with respective hazard ratios of 1.03 (0.95 to 1.11), 1.28 (1.14 to 1.44), and 1.46 (1.28 to 1.67). The association between body mass index and death was J shaped, with the lowest risk at body mass index of 25. In the cohorts with high cardiovascular risk and chronic kidney disease (mean follow-up of six and four years, respectively), risk associations between higher body mass index and GFR decline were weaker than in the general population, and the association between body mass index and death was also J shaped, with the lowest risk between body mass index 25 and 30. In all cohort types, associations between higher waist circumference and higher waist-to-height ratio with GFR decline were similar to that of body mass index; however, increased risk of death was not associated with lower waist circumference or waist-to-height ratio, as was seen with body mass index.

Conclusions Elevated body mass index, waist circumference, and waist-to-height ratio are independent risk factors for GFR decline and death in individuals who have normal or reduced levels of estimated GFR.