{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,14]],"date-time":"2026-07-14T14:45:37Z","timestamp":1784040337658,"version":"3.55.0"},"reference-count":41,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2026,1,2]],"date-time":"2026-01-02T00:00:00Z","timestamp":1767312000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Background\/Objectives: The study aimed to investigate whether malnutrition influences the obesity paradox and to explore the relationship between obesity with\/without malnutrition and in-hospital outcomes among hospitalized ESKD patients. Methods: The study used the National Inpatient Sample database from 2016 to 2021. Hospitalized ESKD patients were included and categorized into three groups: non-obese, obese without malnutrition, and obese with malnutrition. The association between obesity with\/without malnutrition and in-hospital outcomes, compared to non-obese patients, were analyzed. Results: Of 674,367 hospitalized ESKD patients included, 125,978 (18.7%) had obesity. Obese ESKD patients without malnutrition were associated with a decreased risk of mortality (odd ratio [OR] 0.87, 95% CI 0.84\u20130.91), whereas obese patients with malnutrition were associated with an increased risk of mortality (OR 2.08, 95% CI 1.90\u20132.27), compared to non-obese patients. Furthermore, obesity, with or without malnutrition, was linked to higher infection-related complications and resource utilization, especially when malnutrition was present. Conclusions: Our findings show that obesity is significantly associated with lower in-hospital mortality among ESKD patients without malnutrition. However, when malnutrition coexists, this survival advantage is reversed, underscoring the importance of detecting malnutrition in obese ESKD patients.<\/jats:p>","DOI":"10.3390\/nu18010157","type":"journal-article","created":{"date-parts":[[2026,1,2]],"date-time":"2026-01-02T12:23:44Z","timestamp":1767356624000},"page":"157","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Association of Obesity and Malnutrition with In-Hospital Mortality and Clinical Outcomes in Patients Receiving Maintenance Dialysis: A National Database Study"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1765-6159","authenticated-orcid":false,"given":"Wannasit","family":"Wathanavasin","sequence":"first","affiliation":[{"name":"Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA"},{"name":"Nephrology Unit, Department of Medicine, Charoenkrung Pracharak Hospital, Bangkok Metropolitan Administration, Bangkok 10120, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2920-7235","authenticated-orcid":false,"given":"Wisit","family":"Kaewput","sequence":"additional","affiliation":[{"name":"Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charat","family":"Thongprayoon","sequence":"additional","affiliation":[{"name":"Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6103-2338","authenticated-orcid":false,"given":"Supawit","family":"Tangpanithandee","sequence":"additional","affiliation":[{"name":"Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1597-2411","authenticated-orcid":false,"given":"Supawadee","family":"Suppadungsuk","sequence":"additional","affiliation":[{"name":"Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA"},{"name":"Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10540, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9954-9711","authenticated-orcid":false,"given":"Wisit","family":"Cheungpasitporn","sequence":"additional","affiliation":[{"name":"Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,1,2]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1975","DOI":"10.1016\/S0140-6736(14)61601-9","article-title":"Worldwide access to treatment for end-stage kidney disease: A systematic review","volume":"385","author":"Liyanage","year":"2015","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1563","DOI":"10.1001\/jamainternmed.2016.4975","article-title":"Emergency department use and hospital admissions among patients with end-stage renal disease in the United States","volume":"176","author":"Lovasik","year":"2016","journal-title":"JAMA Intern. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2052","DOI":"10.1016\/S0140-6736(18)31694-5","article-title":"Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: Reference and alternative scenarios for 2016\u201340 for 195 countries and territories","volume":"392","author":"Foreman","year":"2018","journal-title":"Lancet"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1159\/000520466","article-title":"Causes of death in end-stage kidney disease: Comparison between the United States renal data system and a large integrated health care system","volume":"53","author":"Bhandari","year":"2022","journal-title":"Am. J. Nephrol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"380","DOI":"10.1053\/j.jrn.2018.08.006","article-title":"Global prevalence of protein-energy wasting in kidney disease: A meta-analysis of contemporary observational studies from the international society of renal nutrition and metabolism","volume":"28","author":"Carrero","year":"2018","journal-title":"J. Ren. Nutr."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1760","DOI":"10.1016\/j.clnu.2024.05.037","article-title":"Malnutrition as a potential predictor of mortality in chronic kidney disease patients on dialysis: A systematic review and meta-analysis","volume":"43","author":"Rashid","year":"2024","journal-title":"Clin. Nutr."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Wathanavasin, W., Thongprayoon, C., Kaewput, W., Tangpanithandee, S., Suppadungsuk, S., and Cheungpasitporn, W. (2025). Temporal Trends and Clinical Impact of Malnutrition on In-Hospital Outcomes Among Patients with Advanced Chronic Kidney Disease: A Nationwide Inpatient Analysis. Nutrients, 17.","DOI":"10.3390\/nu17091508"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Zha, Y., and Qian, Q. (2017). Protein nutrition and malnutrition in CKD and ESRD. Nutrients, 9.","DOI":"10.3390\/nu9030208"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1160","DOI":"10.1093\/jn\/nxaa010","article-title":"End-Stage Renal Disease Patients Lose a Substantial Amount of Amino Acids during Hemodialysis","volume":"150","author":"Hendriks","year":"2020","journal-title":"J. Nutr."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"2646","DOI":"10.1681\/ASN.V7122646","article-title":"Increased energy expenditure in hemodialysis patients","volume":"7","author":"Ikizler","year":"1996","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1167","DOI":"10.1002\/ncp.11040","article-title":"Malnutrition accelerates the occurrence of infectious complications in patients with chronic kidney disease: A cross-sectional survey of 682 patients with chronic kidney disease","volume":"38","author":"Wang","year":"2023","journal-title":"Nutr. Clin. Pract."},{"key":"ref_12","unstructured":"World Health Organization (2025, March 22). Malnutrition. Available online: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/malnutrition."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1016\/j.gheart.2016.01.003","article-title":"Obesity and its Relation With Diabetes and Hypertension: A Cross-Sectional Study Across 4 Geographical Regions","volume":"11","author":"Patel","year":"2016","journal-title":"Glob. Heart"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1001\/jama.2012.113905","article-title":"Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic review and meta-analysis","volume":"309","author":"Flegal","year":"2013","journal-title":"JAMA"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"271","DOI":"10.1016\/j.ekir.2017.01.009","article-title":"The Obesity Paradox in Kidney Disease: How to Reconcile it with Obesity Management","volume":"2","author":"Rhee","year":"2017","journal-title":"Kidney Int. Rep."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"2595","DOI":"10.1007\/s11255-025-04438-w","article-title":"Impact of obesity on in-hospital outcomes in peritoneal dialysis patients: Insights from a nationwide analysis","volume":"57","author":"Kaewput","year":"2025","journal-title":"Int. Urol. Nephrol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"415","DOI":"10.1016\/j.pcad.2013.10.005","article-title":"Obesity paradox in end-stage kidney disease patients","volume":"56","author":"Park","year":"2014","journal-title":"Prog. Cardiovasc. Dis."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1097\/CCM.0000000000000602","article-title":"The relationship among obesity, nutritional status, and mortality in the critically ill","volume":"43","author":"Robinson","year":"2015","journal-title":"Crit. Care Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"201","DOI":"10.1016\/j.ekir.2016.10.008","article-title":"Sarcopenia, obesity, and mortality in US adults with and without chronic kidney disease","volume":"2","author":"Androga","year":"2017","journal-title":"Kidney Int. Rep."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Wathanavasin, W., Banjongjit, A., Avihingsanon, Y., Praditpornsilpa, K., Tungsanga, K., Eiam-Ong, S., and Susantitaphong, P. (2022). Prevalence of sarcopenia and its impact on cardiovascular events and mortality among dialysis patients: A systematic review and meta-analysis. Nutrients, 14.","DOI":"10.3390\/nu14194077"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1159\/000471488","article-title":"The Metabolic Phenotype in Obesity: Fat Mass, Body Fat Distribution, and Adipose Tissue Function","volume":"10","author":"Goossens","year":"2017","journal-title":"Obes. Facts"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"575","DOI":"10.1053\/j.jrn.2023.03.004","article-title":"Impact of abdominal fat distribution on mortality and its changes over time in patients undergoing hemodialysis: A prospective cohort study","volume":"33","author":"Iida","year":"2023","journal-title":"J. Ren. Nutr."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1017\/S095442242400012X","article-title":"Challenges in identifying malnutrition in obesity; An overview of the state of the art and directions for future research","volume":"38","author":"Mwala","year":"2024","journal-title":"Nutr. Res. Rev."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1989","DOI":"10.1016\/j.ekir.2023.07.020","article-title":"Residual Kidney Function and Cause-Specific Mortality Among Incident Hemodialysis Patients","volume":"8","author":"Okazaki","year":"2023","journal-title":"Kidney Int. Rep."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"592","DOI":"10.1111\/1744-9987.12576","article-title":"Residual Renal Function in Hemodialysis and Inflammation","volume":"21","author":"Corchete","year":"2017","journal-title":"Ther. Apher. Dial."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"700","DOI":"10.1056\/NEJMoa2304820","article-title":"Effect of Hemodiafiltration or Hemodialysis on Mortality in Kidney Failure","volume":"389","author":"Blankestijn","year":"2023","journal-title":"N. Engl. J. Med."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"28","DOI":"10.1093\/ndt\/17.suppl_11.28","article-title":"The malnutrition, inflammation, and atherosclerosis (MIA) syndrome\u2014The heart of the matter","volume":"17","author":"Lindholm","year":"2002","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1053\/j.jrn.2017.10.002","article-title":"Effects of Oral Nutritional Supplements on Mortality, Missed Dialysis Treatments, and Nutritional Markers in Hemodialysis Patients","volume":"28","author":"Benner","year":"2018","journal-title":"J. Ren. Nutr."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"100087","DOI":"10.1016\/j.obpill.2023.100087","article-title":"Obesity and malnutrition in children and adults: A clinical review","volume":"8","author":"Bradley","year":"2023","journal-title":"Obes. Pillars"},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Elizabeth, L., Machado, P., Zin\u00f6cker, M., Baker, P., and Lawrence, M. (2020). Ultra-Processed Foods and Health Outcomes: A Narrative Review. Nutrients, 12.","DOI":"10.3390\/nu12071955"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1723","DOI":"10.1093\/ckj\/sfad103","article-title":"Ultraprocessed foods and chronic kidney disease-double trouble","volume":"16","author":"Avesani","year":"2023","journal-title":"Clin. Kidney J."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1007\/s40620-023-01808-4","article-title":"Relationship between dietary fiber and all-cause mortality, cardiovascular mortality, and cardiovascular disease in patients with chronic kidney disease: A systematic review and meta-analysis","volume":"37","author":"Gai","year":"2024","journal-title":"J. Nephrol."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Wathanavasin, W., Cheungpasitporn, W., Thongprayoon, C., and F\u00fcl\u00f6p, T. (2025). Effects of Dietary Fiber Supplementation on Modulating Uremic Toxins and Inflammation in Chronic Kidney Disease Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Toxins, 17.","DOI":"10.3390\/toxins17020057"},{"key":"ref_34","first-page":"2","article-title":"Plant-based diets in patients with chronic kidney disease","volume":"18","author":"Wathanavasin","year":"2024","journal-title":"Asian Biomed. Res. Rev. News"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"525","DOI":"10.1016\/j.mpmed.2009.07.005","article-title":"Infection and malnutrition","volume":"37","author":"Macallan","year":"2009","journal-title":"Medicine"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"435","DOI":"10.1053\/j.jrn.2018.06.005","article-title":"Interactions Between Malnutrition, Inflammation, and Fluid Overload and Their Associations With Survival in Prevalent Hemodialysis Patients","volume":"28","author":"Dekker","year":"2018","journal-title":"J. Ren. Nutr."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1644","DOI":"10.1016\/j.clnu.2021.01.028","article-title":"ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease","volume":"40","author":"Fiaccadori","year":"2021","journal-title":"Clin. Nutr."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"677","DOI":"10.1007\/s12603-019-1215-9","article-title":"The relationship between nutritional status, anemia and other vitamin deficiencies in the elderly receiving home care","volume":"23","author":"Emiroglu","year":"2019","journal-title":"J. Nutr. Health Aging"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"864","DOI":"10.1016\/j.ajkd.2003.07.016","article-title":"Malnutrition-inflammation complex syndrome in dialysis patients: Causes and consequences","volume":"42","author":"Ikizler","year":"2003","journal-title":"Am. J. Kidney Dis."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"2172","DOI":"10.1093\/ndt\/gfz278","article-title":"Propensity score matched mortality comparisons of peritoneal and in-centre haemodialysis: Systematic review and meta-analysis","volume":"35","author":"Elsayed","year":"2020","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"e844","DOI":"10.3928\/01477447-20160509-04","article-title":"Effect of body mass index on blood transfusion in total hip and knee arthroplasty","volume":"39","author":"Frisch","year":"2016","journal-title":"Orthopedics"}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/1\/157\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,2]],"date-time":"2026-01-02T12:27:30Z","timestamp":1767356850000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/1\/157"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,2]]},"references-count":41,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1]]}},"alternative-id":["nu18010157"],"URL":"https:\/\/doi.org\/10.3390\/nu18010157","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,2]]}}}