{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T13:34:39Z","timestamp":1785418479116,"version":"3.56.0"},"reference-count":41,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,4,9]],"date-time":"2026-04-09T00:00:00Z","timestamp":1775692800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Victor Babes University of Medicine and Pharmacy"},{"id":[{"id":"https:\/\/ror.org\/00afdp487","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Obesity, type 2 diabetes mellitus, and hypertension are increasingly prevalent components of metabolic syndrome and major contributors to cardiovascular disease and chronic kidney disease progression; however, in end-stage kidney disease an \u201cobesity paradox\u201d has been described, with higher body mass index (BMI) sometimes associated with improved survival on hemodialysis. Material and methods: This retrospective, single-center Eastern European cohort study aimed to characterize mortality and its causes around hemodialysis initiation in the contemporary era of cardiometabolic prevention and to test whether the obesity paradox persists at this high-risk transition. Adult patients initiating dialysis at the \u201cPius Br\u00e2nzeu\u201d Emergency Clinical Hospital (Timi\u0219oara, Romania) between January 2022 and December 2025 (n = 268; median age 66 years; 61% male; median eGFR 6.4 mL\/min\/1.73 m2) were analyzed using Kaplan\u2013Meier methods and Cox regression, with comprehensive baseline clinical, laboratory, echocardiographic, medication, infection, and vascular access data; follow-up was obtained at 3, 6, 12, 24, and 36 months. Results: Late referral was common (61% &lt; 3 months of nephrology follow-up), dialysis initiation was predominantly urgent (only 16% scheduled), and central venous catheters were the main access (81%), with substantial comorbidity burden (cardiovascular disease 71%, hypertension 90%) and frequent infections at initiation. BMI categories were non-obese (&lt;25 kg\/m2, 30%), overweight (25\u201329.9 kg\/m2, 48%), and obese (\u226530 kg\/m2, 22%); diabetes prevalence rose with BMI (32% to 58%). Unadjusted mortality did not differ by BMI (19.8%, 18.8%, 15.3%; log-rank p = 0.622), yet multivariable Cox models showed overweight status independently reduced mortality (HR 0.22 at 3 months, 0.29 at 1 year, 0.31 at 3 years vs. non-obese), whereas obesity was not protective. Early mortality was driven mainly by age \u2265 65 years, while diabetes and chronic obstructive pulmonary disease predicted later mortality; longer pre-dialysis follow-up time was strongly protective (HR per year 0.70 at 3 years), and higher intact parathyroid hormone showed an inverse association with 1-year mortality. Conclusions: These findings show a modified obesity paradox at dialysis initiation in which moderate excess weight, but not obesity, is associated with improved adjusted survival, underscoring the clinical importance of earlier nephrology engagement and individualized nutritional and risk-factor management during the pre-dialysis and early dialysis periods.<\/jats:p>","DOI":"10.3390\/jcm15082856","type":"journal-article","created":{"date-parts":[[2026,4,9]],"date-time":"2026-04-09T13:09:31Z","timestamp":1775740171000},"page":"2856","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["BMI Category and Survival in Incident Hemodialysis Patients: The Overweight Advantage in an Eastern European Cohort"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4297-077X","authenticated-orcid":false,"given":"Alexandru Catalin","family":"Motofelea","sequence":"first","affiliation":[{"name":"Department of Doctoral Studies, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"},{"name":"Centre for Molecular Research in Nephrology and Vascular Disease\/MOL-NEPHRO-VASC, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-4743-2453","authenticated-orcid":false,"given":"Nicu","family":"Olariu","sequence":"additional","affiliation":[{"name":"Department of Doctoral Studies, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"},{"name":"Centre for Molecular Research in Nephrology and Vascular Disease\/MOL-NEPHRO-VASC, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"},{"name":"Department VII, Internal Medicine II, Division of Nephrology, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-0148-3365","authenticated-orcid":false,"given":"Radu","family":"Pecingina","sequence":"additional","affiliation":[{"name":"Department of Doctoral Studies, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"},{"name":"Centre for Molecular Research in Nephrology and Vascular Disease\/MOL-NEPHRO-VASC, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luciana","family":"Marc","sequence":"additional","affiliation":[{"name":"Centre for Molecular Research in Nephrology and Vascular Disease\/MOL-NEPHRO-VASC, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"},{"name":"Department VII, Internal Medicine II, Division of Nephrology, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3664-1945","authenticated-orcid":false,"given":"Lazar","family":"Chisavu","sequence":"additional","affiliation":[{"name":"Centre for Molecular Research in Nephrology and Vascular Disease\/MOL-NEPHRO-VASC, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"},{"name":"Department VII, Internal Medicine II, Division of Nephrology, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Flaviu","family":"Bob","sequence":"additional","affiliation":[{"name":"Centre for Molecular Research in Nephrology and Vascular Disease\/MOL-NEPHRO-VASC, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"},{"name":"Department VII, Internal Medicine II, Division of Nephrology, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"},{"name":"County Emergency Hospital, L. Rebreanu Street, Nr. 156, 300723 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3220-6623","authenticated-orcid":false,"given":"Adelina","family":"Mihaescu","sequence":"additional","affiliation":[{"name":"Centre for Molecular Research in Nephrology and Vascular Disease\/MOL-NEPHRO-VASC, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"},{"name":"Department VII, Internal Medicine II, Division of Nephrology, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"},{"name":"County Emergency Hospital, L. Rebreanu Street, Nr. 156, 300723 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6684-1759","authenticated-orcid":false,"given":"Adrian","family":"Apostol","sequence":"additional","affiliation":[{"name":"Department VII, Internal Medicine II, Discipline of Cardiology, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square No. 2, 300041 Timisoara, Romania"},{"name":"Department of Cardiology, Pius Brinzeu Clinical Emergency County Hospital Timisoara, 300736 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oana","family":"Schiller","sequence":"additional","affiliation":[{"name":"B Braun Avitum Dialysis Centre, 300417 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-7597-823X","authenticated-orcid":false,"given":"Nadica","family":"Motofelea","sequence":"additional","affiliation":[{"name":"Department of Doctoral Studies, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"},{"name":"Department of Obstetrics and Gynecology, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square No. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9947-8316","authenticated-orcid":false,"given":"Gheorghe Nicusor","family":"Pop","sequence":"additional","affiliation":[{"name":"Center for Modeling Biological Systems and Data Analysis (CMSBAD), \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreea","family":"Crintea","sequence":"additional","affiliation":[{"name":"Department of Molecular Sciences, University of Medicine and Pharmacy \u201cIuliu Ha\u021bieganu\u201d, 400349 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adalbert","family":"Schiller","sequence":"additional","affiliation":[{"name":"Centre for Molecular Research in Nephrology and Vascular Disease\/MOL-NEPHRO-VASC, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"},{"name":"Department VII, Internal Medicine II, Division of Nephrology, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,9]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1027","DOI":"10.1016\/S0140-6736(23)02750-2","article-title":"Worldwide Trends in Underweight and Obesity from 1990 to 2022: A Pooled Analysis of 3663 Population-Representative Studies with 222 Million Children, Adolescents, and Adults","volume":"403","author":"Phelps","year":"2024","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"203","DOI":"10.1016\/S0140-6736(23)01301-6","article-title":"Global, Regional, and National Burden of Diabetes from 1990 to 2021, with Projections of Prevalence to 2050: A Systematic Analysis for the Global Burden of Disease Study 2021","volume":"402","author":"Ong","year":"2023","journal-title":"Lancet"},{"key":"ref_3","unstructured":"(2026, February 02). 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