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Bosch KD, Harrington C, Sulutaura L, Lacea E, Burton K, Fernandez-Munoz N, Dugal N, Sufi P, Al Midani A, Parmar C. Bariatric Surgery as a Bridge to Facilitate Renal Transplantation in Patients with End-Stage Renal Disease. Obes Surg 2024; 34:355-362. [PMID: 38172424 DOI: 10.1007/s11695-023-06985-6] [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: 09/12/2023] [Revised: 11/28/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE Renal transplantation (RT) is not recommended above BMI 40 kg/m2 as post-operative risks (delayed graft function, wound complications) are increased. Bariatric surgery (BS) results in sustained long-term weight loss. However, renal failure (RF) patients are theoretically higher risk candidates. We aim to investigate the safety of BS in patients with RF and the effect of BS on access to renal transplantation. METHODS We reviewed data from 31 patients with RF referred for BS between 2013 and 2021. We compared the outcomes of patients with RF who underwent BS to those who were referred but did not undergo BS. Controls matched for age/BMI/comorbidity (MC) but without RF were used for comparison. RESULTS Of 31 patients referred, 19 proceeded with BS (68% female, median age 52 years, BMI 46.2 ± 4.9 kg/m2) and 12 did not (58% female, median age 58, mean BMI 41.5 ± 4.1). Excess body weight loss (EBWL) was 71.2% ± 20.2% at 2 years in RF patients versus 66.0% ± 28.0% in MC patients. In the operated group, 11/19 (58%) patients reached their treatment target (six transplanted, five placed on waiting list) versus 3/12 (25%) in unoperated patients (three transplanted). There was no difference in perioperative complications between RF and MC groups. Long-term, there were seven deaths amongst RF patients (two operated, five unoperated), none amongst the MC group. CONCLUSION BS in patients with RF increased access to RT and was safe and effective. We therefore recommend consideration of BS in patients with obesity and RF in specialised units.
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Affiliation(s)
- Karen D Bosch
- Department of Bariatric Surgery, Whittington Health NHS Trust, London, N19 5NF, UK.
| | - Cuan Harrington
- Department of Surgery, Royal London Hospital, Barts Health NHS Trust, London, E1 1FR, UK
| | - Liene Sulutaura
- Department of Bariatric Surgery, Whittington Health NHS Trust, London, N19 5NF, UK
| | - Emilane Lacea
- Department of Bariatric Surgery, Whittington Health NHS Trust, London, N19 5NF, UK
| | - Katarina Burton
- Department of Bariatric Surgery, Whittington Health NHS Trust, London, N19 5NF, UK
| | | | - Neal Dugal
- National Kidney Transplant Service, Beaumont Hospital, Dublin, D09V2N0, Ireland
| | - Pratik Sufi
- Department of Bariatric Surgery, Whittington Health NHS Trust, London, N19 5NF, UK
| | - Ammar Al Midani
- Department of Renal Transplantation, Royal Free Hospitals NHS Foundation Trust, London, NW3 2QG, UK
| | - Chetan Parmar
- Department of Surgery, Whittington Hospital, London, N19 5NF, UK
- University College London, London, WC1E 6BT, UK
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Khajeh E, Aminizadeh E, Dooghaie Moghadam A, Sabetkish N, Abbasi Dezfouli S, Morath C, Zeier M, Nickel F, Billeter AT, Müller-Stich BP, Mehrabi A. Bariatric surgery in patients with obesity and end-stage renal disease. Surg Obes Relat Dis 2023; 19:858-871. [PMID: 36801168 DOI: 10.1016/j.soard.2023.01.015] [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: 08/12/2022] [Revised: 12/03/2022] [Accepted: 01/14/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Bariatric surgery has been suggested as a treatment for obesity and end-stage renal disease (ESRD). Although the number of bariatric surgeries in patients with ESRD is increasing, its safety and effectiveness in these patients are still controversial and the surgical method of choice in these patients is under debate. OBJECTIVES To compare the outcomes of bariatric surgery between patients with and without ESRD and to assess different methods of bariatric surgery in patients with ESRD. SETTING Meta-analysis. METHODS A comprehensive search was conducted in Web of Science and Medline (via Pubmed) until May 2022. Tow meta-analyses were performed: A) to compare bariatric surgery outcomes among patients with and without ESRD, and B) to compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) in patients with ESRD. Using a random-effect model, odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were computed for surgical and weight loss outcomes. RESULTS Of 5895 articles, 6 studies were included in meta-analysis A and 8 studies in meta-analysis B. The risk of bias was moderate to serious among studies. Major postoperative complications (OR = 2.82; 95% CI = 1.66-4.77; P = .0001), reoperation (OR = 2.66; 95% CI = 1.99-3.56; P < .00001), readmission (OR = 2.37; 95% CI = 1.55-3.64; P < .0001), and in-hospital/90-d mortality (OR = 4.03; 95% CI = 1.80-9.03; P = .0007) were higher in patients with ESRD. Patients with ESRD also had a longer hospital stay (MD = 1.23; 95% CI = .32-2.14; P = .008). Bleeding, leakage, and total weight loss were comparable among groups. SG showed a 10% lower rate of overall complications and significantly shorter hospital stay than RYGB did. The quality of evidence was very low for the outcomes CONCLUSIONS: Bariatric surgery in patients with ESRD seems to have higher rates of major complications and perioperative mortality than in patients without ESRD, but a comparable rate of overall complications. SG has fewer postoperative complications and could be the method of choice in these patients. These findings should be interpreted cautiously in light of the moderate to high risk of bias in most included studies.
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Affiliation(s)
- Elias Khajeh
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ehsan Aminizadeh
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arash Dooghaie Moghadam
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Nastaran Sabetkish
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Sepehr Abbasi Dezfouli
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Morath
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Adrian T Billeter
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Beat Peter Müller-Stich
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany.
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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.
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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
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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.
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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
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Song R, Nolan BJ, Harb H, Sumithran P. Intensive management of obesity in people with severe chronic kidney disease: A review. Diabetes Obes Metab 2021; 23:1733-1745. [PMID: 33904629 DOI: 10.1111/dom.14409] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/06/2021] [Accepted: 04/22/2021] [Indexed: 12/24/2022]
Abstract
Obesity is highly prevalent worldwide, including among people with chronic kidney disease (CKD). The presence of severe and/or end-stage kidney disease complicates the treatment of obesity for several reasons, including restrictions on protein and fluid intake and renal excretion of several medications indicated for the treatment of obesity. The aim of this review is to assess the safety of intensive obesity treatments, such as very-low-energy diets (VLEDs), obesity pharmacotherapy and/or bariatric surgery, in people with end-stage kidney disease. A literature search was conducted to identify studies reporting safety outcomes for VLEDs, liraglutide, phentermine, phentermine-topiramate, naltrexone-bupropion and bariatric surgery in people with an estimated glomerular filtration rate of less than 30 mL/min/1.73m2 or on dialysis. Limited data were insufficient to recommend VLEDs but highlighted their potential efficacy and the need for close clinical and biochemical monitoring. There were no data regarding centrally acting obesity pharmacotherapy in this population, although some glucagon-like peptide-1 analogues appear to safely induce weight loss at doses used for the treatment of type 2 diabetes. Some studies suggest an increased rate of complications of bariatric surgery in individuals with severe or end-stage CKD. Further prospective evaluation of intensive obesity management in the growing population with obesity and severe, end-stage and dialysis-dependent CKD is required.
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Affiliation(s)
- Richard Song
- Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Brendan J Nolan
- Department of Medicine (Austin), University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology, Austin Health, Melbourne, Victoria, Australia
| | - Hecham Harb
- Department of Endocrinology, Austin Health, 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
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