1
|
Zevallos A, Cornejo J, Sarmiento J, Shojaeian F, Mokhtari-Esbuie F, Adrales G, Li C, Sebastian R. Outcomes of Sleeve Gastrectomy in Patients With Organ Transplant-Related Immunosuppression. J Surg Res 2024; 300:253-262. [PMID: 38833753 DOI: 10.1016/j.jss.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 05/02/2024] [Accepted: 05/08/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Obesity is frequent among organ transplant recipients, increasing the risk of acute graft rejection and overall morbimortality. Laparoscopic sleeve gastrectomy (LSG) effectively improves graft survival and associated comorbidities. We first compared 30-d outcomes between chronic immunosuppressed (CI) and nonchronic immunosuppressed (non-CI) patients. Then, between organ transplant and non-organ transplant CI patients who underwent LSG. METHODS Patients who underwent LSG within the metabolic and bariatric surgery accreditation and quality improvement program 2017-2019 were included. Using 1:1 and 1:4 propensity score matching analysis, the cohorts were matched for 30 characteristics. We then compared 30-d outcomes between CI and non-CI (analysis 1) and between organ transplant and non-organ transplant CI patients who underwent LSG (analysis 2). RESULTS A total of 486,576 patients were included. The matched cohorts in analysis 1 (n = 8978) and analysis 2 (n = 1152, n = 371) had similar preoperative characteristics. Propensity score matching in analysis 1 showed that patients in the CI group had significantly higher rates of renal complications (0.4% versus 0.2%, P = 0.006), unplanned intensive care unit admission (1.1% versus 0.7%, P = 0.003), blood transfusions (1.1% versus 0.7%, P = 0.003), readmissions (4.6% versus 3.5%, P < 0.001), reoperations (1.4% versus 1.0%, P = 0.033), interventions (1.3% versus 1.0%, P = 0.026), and postoperative bleeding (0.6% versus 0.4%, P = 0.013). In analysis 2, patients with organ transplant CI had a higher rate of pulmonary complications (1.1% versus 0.3%, P = 0.043), renal complications (2.4% versus 0.2%, P < 0.001), blood transfusions (6.5% versus 1.3%, P < 0.001), and readmissions (10.0% versus 4.6%, P < 0.001). CONCLUSIONS Patients with transplant-related CI who underwent LSG have higher 30-d postoperative complication rates compared to nontransplant-related CI patients; however, there were no differences in terms of mortality, intensive care unit admissions, staple line leaks, or bleeding. LSG is safe and feasible in this high-risk population.
Collapse
Affiliation(s)
- Alba Zevallos
- Department of Surgery, Northwest Hospital, Randallstown, Maryland; Universidad Cientifica del Sur, Lima, Peru
| | - Jorge Cornejo
- Department of Surgery, Northwest Hospital, Randallstown, Maryland
| | | | - Fatemeh Shojaeian
- Department of Surgery, The Johns Hopkins University, Baltimore, Maryland
| | | | - Gina Adrales
- Department of Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Christina Li
- Department of Surgery, Northwest Hospital, Randallstown, Maryland
| | - Raul Sebastian
- Department of Surgery, Northwest Hospital, Randallstown, Maryland; Department of Surgery, The Johns Hopkins University, Baltimore, Maryland.
| |
Collapse
|
2
|
Higgins MS, Ismail S, Chen M, Agala CB, Detwiler R, Farrell TM, Hodges MM. Evaluating the safety of bariatric surgery as a bridge to kidney transplant: a retrospective cohort study. Surg Endosc 2024:10.1007/s00464-024-11087-0. [PMID: 39085668 DOI: 10.1007/s00464-024-11087-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 07/13/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Bariatric surgery has been proven safe in end-stage kidney disease (ESKD); however, few studies have evaluated whether a history of bariatric surgery impacts transplant-specific outcomes. We hypothesize that a history of bariatric surgery at the time of transplant does not adversely impact transplant-specific outcomes. METHODS The IBM MarketScan Commercial Claims and Encounters database was queried for patients with a history of kidney transplant between 2000 and 2021. Patients were stratified into three groups based on bariatric surgery status and body mass index (BMI) at the time of transplant: patients with obesity (O), patients without obesity (NO), and patients with a history of bariatric surgery (BS). Inverse probability of treatment weighting was used to control for confounding. Adjusted hazard ratios (aHRs) describing the risk of transplant-specific and postoperative outcomes were estimated using weighted Kaplan-Meier curves. Primary outcomes included 30-day and 1-year risk of transplant-specific outcomes. Secondary outcomes included 30-day and 1-year postoperative complications and 30-day and 1-year risk of wound-related complications. RESULTS We identified 14,806 patients; 128 in the BS group, 1572 in the O group, and 13,106 in the NO group. There was no difference in 30-day or 1-year risk of transplant-specific complications between the BS and NO group or the O and NO group. Patients with obesity (O) were more likely to experience wound infection (aHR 1.49, 95% CI 1.12-1.99), wound dehiscence (aHR 2.2, 95% CI 1.5-3.2), and minor reoperation (aHR 1.52, 95% CI 1.23-1.89) at 1 year. BS patients had increased risk of wound infection at 1 year (aHR 2.79, 95% CI 1.26-6.16), but were without increase in risk of minor or major reoperation. CONCLUSION A history of bariatric surgery does not adversely affect transplant-specific outcomes after kidney transplant. Bariatric surgery can be safely utilized to improve the transplant candidacy of patients with obesity with CKD and ESKD.
Collapse
Affiliation(s)
- Madeleine S Higgins
- Division of Gastrointestinal Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Sherin Ismail
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Melissa Chen
- Division of Abdominal Transplantation, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Chris B Agala
- Division of Gastrointestinal Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Randal Detwiler
- Division of Nephrology and Hypertension, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Timothy M Farrell
- Division of Gastrointestinal Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Maggie M Hodges
- Division of Gastrointestinal Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, USA.
- Division of Gastrointestinal Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Burnett Womack Bldg, Suite 4034, 101 Manning Drive, Chapel Hill, NC, 27599-7081, USA.
| |
Collapse
|
3
|
Spaggiari M, Martinino A, Bencini G, Masrur MA, Petrochenkov E, Lian A, Olazar J, Di Cocco P, Almario-Alvarez J, Benedetti E, Tzvetanov I. Timing Considerations for Sleeve Gastrectomy in Kidney Transplant Patients: A Single Center Evaluation. Transpl Int 2024; 37:12690. [PMID: 38957660 PMCID: PMC11217181 DOI: 10.3389/ti.2024.12690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 06/07/2024] [Indexed: 07/04/2024]
Abstract
Current scientific literature is deficient in detailing the optimal timing for conducting bariatric surgery in relation to kidney transplantation. In this study, we performed a retrospective evaluation of kidney transplant recipients with BMI >35 kg/m2. It aimed to provide data on those who received both sleeve gastrectomy (SG) and kidney transplantation (KT) simultaneously, as well as on patients who underwent SG and KT at different times, either before or after. In addition, the acceptance levels of the bariatric surgery among different scenarios were assessed. Our findings demonstrated that combined KT and SG led to successful weight loss, in contrast to undergoing kidney transplant alone, while maintaining comparable rates of graft and patient survival. Weight loss was similar between recipients who had a combined operation and those who underwent SG following the transplant. Additionally, over a median time frame of 1.7 years, patients who underwent SG before KT exhibited a statistically significant reduction in BMI at the time of the transplant. Notably, our study highlights that patients offered the combined procedure were significantly more likely to undergo SG compared to those for whom SG was presented at a different operative time than the transplant.
Collapse
Affiliation(s)
- Mario Spaggiari
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
| | - Alessandro Martinino
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
| | - Giulia Bencini
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
| | - Mario A. Masrur
- Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
| | - Egor Petrochenkov
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
| | - Amy Lian
- University of Illinois at Chicago College of Medicine, Chicago, IL, United States
| | - Joanna Olazar
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
| | - Pierpaolo Di Cocco
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
| | - Jorge Almario-Alvarez
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
| | - Enrico Benedetti
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
| | - Ivo Tzvetanov
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
| |
Collapse
|
4
|
Alajous S, Budhiraja P. New-Onset Diabetes Mellitus after Kidney Transplantation. J Clin Med 2024; 13:1928. [PMID: 38610694 PMCID: PMC11012473 DOI: 10.3390/jcm13071928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/19/2024] [Accepted: 03/24/2024] [Indexed: 04/14/2024] Open
Abstract
New-Onset Diabetes Mellitus after Transplantation (NODAT) emerges as a prevalent complication post-kidney transplantation, with its incidence influenced by variations in NODAT definitions and follow-up periods. The condition's pathophysiology is marked by impaired insulin sensitivity and β-cell dysfunction. Significant risk factors encompass age, gender, obesity, and genetics, among others, with the use of post-transplant immunosuppressants intensifying the condition. NODAT's significant impact on patient survival and graft durability underscores the need for its prevention, early detection, and treatment. This review addresses the complexities of managing NODAT, including the challenges posed by various immunosuppressive regimens crucial for transplant success yet harmful to glucose metabolism. It discusses management strategies involving adjustments in immunosuppressive protocols, lifestyle modifications, and pharmacological interventions to minimize diabetes risk while maintaining transplant longevity. The importance of early detection and proactive, personalized intervention strategies to modify NODAT's trajectory is also emphasized, advocating for a shift towards more anticipatory post-transplant care.
Collapse
Affiliation(s)
| | - Pooja Budhiraja
- Division of Medicine, Mayo Clinic Arizona, Phoenix, AZ 85054, USA;
| |
Collapse
|
5
|
Moreau K, Couzi L, Kaminski H, Merville P, Monsaingeon-Henry M, Pupier E, Gronnier C, Gatta-Cherifi B. High Risk of Acute Kidney Failure in Kidney Transplant Recipients Early after Bariatric Surgery. Obes Facts 2023; 17:98-102. [PMID: 38043514 PMCID: PMC10836936 DOI: 10.1159/000533710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 08/18/2023] [Indexed: 12/05/2023] Open
Abstract
Bariatric surgery is routinely proposed to patients suffering from obesity including kidney transplant recipients. In this specific population, bariatric surgery has a positive impact in long-term outcomes in terms of patient and graft survival. We report here the cases of 4 patients with five post-kidney transplantation bariatric surgeries who experimented acute renal injury early after surgery. Creatinine rising occurred between day 14 and day 20 after surgery. In all cases, it was due to dehydration leading to a pre-renal acute renal failure. The specific care of kidney transplanted patients is discussed: single kidney associated with pre-existing altered kidney function associated with concomitant use of nephrotoxic drugs. Specific education intervention before surgery associated with careful early management of hydration after surgery is mandatory for these patients.
Collapse
Affiliation(s)
| | - Lionel Couzi
- Renal Transplant Unit, Bordeaux, France
- Univ. Bordeaux, CNRS, ImmunoConcEpT, Bordeaux, France
| | - Hannah Kaminski
- Renal Transplant Unit, Bordeaux, France
- Univ. Bordeaux, CNRS, ImmunoConcEpT, Bordeaux, France
| | - Pierre Merville
- Renal Transplant Unit, Bordeaux, France
- Univ. Bordeaux, CNRS, ImmunoConcEpT, Bordeaux, France
| | | | - Emilie Pupier
- Endocrinology Department, Hospital Haut Leveque, CHU de Bordeaux, Bordeaux, France
| | - Caroline Gronnier
- Inserm Unit 1053, Esogastric and Endocrine Unit, Department of Digestive Surgery Magellan Center Bordeaux University Hospital, Bordeaux, France
| | - Blandine Gatta-Cherifi
- Endocrinology Department, Hospital Haut Leveque, CHU de Bordeaux, Bordeaux, France,
- Inserm U1215 Université de Bordeaux, Bordeaux, France,
| |
Collapse
|
6
|
Di Cocco P, Bencini G, Spaggiari M, Petrochenkov E, Akshelyan S, Fratti A, Zhang JC, Almario Alvarez J, Tzvetanov I, Benedetti E. Obesity and Kidney Transplantation-How to Evaluate, What to Do, and Outcomes. Transplantation 2023; 107:1903-1909. [PMID: 36855222 DOI: 10.1097/tp.0000000000004564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Obesity is a growing issue that is spreading worldwide; its prevalence is ever increasing in patients with end-stage renal disease and represents a potential barrier to transplantation. The lack of unanimous guidelines exacerbates the current disparity in treatment, which can affect outcomes, leading to a significantly longer time on the waiting list. Multidisciplinary and multimodal management (encompassing several healthcare professionals such as nephrologists, transplant physicians and surgeons, primary care providers, and nurses) is of paramount importance for the optimal management of this patient population in a continuum from waitlisting to transplantation. Development of this guideline followed a standardized protocol for evidence review. In this review, we report on our clinical experience in transplantation of obese patients; strategies to manage this condition, including bariatric surgery, suitable timing for transplantation among this patient population, and clinical experience in robotic sleeve gastrectomy; and simultaneous robotic kidney transplantation to achieve optimal outcomes.
Collapse
Affiliation(s)
- Pierpaolo Di Cocco
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Giulia Bencini
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Mario Spaggiari
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Egor Petrochenkov
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Stepan Akshelyan
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Alberto Fratti
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Jing Chen Zhang
- University of Illinois College of Medicine at Chicago, Chicago, IL
| | - Jorge Almario Alvarez
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Ivo Tzvetanov
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Enrico Benedetti
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| |
Collapse
|
7
|
Fernando S, Varma J, Dengu F, Menon V, Malik S, O'Callaghan J. Bariatric surgery improves access to renal transplantation and is safe in renal failure as well as after transplantation: A systematic review and meta-analysis. Transplant Rev (Orlando) 2023; 37:100777. [PMID: 37459746 DOI: 10.1016/j.trre.2023.100777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 07/01/2023] [Accepted: 07/02/2023] [Indexed: 07/31/2023]
Abstract
INTRODUCTION Effective workup and listing of end-stage renal disease (ESRD) patients for renal transplantation, often with multiple co-morbidities, poses a challenge for transplant teams. Obesity is a common co-morbidity associated with adverse outcomes in ESRD and kidney transplant (KT) recipients. Bariatric and metabolic surgery (BMS) has long been established as a safe and effective treatment for morbid obesity. In this study, the authors aimed to evaluate the strength of evidence for both the efficacy and safety of bariatric surgery in patients with ESRD or kidney transplantation. METHODS A literature search was performed using key terms including "transplantation", "kidney", "renal", "obesity", and "bariatric". Databases searched include MEDLINE, EMBASE and Web of Science from inception to date (April 2021). Methodological quality was assessed using the Newcastle-Ottawa tool. Selected articles were then categorised into patients awaiting waiting list acceptance, patients awaiting transplantation, patients undergoing simultaneous BMS + KT and patients undergoing BMS following a previous renal transplant. Summary effects are presented with a level of statistical significance and 95% Confidence Intervals. RESULTS A total of 28 articles were selected following the literature search. Fourteen studies on patients awaiting listing (n = 1903), nine on patients on the KT waiting list (n = 196), a single study on simultaneous BMS and KT and ten studies on patients undergoing BMS following KT (n = 198). Mean change in BMI for patients awaiting listing was -11.3 kg/m2 (95%CI: -15.3 to -7.3, p < 0.001), mean change in BMI for patients listed for KT was -11.2 kg/m 2(95%CI: -12.9 to -9.5, p 0.001) and mean change for patients with prior KT was -11.0 kg/m2 (95%CI: -7.09 to -14.9, p < 0.001). The combined mortality rate for patients who had undergone both BMS and KT was 4% (n = 15). DISCUSSION This review demonstrates BMS is both safe and efficacious in patients with ESRD prior to KT and in those post KT. It would enable difficult-to-list obese recipients the possibility to undergo transplantation and should be considered as part of the work up process.
Collapse
Affiliation(s)
- Sherwin Fernando
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Rd, Coventry CV2 2DX, United Kingdom.
| | - Jonny Varma
- University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin St, Bristol BS2 8HW, United Kingdom
| | - Fungai Dengu
- Oxford University Hospitals NHS Foundation Trust, Old Rd, Headington, Oxford OX3 7LE, United Kingdom
| | - Vinod Menon
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Rd, Coventry CV2 2DX, United Kingdom
| | - Shafi Malik
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Rd, Coventry CV2 2DX, United Kingdom
| | - John O'Callaghan
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Rd, Coventry CV2 2DX, United Kingdom; Centre for Evidence in Transplantation, University of Oxford, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom
| |
Collapse
|
8
|
Shi B, Ying T, Xu J, Wyburn K, Laurence J, Chadban SJ. Obesity is Associated With Delayed Graft Function in Kidney Transplant Recipients: A Paired Kidney Analysis. Transpl Int 2023; 36:11107. [PMID: 37324221 PMCID: PMC10261700 DOI: 10.3389/ti.2023.11107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 05/11/2023] [Indexed: 06/17/2023]
Abstract
Obesity is increasingly prevalent among candidates for kidney transplantation. Existing studies have shown conflicting post-transplant outcomes for obese patients which may relate to confounding bias from donor-related characteristics that were unaccounted for. We used ANZDATA Registry data to compare graft and patient survival between obese (BMI >27.5 kg/m2 Asians; >30 kg/m2 non-Asians) and non-obese kidney transplant recipients, while controlling for donor characteristics by comparing recipients of paired kidneys. We selected transplant pairs (2000-2020) where a deceased donor supplied one kidney to an obese candidate and the other to a non-obese candidate. We compared the incidence of delayed graft function (DGF), graft failure and death by multivariable models. We identified 1,522 pairs. Obesity was associated with an increased risk of DGF (aRR = 1.26, 95% CI 1.11-1.44, p < 0.001). Obese recipients were more likely to experience death-censored graft failure (aHR = 1.25, 95% CI 1.05-1.49, p = 0.012), and more likely to die with function (aHR = 1.32, 95% CI 1.15-1.56, p = 0.001), versus non-obese recipients. Long-term patient survival was significantly worse in obese patients with 10- and 15-year survival of 71% and 56% compared to 77% and 63% in non-obese patients. Addressing obesity is an unmet clinical need in kidney transplantation.
Collapse
Affiliation(s)
- Bree Shi
- Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australia
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medicine Research Institute, Adelaide, SA, Australia
| | - Tracey Ying
- Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australia
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medicine Research Institute, Adelaide, SA, Australia
- Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Josephine Xu
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medicine Research Institute, Adelaide, SA, Australia
- Department of Transplant Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Kate Wyburn
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medicine Research Institute, Adelaide, SA, Australia
- Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jerome Laurence
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medicine Research Institute, Adelaide, SA, Australia
- Department of Transplant Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Steven J Chadban
- Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australia
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medicine Research Institute, Adelaide, SA, Australia
- Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| |
Collapse
|
9
|
Sarno G, Frias-Toral E, Ceriani F, Montalván M, Quintero B, Suárez R, García Velasquèz E, Muscogiuri G, Iannelli A, Pilone V, Schiavo L. The Impact and Effectiveness of Weight Loss on Kidney Transplant Outcomes: A Narrative Review. Nutrients 2023; 15:nu15112508. [PMID: 37299471 DOI: 10.3390/nu15112508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
Obesity is a worldwide epidemic that leads to several non-communicable illnesses, including chronic kidney disease (CKD). Diet and lifestyle modifications have shown a limited impact in the treatment of obesity. Because the group of end-stage renal disease (ESRD) patients examined in this study had limited access to kidney transplantation (KT), patients with obesity were thought to be at an increased risk of intraoperative and postoperative KT complications. Although bariatric surgery (BS) is now recognized as the gold standard treatment for morbid obesity, its role in ESRD or kidney transplant patients remains unknown. It is critical to know the correlation between weight loss and complications before and after KT, the impact of the overall graft, and patients' survival. Hence, this narrative review aims to present updated reports addressing when to perform surgery (before or after a KT), which surgical procedure to perform, and again, if strategies to avoid weight regain must be specific for these patients. It also analyzes the metabolic alterations produced by BS and studies its cost-effectiveness pre- and post-transplantation. Due to the better outcomes found in KT recipients, the authors consider it more convenient to perform BS before KT. However, more multicenter trials are required to provide a solid foundation for these recommendations in ERSD patients with obesity.
Collapse
Affiliation(s)
- Gerardo Sarno
- San Giovanni di Dio e Ruggi D'Aragona, University Hospital, Scuola Medica Salernitana, 84131 Salerno, Italy
| | - Evelyn Frias-Toral
- School of Medicine, Universidad Espìritu Santo, Samborondòn 091952, Ecuador
| | - Florencia Ceriani
- Nutrition School, Universidad de la República (UdelaR), Ricaldoni s/n, Montevideo 11300, Uruguay
| | - Martha Montalván
- School of Medicine, Universidad Catòlica Santiago de Guayaquil, Av. Pdte. Carlos Julio Arosemena Tola, Guayaquil 090615, Ecuador
| | - Beatriz Quintero
- School of Medicine, Universidad Técnica Particular de Loja, Calle París, San Cayetano Alto, Loja 110101, Ecuador
| | - Rosario Suárez
- School of Medicine, Universidad Técnica Particular de Loja, Calle París, San Cayetano Alto, Loja 110101, Ecuador
| | | | - Giovanna Muscogiuri
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Antonio Iannelli
- Department of Clinical Research and Innovation, University Hospital of Nice, Cimiez Hospital, 06000 Nice, France
- Digestive Surgery and Liver Transplantation Unit, University Hospital of Nice, Archet 2 Hospital, 06200 Nice, France
- Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", 06204 Nice, France
| | - Vincenzo Pilone
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081 Baronissi, Italy
| | - Luigi Schiavo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081 Baronissi, Italy
- National Biodiversiy Future Center, 90133 Palermo, Italy
| |
Collapse
|
10
|
Liu Y, Bendersky VA, Chen X, Ghildayal N, Harhay MN, Segev DL, McAdams-DeMarco M. Post-kidney transplant body mass index trajectories are associated with graft loss and mortality. Clin Transplant 2023; 37:e14947. [PMID: 36811329 PMCID: PMC10175140 DOI: 10.1111/ctr.14947] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/11/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Early post-kidney transplantation (KT) changes in physiology, medications, and health stressors likely impact body mass index (BMI) and likely impact all-cause graft loss and mortality. METHODS We estimated 5-year post-KT (n = 151 170; SRTR) BMI trajectories using an adjusted mixed effects model. We estimated long-term mortality and graft loss risks by 1-year BMI change quartile (decrease [1st quartile]: change < -.07 kg/m2 /month; stable [2nd quartile]: -.07 ≤ change ≤ .09 kg/m2 /month; increase [3rd, 4th quartile]: change > .09 kg/m2 /month) using adjusted Cox proportional hazards models. RESULTS BMI increased in the 3 years post-KT (.64 kg/m2 /year, 95% CI: .63, .64) and decreased in years 3-5 (-.24 kg/m2 /year, 95% CI: -.26, -.22). 1-year post-KT BMI decrease was associated with elevated risks of all-cause mortality (aHR = 1.13, 95% CI: 1.10-1.16), all-cause graft loss (aHR = 1.13, 95% CI: 1.10-1.15), death-censored graft loss (aHR = 1.15, 95% CI: 1.11-1.19), and mortality with functioning graft (aHR = 1.11, 95% CI: 1.08-1.14). Among recipients with obesity (pre-KT BMI≥30 kg/m2 ), BMI increase was associated with higher all-cause mortality (aHR = 1.09, 95% CI: 1.05-1.14), all-cause graft loss (aHR = 1.05, 95% CI: 1.01-1.09), and mortality with functioning graft (aHR = 1.10, 95% CI: 1.05-1.15) risks, but not death-censored graft loss risks, relative to stable weight. Among individuals without obesity, BMI increase was associated with lower all-cause graft loss (aHR = .97, 95% CI: .95-.99) and death-censored graft loss (aHR = .93, 95% CI: .90-.96) risks, but not all-cause mortality or mortality with functioning graft risks. CONCLUSIONS BMI increases in the 3 years post-KT, then decreases in years 3-5. BMI loss in all adult KT recipients and BMI gain in those with obesity should be carefully monitored post-KT.
Collapse
Affiliation(s)
- Yi Liu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Xiaomeng Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nidhi Ghildayal
- Department of Surgery, New York University School of Medicine, New York, NY
| | - Meera N. Harhay
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA
- Tower Health Transplant Institute, Tower Health System, West Reading, Pennsylvania
| | - Dorry L. Segev
- Department of Surgery, New York University School of Medicine, New York, NY
- Department of Population, New York University School of Population Health, New York, NY
- Scientific Registry of Transplant Recipients, Minneapolis, MN
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University School of Medicine, New York, NY
- Department of Population, New York University School of Population Health, New York, NY
| |
Collapse
|
11
|
A 5-year propensity-matched analysis of perioperative outcomes in patients with chronic kidney disease undergoing bariatric surgery. Surg Endosc 2023; 37:2335-2346. [PMID: 36401102 DOI: 10.1007/s00464-022-09756-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/01/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Bariatric surgery can improve renal function in patients with comorbid chronic kidney disease (CKD) and obesity. Additionally, bariatric surgery can enhance outcomes following renal transplantation. The safety of bariatric surgery in patients with CKD has been debated in the literature. This study evaluates the frequency of perioperative complications associated with CKD. METHODS The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried from 2015-2019. Patients were included if they had a vertical sleeve gastrectomy (VSG) or Roux-en-Y gastric bypass (RYGB) and were stratified based on CKD status. An unmatched and propensity-matched analysis was performed comparing 30-day perioperative outcomes between the groups. RESULTS A total of 717,809 patients included in this study, 5817(0.8%) had CKD, of whom 2266(0.3%) were on dialysis. 74.3% of patients with CKD underwent VSG with 25.7% underwent RYGB. Comparing RYGB to VSG, patients who underwent RYGB had a higher rate of deep organ space infection (0.7%vs.0.1%,p = 0.021) and re-intervention (5.0% vs. 2.2%,p < 0.001). Within the VSG cohort, a matched analysis was performed for those with CKD and without CKD. The CKD cohort had higher risk of complications such as bleeding (2.1%vs. 0.9%,p < 0.001), readmission (9.3%vs.4.9%,p < 0.001), reoperation (2.7%vs.1.3%,p < 0.001), and need for reintervention (2.2%vs.1.3%,p < 0.001). Notably, patients with CKD also had a higher mortality (0.6%vs.0.2%,p = 0.003). No difference was seen between patients with renal insufficiency and patients on dialysis. CONCLUSION VSG has been the operation of choice in patients with CKD. Our results showed it is the safer option for patients with CKD compared to RYGB. Although this patient population does have an increased risk of adverse perioperative events, dialysis didn't affect the outcome. Bariatric surgeons who operate on patients with CKD should be well informed and remain vigilant given the increased perioperative risk. The risk is still considerably low, and the potential benefit on renal function and improvement in candidacy for renal transplant outweigh the risk. They should be considered as surgical candidates.
Collapse
|
12
|
Tan SYT, Lee PC, Ganguly S, Kek PC, Kee T, Ho QY, Thangaraju S. Bariatric Surgery in Kidney Transplant Candidates and Recipients: Experience at an Asian Center. J Obes Metab Syndr 2022; 31:325-333. [PMID: 36416037 PMCID: PMC9828702 DOI: 10.7570/jomes21090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/25/2022] [Accepted: 10/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background Kidney transplant (KT) candidates and recipients with obesity experience more frequent complications such as infection, poorer allograft outcomes, diabetes, and mortality, limiting their eligibility for transplantation. Bariatric surgery (BS) is not commonly performed among KT patients given concerns about immunosuppression absorption, wound healing, infections, and graft outcomes. Its role has not been described before in an Asian KT patient setting. Methods A retrospective review of patients who underwent BS at the largest KT center in Singapore from 2008 to 2020 was conducted. Metabolic outcomes, immunosuppression doses, graft outcomes, and mortality were studied. Results Seven patients underwent BS and KT (4 underwent BS before KT, 3 underwent BS after KT; 4 underwent sleeve gastrectomy, 3 underwent gastric bypass). Mean total weight losses of 23.8% at 1 year and 18.6% at 5 years post-BS were achieved. Among the five patients with diabetes, glycemic control improved after BS. There were no deaths in the first 90 days or graft loss in the first year after KT and BS. Patients who underwent BS after KT had no significant changes in immunosuppression dose. Conclusion BS can be safely performed in KT recipients and candidates and results in sustainable weight losses and improvements in metabolic comorbidities. Although no major complications were observed in our study, close monitoring of this complex group of patients is imperative.
Collapse
Affiliation(s)
- Sarah Ying Tse Tan
- Department of Endocrinology, Singapore General Hospital, Singapore,Corresponding author Sarah Ying Tse Tan https://orcid.org/0000-0001-5451-788X Department of Endocrinology, Singapore General Hospital, 20 College Rd, Singapore 169856, Singapore Tel: +65-8123-9629 Fax: +65-6576-7832 E-mail:
| | - Phong Ching Lee
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Sonali Ganguly
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Peng Chin Kek
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Terence Kee
- Department of Renal Medicine, Singapore General Hospital, Singapore,SingHealth Duke-National University of Singapore Transplant Centre, Singapore
| | - Quan Yao Ho
- Department of Renal Medicine, Singapore General Hospital, Singapore,SingHealth Duke-National University of Singapore Transplant Centre, Singapore
| | - Sobhana Thangaraju
- Department of Renal Medicine, Singapore General Hospital, Singapore,SingHealth Duke-National University of Singapore Transplant Centre, Singapore
| |
Collapse
|
13
|
Potrykus M, Czaja-Stolc S, Małgorzewicz S, Proczko-Stepaniak M, Dębska-Ślizień A. Diet Management of Patients with Chronic Kidney Disease in Bariatric Surgery. Nutrients 2022; 15:nu15010165. [PMID: 36615822 PMCID: PMC9824280 DOI: 10.3390/nu15010165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/23/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022] Open
Abstract
Morbid obesity is considered a civilization disease of the 21st century. Not only does obesity increase mortality, but it is also the most important cause of the shortening life expectancy in the modern world. Obesity is associated with many metabolic abnormalities: dyslipidemia, hyperglycemia, cardiovascular diseases, and others. An increasing number of patients diagnosed with chronic kidney disease (CKD) are obese. Numerous additional disorders associated with impaired kidney function make it difficult to conduct slimming therapy and may also be associated with a greater number of complications than in people with normal kidney function. Currently available treatments for obesity include lifestyle modification, pharmacotherapy, and bariatric surgery (BS). There are no precise recommendations on how to reduce excess body weight in patients with CKD treated conservatively, undergoing chronic dialysis, or after kidney transplantation. The aim of this study was to analyze studies on the bariatric treatment of obesity in this group of people, as well as to compare the recommendations typical for bariatrics and CKD.
Collapse
Affiliation(s)
- Marta Potrykus
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, 80-211 Gdańsk, Poland
| | - Sylwia Czaja-Stolc
- Department of Clinical Nutrition, Medical University of Gdansk, 80-211 Gdańsk, Poland
- Correspondence: ; Tel.: +48-(58)-349-27-24
| | - Sylwia Małgorzewicz
- Department of Clinical Nutrition, Medical University of Gdansk, 80-211 Gdańsk, Poland
| | - Monika Proczko-Stepaniak
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, 80-211 Gdańsk, Poland
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdansk, 80-952 Gdańsk, Poland
| |
Collapse
|
14
|
Bariatric surgery before and after kidney transplantation: a propensity score-matched analysis. Surg Obes Relat Dis 2022; 19:501-509. [PMID: 36572583 DOI: 10.1016/j.soard.2022.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 09/27/2022] [Accepted: 11/13/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Obesity is becoming more prevalent in the end-stage renal disease population. Bariatric surgery (BS) is increasingly considered as an approach to become eligible for kidney transplant (KT) or reduce obesity-related morbidities. OBJECTIVES To assess the short- and long-term outcomes of patients who underwent both BS and KT and to determine the optimal timing of BS. METHODS Patients who underwent both KT and BS between January 2000 and December 2020 were included and stratified according to the sequence of the 2 operations. The primary outcomes were patient and graft survival. The secondary outcomes were postoperative complications and efficacy of weight loss. RESULTS Twenty-two patients were included in the KT first group and 34 in the BS first group. Death-uncensored graft survival in the KT first group was significantly higher than in the BS first group (90.9% versus 71.4%, P = .009), without significant difference in patient survival and death-censored graft survival (100% versus 90.5%, P = .082; 90.9% versus 81.0%, P = .058). There was no significant difference in 1-year total weight loss (1-yr TWL: median [interquartile range {IQR}], 36.0 [28.0-42.0] kg versus 29.6 [21.5-40.6] kg, P = .424), 1-year percentage of excess weight loss (1-yr %EWL: median [IQR], 74.9 [54.1-99.0] versus 57.9 [47.5-79.4], P = .155), and the incidence of postoperative complications (36.4% versus 50.0%, P = .316) between the KT first and BS first groups. CONCLUSION Both pre- and posttransplant BS are effective and safe. Different conditions of each transplant candidate should be considered in detail to determine the optimal timing of BS.
Collapse
|
15
|
Bariatric Surgery Outcomes in Patients with Kidney Transplantation. J Clin Med 2022; 11:jcm11206030. [PMID: 36294351 PMCID: PMC9604744 DOI: 10.3390/jcm11206030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/03/2022] [Accepted: 10/11/2022] [Indexed: 11/17/2022] Open
Abstract
Obesity and kidney transplantation (KTx) are closely related. Obesity increases the risk of chronic kidney disease and can be a relative contraindication for KTx. Besides, KTx recipients are predisposed to obesity and its comorbidities. Consequently, bariatric surgery (BS) emerges as a powerful therapeutic tool either before or after KTx. Since evidence regarding the best approach is still scarce, we aimed to describe renal and metabolic outcomes in a single centre with more than 15-year experience in both surgeries. Methods: A retrospective study including patients who had received a KTx either before or after BS. Usual metabolic and renal outcomes, but also new variables (as renal graft dysfunction) were collected for a minimum follow-up of 1-year post-BS. Results: A total of 11 patients were included: n = 6 (BS-post-KTx) and n = 5 (BS-pre-KTx). One patient was assessed in both groups. No differences in the main outcomes were identified, but BS-post-KTx group tended to gain more weight during the follow-up. The incidence of renal graft dysfunction was comparable (4/6 for BS-post-KTx, 3/5 for BS-pre-KTx) between groups. Conclusions: BS in patients with KTx appears to be safe and effective attending to metabolic and renal outcomes. These results seem irrespective of the time course, except for weight regain, which appears to be a common pattern in the BS-post-KTx group.
Collapse
|
16
|
Comparison of Kidney Transplantation Outcomes Between Patients with and Without Pre-transplantation Bariatric Surgery: a Systematic Review. Obes Surg 2022; 32:4066-4081. [PMID: 36227430 DOI: 10.1007/s11695-022-06308-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/24/2022] [Accepted: 09/28/2022] [Indexed: 10/17/2022]
Abstract
This systematic review evaluated the impact of bariatric surgery, performed to improve eligibility for kidney transplantation, on post-transplantation outcomes. A systematic literature search was performed for articles published by 30 January 2022. A total of 31 studies were included. Among patients without pre-transplantation bariatric surgery, 18 studies reported 13.7% graft loss and 9.1% mortality within 5 years' post-transplantation. Among recipients with pre-transplantation bariatric surgery, 15 studies reported 8.7% graft loss and 2.8% mortality within 1 month to over 5 years' post-transplantation. Two case-control studies comparing post-transplantation outcomes between recipients with and without prior bariatric surgery demonstrated no significant differences between groups for graft loss, patient mortality, delayed graft function, wound complications and lymphocele. Non-randomized selection of patients and different lengths of follow-up limit the results of this study.
Collapse
|
17
|
Kanbay M, Copur S, Ucku D, Zoccali C. Donor obesity and weight gain after transplantation: two still overlooked threats to long-term graft survival. Clin Kidney J 2022; 16:254-261. [PMID: 36755848 PMCID: PMC9900567 DOI: 10.1093/ckj/sfac216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Indexed: 11/12/2022] Open
Abstract
The effect of donor obesity on kidney transplantation success has long been an overlooked clinical research area. Even though there is no strict guideline in most countries prohibiting donation from obese individuals, most candidates with a body mass index >35-40 kg/m2 are rejected due to concerns regarding long-term renal functional deterioration in the donor. The effects of excessive fat mass on renal function and allograft survival have been analysed by several longitudinal and follow-up studies. These studies have documented the deleterious effect on long-term graft outcomes of excessive body mass in living kidney donors and de novo obesity or pre-existing obesity worsening after transplantation on kidney outcomes. However, there is a paucity of clinical trials aimed at countering overweight and obesity in living and deceased kidney donors and in transplant patients. In this review we will briefly discuss the mechanism whereby fat excess induces adverse kidney outcomes and describe the effects on graft function and survival in living obese donors.
Collapse
Affiliation(s)
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Duygu Ucku
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Carmine Zoccali
- Renal Research Institute, New York, NY, USA,Department of Medicine, Division of Nephrology, Associazione Ipertensione, Nefrologia e Trapianto Renale, Nefrologia, Ospedali Riuniti, Reggio Calabria, Italy
| |
Collapse
|
18
|
Tan A, Wilson S, Sumithran P. The application of body mass index-based eligibility criteria may represent an unjustified barrier to renal transplantation in people with obesity. Clin Obes 2022; 12:e12505. [PMID: 34964256 DOI: 10.1111/cob.12505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/07/2021] [Accepted: 12/11/2021] [Indexed: 12/22/2022]
Abstract
The prevalence of both obesity and end-stage kidney disease is increasing. In many centres, obesity is considered a relative contraindication to kidney transplantation due to an association with short- and longer-term adverse outcomes. This leads to delayed transplant waitlisting and longer organ waiting times for people with obesity. This review evaluates whether intentional pre-transplant weight loss in people with obesity improves kidney transplant outcomes. There are currently no data showing that non-surgical weight loss of 10% or more improves graft or patient survival over 4-5 years. Outcomes from bariatric surgery cohorts have been generally neutral or favourable after pre-transplant weight loss of ~25%. Given the survival benefit of kidney transplantation compared to maintenance dialysis, and the difficulty of achieving and maintaining weight loss, the common practice of recommending weight loss to achieve arbitrary targets prior to waiting list activation needs to be carefully considered.
Collapse
Affiliation(s)
- Alanna Tan
- Department of Endocrinology, Austin Health, Melbourne, Victoria, Australia
| | - Scott Wilson
- Department of Nephrology, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Priya Sumithran
- Department of Endocrinology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine (St Vincent's), University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
19
|
Assessment and management of obesity and metabolic syndrome in children with CKD stages 2-5 on dialysis and after kidney transplantation-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol 2022; 37:1-20. [PMID: 34374836 PMCID: PMC8674169 DOI: 10.1007/s00467-021-05148-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/04/2021] [Accepted: 05/18/2021] [Indexed: 12/12/2022]
Abstract
Obesity and metabolic syndrome (O&MS) due to the worldwide obesity epidemic affects children at all stages of chronic kidney disease (CKD) including dialysis and after kidney transplantation. The presence of O&MS in the pediatric CKD population may augment the already increased cardiovascular risk and contribute to the loss of kidney function. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists who develop clinical practice recommendations (CPRs) for the nutritional management of children with kidney diseases. We present CPRs for the assessment and management of O&MS in children with CKD stages 2-5, on dialysis and after kidney transplantation. We address the risk factors and diagnostic criteria for O&MS and discuss their management focusing on non-pharmacological treatment management, including diet, physical activity, and behavior modification in the context of age and CKD stage. The statements have been graded using the American Academy of Pediatrics grading matrix. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. Research recommendations are provided. The CPRs will be periodically audited and updated by the PRNT.
Collapse
|
20
|
Oniscu GC, Abramowicz D, Bolignano D, Gandolfini I, Hellemans R, Maggiore U, Nistor I, O'Neill S, Sever MS, Koobasi M, Nagler EV. Management of obesity in kidney transplant candidates and recipients: A clinical practice guideline by the Descartes working group of ERA. Nephrol Dial Transplant 2021; 37:i1-i15. [PMID: 34788854 PMCID: PMC8712154 DOI: 10.1093/ndt/gfab310] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The clinical practice guideline Management of Obesity in Kidney Transplant Candidates and Recipients was developed to guide decision-making in caring for people with end-stage kidney disease (ESKD) living with obesity. The document considers the challenges in defining obesity, weighs interventions for treating obesity in kidney transplant candidates as well as recipients and reflects on the impact of obesity on the likelihood of wait-listing as well as its effect on transplant outcomes. It was designed to inform management decisions related to this topic and provide the backdrop for shared decision-making. This guideline was developed by the European Renal Association’s Developing Education Science and Care for Renal Transplantation in European States working group. The group was supplemented with selected methodologists to supervise the project and provide methodological expertise in guideline development throughout the process. The guideline targets any healthcare professional treating or caring for people with ESKD being considered for kidney transplantation or having received a donor kidney. This includes nephrologists, transplant physicians, transplant surgeons, general practitioners, dialysis and transplant nurses. Development of this guideline followed an explicit process of evidence review. Treatment approaches and guideline recommendations are based on systematic reviews of relevant studies and appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendations Assessment, Development and Evaluation approach. Limitations of the evidence are discussed and areas of future research are presented.
Collapse
Affiliation(s)
| | | | - Davide Bolignano
- Department of Medical and Surgical Sciences. Nephrology and Dialysis Unit. Magna Graecia University of Catanzaro, Italy
| | - Ilaria Gandolfini
- Dipartimento di Medicina e Chirurgia Università di Parma, UO Nefrologia, Azienda Ospedaliera-Universitaria Parma, Parma Italy
| | | | - Umberto Maggiore
- Dipartimento di Medicina e Chirurgia Università di Parma, UO Nefrologia, Azienda Ospedaliera-Universitaria Parma, Parma Italy
| | - Ionut Nistor
- Methodological Center for Medical Research and Evidence-Based Medicine, University of Medicine and Pharmacy "Grigore T. Popa", Iași, Romania
| | | | | | - Muguet Koobasi
- Knowledge Centre for Health Ghent, Ghent University Hospital, Belgium
| | - Evi V Nagler
- Department of Nephrology, Ghent University Hospital, Belgium
| |
Collapse
|
21
|
Ku E, McCulloch CE, Roll GR, Posselt A, Grimes BA, Johansen KL. Bariatric surgery prior to transplantation and risk of early hospital re-admission, graft failure, or death following kidney transplantation. Am J Transplant 2021; 21:3750-3757. [PMID: 34331744 PMCID: PMC10184683 DOI: 10.1111/ajt.16779] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/05/2021] [Accepted: 07/22/2021] [Indexed: 01/25/2023]
Abstract
Bariatric surgery has been shown to be safe in the dialysis population. Whether bariatric surgery before kidney transplantation influences posttransplant outcomes has not been examined nationally. We included severely obese (BMI >35) dialysis patients between 18 and 70 years who received a kidney transplant according to the US Renal Data System. We determined the association between history of bariatric surgery and risk of 30-day readmission, graft failure, or death after transplantation using multivariable logistic, Fine-Gray, and Cox models. We included 12 573 patients, of whom 503 (4%) received bariatric surgery before transplantation. Median age at transplant was 53 years; 42% were women. Overall, history of bariatric surgery was not statistically significantly associated with graft failure (HR 1.02; 95% CI 0.77-1.35) or death (HR 1.10; 95% CI 0.84-1.45). However, sleeve gastrectomy (vs. no bariatric surgery) was associated with lower risk of graft failure (HR 0.39; 95% CI 0.16-0.95). In conclusion, history of bariatric surgery prior to kidney transplantation was not associated with allograft or patient survival, but findings varied by surgery type. Sleeve gastrectomy was associated with better graft survival and should be considered in severely obese transplant candidates receiving dialysis.
Collapse
Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California.,Division of Pediatric Nephrology, Department of Pediatrics, University of California San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Garrett R Roll
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, California
| | - Andrew Posselt
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, California
| | - Barbara A Grimes
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Kirsten L Johansen
- Division of Nephrology, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| |
Collapse
|
22
|
Freeman J, Konradsen H, Lindhard K, Hansen D. Weight Loss Challenges in Achieving Transplant Eligibility in Patients With Kidney Failure: A Qualitative Study. Kidney Med 2021; 4:100388. [PMID: 35386600 PMCID: PMC8978089 DOI: 10.1016/j.xkme.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Rationale & Objective Patients with kidney failure need kidney replacement therapy to maximize survival. Kidney transplant is a superior mode of kidney replacement therapy for most individuals with kidney failure. Patients with obesity often are not approved for kidney transplant until they lose sufficient weight, as obesity may complicate the surgical procedure, and the risk of graft loss increases with a higher body mass index. To help potential kidney transplant recipient candidates lose weight, further knowledge of their thoughts, feelings, and attitudes is needed. Study Design Qualitative study with semistructured interviews and an exploratory research design, guided by qualitative content analysis. Setting & Participants Patients at a hospital in Denmark required to lose weight to achieve kidney transplant eligibility. Analytical Approach From patients’ responses, we identified descriptive themes using a phenomenological approach. The factors affecting outcomes were derived reflexively from these themes. Results Ten interviews were analyzed. Experiences of obesity and weight-loss attempts were described across 4 themes; (1) restrictions and exhaustion, (2) hope and hopelessness, (3) support and self-discipline, and (4) motivation based on severity. A major motivating factor to achieving weight loss in the studied group of patients was their declining kidney function and the fact that kidney transplant cannot be considered until sufficient weight loss is achieved. Limitations Thematic saturation was reached after an unexpectedly low number of participants. The patients were only interviewed once and over the phone. Conclusions Patients with obesity who are seeking kidney transplant need additional help with the dietary restrictions brought on by kidney disease. They need assistance bridging between a kidney-friendly diet and a sustainable diet that will ensure weight loss. These patients also express not wanting to feel alone in their weight-loss battle. They are looking for help and support to achieve weight loss.
Collapse
|
23
|
Lee JH, McDonald EO, Harhay MN. Obesity Management in Kidney Transplant Candidates: Current Paradigms and Gaps in Knowledge. Adv Chronic Kidney Dis 2021; 28:528-541. [PMID: 35367021 DOI: 10.1053/j.ackd.2021.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 09/07/2021] [Accepted: 09/16/2021] [Indexed: 12/18/2022]
Abstract
In this review, we discuss the increasing prevalence of obesity among people with chronic and end-stage kidney disease (ESKD) and implications for kidney transplant (KT) candidate selection and management. Although people with obesity and ESKD receive survival and quality-of-life benefits from KT, most KT programs maintain strict body mass index (BMI) cutoffs to determine transplant eligibility. However, BMI does not distinguish between visceral adiposity, which confers higher cardiovascular risks and risks of perioperative and adverse posttransplant outcomes, and muscle mass, which is protective in ESKD. Furthermore, requirements for patients with obesity to lose weight before KT should be balanced with the findings of numerous studies that show weight loss is a risk factor for death among patients with ESKD, independent of starting BMI. Data suggest that KT is associated with survival benefits relative to remaining on dialysis for candidates with obesity although recipients without obesity have higher delayed graft function rates and longer transplant hospitalization durations. Research is needed to determine the optimal body composition metrics for KT candidacy assessments and risk stratification. In addition, ESKD-specific obesity management guidelines are needed that will address the neurologic, behavioral, socioeconomic, and physical underpinnings of this increasingly common disease.
Collapse
|
24
|
Veroux M, Mattone E, Cavallo M, Gioco R, Corona D, Volpicelli A, Veroux P. Obesity and bariatric surgery in kidney transplantation: A clinical review. World J Diabetes 2021; 12:1563-1575. [PMID: 34630908 PMCID: PMC8472502 DOI: 10.4239/wjd.v12.i9.1563] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/30/2021] [Accepted: 08/09/2021] [Indexed: 02/06/2023] Open
Abstract
Obesity is increasing worldwide, and this has major implications in the setting of kidney transplantation. Patients with obesity may have limited access to transplantation and increased posttransplant morbidity and mortality. Most transplant centers incorporate interventions aiming to target obesity in kidney transplant candidates, including dietary education and lifestyle modifications. For those failing nutritional restriction and medical therapy, the use of bariatric surgery may increase the transplant candidacy of patients with obesity and end-stage renal disease (ESRD) and may potentially improve the immediate and late outcomes. Bariatric surgery in ESRD patients is associated with weight loss ranging from 29.8% to 72.8% excess weight loss, with reported mortality and morbidity rates of 2% and 7%, respectively. The most commonly performed bariatric surgical procedures in patients with ESRD and in transplant patients are laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass. However, the correct timing of bariatric surgery and the ideal type of surgery have yet to be determined, although pretransplant LSG seems to be associated with an acceptable risk-benefit profile. We review the impact of obesity on kidney transplant candidates and recipients and in potential living kidney donors, exploring the potential impact of bariatric surgery in addressing obesity in these populations, thereby potentially improving posttransplant outcomes.
Collapse
Affiliation(s)
- Massimiliano Veroux
- Department of Medical and Surgical Sciences and Advanced Technologies GF Ingrassia, University of Catania, Catania 95123, Italy
| | - Edoardo Mattone
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, Catania 95123, Italy
| | - Matteo Cavallo
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, Catania 95123, Italy
| | - Rossella Gioco
- General Surgery Unit, University Hospital of Catania, Catania 95123, Italy
| | - Daniela Corona
- General Surgery Unit, University Hospital of Catania, Catania 95123, Italy
| | - Alessio Volpicelli
- General Surgery Unit, University Hospital of Catania, Catania 95123, Italy
| | - Pierfrancesco Veroux
- Department of General Surgery and Medical Specialities, University of Catania, Catania 95123, Italy
| |
Collapse
|
25
|
Shikora SA, Edgerton C, Harris D, Buchwald H. Metabolic surgery. Curr Probl Surg 2021; 59:101059. [DOI: 10.1016/j.cpsurg.2021.101059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 09/03/2021] [Indexed: 11/29/2022]
|
26
|
Moreau K, Monsaingeon-Henry M, Pupier E, Jambon F, Merville P, Couzi L, Kaminski H, Gatta-Cherifi B. Chirurgie bariatrique après transplantation rénale : risque accru de survenue d’insuffisance rénale fonctionnelle. Nephrol Ther 2021. [DOI: 10.1016/j.nephro.2021.07.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
27
|
Kotta PA, Elango M, Papalois V. Preoperative Cardiovascular Assessment of the Renal Transplant Recipient: A Narrative Review. J Clin Med 2021; 10:2525. [PMID: 34200235 PMCID: PMC8201125 DOI: 10.3390/jcm10112525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 12/23/2022] Open
Abstract
Patients with end-stage kidney disease (ESKD) have a high prevalence of cardiovascular disease; it is the leading cause of death in these patients and the optimisation of their cardiovascular health may improve their post-transplant outcomes. Patients awaiting renal transplant often spend significant amounts of time on the waiting list allowing for the assessment and optimisation of their cardiovascular system. Coronary artery disease (CAD) is commonly seen in these patients and we explore the possible functional and anatomical investigations that can help assess and manage CAD in renal transplant candidates. We also discuss other aspects of cardiovascular assessment and management including arrhythmias, impaired ventricular function, valvular disease, lifestyle and pulmonary arterial hypertension. We hope that this review can form a basis for centres hoping to implement an enhanced recovery after surgery (ERAS) protocol for renal transplantation.
Collapse
Affiliation(s)
| | - Madhivanan Elango
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
| | - Vassilios Papalois
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
| |
Collapse
|
28
|
Soliman BG, Tariq N, Law YY, Yi S, Nwana N, Bosetti R, Kash B, Moore LW, Gaber AO, Sherman V. Effectiveness of Bariatric Surgery in Increasing Kidney Transplant Eligibility in Patients with Kidney Failure Requiring Dialysis. Obes Surg 2021; 31:3436-3443. [PMID: 33945099 DOI: 10.1007/s11695-021-05435-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Severe obesity can increase risk of complications after kidney transplantation. There is a paucity of literature on bariatric surgery outcomes in renal transplant candidates. The objective of this study was to analyze outcomes of bariatric surgery as a weight reduction strategy for patients with kidney failure to enhance eligibility for kidney transplantation. MATERIALS AND METHODS We performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database at a single institution for patients with chronic kidney disease receiving hemodialysis therapy (CKD G5D) undergoing bariatric surgery between 2011 and 2018. RESULTS Of 2363 patients who underwent bariatric surgery, 38 (1.6%) had CKD G5D; median age (range) was 49 years (33; 69), 52.6% were female, and mean BMI was 44.2 kg/m2. Twenty-four patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB), and 14 patients underwent laparoscopic sleeve gastrectomy. Seventeen patients (46%, n=37) had a BMI≤35 at 6 months, while 25 patients (75.8%, n=33) achieved a BMI≤35 at 12 months. Of these, 18 patients (47%) were listed for kidney transplant, and 8 patients (21%) received kidney transplant. There was no statistically significant difference between sleeve and LRYGB procedures in patients who reached BMI of 35 at 12 months (P=0.58). Median length of stay was 2.3 days. Thirty-day readmission rate was 2 patients (5.3%), and 2 patients (5.3%) required reoperation (one for bleeding, one for acute recurrent hiatal hernia). No mortality occurred. CONCLUSION Laparoscopic bariatric surgery offers effective weight loss for CKD G5D patients to achieve transplant eligibility with acceptable outcomes.
Collapse
Affiliation(s)
- Basem G Soliman
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
| | - Nabil Tariq
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA.
- Department of General Surgery, Weill Cornell Medical College, New York, NY, USA.
| | - Yi Ying Law
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
| | - Stephanie Yi
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
| | - Nwabunie Nwana
- Center for Outcomes Research, Houston Methodist Hospital, Houston, TX, USA
| | - Rita Bosetti
- Center for Outcomes Research, Houston Methodist Hospital, Houston, TX, USA
| | - Bita Kash
- Center for Outcomes Research, Houston Methodist Hospital, Houston, TX, USA
| | - Linda W Moore
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
- Center for Outcomes Research, Houston Methodist Hospital, Houston, TX, USA
| | - A Osama Gaber
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
- Department of General Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Vadim Sherman
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
- Department of General Surgery, Weill Cornell Medical College, New York, NY, USA
| |
Collapse
|
29
|
Fagenson AM, Mazzei MM, Zhao H, Lu X, Edwards MA. Bariatric Surgery Outcomes in Patients with Prior Solid Organ Transplantation: an MBSAQIP Analysis. Obes Surg 2021; 30:2313-2324. [PMID: 32096014 PMCID: PMC7222903 DOI: 10.1007/s11695-020-04490-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Introduction Obesity is a risk factor for poor patient outcomes after organ transplantation (TXP). While metabolic and bariatric surgery (MBS) is safe and effective in treating severe obesity, the role of MBS in transplant patients continues to evolve. Methods A retrospective analysis was performed of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) patients in the 2017 Metabolic and Bariatric Surgery Accreditation Quality and Improvement Project (MBSAQIP) database. Propensity and case-control matching, and multivariable logistic regression were performed for 30-day post-operative outcomes. Results A total of 336 transplant patients were compared with 157,413 patients without transplant. Propensity and case-control matching reveal no significant differences in mortality (p > 0.2). However, case-control matching revealed longer operative time (104 min versus 76 min, p < 0.001), increased length of stay (2 days versus 1 day, p < 0.05), perioperative transfusions (2% versus 0.22%, p = 0.009), and leak rates (2.2% versus 0.55%, p = 0.02) in the transplant cohort. On multivariable regression analysis, prior transplantation was associated with higher rates of overall (OR 1.6, p = 0.007) and bariatric-related morbidity (OR 1.78, p = 0.004), leak (OR 3.47, p = 0.0027), and surgical site infection (OR 3.32, p = 0.004). Prior transplantation did not predict overall (p = 0.55) nor bariatric-related mortality (p = 0.99). Conclusion MBS in prior solid organ transplantation patients is overall safe, but is associated with increased operative time and length of stay, as well as higher rates of some post-operative morbidity.
Collapse
Affiliation(s)
- Alexander M Fagenson
- Department of Surgery, Temple University Hospital, Suite, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Michael M Mazzei
- Department of Surgery, Temple University Hospital, Suite, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Huaqing Zhao
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, 19140, USA
| | - Xiaoning Lu
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, 19140, USA
| | - Michael A Edwards
- Department of Surgery, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA.
| |
Collapse
|
30
|
Abstract
Obesity has a fundamental role in driving the global kidney disease burden. The perplexing relationship of obesity with chronic kidney disease remains debated. However, a thorough understanding of the interplay of obesity in conjunction with chronic kidney disease and appropriate management options is lacking, leading to further increases in morbidity and mortality. Moreover, underutilization of bariatric procedures and unrealistic expectations of weight reduction based on body mass index, leading to poor access to kidney transplantation, are fueling the fire. In this review, we summarize the available data related to the obesity and chronic kidney disease association and its novel management options.
Collapse
|
31
|
Chintam K, Chang AR. Strategies to Treat Obesity in Patients With CKD. Am J Kidney Dis 2021; 77:427-439. [PMID: 33075388 PMCID: PMC7904606 DOI: 10.1053/j.ajkd.2020.08.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/11/2020] [Indexed: 12/17/2022]
Abstract
Obesity prevalence continues to increase worldwide, accompanied by a rising tide of hypertension, diabetes, and chronic kidney disease (CKD). Although body mass index is typically used to assess obesity in clinical practice, altered body composition (eg, reduced muscle mass and increased visceral adiposity) are common among patients with CKD. Weight loss achieved through behavioral modification or medications reduces albuminuria and in some cases slows the decline in estimated glomerular filtration rate. Use of medications that promote weight loss with favorable cardiovascular risk profiles should be promoted, particularly in patients with type 2 diabetes, obesity, and CKD. For those who fail to achieve weight loss through lifestyle modification, bariatric surgery should be considered because observational studies have shown reductions in risk for estimated glomerular filtration rate decline and kidney failure. Uncertainty persists on the risk to benefit ratio of intentional weight loss in patients with kidney failure due to the lack of prospective trials and limitations of observational data. Regardless, sleeve gastrectomy is increasingly being used for patients with kidney failure and severe obesity, with success in achieving sustained weight loss, improved access to kidney transplantation, and favorable posttransplantation outcomes. More research is needed assessing long-term cardiovascular and kidney outcomes of most weight loss medications.
Collapse
Affiliation(s)
| | - Alex R Chang
- Department of Population of Health Sciences, Geisinger, Danville, PA; Kidney Health Research Institute, Geisinger, Danville, PA; Department of Nephrology, Geisinger, Danville, PA.
| |
Collapse
|
32
|
Riordan M, Oreschak K, Peters LL, Aquilante CL, Ambardekar AV. Bariatric Surgery Is Associated With Decreased Calcineurin Inhibitor Time in Therapeutic Range After Heart Transplantation. Transplant Proc 2021; 53:681-685. [PMID: 33549348 DOI: 10.1016/j.transproceed.2021.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/11/2020] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
Bariatric surgery (BSg) is an effective treatment for morbid obesity, but little is known about the outcomes of BSg patients who undergo orthotopic heart transplantation (OHT). The aim of this study was to determine if BSg alters calcineurin inhibitor (CNI) level variability after OHT. Data were collected from 58 consecutive patients who underwent OHT at a single center from 1/2018 to 4/2019: 4 with BSg prior to OHT (BSg + OHT) and 54 without prior BSg (OHT). CNI level, cardiac biopsy, and left ventricular ejection fraction (LVEF) data were collected during the first 6 months post-OHT. Comparisons were made for 3 measures of CNI variability: coefficient of variation, time in therapeutic range (TTR), and TTR by the Rosendaal method. A Pearson's correlation coefficient was calculated to assess the relationship between CNI TTR, episodes of rejection, and LVEF. The results show TTR was lower in BSg + OHT compared to OHT (12.5% vs 31.3%, P < .05). For the entire cohort, greater TTR correlated with fewer episodes of rejection (r = 0.31, P < .05). In conclusion, these findings suggest BSg + OHT patients may warrant closer monitoring of CNI levels post-OHT. Furthermore, episodes of rejection and LVEF were similar for BSg + OHT patients, indicating that BSg should not be a contraindication to transplant.
Collapse
Affiliation(s)
- Maeveen Riordan
- Department of Medicine, University of Colorado, Aurora, Colorado
| | - Kris Oreschak
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Laura L Peters
- Department of Medicine, Division of Cardiology, University of Colorado, Aurora, Colorado
| | - Christina L Aquilante
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Amrut V Ambardekar
- Department of Medicine, Division of Cardiology, University of Colorado, Aurora, Colorado.
| |
Collapse
|
33
|
Tantisattamo E, Kalantar-Zadeh K, Halleck F, Duettmann W, Naik M, Budde K. Novel approaches to sarcopenic obesity and weight management before and after kidney transplantation. Curr Opin Nephrol Hypertens 2021; 30:14-26. [PMID: 33186218 DOI: 10.1097/mnh.0000000000000673] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Although a widely recognized and complex pathophysiological condition, sarcopenic obesity remains less appreciated and may elude diagnosis and workup in both kidney transplant waitlisted candidates and kidney transplant recipients. The lack of consensus definition, and practical diagnostic tools for evaluating waitlisted candidates and transplant recipients are barriers to early detect and initiate therapeutic management for sarcopenic obesity. Although sarcopenia leads to poor clinical outcomes, posttransplant obesity yields conflicting results. Exercise and nutritional managements are common therapies for sarcopenic obese patients; however, surgery weight loss or bariatric surgery in both transplant candidates and potential living kidney donors shows promising benefits for kidney transplant access in waitlist obese candidates but may require to be selected for appropriate patients. RECENT FINDINGS Pathogenesis and management for sarcopenia and obesity are interconnected. The benefits of exercise to improve muscle mass and function is clear in waitlist kidney transplant candidates and transplant recipients. However, there are several barriers for those to increase exercise and improve physical activity including patient, provider, and healthcare or environmental factors. The advantages of fat mass reduction to lose weight can promote muscle mass and strength. However, epidemiological data regarding the obesity paradox in dialysis-dependent patients when overnutrition provides survival benefits for this population should be taken into account when performing weight loss especially bariatric surgery. SUMMARY Barriers in providing optimal care to kidney transplant waitlisted candidates and transplant recipients may partly result from underdiagnosis of sarcopenic obesity; notwithstanding that this entity has increasingly been more recognized. Mechanistic studies to better understand pathogenesis of sarcopenic obesity will help determine pathogenesis and clinical tools for diagnosis of this entity, which can facilitate further studies related to the outcomes and weight management to ultimately improve kidney transplant outcomes.
Collapse
Affiliation(s)
- Ekamol Tantisattamo
- Division of Nephrology, Hypertension and Kidney Transplantation, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange
- Nephrology Section, Department of Medicine, Veterans Affairs Long Beach Healthcare System, Long Beach, California
- Section of Nephrology, Department of Internal Medicine, Multi-Organ Transplant Center, Oakland University William Beaumont School of Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange
- Nephrology Section, Department of Medicine, Veterans Affairs Long Beach Healthcare System, Long Beach, California
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Wiebke Duettmann
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Marcel Naik
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
34
|
Rössler F, Hübel K, Di Natale S, Oberkofler C, Gerber P, Bueter M, de Rougemont O. Sleeve gastrectomy enables simultaneous pancreas and kidney transplantation in severely obese recipients. Clin Transplant 2020; 35:e14197. [PMID: 33340422 DOI: 10.1111/ctr.14197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/02/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Obesity adversely affects wait-listing and precludes patients with concomitant end-stage renal disease and type 1 diabetes mellitus from getting a simultaneous pancreas and kidney transplantation (SPK). OBJECTIVE To analyze safety and efficacy of laparoscopic sleeve gastrectomy (LSG) before SPK in severely obese type I diabetics. METHODS We assessed weight curve, complications, and graft function of three patients who underwent LSG before SPK. RESULTS LSG was uneventful in all patients. Body mass index dropped from 38.4 (range 35.7 - 39.9) before LSG to 28.5 (26.8 - 30.9) until SPK, with a mean loss of 25.8% (22.4 - 32.3). Interval between LSG and SPK was 364.3 (173 - 587) days. Pancreas and kidney graft function was excellent, with 100% insulin-free and dialysis-free survival over a mean follow-up of 3.6 (2.9 - 4.5) years. A1C dropped from 7% (6.3 - 8.2) before LSG to 4.9% (4.7 - 5.3) and 4.8% (4.5 - 5.1) 1 and 2 years after SPK, respectively. CONCLUSION LSG before SPK is safe and effective to enable severely obese type I diabetics to receive a lifesaving transplant. This is the first study analyzing the role of bariatric surgery before simultaneous pancreas and kidney transplantation.
Collapse
Affiliation(s)
- Fabian Rössler
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Kerstin Hübel
- Department of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Samuela Di Natale
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Christian Oberkofler
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Philipp Gerber
- Department of Endocrinology, University Hospital Zurich, Zurich, Switzerland
| | - Marco Bueter
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Olivier de Rougemont
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
35
|
Chronic Histologic Changes Are Present Regardless of HLA Mismatches: Evidence from HLA Identical Living Donor Kidney Transplants. Transplantation 2020; 105:e244-e256. [PMID: 33315759 DOI: 10.1097/tp.0000000000003579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND At 5 and 10 years after kidney transplantation, chronic histologic changes such as arteriolar hyalinosis and mesangial expansion are common, however, determining etiology is difficult. We compared surveillance biopsies in living donor kidney transplants (LDKTx) from HLA matched siblings (termed HLA-identical (HLA-ID)) to HLA non-ID to investigate which histologic changes were likely due to alloimmune injury and which were due to non-alloimmune injury. METHODS We performed a retrospective, cohort study comparing HLA-ID sibling LDKTx (n=175) to HLA non-ID LDKTx (n=175; matched for age, sex and year of transplant +/- 2 years) performed at a single institution from 03/1999 to 11/2018. RESULTS Baseline characteristics and maintenance immunosuppression were similar. Mortality rates were similar, but in the HLA-ID group, 10-year death-censored graft survival was higher (93.8% vs 80.9% HLA non-ID LDKTx, p<0.001), rejection rates were lower (after 1 year 9.6% vs 27.1%; p<0.001) and Banff inflammation scores including glomerulitis and peritubular capillaritis were lower on surveillance biopsies at 1, 5 and 10 years. In contrast, chronic Banff scores (interstitial fibrosis, arteriolar hyalinosis, mesangial expansion, etc.) were similar in prevalence and severity on surveillance biopsies at 1, 5 and 10 years. CONCLUSIONS HLA-ID LDKTx have less inflammation and less transplant glomerulopathy, but most chronic histologic changes were similar to less-well matched LDKTx. We conclude that these types of chronic changes are not associated with HLA mismatches and may be due to non-immunologic causes (hypertension, obesity, etc.) suggesting that new management approaches to prevent these lesions may be needed.
Collapse
|
36
|
Montgomery JR, Cohen JA, Brown CS, Sheetz KH, Chao GF, Waits SA, Telem DA. Perioperative risks of bariatric surgery among patients with and without history of solid organ transplant. Am J Transplant 2020; 20:2530-2539. [PMID: 32243667 PMCID: PMC7838764 DOI: 10.1111/ajt.15883] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/05/2020] [Accepted: 03/18/2020] [Indexed: 01/25/2023]
Abstract
Bariatric surgery is effective among patients with previous transplant in limited case series. However, the perioperative safety of bariatric surgery in this patient population is poorly understood. Therefore, we assessed the safety of bariatric surgery among previous-transplant patients using a database that captures >92% of all US bariatric procedures. All primary, laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass procedures between 2017 and 2018 were identified from the MBSAQIP dataset. Patients with previous transplant (n = 610) were compared with patients without previous transplant (n = 321 447). Primary outcomes were 30 day readmissions, surgical complications, medical complications, and death. Multivariable logistic regression with predictive margins was used to compare outcomes. Previous transplant patients experienced higher incidence of readmissions (8.0% vs 3.5%), surgical complications (5.0% vs 2.7%), and medical complications (4.3% vs 1.5%). There was no difference in incidence of death (0.2% vs 0.1%). Among individual complications, there no statistical differences in intraabdominal leak, unplanned reoperation, myocardial infarction, or infectious complications. Baseline estimated glomerular filtration rate was found to be a strong moderator of primary outcomes, with the highest risk of complications occurring at the lowest baseline estimated glomerular filtration rate. Given the many long-term benefits of bariatric surgery among patients with previous transplant, our findings should not preclude this patient population from operative consideration.
Collapse
Affiliation(s)
| | | | - Craig S. Brown
- Department of General Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Kyle H. Sheetz
- Department of General Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Grace F. Chao
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut,National Clinician Scholars Program, Veterans Affairs, Ann Arbor, Michigan
| | - Seth A. Waits
- Department of Transplant Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Dana A. Telem
- Department of General Surgery, Michigan Medicine, Ann Arbor, Michigan
| |
Collapse
|
37
|
Diwan TS, Lee TC, Nagai S, Benedetti E, Posselt A, Bumgardner G, Noria S, Whitson BA, Ratner L, Mason D, Friedman J, Woodside KJ, Heimbach J. Obesity, transplantation, and bariatric surgery: An evolving solution for a growing epidemic. Am J Transplant 2020; 20:2143-2155. [PMID: 31965711 DOI: 10.1111/ajt.15784] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 01/05/2020] [Accepted: 01/08/2020] [Indexed: 01/25/2023]
Abstract
The increasing obesity epidemic has major implications in the realm of transplantation. Patients with obesity face barriers in access to transplant and unique challenges in perioperative and postoperative outcomes. Because of comorbidities associated with obesity, along with the underlying end-stage organ disease leading to transplant candidacy, these patients may not even be referred for transplant evaluation, much less be waitlisted or actually undergo transplant. However, the use of bariatric surgery in this population can help optimize the transplant candidacy of patients with obesity and end-stage organ disease and improve perioperative and postoperative outcomes. We review the impact of obesity on kidney, liver, and cardiothoracic transplant candidates and recipients and explore potential interventions to address obesity in these populations.
Collapse
Affiliation(s)
| | | | | | | | - Andrew Posselt
- University of California at San Francisco, San Francisco, California, USA
| | | | | | | | - Lloyd Ratner
- Columbia University Medical Center, New York, New York, USA
| | | | | | | | | |
Collapse
|
38
|
Nöhre M, Schieffer E, Hanke A, Pape L, Schiffer L, Schiffer M, de Zwaan M. Obesity After Kidney Transplantation-Results of a KTx360°Substudy. Front Psychiatry 2020; 11:399. [PMID: 32457669 PMCID: PMC7227415 DOI: 10.3389/fpsyt.2020.00399] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/20/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE There is solid evidence that kidney transplant (KTx) patients are susceptible to weight gain after transplantation. Post-transplantation obesity [body mass index (BMI) ≥ 30 kg/m2] seems to be associated with higher risks of hypertension, dyslipidemia, diabetes mellitus, and cardiovascular events, while there are contradicting findings regarding the association between obesity and mortality, graft failure after transplantation as well as other variables. We aimed to evaluate the course of weight after KTx and to assess the prevalence of post-transplant obesity in a large sample of German KTx patients. Further, we focused on potential associations between weight gain, obesity, and BMI after transplantation with sociodemographic, medical, psychological [levels of anxiety and depression measured with the Hospital Anxiety and Depression Scale (HADS)], and donation-specific variables. METHODS In a structured post-transplant care program 433 KTx patients were evaluated at Hannover Medical School. Information on the pre-transplant body weight/dry weight of dialysis patients was taken from the electronic patient charts. At post-transplant assessment body weight was measured in the transplant center. For statistical analyses, descriptive statistics, analyses of variance, tests for correlations, and regression analyses were used. RESULTS Mean age was 51.3 years, 59% were male and 26.3% had ≥12 years of school attendance. Regarding somatic conditions 6.0% were suffering from type 2 diabetes mellitus, 6.9% were affected by new-onset diabetes after transplantation (NODAT), and the mean estimated glomerular filtration rate (eGFR) was 47.7 ml/min/1.73m2. The prevalence rates of obesity before and after kidney transplantation were 14.8 and 19.9%, respectively. This represents an increase of 34%. Obesity after transplantation was associated with higher rates of type 2 diabetes mellitus and of NODAT. Additionally, there was an association between increasing pre-transplant as well as post-transplant BMI and decreasing eGFR. Higher age and female sex were associated with higher rates of post-transplant obesity. CONCLUSIONS Our results suggest that obesity represents a serious problem in KTx patients, especially regarding the association between increasing BMI and decreasing graft functioning (eGFR). However, this aspect is often overlooked and information on effective treatment options for these patients are scarce making further research on this topic necessary.
Collapse
Affiliation(s)
- Mariel Nöhre
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover, Germany
- Project Kidney Transplantation 360° (NTX360°), Hannover Medical School, Hannover, Germany
| | - Elisabeth Schieffer
- Project Kidney Transplantation 360° (NTX360°), Hannover Medical School, Hannover, Germany
- Department of Sports Medicine, Hannover Medical School, Hannover, Germany
| | - Alexander Hanke
- Project Kidney Transplantation 360° (NTX360°), Hannover Medical School, Hannover, Germany
- Department of Sports Medicine, Hannover Medical School, Hannover, Germany
| | - Lars Pape
- Project Kidney Transplantation 360° (NTX360°), Hannover Medical School, Hannover, Germany
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Lena Schiffer
- Project Kidney Transplantation 360° (NTX360°), Hannover Medical School, Hannover, Germany
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Mario Schiffer
- Project Kidney Transplantation 360° (NTX360°), Hannover Medical School, Hannover, Germany
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
- Department of Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Germany
| | - Martina de Zwaan
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover, Germany
- Project Kidney Transplantation 360° (NTX360°), Hannover Medical School, Hannover, Germany
| |
Collapse
|
39
|
Bariatric surgery and heart transplantation outcomes: A note of caution. J Heart Lung Transplant 2020; 39:986-987. [PMID: 32307249 DOI: 10.1016/j.healun.2020.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 01/31/2023] Open
|
40
|
Martin WP, White J, López-Hernández FJ, Docherty NG, le Roux CW. Metabolic Surgery to Treat Obesity in Diabetic Kidney Disease, Chronic Kidney Disease, and End-Stage Kidney Disease; What Are the Unanswered Questions? Front Endocrinol (Lausanne) 2020; 11:289. [PMID: 33013677 PMCID: PMC7462008 DOI: 10.3389/fendo.2020.00289] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 04/17/2020] [Indexed: 12/11/2022] Open
Abstract
Obesity is a major factor in contemporary clinical practice in nephrology. Obesity accelerates the progression of both diabetic and non-diabetic chronic kidney disease and, in renal transplantation, both recipient and donor obesity increase the risk of allograft complications. Obesity is thus a major driver of renal disease progression and a barrier to deceased and living donor kidney transplantation. Large observational studies have highlighted that metabolic surgery reduces the incidence of albuminuria, slows chronic kidney disease progression, and reduces the incidence of end-stage kidney disease over extended follow-up in people with and without type 2 diabetes. The surgical treatment of obesity and its metabolic sequelae has therefore the potential to improve management of diabetic and non-diabetic chronic kidney disease and aid in the slowing of renal decline toward end-stage kidney disease. In the context of patients with end-stage kidney disease, although complications of metabolic surgery are higher, absolute event rates are low and it remains a safe intervention in this population. Pre-transplant metabolic surgery increases access to kidney transplantation in people with obesity and end-stage kidney disease. Metabolic surgery also improves management of metabolic complications post-kidney transplantation, including new-onset diabetes. Procedure selection may be critical to mitigate the risks of oxalate nephropathy and disruption to immunosuppressant pharmacokinetics. Metabolic surgery may also have a role in the treatment of donor obesity, which could increase the living kidney donor pool with potential downstream impact on kidney paired exchange programmes. The present paper provides a comprehensive coverage of the literature concerning renal outcomes in clinical studies of metabolic surgery and integrates findings from relevant mechanistic pre-clinical studies. In so doing the key unanswered questions for the field are brought to the fore for discussion.
Collapse
Affiliation(s)
- William P. Martin
- Diabetes Complications Research Centre, School of Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
- *Correspondence: William P. Martin
| | - James White
- Diabetes Complications Research Centre, School of Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
| | - Francisco J. López-Hernández
- Instituto de Estudios de Ciencias de la Salud de Castilla y León-Instituto de Investigación Biomédica de Salamanca (IECSCYL-IBSAL), Hospital Virgen Vega, Salamanca, Spain
| | - Neil G. Docherty
- Diabetes Complications Research Centre, School of Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
| | - Carel W. le Roux
- Diabetes Complications Research Centre, School of Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
- Division of Investigative Science, Imperial College London, London, United Kingdom
| |
Collapse
|