A public health perspective on CKD and obesity

End-stage renal disease (ESRD) is a growing health burden for global populations, which has generated keen interest in interventions to prevent or delay the progression of its antecedent chronic kidney disease (CKD). There are biologically plausible mechanisms that link increased adiposity to pathways of kidney injury, animal models of obesity-related kidney disease and specific glomerular disease that is observed in extremely obese humans. Further, individuals with progressive kidney disease and incident ESRD are more obese than their counterparts in the general population. These observations raise the consideration that population-based policies targeted at delaying progressive CKD should recommend interventions for treatment of obesity in these individuals. We examine this proposition first by describing the public health infrastructure that exists to translate CKD public health policy, illustrating it by examples familiar to the practicing nephrologist. Next, we suggest that, despite the evidence supporting an association between increased body weight and progressive CKD, it is premature to contemplate public health recommendations for weight reduction in CKD patients. This prematurity reflects the lack of strong evidence that reduction in body weight delays or prevents the progression of CKD and persistent uncertainty about the direction of the association between obesity and mortality in individuals with advanced kidney failure. We conclude by noting that this position is not that of therapeutic nihilism but rather a caution to approach weight management in CKD on an individual, patient-to-patient basis, and an emphasis for further randomized clinical trials to resolve these uncertainties.