title: Body mass index and mortality in kidney transplant recipients: a systematic review and meta-analysis.
abstract: BACKGROUND
  A higher body mass index (BMI) seems to be linked to survival advantage in maintenance hemodialysis patients. However, it is uncertain if this 'obesity survival paradox' is also observed in kidney transplant recipients. Hence, we systematically reviewed the literature on the impact of pre-transplantation BMI on all-cause mortality in this population.
  
  
  METHODS
  We searched MEDLINE, EMBASE, Web of Science, CINAHL, and Cochrane CENTRAL for relevant studies up to July 2013. Two investigators independently selected the studies using predefined criteria, abstracted the data from the included studies, and independently assessed each study's quality using the Newcastle-Ottawa Quality Assessment Scale. In addition to the qualitative synthesis, we quantitatively pooled the results of the studies with clinical, methodological, and statistical homogeneity.
  
  
  RESULTS
  We screened 7,123 records, from which we included 11 studies (with a total of 305,392 participants) in this systematic review and 4 studies in the meta-analyses. In the only study that included children, obesity was linked to higher mortality in children of 6-12 years old. For adults, our meta-analyses indicated that compared to normal BMI, underweight [Hazard Ratio (HR): 1.09; 95% Confidence Interval (CI): 1.02-1.20], overweight (HR: 1.07; 95% CI: 1.04-1.12), and obese (HR: 1.20; 95% CI: 1.14-1.23) levels of BMI were associated with higher mortality.
  
  
  CONCLUSIONS
  The presence of the obesity survival paradox is unlikely in kidney transplant recipients since both extremes of pre-transplantation BMI are linked to higher mortality in this population.
authors.affiliation: Harold Simmons Center for Kidney Disease Research and Epidemiology; Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, Calif., USA.
authors.forename: Seyed-Foad
authors.initials: SF
authors.lastname: Ahmadi
authors.forename: Golara
authors.initials: G
authors.lastname: Zahmatkesh
authors.forename: Elani
authors.initials: E
authors.lastname: Streja
authors.forename: Miklos Z
authors.initials: MZ
authors.lastname: Molnar
authors.forename: Connie M
authors.initials: CM
authors.lastname: Rhee
authors.forename: Csaba P
authors.initials: CP
authors.lastname: Kovesdy
authors.forename: Daniel L
authors.initials: DL
authors.lastname: Gillen
authors.forename: Shah
authors.initials: S
authors.lastname: Steiner
authors.forename: Kamyar
authors.initials: K
authors.lastname: Kalantar-Zadeh
mesh_terms: D000328:Adult; D015992:Body Mass Index; D002648:Child; D006085:Graft Survival; D006801:Humans; D016030:Kidney Transplantation / Q000401:mortality*