Bariatric Surgery in Kidney Transplant Candidates and Recipients: Experience at an Asian Center

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.

An Unusual Long-Term Complication of Bariatric Surgery

Roux-en-Y gastric bypass (RNYGB) has become the standard of care in treating obesity, a global health concern with associated comorbidities contributing to rising health care costs [1]. The positive outcomes of RNYGB have been well documented along with adverse effects such as nutrient deficiencies, hernia, postprandial dumping syndrome, chronic kidney disease and hypoglycemia. A lesser-known long term complication of RNYGB is liver failure. Here, we present a case where RNYGB performed 10 years prior contributed to acute liver failure.

Sleeve Gastrectomy Is Associated with a Greater Reduction in Plasma Liver Enzymes Than Bypass Surgeries-A Registry-Based Two-Year Follow-Up Analysis

Bariatric surgeries may lead to an improvement in metabolic fatty liver disease, and a reduction in the levels of the hepatic enzyme Alanine Aminotransferase (ALT). We compared the effects of Sleeve Gastrectomy (SG), Roux en Y Gastric Bypass (RYGB) and One Anastomosis Gastric Bypass (OAGB) on the levels of ALT by analysis of two-year follow-up data from 4980 patients in the Israeli Bariatric Registry that included laboratory tests and demographic information. Pre-operative characteristics of patients, and particularly levels of liver enzymes, were similar across surgery types. Regression modeling and retrospective matching showed that SG was superior to RYGB and OAGB in reducing ALT levels, and in reducing the fraction of patients with abnormally high ALT levels. Two-year post-surgery, an increase in ALT levels from normal to abnormal levels was observed in 5% of SG patients, and in 18% and 23% of RYGB and OAGB patients. In conclusion, SG leads to a greater reduction in ALT levels compared with bypass surgeries and a lower incidence of post-surgical elevation of ALT levels. Further studies are required to identify the cause for the rise in liver enzymes, and to determine whether ALT levels correlate with liver pathology especially following bariatric surgery.

Alterations in Small Intestine and Liver Morphology, Immunolocalization of Leptin, Ghrelin and Nesfatin-1 as Well as Immunoexpression of Tight Junction Proteins in Intestinal Mucosa after Gastrectomy in Rat Model

The stomach is responsible for the processing of nutrients as well as for the secretion of various hormones which are involved in many activities throughout the gastrointestinal tract. Experimental adult male Wistar rats (n = 6) underwent a modified gastrectomy, while control rats (n = 6) were sham-operated. After six weeks, changes in small intestine (including histomorphometrical parameters of the enteric nervous plexuses) and liver morphology, immunolocalization of leptin, ghrelin and nesfatin-1 as well as proteins forming adherens and tight junctions (E-cadherin, zonula occludens-1, occludin, marvelD3) in intestinal mucosa were evaluated. A number of effects on small intestine morphology, enteric nervous system ganglia, hormones and proteins expression were found, showing intestinal enteroplasticity and neuroplasticity associated with changes in gastrointestinal tract condition. The functional changes in intestinal mucosa and the enteric nervous system could be responsible for the altered intestinal barrier and hormonal responses following gastrectomy. The results suggest that more complicated regulatory mechanisms than that of compensatory mucosal hypertrophy alone are involved.

Jejunal-Ileal Bypass and its Complications: Case Report and Review of the Literature

Herein, we describe an interesting case of a patient who underwent a jejunal-ileal bypass (JIB). She presented to the hospital with gastrointestinal bleeding after which her hospital course was complicated by electrolyte abnormalities. She was a 76-year-old Caucasian female with a past medical history of hypertension, type II diabetes, atrial fibrillation on warfarin, chronic obstructive pulmonary disease (COPD) treated with 3 liters of oxygen at home, obstructive sleep apnea, and morbid obesity, with history of an unknown type of bariatric procedure done in the 1970s. Her upper endoscopy showed a normal esophagus, stomach, and duodenum despite her history of bariatric surgery. Her colonoscopy revealed stenotic terminal ileum and an incidental colonic anastomosis at 35 cm from the anal verge with spot tattoo ink of unknown significance. Also noted were moderate internal hemorrhoids and large external hemorrhoids which were likely the source of her bleeding. Post endoscopy she had marked derangement in electrolytes, specifically hypocalcemia, hypomagnesemia, and hypo-phosphatemia. 

JIB was first popularized in the 1960s for the treatment of obesity. There are two variations of the procedure, colloquially known as the Scott bypass and the Payne bypass. Our patient underwent the Scott JIB. The relatively longer intestinal tract combined with her ileal stenosis may explain her 50 years of relatively stable adaptation. It is imperative that treating physicians have a keen understanding of anatomy and physiology to adequately care for the long-term needs of these patients.