The Longevity Project Reflections

This discussion was very informative and interesting! Dr. Gardiner presented her research on how a provider’s perception and policies on BMI affect a patient’s eligibility for kidney transplantation. Study one explored provider attitudes for BMI as an indicator for eligibility while study two explored the role of BMI in determining eligibility for kidney transplantation. The results showed discrepancies between the provider’s perception and the policy statement on what an appropriate BMI should be. The policy benchmarks were lower than what the providers thought the BMI cutoff should be. Furthermore, there is a lack in educating those with a higher BMI on how to lose weight to meet the benchmarks and get a transplant.

Kidney disease is a very difficult condition to treat especially in regards to BMI. For one, when a patient is on dialysis, they’re discouraged to lose weight as it may hinder treatment. However, what should they do once they need to get a transplant in the long term but need to stay on dialysis in the long term? This puts the patient in a difficult position and could definitely affect them psychologically if they feel like they do not know what to do.

Something I wish the speaker could further discuss are the existing institutional power structures/beliefs that minorities may face that prevent them from getting transplant/treatments. She did mention that Caucasians might be more likely to receive a transplant from a living donor while minorities may not have someone healthy enough to donate within their social network and thus, that can be a reason why transplantation rates are higher for them. Another interesting part she mentioned was that while being on Medicaid/Medicare, most patients wouldn’t be able to get on a waiting list for transplantation until recently. She also mentioned how in Spain, it is assumed that people will donate their organs after death since they see it as a social good while we value autonomy in the USA. I wish more information could be given on these topics but it also seems like this research is still in its preliminary stages and we still have a lot to learn.

I found Dr. Heather Gardiner’s talk this past Friday very interesting. While I got the impression that a fair bit of her current work and research is still in the early stages (early meaning there are still follow up studies to be done and/or that are currently in the process of being conducted/analyzed/reviewed), I believe her and her team(s) findings are very important in helping to treat and prevent End Stage Renal Disease (ESRD). I was particularly interested because she studies racial disparities in treatment and prevention of ESRD—at least, that is a portion of her research. In taking Health Psych this semester and being knowledgeable about racial disparities on many other fronts, I was not surprised by the fact that racial/ethnic minorities are at greater risk of ESRD than whites. I briefly was taken aback by Native Americans being 9.5 times greater, but when all is taken into account it, unfortunately, makes sense.

I must say I couldn’t help but be annoyed when I learned of how hemodialysis patients are dealt with, specifically with regards to weight loss (of course, this is no fault of Dr. Gardiner—my annoyance is with the System). What would seem illogical to me in telling obese patients to not lose weight somehow turns out to be “best practice.” As Dr. Gardiner explained, this is so because the extra weight (and therefore extra water within the person) is good to have because the point of dialysis is to suck out a bunch of toxins and water because his/her kidneys are not working properly to perform this function… I apologize for using “because” three times in one sentence… Nonetheless, what further irked me was the fact that to get a transplant, doctors want you to be “healthy enough” (e.g. not obese), so you go from being encouraged not to lose weight to being told you need to lose weight in order to receive the very best treatment and live your best life. And to add to all of that, of course minority populations have access to poorer healthcare, or access to less healthcare in general, as well as are more likely to live in food deserts, and therefore are just unhealthier (on average) overall. Thus, when a racial/ethnic minority is eligible for a transplant, his/her odds of finding a proper match are significantly reduced because his/her family members are more likely to be unhealthy and therefore unfit to transplant with.

This was all news to me despite it all making very plain sense. I’m glad I had the chance to hear Dr. Gardiner speak and learn more about ESRD. Though it does not affect anyone in my immediate family (that I know of and hope that remains the same), having now learned about hemodialysis and the poor measures of differentiating between adiposity and muscle mass (BMI still being the main measure), I am that much more encouraged to sustain my healthy lifestyle and to continue to encourage others around me.

I thought that Heather Gardiners’ research on Kidney Transplants and BMI/obesity was very interesting. I learned a lot through this presentation that I otherwise would not have been aware of. To begin, I thought it was interesting when she mentioned that BMI may not be the best way to measure obesity because it does not take into account muscle mass. I know that we learned this in class, but it was interesting to hear how BMI plays a role in assessing someone’s eligibility for a kidney transplant. In addition, it was interesting to hear some of the other ways that weight could be assessed, such as water displacement, or formulas that take into account age and gender. It makes me wonder why BMI is the widely accepted obesity measurement.

Through this presentation, I learned how extensive the process is to receive a transplant. I was not aware that there are restrictions for being placed on a transplant list. I was under the impression that if you needed a transplant then you were automatically placed on the list, maybe in a certain order of who is in the most critical condition. I also learned that different transplant centers have different obesity criteria for receiving a transplant. To me this was shocking and also seems unfair due to the inconsistency across centers. It seems like wealthy white individuals have an advantage over those who may not be of high Socioeconomic status. Heather brought up Steve Jobs and how he was able to fly to another transplant center in order to have his name on multiple waitlists. I also thought it was astounding how Heather Gardiner had such a difficult time acquiring the transplant centers policies. I believe that this is something that any potential patient should be able to easily obtain.

I personally know a young boy who was waiting a heart transplant and I know that the process was grueling and stressful, knowing that his condition was only getting worse. The research Heather Gardiner is conducting is extremely important and the general public should be made aware of these discrepancies across treatment facilities.

Before this talk, I knew little information about kidney disease and transplantation. I was surprised that American Indians/Alaska Natives are 9.5 times greater to get kidney disease than Caucasians. It was also surprising to find out that 38% of transplant candidates meet the criteria for obesity and that obesity can prevent someone from getting a kidney transplant. I liked how both studies dealt with attitudes toward BMI and and eligibility for transplantation. The premise of study 1 was very interesting to me and it was shocking that 80% of providers thought that it was okay to transplant someone with a BMI between 30 and 35. In my personal opinion, I think that it is okay to transplant someone with a BMI between 30 and 35 as long as they are educated on the risks and possible outcomes of the transplant. In study 2, the purpose was to explore the role of BMI in determining patient eligibility for kidney transplantation. 5 programs identified a maximum BMI as a absolute contraindication and 9 programs identified it as a relative contraindication. Overall, the main limitation from these 2 studies is that it is mainly an opinion based study, the questions asked to providers could be based on their own personal opinion rather than policy. What fascinated me the most was that weight loss prior to transplant has not been shown to improve outcomes, which is ironic because providers urge people to lose weight to become eligible for a transplant, but the outcome is not improved. I also feel as though providers should run more tests to see if an individual is eligible for a transplant rather than just judging off of their BMI.

I thought Dr. Gardiner’s talk was very interesting, and she brought up points I had not thought about much before. Although it makes sense, it was certainly disheartening to hear the truth about how difficult it is to successfully get a kidney transplant in this country. Considering there are an estimated 160 million Americans who are either obese or overweight, I couldn’t help but think about how many are denied the right to be placed on a waiting list, if they are in need of a kidney transplant. What surprised me more, though, was that only half of the people who are obese/overweight make it back onto the waiting list for a transplant — I would think that being placed on this list would be a person’s top priority if they needed it.

It was also disheartening to hear about the major disparity that exists among the races, when it comes to the waiting list to receive a kidney transplant. Being black or white should evidently not be a deciding factor in whether you live or not, but in this case it seems to be just that. The fact that the majority of the people on these waiting lists are white is, sadly, not surprising. But I do think a lot more can be done in decreasing these types of disparities. I also refer to the weight disparity when I say this. America is biased against obesity, but rather than simply telling people they need to lose wight and wishing them luck in doing so, I think these same people should have a clear understanding of the fact that they can’t even be a recipient for a kidney transplant if they surpass their weight limit.

Something I never knew about was the variety of alternatives for measuring BMI. I had heard about underweight weighing and the whole body air displacement methods before, but that’s it. I think some of the ones Dr. Gardiner displayed for us were valid recommendations, but again, it is unknown how well people will respond to these or listen to suggestions about changing their habits in order to become healthier individuals altogether. Another factor Dr. Gardiner mentioned that got me thinking, was the amount of donors in the United States, compared to countries such as Spain. As someone who studied abroad in Madrid last semester, I realized that the Spaniards are very practical people. I think their process for attaining donors is practical as well, even more so than the system we have in the U.S. I understand how and why automatically becoming a donor after death could seem to be a problem for many people, but knowing you could save a life when you no longer need certain parts of your body could serve as motivation to be a donor, if you really think about it.

Dr. Gardiner’s talk about kidney transplantation and BMI was honestly shocking to me. I had no idea how prevalent renal failure is, or how much of an issue obesity is as a barrier. Yet, obesity and severe obesity continue to prohibit many individuals from receiving an organ transplant. What’s most upsetting about it is that much of this barrier to access is based on conflicting evidence. Some studies have found that obese patients (BMI 30-35) have worse transplant outcomes, but others have found that there is no significant difference. As a result, there is very little consistency in BMI-oriented policy in the 200+ transplant centers across the US. Centers often set a hard boundary for BMI limits, above which a patient is prevented from being on the waitlist. Alternatively, many centers do have flexibility on a patient-by-patient basis, but still err towards withholding transplant eligibility until patients lose weight. This means that where an obese patient goes to be evaluated for transplant determines whether or not they’re able to get a transplant, an inconsistency that should not exist. The policy regarding renal transplant and BMI criteria is arbitrary and unnecessarily limiting for obese patients–despite the fact that the Renal Association(?) now recommends that BMI not be used as a criteria for renal transplant eligibility. I found this to be pretty disturbing.

Dr. Gardiner also discussed the connection between minority status, obesity, and transplantation. There is a significant disparity in transplant rates for obese individuals, especially obese individuals of minority status. The interplay of biopsychosocial factors for ethnic minorities in the United States often puts minority populations at an especially harsh disadvantage; ethnic minorities tend to have lower socioeconomic status, poorer health literacy, worse health care access, and are more likely to be uninsured. Additionally, rates of obesity, hypertension, and diabetes are higher for ethnic minorities, particularly African Americans and Native Americans/Pacific Islander populations, which makes them much more likely to develop renal failure. Yet, despite the fact that the majority of the kidney transplant waitlist is comprised of minorities, the vast majority of individuals that receive kidney transplants are white. This indicates a serious disparity in transplant resource allocation.

All of this information points to a serious need for reconsidering renal transplant eligibility for obese and severely obese patients. The disparities in access faced by obese patients, many of whom belong to an ethnic minority, is a largely unjustified barrier based on conflicting evidence. Whether or not these policies are grounded in biases needs examination, and Dr. Gardiner made it clear how poignant these barriers to access are for many renal failure patients.

Heather Gardiner discussed the issues of using BMI to determine eligibility for a kidney transplant. There are many issues using BMI, as it does not take into account muscle mass. As well as, does not take into account gender and age. Many individuals who have high BMI’s are obese and later suffer from kidney disease. Chronic kidney disease can be dormant until it reaches end-stage renal disease. 703,000 individuals suffer from ESRD, and minorities are more affected due to high rates of diabetes and hypertension in a lot of their communities. Once a patient is diagnosed with ESRD, they are put on dialysis in hopes of one day receiving a kidney transplant. Majority of the individuals on the waitlist for a transplant are minorities, but whites receive most of the transplants. There is conflicting evidence regarding obesity and kidney transplantation. Many centers encourage weight loss before receiving a kidney transplant, but evidence shows it is good to be a little overweight in the long run when having received a transplant. While other evidence shows, obesity negative effects the ability to perform a kidney transplantation and has lower success rates in the short term. Many centers/programs have their own criteria for eligibility for a kidney transplant, which mainly uses BMI and other factors. To get a better understanding of how healthcare professionals view these policies, Gardiner and peers performed a study. The study looked at how these individuals viewed the policies, and whether they agreed with the policy or were even aware there was a policy. Gardiner also asked what the cutoff for kidney transplant should be in regards to BMI. Gardiner then performed another study to view the criteria from kidney transplant centers. She was only able to receive 19, as she found that centers were not very willing to hand over this information. Information that should be easily accessible to potential patients. Many centers had cutoffs for eligibility that were in terms BMI levels. She found that this is an issue because many individuals can not lose the weight required when on dialysis and that many of the programs don’t offer any assistance in achieving the weight loss required. As well as, the increasing difficulty to get put back on the waitlist, once made inactive by the center. She proposed many recommendations on how to better the system, but we need to assess provider/program bias (implicit and explicit). Weight loss prior to transplant has not been shown to improve transplant outcome. As well as, using different measurements instead of BMI that differentiate muscle mass and adiposity.

I found the talk very interesting, as I did not have much knowledge of the process of kidney transplantation or what goes into being eligible for a kidney transplant. Unsurprisingly, I was not shocked that minority groups as the ones who suffer most when discussing these issues. While I personally do not know anyone who is on dialysis or needs a kidney transplant, it was still sad to hear all the issues of using BMI to determine eligibility. If we know using BMI is not a good indicator, why do we continue to use it and not adopt some of the alternatives? Why do we use hemodialysis most often in the US, when peritoneal dialysis is proven to be better? The talk overall was very interesting, and I thought she presented the information clearly and made it thought provoking.

This talk was actually really enlightening for me. I really had no idea to what degree there were restrictions on transplants and other similar procedures. However, it does make sense that since there is a limited supply of organs for transplantation that there would be regulations in place to promote the highest level of viability.

The research that Dr. Gardiner brought up about the amount of discrepancy there is concerning the threshold of obesity for kidney transplant was really astounding. It seems that there should be more consistency across transplant centers and wait lists especially for a matter that can be life and death for a lot of people. Even more surprising was how reluctant the transplant centers were to give out their policy to Dr. Gardiner when this information is supposed to be available to the public in the first place.

Concerning the topic of obesity in relation to kidney transplants, it was surprising how conflicting some of the data was from previous studies that Dr. Gardiner presented on. I think it’s really great that she has taken such an interest in the subject, especially considering that the level of obesity in the United States is on the rise and will continue to rise rather quickly. Therefore, a significantly larger amount of people in the future will be potentially affected by the restrictions on kidney transplants in the future.

I would definitely be excited to see what her research produces in the future and if it will have any significant impact on the policies of kidney transplants in. Please keep us posted!

Dr. Heather Gardiner from Temple University discussed her research on BMI as being a factor in a patient’s eligibility for a kidney transplant. She explained how kidney disease affects more than 200,000 people per year. With kidney disease, patients are administered dialysis. Yet, with this treatment, they can’t travel, they are in pain and often fall into a state of depression. Therefore, surgery to help them get off of dialysis is very ideal. However, patients are tested on BMI and those over a threshold determined by the clinic cannot get the surgery.

Dr. Gardiner’s research stemmed from this difficulty that patients experience due to being turned away from surgery. She discovered that BMI was not a true indicator of obesity however it continues to be used to indicate transplant abilities. Additionally, there is an obesity paradox that having a little extra weight can help to cope with dialysis yet they are told to lose weight for a transplant. It does not follow. Among transplant candidates with obesity defined by BMI, just half ever achieve active status and another 15% die before reaching active status. Therefore, Dr. Gardiner had some recommendations. Her research recommended that transplant facilities need to assess the provider or program bias and reconsider using BMI during evaluation for surgery. Of the policies of 19 transplant centers, only eight had documented plans to help weight loss. Her recommended alternatives included alternative ways to accurately test for obesity. This is where I began to question it. It seemed that her alternatives were costly and that weight was a true indicator of how the surgery was going to be successful or not. Therefore, removing BMI, while the reasons follow, it does not follow that transplant centers will remove BMI from their programs and replace it with ways that are more time consuming and costly to do. Also, she did not know a lot of the science behind the transplants that frustrated me when answers I would have liked to know could not be answered. She was a very captivating speaker and I would like to know more of how her research will play out.

Heather Gardiner’s talk regarding patient eligibility for kidney transplants raised questions about using BMI as surgery criteria and challenged disparities in transplant access. Minorities are disproportionately effected by kidney disease, largely because of greater risk for diabetes and hypertension, with American Indians 9.5 times more likely than Caucasian individuals to develop kidney failure. Although frequently used in the US, hemodialysis is a time-intensive and arduous treatment, so transplants are preferred treatment for kidney disease, yet it is difficult to obtain a transplant, especially for non-white patients. In addition to this, BMI is often used as criteria for transplant eligibility, despite the fact that studies on short-term success of transplants in obese patients are contested and long-term studies show good outcomes, suggesting obesity may not be a significant surgery risk factor. As well, using obesity as criteria compounds minority inaccess to transplants, due to higher obesity rates in disadvantaged populations. Using obesity as criteria also creates barriers to treatment as it is unrealistic to ask low-energy and ill patients to lose weight after undergoing dialysis, and once individuals are moved to inactive status on the transplant waiting list, the status of only about half later changes. Interestingly, Gardiner described one study in which treatment center professionals were interviewed about performing transplant surgery on obese patients and participants described a wide range of beliefs about an appropriate BMI cutoff, with many unsure or feeling the decision would be contextual. Gardiner also described a study of 19 kidney treatment center policies, with the finding that respondants desired  a higher BMI cutoff and believed in a more holistic assessment of patients.

Gardiner’s talk was relevant to our class’s exploration of health disparities and exemplified how health illiteracy and low SES causes minority populations to inordinately struggle with disease. As well, Gardiner’s speech exemplified lack of transparency in the healthcare system, as many patients are unaware of a kidney center’s policies before joining and later cannot switch, and hemodialysis has many drawbacks but is likely used partly for its profitability. Finally, Gardiner’s talk exemplified the role of community and lifestyle in disease prevention, as increased rates of kidney disease in minority populations largely result from inaccess to healthy foods, exercise and information.

I agree with Gardiner’s point that there are more accurate forms of measuring adipose tissue than BMI, and I think more research needs to be done about the outcome of surgery for obese patients to determine if adipose tissue should be a consideration for surgery at all, as current information is somewhat mixed. If more research shows adipose tissue is not a high-risk factor for surgery, it will be difficult to change BMI requirements, particularly due to lack of transparency about center policies. Possible solutions might include government requirement of increased transparency, allowing patients to begin treatment only at centers that do not have BMI requirements. As well, more research may convince professionals the requirement is unecessary, increasing the number of centers that perform transplant surgery on high-BMI patients.