Gastroplasty for Morbid Obesity after Cardiac and Renal Transplantation

Bariatric surgery outcomes following organ transplantation: A review study

Weight gain is a frequent postoperative complication following a solid organ transplant which can be solved by bariatric surgery. The outcomes of bariatric surgery among patients with an organ transplant history are always a challengeable subject for surgeons and surgery candidates. In this review article, we aim to investigate the existence literature about the rates of morbidity and mortality, frequent complications in terms of graft function, remission in diabetes, hypertension, pulmonary and cardiovascular disorders, hepatic and renal functions, and immunosuppressive stability, as well as the safety of bariatric surgery among patients.

Bariatric surgery in transplant recipients: A narrative review

Morbidity and mortality rates are increased due to obesity after organ transplantation; in this regards, bariatric surgery (BS) is believed to be an effective treatment for posttransplant obese patients. Nevertheless, some studies are doubtful in terms of the effectiveness of BS, the most suitable bariatric procedure, and management of immunosuppressant drugs in some kinds of organ transplants. We evaluated nonsurgical therapies, weight reduction, adjustment of immunosuppressants, comorbidities, and the recommended surgical procedures for posttransplant BS for different types of organ transplantations.

Obesity in Kidney Transplantation: Impact on Transplant Candidates, Recipients, and Donors

Obesity is now common among children and adults who are kidney transplant candidates and recipients. It is associated with an increased risk of cardiovascular disease and kidney failure. This also pertains to potential living kidney donors with obesity. Obese patients with end-stage renal disease benefit from transplantation as do nonobese patients, but obesity is also associated with more risk. A complicating factor is that obesity is also associated with increased survival on maintenance dialysis in adults, but not in children. The assessment of obesity and body habitus should be individualized. Body mass index is a common but imperfect indicator of obesity. The medical management of obesity in renal failure patients is often unsuccessful. Bariatric surgery, specifically laparoscopic sleeve gastrectomy, can result in significant weight loss with reduced morbidity, but many patients do not agree to undergo this treatment. The best approach to manage obese transplant candidates and recipients is yet unresolved.

The impact and treatment of obesity in kidney transplant candidates and recipients

The prevalence of obesity in patients with chronic kidney failure and renal transplant candidates has paralleled the epidemic in the general population. The associated risks of surgical complications and long-term cardiovascular death are significant: most transplant centers consider obesity a relative contra-indication for transplant.

Few studies have focused on conservative weight loss strategies in transplant patients. Studies using administrative databases have found that only a minority of wait-listed patients lose weight and with no apparent benefit to transplant outcomes. The only clinical trial in this area found that an intensive weight-loss program had significantly better success (to listing) than self-directed weight loss. However, only a minority that succeeded with the help of a program (36 %), while the “diet and exercise” group had negligible results.

Laparoscopy has radically shortened the recovery time and decreased the complications associated with bariatric surgery. Reports in transplant patients, who were previously deemed too medically complex, have demonstrated a dramatic and rapid weight loss. The only randomized clinical trial in patients with CKD, which compared sleeve gastrectomy to best medical care clearly favoured the surgical arm for weight loss, but was too small to assess other outcomes. The emerging experience is small but quite promising.

Surgical complications and the effect on immunosuppression remain the chief concerns regarding the use of bariatric surgery in transplant patients. Rigorous prospective studies will be essential to properly evaluate the expected weight loss and the effect on pharmacokinetics of immunosuppressive medications. A routine role for bariatric surgery in transplantation would require evidence of improvements in patient-important outcomes and evidence of safety.

Acute cellular transplant rejection following laparoscopic adjustable gastric banding in a morbidly obese patient post heart transplantation

BACKGROUND

Obesity is a worldwide health problem that is often worsened after organ transplantation. As obesity is associated with increased incidence of metabolic syndrome, cardiovascular events and death, it is essential to control weight and avoid weight gain in patients especially following cardiac transplantation. Of the various strategies that are available for weight reduction, bariatric surgery seems to be the most effective in achieving weight loss and in maintaining the reduced body weight. However, this has not been frequently performed in organ-transplant recipients.

CASE REPORT

We are reporting a unique case of a bariatric surgery procedure performed in a patient after cardiac transplantation. A 30-year-old African-American man with a history of end-stage heart failure due to idiopathic dilated cardiomyopathy underwent orthotopic cardiac transplantation. Three years after transplantation, the patient underwent laparoscopic adjustable gastric banding surgery for morbid obesity. Two months later, the patient presented with severe heart failure and was diagnosed with acute cellular rejection as evidenced by endomyocardial biopsy results despite continued combined immunosuppressive therapy that had not been changed but with significantly reduced blood levels of calcineurin inhibitors.

CONCLUSION

We hypothesize that the altered gastro-intestinal motility and delayed gastric emptying due to laparoscopic adjustable gastric banding may have caused incomplete absorption of the administered immunosuppressant drugs in this particular case, as evidenced by the low tacrolimus level, resulting in acute cellular rejection of the transplanted heart, which has never been described before.

Outcomes of laparoscopic bariatric surgery after renal transplant

Obesity has been associated with poor graft and patient survival after kidney transplantation, requiring functional increase of anti-rejection drugs. Weight loss surgery may be a good alternative in this clinical scenario. The aim of this report is to describe the outcomes of bariatric procedures performed in patients after kidney transplantation at our institution. A retrospective chart review of a prospectively collected database was conducted to analyze the outcomes of morbidly obese patients after kidney transplantation who underwent laparoscopic bariatric procedures between November 2004 and October 2007. Our series included five patients who underwent a bariatric procedure following kidney transplantation. All patients were females, with a mean age of 40.8 years (range 30-48) and mean body mass index (BMI) of 52.2 (range 48-69). Percent of excess weight loss (%EWL) at 2 years was over 50% for all patients; other comorbidities that might affect postoperative renal function were diabetes mellitus in 2/5 patients, hypertension in 5/5 patients, and chronic heart failure in 1/5 patients. Four patients had laparoscopic Roux-en-Y gastric bypass and one had laparoscopic sleeve gastrectomy. There were no postoperative complications in any patients, and no alteration to the dosages of the immunosuppressant drugs were recorded after bariatric surgery. Laparoscopic bariatric surgical techniques may be used safely and effectively to control obesity in renal transplant patients.

Bariatric surgery for morbid obesity: risks and benefits in chronic kidney disease patients

Obesity is one of the most preventable causes of morbidity and mortality of the 21st century. Chronic kidney disease (CKD) has been a largely overlooked consequence of obesity; however, accumulating evidence elucidates the association. Obesity is at the core, promoting a cascade of secondary pathologies including diabetes, dyslipidemia, inflammation, hypertension, and the metabolic syndrome; these comorbidities constitute great risk for CKD. With the diagnosis of CKD, there is an increased threat of cardiovascular disease and the attendant increase in morbidity and mortality rates. Substantial weight loss in the obese population can be effectively achieved and maintained through bariatric surgery, which confers major health benefits by producing resolution or improvement of obesity-related comorbidities. This surgical procedure presents an early hazard of acute on chronic kidney failure, which is offset by a potential improvement in the risk of CKD progression with anticipated improvement in hypertension, diabetes, and CKD risk factors. Future research is needed to describe the clinical course and risks and benefits of bariatric surgery in the CKD population.