# Patient and clinician perspectives on the management of obesity in kidney failure prior to kidney transplantation: a mixed-methods systematic review

## TL;DR

This study explores how patients and clinicians manage obesity in kidney failure patients before kidney transplants, highlighting barriers and the need for better support.

## Contribution

The paper provides a mixed-methods synthesis of patient and clinician perspectives on obesity management in kidney failure, emphasizing equity in transplantation.

## Key findings

- Barriers include dialysis impacting eating behavior and lack of resources for weight loss.
- Weight stigma and poor communication were identified as significant challenges.
- A paradigm shift is needed to move beyond BMI for equitable access to transplantation.

## Abstract

Obesity increases the risk of developing chronic kidney disease and progression to kidney failure (KF) and precludes kidney transplantation (KT). Challenges exist in people with KF losing weight to access KT, therefore understanding patients' and clinicians lived experiences of obesity management is crucial to improving equitable access to KT. This review aimed to synthesise qualitative and quantitative evidence to better understand patients' and clinicians’ experiences of obesity management in KF prior to transplantation.

This mixed-methods systematic review followed the integrated methodological framework by the Joanna Briggs Institute. MEDLINE, Embase, and Web of Sciences were searched from 1st January 1980 to 16th April 2025 for studies investigating patients' and clinicians' perspectives on obesity management in KF. Qualitative, quantitative and mixed methods studies published in English in which patients or clinicians reported on their experiences of obesity management in kidney failure were included. Two investigators independently screened studies, extracted data, and assessed the risk of bias. Summary data were extracted from published reports and quantitative data underwent transformation into ‘qualitised’ data, Qualitative findings and qualitised survey results were analysed inductively using thematic synthesis. The study was registered with PROSPERO, CRD42024510237. The Mixed Methods Appraisal Tool version 2018 was used to evaluate the quality of selected studies.

Of 6525 records identified, 5203 remained after de-duplication and 7 studies met inclusion criteria with a total of 738 participants The overall quality of the studies was low and only one study scored highly on the quality assessment. Four main themes were constructed 1) Hungry and exhausted: The impact of dialysis on eating behaviour and activity (six studies [n = 339]) 2) Weight stigma–lack of support, trust and open communication (five studies [n = 212]) 3) Lack of resources as a barrier for weight loss (six studies [n = 339]) 4) Who gets a transplant? Moving beyond BMI to improve equity in transplantation (four studies [n = 631]).

Significant barriers to accessing and delivering obesity management were identified. When interpreting the results it should be appreciated that the overall quality of the studies was low. and clinician perspectives were limited to dietitians, nephrologists and transplant surgeons. To address these barriers, targeted strategies are recommended, such as enhanced training for health professional on obesity and communication about weight and weight stigma. There is an urgent paradigm shift needed to ensure equitable access to obesity management for people with obesity and KF.

10.13039/501100000272National Institute for Health and Care Research.