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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.
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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
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2
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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.
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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
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3
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Kheirvari M, Goudarzi H, Hemmatizadeh M, Anbara T. Bariatric surgery outcomes following organ transplantation: A review study. World J Exp Med 2022; 12:92-99. [PMID: 36196436 PMCID: PMC9526996 DOI: 10.5493/wjem.v12.i5.92] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/29/2022] [Accepted: 08/16/2022] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Milad Kheirvari
- Microbiology Research Center, Pasteur Institute of Iran, Tehran 14758-94433, Iran
| | | | | | - Taha Anbara
- Department of Surgery, Erfan Niayesh Hospital, Tehran 14758-94433, Iran
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4
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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: 0.3] [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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5
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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: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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)
- Gabriel C Oniscu
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Davide Bolignano
- Department of Medical and Surgical Sciences, Nephrology and Dialysis Unit, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Ilaria Gandolfini
- Dipartimento di Medicina e Chirurgia, Università di Parma, UO Nefrologia, Azienda Ospedaliera–Universitaria di Parma, Parma,Italy
| | | | - Umberto Maggiore
- Dipartimento di Medicina e Chirurgia, Università di Parma, UO Nefrologia, Azienda Ospedaliera–Universitaria di Parma, Parma,Italy
| | - Ionut Nistor
- Methodological Center for Medical Research and Evidence-Based Medicine, University of Medicine and Pharmacy ‘Grigore T. Popa’, Iași, Romania
| | - Stephen O'Neill
- Department of Transplant Surgery, Belfast City Hospital, Belfast, UK
| | - Mehmet Sukru Sever
- Department of Nephrology, Istanbul School of Medicine, Istanbul University, Istanbul,Turkey
| | - Muguet Koobasi
- Knowledge Centre for Health Ghent, Ghent University Hospital, Ghent, Belgium
| | - Evi V Nagler
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
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6
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Kermansaravi M, Davarpanah Jazi AH, Talebian P, Rokhgireh S, Kabir A, Pazouki A. Bariatric surgery in transplant recipients: A narrative review. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2021; 26:44. [PMID: 34484376 PMCID: PMC8384002 DOI: 10.4103/jrms.jrms_631_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/20/2020] [Accepted: 02/09/2021] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Mohammad Kermansaravi
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.,Center of Excellence of European Branch of International Federation for Surgery of Obesity, Hazrat-e-Rasool Hospital, Tehran, Iran
| | - Amir Hossein Davarpanah Jazi
- Department of Surgery, Minimally Invasive Surgery Research Center, Al Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran.,Department of General Surgery, Shariati Hospital, Isfahan, Iran
| | - Pedram Talebian
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Samaneh Rokhgireh
- Endometriosis Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Kabir
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Abdolreza Pazouki
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.,Center of Excellence of European Branch of International Federation for Surgery of Obesity, Hazrat-e-Rasool Hospital, Tehran, Iran
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7
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Comparison of eGFR formulas in determining chronic kidney disease stage in bariatric patients and the impact on perioperative outcomes. Surg Obes Relat Dis 2021; 17:1317-1326. [PMID: 33879423 DOI: 10.1016/j.soard.2021.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/31/2021] [Accepted: 03/08/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) independently increases the risk of 30-day adverse outcomes following metabolic and bariatric surgery (MBS). However, no studies have evaluated the stage of CKD at which increased perioperative risk is manifested. Here, we correlate 30-day major morbidities after MBS with extent of renal disease based on CKD Stage. OBJECTIVES To determine the impact of CKD stage on perioperative outcomes after bariatric surgery. SETTING Academic Hospital. METHODS From the 2017 Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) database, we identified patients with CKD who underwent sleeve gastrectomy or laparoscopic gastric bypass surgery. Glomerular filtration rates (GFRs) were calculated and cohorts were generated based on CKD Stage. Complication rates and rates of morbidity and mortality were compared between stages, and strengths of correlation were calculated. RESULTS GFR and CKD Stage were calculated for 150,283 patients. There was a significant increase in the risk of major morbidity at each progressive stage of CKD (P < .001 for all compared stages). There was a strong positive linear correlation between increasing CKD Stage and total morbidity (r2 = .983), including reoperation ( r2 = .784), readmission (r2 = .936), unplanned ICU transfer (r2 = .853), and aggregate complications such as pulmonary (r2 = .900), bleeding (r2 = .878), or progressive worsening of renal function (r2 = .845). In logistic regression, for every 10-point decrease in GFR, odds of total morbidity increased by 6%. CONCLUSION An increased risk of perioperative complications may be seen in early stages of CKD, and risk is compounded in more advanced stages. Bariatric surgical candidates should be counseled on their increased risk of surgical complications even with mild CKD, and the benefits of bariatric surgery should be carefully weighed against significantly increased risks of complications in severe CKD.
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8
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Guggino J, Coumes S, Wion N, Reche F, Arvieux C, Borel AL. Effectiveness and Safety of Bariatric Surgery in Patients with End-Stage Chronic Kidney Disease or Kidney Transplant. Obesity (Silver Spring) 2020; 28:2290-2304. [PMID: 33230959 DOI: 10.1002/oby.23001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/25/2020] [Accepted: 07/29/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE This study aimed to evaluate (1) the effectiveness, complications, and postoperative access to transplantation in end-stage chronic kidney disease (ECKD) and (2) the effectiveness and complications of bariatric surgery in patients who had already undergone kidney transplant. METHODS A systematic review and meta-analysis of mortality and complications rates were performed. Thirty studies were reviewed. RESULTS After bariatric surgery, patients with ECKD had similar postoperative weight loss to patients from the general population. Meta-analysis showed post-bariatric surgery rates of 2% (95% CI: 0%-3%) for mortality and 7% (95% CI: 2%-14%) for complications. Approximately one-fifth of the patients had access to a transplant. This rate may be underestimated because of the short duration of follow-up. The lack of control groups did not allow for a conclusion on the role of bariatric surgery in facilitating access to kidney transplantation. In patients who had received a kidney transplant, bariatric surgery seemed to improve renal function but increased graft-rejection risk, possibly because of changes in the bioavailability of immunosuppressant drugs. CONCLUSIONS Bariatric surgery yields significant weight loss in patients with ECKD that improves patients' chances of accessing a transplant but does not guarantee it; however, the risk for complications and death is higher than in other patients. After transplantation, bariatric surgery-induced weight loss appeared to positively impact the function of the grafted kidney, but careful monitoring of immunosuppressant medications is required.
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Affiliation(s)
- Jessica Guggino
- Endocrinology, Diabetology, Nutrition, Grenoble Alpes University Hospital, Grenoble, France
| | - Sandrine Coumes
- Endocrinology, Diabetology, Nutrition, Grenoble Alpes University Hospital, Grenoble, France
| | - Nelly Wion
- Endocrinology, Diabetology, Nutrition, Grenoble Alpes University Hospital, Grenoble, France
| | - Fabian Reche
- Digestive Surgery, Grenoble Alpes University Hospital, Grenoble, France
- CNRS, UMR 5525, TIMC-IMAG, Domaine de la Merci, Grenoble, France
| | - Catherine Arvieux
- Digestive Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Anne-Laure Borel
- Endocrinology, Diabetology, Nutrition, Grenoble Alpes University Hospital, Grenoble, France
- Hypoxia Pathophysiology (HP2) INSERM U1042, Grenoble Alpes University, Grenoble, France
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9
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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: 1.2] [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.
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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
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10
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Angeles PC, Robertsen I, Seeberg LT, Krogstad V, Sandbu R, Åsberg A, Hjelmesaeth J. Reply to letter: "What about drug bioavailability in patients who had bariatric surgery and dependent on immunosuppressives?". Obes Rev 2020; 21:e12954. [PMID: 31746506 DOI: 10.1111/obr.12954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 09/09/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Philip Carlo Angeles
- Morbid Obesity Centre, Department of Medicine, Vestfold Hospital Trust, Tønsberg, Norway.,Department of Surgery, Vestfold Hospital Trust, Tønsberg, Norway.,Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ida Robertsen
- Section of Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | | | | | - Rune Sandbu
- Department of Surgery, Vestfold Hospital Trust, Tønsberg, Norway
| | - Anders Åsberg
- Section of Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway.,Department of Transplantation, Oslo University Hospital, Oslo, Norway
| | - Jøran Hjelmesaeth
- Morbid Obesity Centre, Department of Medicine, Vestfold Hospital Trust, Tønsberg, Norway.,Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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11
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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: 26] [Impact Index Per Article: 5.2] [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.
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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
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12
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Abstract
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.
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Abstract
Kidney transplantation (KT) is the most effective way to decrease the high morbidity and mortality of patients with end-stage renal disease. However, KT does not completely reverse the damage done by years of decreased kidney function and dialysis. Furthermore, new offending agents (in particular, immunosuppression) added in the post-transplant period increase the risk of complications. Cardiovascular (CV) disease, the leading cause of death in KT recipients, warrants pre-transplant screening based on risk factors. Nevertheless, the screening methods currently used have many shortcomings and a perfect screening modality does not exist. Risk factor modification in the pre- and post-transplant periods is of paramount importance to decrease the rate of CV complications post-transplant, either by lifestyle modification (for example, diet, exercise, and smoking cessation) or by pharmacological means (for example, statins, anti-hyperglycemics, and so on). Post-transplantation diabetes mellitus (PTDM) is a major contributor to mortality in this patient population. Although tacrolimus is a major contributor to PTDM development, changes in immunosuppression are limited by the higher risk of rejection with other agents. Immunosuppression has also been implicated in higher risk of malignancy; therefore, proper cancer screening is needed. Cancer immunotherapy is drastically changing the way certain types of cancer are treated in the general population; however, its use post-transplant is limited by the risk of allograft rejection. As expected, higher risk of infections is also encountered in transplant recipients. When caring for KT recipients, special attention is needed in screening methods, preventive measures, and treatment of infection with BK virus and cytomegalovirus. Hepatitis C virus infection is common in transplant candidates and in the deceased donor pool; however, newly developed direct-acting antivirals have been proven safe and effective in the pre- and post-transplant periods. The most important and recent developments on complications following KT are reviewed in this article.
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Affiliation(s)
- Abraham Cohen-Bucay
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, 14080, Mexico.,Nephrology Department, American British Cowdray Medical Center, Mexico City, 05300, Mexico
| | - Craig E Gordon
- Division of Nephrology, Tufts Medical Center, Boston, MA, 02111, USA
| | - Jean M Francis
- Renal Section, Boston University Medical Center, Boston, MA, 02118, USA
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Yemini R, Nesher E, Winkler J, Carmeli I, Azran C, Ben David M, Mor E, Keidar A. Bariatric surgery in solid organ transplant patients: Long-term follow-up results of outcome, safety, and effect on immunosuppression. Am J Transplant 2018; 18:2772-2780. [PMID: 29569341 DOI: 10.1111/ajt.14739] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 03/09/2018] [Accepted: 03/11/2018] [Indexed: 01/25/2023]
Abstract
The surgical risk of transplanted patients is high, and the modified gastrointestinal anatomy after bariatric surgery (BS) may lead to pharmacokinetic alterations in the absorption of immunosuppressive drugs. Data on outcomes of BS and the safety and feasibility of maintaining immunosuppression and graft safety among solid organ transplanted patients are scarce. In the current study, weight loss, improvement in comorbidities, and changes in dosage and trough levels of immunosuppression drugs before and after BS were analyzed for all transplanted patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) in our institution between November 2011 and January 2017. Thirty-four patients (13 females, 21 males, average age 53 years) were included in the study. A successful weight loss (>50% excess weight loss in 28 of them [82%]) was recorded at the last follow-up. Comorbidities improved significantly. Immunosuppressive stability increased from 39% to 47% among all patients. The tacrolimus blood trough levels declined slightly, but remained within therapeutic range. These data suggest that LSG and LRYGB ensure good immunosuppressive maintenance together with significant weight loss and improvement in comorbidities without serious graft rejection or dysfunction. The surgical risk is higher than in the regular BS population.
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Affiliation(s)
- Renana Yemini
- Bariatric Clinic, Department of Surgery, Beilinson Medical Center, Petach-Tikva, Israel
| | - Eviatar Nesher
- Department of Transplant Surgery, Beilinson Medical Center, Petach-Tikva, Israel
| | - Janos Winkler
- Department of Nephrology, Beilinson Medical Center, Petach-Tikva, Israel
| | - Idan Carmeli
- Bariatric Clinic, Department of Surgery, Beilinson Medical Center, Petach-Tikva, Israel
| | | | - Matan Ben David
- Bariatric Clinic, Department of Surgery, Beilinson Medical Center, Petach-Tikva, Israel
| | - Eytan Mor
- Department of Transplant Surgery, Beilinson Medical Center, Petach-Tikva, Israel
| | - Andrei Keidar
- Bariatric Clinic, Department of Surgery, Beilinson Medical Center, Petach-Tikva, Israel
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Dziodzio T, Biebl M, Öllinger R, Pratschke J, Denecke C. The Role of Bariatric Surgery in Abdominal Organ Transplantation-the Next Big Challenge? Obes Surg 2018; 27:2696-2706. [PMID: 28791580 DOI: 10.1007/s11695-017-2854-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Obesity is linked to inferior transplant outcome. Bariatric surgery (BS) is an established treatment of morbid obesity. We provide an overview on BS in the field of kidney (KT) and liver transplantation (LT). In end-stage renal disease (ESRD) and KT patients, BS seems safe and feasible. Complication rates were slightly higher compared to the non-transplant population, whereas weight loss and improvement of comorbidities were comparable. Sleeve gastrectomy (SG) was the preferred procedure before KT and superior to gastric bypass (GB) in regard to mortality and morbidity. If conducted after KT, both procedures showed comparable results. BS before LT was associated with high complication rates, in particular after GB. Albeit distinct complications, SG conducted after LT showed the best results. Immunosuppression (IS) changes after BS were rare.
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Affiliation(s)
- Tomasz Dziodzio
- Department of Surgery, Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13352, Berlin, Germany.
| | - Matthias Biebl
- Department of Surgery, Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13352, Berlin, Germany
| | - Robert Öllinger
- Department of Surgery, Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13352, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13352, Berlin, Germany
| | - Christian Denecke
- Department of Surgery, Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13352, Berlin, Germany
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Tsamalaidze L, Elli EF. Solid Organ Transplantation and Bariatric Surgery. THE SAGES MANUAL OF BARIATRIC SURGERY 2018:615-633. [DOI: 10.1007/978-3-319-71282-6_45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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18
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Gazzetta P, Bissolati M, Saibene A, Ghidini C, Guarneri G, Giannone F, Adamenko O, Secchi A, Rosati R, Socci C. Bariatric Surgery to Target Obesity in the Renal Transplant Population: Preliminary Experience in a Single Center. Transplant Proc 2017; 49:646-649. [DOI: 10.1016/j.transproceed.2017.02.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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19
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Gheith O, Al-Otaibi T, Halim MA, Mahmoud T, Mosaad A, Yagan J, Zakaria Z, Rida S, Nair P, Hassan R. Bariatric Surgery in Renal Transplant Patients. EXP CLIN TRANSPLANT 2017; 15:164-169. [PMID: 28260459 DOI: 10.6002/ect.mesot2016.p35] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The idea of transplanting organs is not new, nor is the disease of obesity. Obese transplant recipients have greater risk of early death than their cohorts, which is not due to increased rejection but due to obesity-related complications, including arterial hypertension, diabetes, and delayed graft function. Here, our aim was to evaluate the effects of bariatric surgery versus lifestyle changes on outcomes of moderate to severely obese renal transplant recipients. MATERIALS AND METHODS Twenty-two morbidly obese patients with stable graft function who underwent bariatric surgery were compared with 44 obese patients on lifestyle management (control group). Both groups were evaluated regarding graft and patient outcomes. RESULTS The studied groups were comparable demographically. In the bariatric study group versus control group, we observed that the mean body mass index was 38.49 ± 9.1 versus 44.24 ± 6 (P = .024) at transplant and 34.34 ± 7.6 versus 44.38 ± 6.7 (P = .002) at 6 months of bariatric surgery. Both groups received a more potent induction immunosuppression, but this was significantly higher in the obese nonbariatric control group (P < .05). There were more patients with slow and delayed graft functions in the same nonbariatric group. The 2 groups were comparable regarding new-onset diabetes after transplant, total patients with diabetes, and graft outcomes (P > .05). CONCLUSIONS Bariatric surgeries are feasible, safe pro cedures for selected obese renal transplant recipients.
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Affiliation(s)
- Osama Gheith
- Urology and Nephrology Center, Mansoura University, Mansoura, Egypt; the Nephrology Department, Hamed Al-Essa Organ Transplant Center, Sabah Area, Kuwait
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Abstract
The prevalence of severe obesity in both the general and the chronic kidney disease (CKD) populations continues to rise, with more than one-fifth of CKD patients in the United States having a body mass index of ≥35 kg/m2. Severe obesity has significant renal consequences, including increased risk of end-stage renal disease (ESRD) and nephrolithiasis. Bariatric surgery represents an effective method for achieving sustained weight loss, and evidence from randomized controlled trials suggests that bariatric surgery is also effective in improving blood pressure, reducing hyperglycemia, and even inducing diabetes remission. There is also observational evidence suggesting that bariatric surgery may diminish the long-term risk of kidney function decline and ESRD. Bariatric surgery appears to be relatively safe in patients with CKD, with postoperative complications only slightly higher than in the general bariatric surgery population. The use of bariatric surgery in patients with CKD might help prevent progression to ESRD or enable selected ESRD patients with severe obesity to become candidates for kidney transplantation. However, there are also renal risks in bariatric surgery, namely, acute kidney injury, nephrolithiasis, and, in rare cases, oxalate nephropathy, particularly in types of surgery involving higher degrees of malabsorption. Although bariatric surgery may improve long-term kidney outcomes, this potential benefit remains unproved and must be balanced with potential adverse events.
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Affiliation(s)
- Alex R Chang
- Kidney Health Research Institute, Geisinger Health System, Danville, Pennsylvania, USA.,Department of Epidemiology and Health Services Research, Geisinger Health System, Danville, Pennsylvania, USA
| | - Morgan E Grams
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA.,Divison of Nephrology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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21
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La transplantation rénale et ses défis. Prog Urol 2016; 26:1001-1044. [PMID: 27720627 DOI: 10.1016/j.purol.2016.09.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 01/09/2023]
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22
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Patient Selection and Surgical Management of High-Risk Patients with Morbid Obesity. Surg Clin North Am 2016; 96:743-62. [DOI: 10.1016/j.suc.2016.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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23
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Camilleri B, Bridson JM, Sharma A, Halawa A. From chronic kidney disease to kidney transplantation: The impact of obesity and its treatment modalities. Transplant Rev (Orlando) 2016; 30:203-11. [PMID: 27534874 DOI: 10.1016/j.trre.2016.07.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/25/2016] [Accepted: 07/22/2016] [Indexed: 12/19/2022]
Abstract
Obesity is associated with worse short-term outcomes after kidney transplantation but the effect on long-term outcomes is unknown. Although some studies have reported worse outcomes for obese recipients when compared to recipients with a BMI in the normal range, obese recipients who receive a transplant have better outcomes than those who remain wait-listed. Whether transplant candidates should be advised to lose weight before or after transplant has been debated and this is mainly due to the gap in the literature linking pre-transplant weight loss with better outcomes post-transplantation. The issue is further complicated by the use of BMI as a metric of body fat, the obesity paradox in dialysis patients and the different ethical viewpoints of utility versus equity. Measures used to reduce weight loss, including orlistat and bariatric surgery (in particular those with a malabsorptive component), have been associated with enteric hyperoxaluria with consequent risk of nephrolithiasis and oxalate nephropathy. In this review, we discuss the evidence regarding the use of weight loss measures in the kidney transplant candidate and recipient with a view to recommending whether weight loss should be pursued before or after kidney transplantation.
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Affiliation(s)
- Brian Camilleri
- Renal Unit, Ipswich Hospital NHS Trust, Heath Road, Ipswich, United Kingdom IP4 5PD; Faculty of Health and Life Sciences, Cedar House, Ashton Street, University of Liverpool, Liverpool, United Kingdom L69 3GB.
| | - Julie M Bridson
- Faculty of Health and Life Sciences, Cedar House, Ashton Street, University of Liverpool, Liverpool, United Kingdom L69 3GB
| | - Ajay Sharma
- Faculty of Health and Life Sciences, Cedar House, Ashton Street, University of Liverpool, Liverpool, United Kingdom L69 3GB; Link 9C, Royal Liverpool University Hospital, Liverpool, United Kingdom L7 8XP
| | - Ahmed Halawa
- Faculty of Health and Life Sciences, Cedar House, Ashton Street, University of Liverpool, Liverpool, United Kingdom L69 3GB; Northern General Hospital, Herries Road, Sheffield, United Kingdom S5 7AU
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24
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Adams TD, Arterburn DE, Nathan DM, Eckel RH. Clinical Outcomes of Metabolic Surgery: Microvascular and Macrovascular Complications. Diabetes Care 2016; 39:912-23. [PMID: 27222549 PMCID: PMC5562446 DOI: 10.2337/dc16-0157] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 03/10/2016] [Indexed: 02/03/2023]
Abstract
Understanding of the long-term clinical outcomes associated with bariatric surgery has recently been advanced. Research related to the sequelae of diabetes-in particular, long-term microvascular and macrovascular complications-in patients who undergo weight-loss surgery is imperative to this pursuit. While numerous randomized control trials have assessed glucose control with bariatric surgery compared with intensive medical therapy, bariatric surgery outcome data relating to microvascular and macrovascular complications have been limited to observational studies and nonrandomized clinical trials. As a result, whether bariatric surgery is associated with a long-term reduction in microvascular and macrovascular complications when compared with current intensive glycemic control therapy cannot be determined because the evidence is insufficient. However, the consistent salutary effects of bariatric surgery on diabetes remission and glycemic improvement support the opportunity (and need) to conduct high-quality studies of bariatric surgery versus intensive glucose control. This review provides relevant background information related to the treatment of diabetes, hyperglycemia, and long-term complications; reports clinical findings (to date) with bariatric surgery; and identifies ongoing research focusing on long-term vascular outcomes associated with bariatric surgery.
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Affiliation(s)
- Ted D Adams
- Intermountain LiVe Well Center, Intermountain Healthcare, and Division of Cardiovascular Genetics, University of Utah, Salt Lake City, UT
| | | | - David M Nathan
- Diabetes Center, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Robert H Eckel
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora, CO
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25
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Tran MH, Foster CE, Kalantar-Zadeh K, Ichii H. Kidney transplantation in obese patients. World J Transplant 2016; 6:135-143. [PMID: 27011911 PMCID: PMC4801789 DOI: 10.5500/wjt.v6.i1.135] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 10/25/2015] [Accepted: 12/18/2015] [Indexed: 02/05/2023] Open
Abstract
The World Health Organization estimated that in 2014, over 600 million people met criteria for obesity. In 2011, over 30% of individuals undergoing kidney transplant had a body mass index (BMI) 35 kg/m2 or greater. A number of recent studies have confirmed the relationship between overweight/obesity and important comorbidities in kidney transplant patients. As with non-transplant surgeries, the rate of wound and soft tissue complications are increased following transplant as is the incidence of delayed graft function. These two issues appear to contribute to longer length of stay compared to normal BMI. New onset diabetes after transplant and cardiac outcomes also appear to be increased in the obese population. The impact of obesity on patient survival after kidney transplantation remains controversial, but appears to mirror the impact of extremes of BMI in non-transplant populations. Early experience with (open and laparoscopic) Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy support excellent weight loss (in the range of 50%-60% excess weight lost at 1 year), but experts have recommended the need for further studies. Long term nutrient deficiencies remain a concern but in general, these procedures do not appear to adversely impact absorption of immunosuppressive medications. In this study, we review the literature to arrive at a better understanding of the risks related to renal transplantation among individuals with obesity.
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Hadjievangelou N, Kulendran M, McGlone ER, Reddy M, Khan OA. Is bariatric surgery in patients following renal transplantation safe and effective? A best evidence topic. Int J Surg 2016; 28:191-5. [PMID: 26941053 DOI: 10.1016/j.ijsu.2016.02.095] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 02/11/2016] [Accepted: 02/28/2016] [Indexed: 02/06/2023]
Abstract
Obesity is common amongst patients with renal transplants (RT). It is associated not only with generic obesity-related complications including diabetes, but also with higher rates of graft rejection and loss. A Best Evidence Topic in surgery was written according to a structured protocol: this is a systematic review of the literature, suitable when the quality of available evidence is low. The question addressed was: is weight-loss surgery (WLS) safe and effective in patients that have had a previous renal transplant? Three prospective case series and one multicentre retrospective study were identified, together reporting on a total of 112 patients who underwent WLS after RT. Eighty-seven patients underwent open WLS and 25 patients underwent laparoscopic operations of which 11 had sleeve gastrectomy and 14 RYGB. Percentage excess weight loss was highly variable between the studies, ranging from an average of 30.8%-75% at 12 months. One graft rejection occurred within 30 days of surgery. All studies were limited by lack of suitable comparison group, short follow-up and heterogeneity in type of bariatric procedure and approach. To date, there is limited evidence to suggest that bariatric surgery is safe and has good short-term outcomes for selected obese patients post-renal transplant.
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Affiliation(s)
- Nancy Hadjievangelou
- Department of Upper GI Surgery, St. George's University Hospital, NHS Foundation Trust, United Kingdom.
| | - Myutan Kulendran
- Department of Upper GI Surgery, St. George's University Hospital, NHS Foundation Trust, United Kingdom
| | - Emma Rose McGlone
- Department of Upper GI Surgery, St. George's University Hospital, NHS Foundation Trust, United Kingdom
| | - Marcus Reddy
- Department of Upper GI Surgery, St. George's University Hospital, NHS Foundation Trust, United Kingdom
| | - Omar A Khan
- Department of Upper GI Surgery, St. George's University Hospital, NHS Foundation Trust, United Kingdom
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Elli EF, Gonzalez-Heredia R, Sanchez-Johnsen L, Patel N, Garcia-Roca R, Oberholzer J. Sleeve gastrectomy surgery in obese patients post-organ transplantation. Surg Obes Relat Dis 2015; 12:528-534. [PMID: 26823089 DOI: 10.1016/j.soard.2015.11.030] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 11/11/2015] [Accepted: 11/28/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Among organ transplant recipients, a common side effect of immunosuppressive therapy is the development of obesity, which affects a third of the patients within 3 years after transplantation. Bariatric surgery represents a possible surgical option for weight loss among posttransplant patients. OBJECTIVES The aim of this study was to examine percent excess weight loss (%EWL), and percent weight loss (%WL) and perioperative and postoperative complications in posttransplant obese patients after sleeve gastrectomy (SG) compared with nontransplant patients. We hypothesize that transplant patients who undergo SG will not significantly differ in their perioperative or postoperative complications or in their %EWL and %WL compared with nontransplant patients who undergo SG. The second aim was to evaluate the impact of SG on graft function and immunosuppressive therapy in transplant patients. SETTING University hospital. METHODS Among 500 consecutive patients who underwent SG from January 2008 to June 2014, 10 patients were organ transplant recipients. The following variables were compared between groups: patient demographic characteristics and co-morbidities, type of transplant surgery, date of transplant surgery, pretransplant body mass index (BMI), date of bariatric surgery, prebariatric surgery BMI, operative time, length of hospitalization, postoperative complications, and change in BMI, %EWL, and %WL. Data were also collected on renal, liver, and pancreas graft function parameters and changes in immunosuppressive medications. RESULTS Six patients had a kidney transplant, 2 patients had a liver transplant, and 2 had a pancreas transplant. No significant differences were observed in %EWL or %WL at 6 and 12 months follow-up between transplant and nontransplant patients. No transplant patients were lost to follow-up at 6 and 12 months. Among nontransplant patients, 36.7% and 35.7% were lost to follow-up at 6 and 12 months, respectively. No postoperative complications were registered in the transplant group. SG did not negatively affect the graft function. CONCLUSION Initials results found that there were no significant differences in %EWL or %WL at 6 and 12 months follow-up between transplant and nontransplant patients. There were also no perioperative and postoperative complications among transplant patients after SG.
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Affiliation(s)
- Enrique F Elli
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | | | | | - Neil Patel
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Raquel Garcia-Roca
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Jose Oberholzer
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
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28
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Chan G, Garneau P, Hajjar R. The impact and treatment of obesity in kidney transplant candidates and recipients. Can J Kidney Health Dis 2015; 2:26. [PMID: 26236496 PMCID: PMC4522095 DOI: 10.1186/s40697-015-0059-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 06/19/2015] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Gabriel Chan
- Département de Chirurgie, Université de Montréal and Service de Transplantation Rénale, Hôpital Maisonneuve-Rosemont, Montreal, Canada
| | - Pierre Garneau
- Département de Chirurgie, Université de Montréal, Hôpital Sacre-Cœur de Montréal, Montreal, Canada
| | - Roy Hajjar
- Département de Chirurgie, Université de Montréal and Service de Transplantation Rénale, Hôpital Maisonneuve-Rosemont, Montreal, Canada
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Laparoscopic placement of adjustable gastric band in patients with autoimmune disease or chronic steroid use. Obes Surg 2015; 24:584-7. [PMID: 24272886 DOI: 10.1007/s11695-013-1122-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Past medical or family history of autoimmune diseases and patient chronic steroid use are label contraindications for laparoscopic placement of adjustable gastric band (LAGB). We reviewed our experience with placement of LAGB in patients with autoimmune disease or chronic steroid use. METHODS This was a retrospective review of our prospective bariatric database. All patients who underwent LAGB and had a diagnosis of autoimmune disease or chronic steroid use with at least 1-year follow-up data were included in the study. Data on demographics, weight loss, and complications were collected. RESULTS Sixteen patients with autoimmune diseases or chronic steroid use underwent LAGB. Diseases included were lupus (n = 6), sarcoidosis (n = 4), renal transplant (n = 2), rheumatoid arthritis (n = 1), ulcerative colitis (n = 1), Grave's disease (n = 1), and celiac disease (n = 1). No patients developed infectious complications. One patient required port replacement due to malfunction, and one patient underwent a conversion to gastric bypass due to failure of weight loss. The average preoperative body mass index was 46.8 kg/m(2) with an average weight of 292.0 lbs. Average excess weight loss was 39.8 % (range, 7.4 to 95.5 %) at a median follow-up of 54 months. CONCLUSIONS Our review indicates that LAGB in patients with autoimmune diseases or chronic steroid use is safe, with no infectious complications and only one explant. Some of these autoimmune conditions may improve following significant weight loss, but larger studies are required to further substantiate these findings.
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30
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Lafranca JA, IJermans JNM, Betjes MGH, Dor FJMF. Body mass index and outcome in renal transplant recipients: a systematic review and meta-analysis. BMC Med 2015; 13:111. [PMID: 25963131 PMCID: PMC4427990 DOI: 10.1186/s12916-015-0340-5] [Citation(s) in RCA: 136] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 03/31/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Whether overweight or obese end stage renal disease (ESRD) patients are suitable for renal transplantation (RT) is often debated. The objective of this review and meta-analysis was to systematically investigate the outcome of low versus high BMI recipients after RT. METHODS Comprehensive searches were conducted in MEDLINE OvidSP, Web of Science, Google Scholar, Embase, and CENTRAL (the Cochrane Library 2014, issue 8). We reviewed four major guidelines that are available regarding (potential) RT recipients. The methodology was in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and written based on the PRISMA statement. The quality assessment of studies was performed by using the GRADE tool. A meta-analysis was performed using Review Manager 5.3. Random-effects models were used. RESULTS After identifying 5,526 studies addressing this topic, 56 studies were included. We extracted data for 37 outcome measures (including data of more than 209,000 RT recipients), of which 26 could be meta-analysed. The following outcome measures demonstrated significant differences in favour of low BMI (<30) recipients: mortality (RR = 1.52), delayed graft function (RR = 1.52), acute rejection (RR = 1.17), 1-, 2-, and 3-year graft survival (RR = 0.97, 0.95, and 0.97), 1-, 2-, and 3-year patient survival (RR = 0.99, 0.99, and 0.99), wound infection and dehiscence (RR = 3.13 and 4.85), NODAT (RR = 2.24), length of hospital stay (2.31 days), operation duration (0.77 hours), hypertension (RR = 1.35), and incisional hernia (RR = 2.72). However, patient survival expressed in hazard ratios was in significant favour of high BMI recipients. Differences in other outcome parameters were not significant. CONCLUSIONS Several of the pooled outcome measurements show significant benefits for 'low' BMI (<30) recipients. Therefore, we postulate that ESRD patients with a BMI >30 preferably should lose weight prior to RT. If this cannot be achieved with common measures, in morbidly obese RT candidates, bariatric surgery could be considered.
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Affiliation(s)
- Jeffrey A Lafranca
- Department of Surgery, division of HPB & Transplant Surgery, Erasmus MC, University Medical Center Rotterdam, 's Gravendijkwal 230, PO BOX 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Jan N M IJermans
- Department of Surgery, division of HPB & Transplant Surgery, Erasmus MC, University Medical Center Rotterdam, 's Gravendijkwal 230, PO BOX 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Michiel G H Betjes
- Department of Nephrology, Erasmus MC, University Medical Center Rotterdam, 's Gravendijkwal 230, PO BOX 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Frank J M F Dor
- Department of Surgery, division of HPB & Transplant Surgery, Erasmus MC, University Medical Center Rotterdam, 's Gravendijkwal 230, PO BOX 2040, 3000, CA, Rotterdam, The Netherlands.
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Quante M, Dietrich A, ElKhal A, Tullius SG. Obesity-related immune responses and their impact on surgical outcomes. Int J Obes (Lond) 2015; 39:877-83. [PMID: 25697667 DOI: 10.1038/ijo.2015.21] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 11/11/2014] [Accepted: 11/26/2014] [Indexed: 02/07/2023]
Abstract
The obesity epidemic represents a critical disease burden with broad clinical consequences. At the same time, obesity has been linked to inferior surgical outcomes and considered a contraindication for some elective surgical procedures. A growing body of mechanistic evidence has accumulated linking obesity to changes of metabolism and immune responses. This concept provides an integrated inflammatory network based on the perception of obesity as a state of chronic low-grade inflammation. With a more detailed understanding of this dynamic network and mechanistic insights, novel treatment and management strategies may be developed with the goal to optimize surgical outcomes in obese patients.
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Affiliation(s)
- M Quante
- 1] Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA [2] IFB Integrated Research and Treatment Centre Adiposity Diseases, University of Leipzig, Leipzig, Germany [3] Department of Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - A Dietrich
- 1] IFB Integrated Research and Treatment Centre Adiposity Diseases, University of Leipzig, Leipzig, Germany [2] Department of Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - A ElKhal
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - S G Tullius
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Salinas A, Mc Quattie Pimentel AC, Salinas HM. Roux-en-Y gastric bypass as metabolic treatment in a heart transplant patient with type 2 diabetes: 4 years later. Surg Obes Relat Dis 2014; 10:e81-3. [DOI: 10.1016/j.soard.2014.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 03/04/2014] [Accepted: 03/05/2014] [Indexed: 01/06/2023]
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Jamal MH, Corcelles R, Daigle CR, Rogula T, Kroh M, Schauer PR, Brethauer SA. Safety and effectiveness of bariatric surgery in dialysis patients and kidney transplantation candidates. Surg Obes Relat Dis 2014; 11:419-23. [PMID: 25813752 DOI: 10.1016/j.soard.2014.09.022] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 08/07/2014] [Accepted: 09/21/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Chronic renal disease is known to adversely affect the results of bariatric surgery. There is a paucity of literature on the safety and effectiveness of bariatric surgery on dialysis patients who are at very advanced stages in their renal disease. The objective of this study was to determine the safety and effectiveness of bariatric surgery in dialysis patients. METHODS A retrospective review of a prospectively collected database was conducted for dialysis patients who underwent bariatric surgery between January 2006 and January 2012. Age, gender, body mass index (BMI), cause of renal failure, associated co-morbidities, type of surgery, early and late complications, and mortality were collected. RESULTS Of the 3048 patients undergoing bariatric surgery during the study period, 21 dialysis patients (.7%) were identified. Eighteen patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB), 2 patients underwent laparoscopic sleeve gastrectomy, and 1 patient underwent laparoscopic adjustable gastric banding. Mean preoperative BMI was 47.1±5.5 kg/m(2), and BMI decreased to 35.3±8.4 kg/m(2) after a mean follow-up period of 27.6 months (range = 1.4-78.0 mo). Early major complications (<30 days of surgery) occurred in 2 patients (1 anastomotic leak and 1 anastomotic stricture). Four patients had a late complication, including 1 marginal ulcer with bleeding managed endoscopically, 1 small bowel obstruction requiring laparoscopic lysis of adhesions, 1 cholecystitis requiring cholecystectomy, and 1 anastomotic stricture requiring endoscopic dilation. There was 1 death in this cohort, at 45 days after LRYGB, that was unrelated to a surgery. CONCLUSIONS Chronic renal failure requiring dialysis should not be considered a contraindication to bariatric surgery. Our experience with this patient population has shown excellent medium-term weight loss and an acceptable (albeit increased) risk/benefit ratio.
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Affiliation(s)
- Mohammad H Jamal
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Surgery, Kuwait University, Kuwait City, Kuwait
| | - Ricard Corcelles
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | - Tomasz Rogula
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Matthew Kroh
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Philip R Schauer
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Stacy A Brethauer
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio.
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Golomb I, Winkler J, Ben-Yakov A, Benitez CC, Keidar A. Laparoscopic sleeve gastrectomy as a weight reduction strategy in obese patients after kidney transplantation. Am J Transplant 2014; 14:2384-90. [PMID: 25139661 DOI: 10.1111/ajt.12829] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 05/14/2014] [Accepted: 05/14/2014] [Indexed: 01/25/2023]
Abstract
Morbid obesity is associated with increased graft loss and shortened graft survival in kidney transplant patients. Treating obesity in transplant patients may improve graft outcomes. Laparoscopic sleeve gastrectomy (LSG), an effective bariatric operation, is relatively unlikely to interfere with absorption of anti-rejection medications. Data on relevant renal function parameters were collected from all LSGs performed on renal transplant patients at our center (n = 10). The procedure was successful in eight patients, with no mortality, graft rejection or dysfunction. The median age and follow-up were 57 years and 14 months, respectively. Seven patients had over 1 year of follow-up. The median preoperative weight and BMI were 119 kg (96-152) and 42 kg/m(2) (37-49), respectively. The median hospital stay was 4 days. The median postoperative weight and BMI at 6 months and 1 year were 86 kg and 31 kg/m(2) and 83 kg and 29 kg/m(2) , respectively. Urinary protein excretion and serum creatinine decreased significantly in all patients (p < 0.05). One patient developed two complications, acute renal failure and sleeve stricture, both of which resolved with treatment. LSG provided effective weight loss in renal transplant patients without adverse effects on graft function and immunosuppression.
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Affiliation(s)
- I Golomb
- Bariatric Clinic, Beilinson Medical Center, Petah-Tikva, Israel
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DiCecco SR, Francisco-Ziller N. Obesity and organ transplantation: successes, failures, and opportunities. Nutr Clin Pract 2014; 29:171-91. [PMID: 24503157 DOI: 10.1177/0884533613518585] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The increasing rate of societal obesity is also affecting the transplant world through obesity in candidates and donors as well as its posttransplant repercussions. Being overweight and obese has been shown to have significant effects on both short- and long-term complications as well as patient and graft survival. However, much of the comorbidity can be controlled or prevented with careful patient selection and aggressive management. A team approach to managing obesity and its comorbidities both pre- and posttransplant is essential for successful transplant outcomes. Complicating understanding the results of obesity research is the inclusion different weight categories, use of listing vs transplant weights, patient populations large enough for statistical power, and changes in transplant management, especially immunosuppression protocols, anti-infection protocols, and operative techniques. Much more research is needed regarding many elements, including safe weight loss before transplantation, prevention of weight gain after transplant, genomic influences, and the role of bariatric surgery in the transplant process.
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Affiliation(s)
- Sara R DiCecco
- Sara R. DiCecco, Mayo Clinic Hospital-Rochester Methodist Campus, 201 West Center Street, Rochester, MN 55902, USA.
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Tariq N, Moore LW, Sherman V. Bariatric Surgery and End-Stage Organ Failure. Surg Clin North Am 2013; 93:1359-71. [DOI: 10.1016/j.suc.2013.08.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Proczko M, Kaska L, Kobiela J, Stefaniak T, Zadrożny D, Sledziński Z. Roux-en-Y gastric bypass in dialysed morbidly obese patients as a preparation for a kidney transplantation: case series. Wideochir Inne Tech Maloinwazyjne 2013; 8:174-7. [PMID: 23837104 PMCID: PMC3699771 DOI: 10.5114/wiitm.2011.32852] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 12/20/2012] [Accepted: 12/27/2012] [Indexed: 11/17/2022] Open
Abstract
Morbid obesity in group of patients with chronic kidney failure has an important impact on access to kidney transplantation. Bariatric procedures can be used as an preparation for potential recipients, which can help to improve their metabolic status and reduce weight. We present the first experience of our centre based on a series of 3 morbidly obese patients with chronic kidney disease underwent Roux-en-Y gastric bypass before being reported to the national registry of recipients.
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Affiliation(s)
- Monika Proczko
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Poland
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Johnson BL, Blackhurst DW, Latham BB, Cull DL, Bour ES, Oliver TL, Williams B, Taylor SM, Scott JD. Bariatric surgery is associated with a reduction in major macrovascular and microvascular complications in moderately to severely obese patients with type 2 diabetes mellitus. J Am Coll Surg 2013; 216:545-56; discussion 556-8. [PMID: 23391591 DOI: 10.1016/j.jamcollsurg.2012.12.019] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 12/12/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bariatric surgery (BAR) has been established as an effective treatment for type 2 diabetes mellitus (T2DM) in obese patients. However, few studies have examined the mid- to long-term outcomes of bariatric surgery in diabetic populations. Specifically, no comparative studies have broadly examined major macrovascular and microvascular complications in bariatric surgical patients vs similar, nonbariatric surgery controls. STUDY DESIGN We conducted a large, population-based, retrospective cohort study of adult obese patients with T2DM, from 1996 to 2009, using UB-04 administrative data and vital records. Eligible patients undergoing bariatric surgery (BAR [n = 2,580]) were compared with nonbariatric surgery controls (CON [n = 13,371]) for the outcomes of any first major macrovascular event (myocardial infarction, stroke, or all-cause death) or microvascular event (new diagnosis of blindness, laser eye or retinal surgery, nontraumatic amputation, or creation of permanent arteriovenous access for hemodialysis), assessed in combination and separately, as well as other vascular events (carotid, coronary or lower extremity revascularization or new diagnosis of congestive heart failure or angina pectoris). RESULTS Bariatric surgery was associated with favorable unadjusted 5-year event-free survival estimates for the combined primary outcome (95% ± 1% vs 81% ± 1%, log-rank p < 0.01) and each secondary outcome (log-rank p < 0.01). Multivariate-adjusted and propensity-based relative risk estimates showed BAR to be associated with a 60% to 70% reduction (adjusted hazard ratio [HR] 0.36, 95% CI 0.27 to 0.47) in the combined primary outcome and 60% to 80% risk reductions for each secondary outcome (macrovascular events [adjusted HR 0.39, 95% CI 0.29 to 0.51]; microvascular events [adjusted HR 0.22, 95% CI 0.09 to 0.49]; and other vascular events [adjusted HR 0.25, 95% CI 0.19 to 0.32]). CONCLUSIONS Bariatric surgery is associated with a 65% reduction in major macrovascular and microvascular events in moderately and severely obese patients with T2DM.
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Affiliation(s)
- Brent L Johnson
- Greenville Hospital System University Medical Center, University of South Carolina School of Medicine, Greenville, SC 29605, USA
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Transplantation rénale et receveurs obèses : revue du comité de transplantation de l’Association française d’urologie. Prog Urol 2012; 22:678-87. [DOI: 10.1016/j.purol.2012.04.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 03/15/2012] [Accepted: 04/30/2012] [Indexed: 01/31/2023]
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Zelones J, Biswas O, Mehran A. Laparoscopic Sleeve Gastrectomy after Simultaneous Pancreas-Kidney Transplant. Am Surg 2012. [DOI: 10.1177/000313481207800546] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Justin Zelones
- Department of Surgery University of California Los Angeles Los Angeles, California
| | - Olivia Biswas
- Department of Surgery University of California Los Angeles Los Angeles, California
| | - Amir Mehran
- Department of Surgery University of California Los Angeles Los Angeles, California
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Elli EF, Masrur MA, Giulianotti PC. Robotic sleeve gastrectomy after liver transplantation. Surg Obes Relat Dis 2012; 9:e20-2. [PMID: 22365186 DOI: 10.1016/j.soard.2012.01.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 01/15/2012] [Indexed: 12/11/2022]
Affiliation(s)
- E Fernando Elli
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois 60612, USA
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Sung TC, Lee WJ, Yu HI, Tu CW, Chiang CC, Liao CS. Laparoscopic Roux-en-Y gastric bypass in a morbidly obese patient with renal transplant: a case report. Asian J Endosc Surg 2011; 4:189-91. [PMID: 22776307 DOI: 10.1111/j.1758-5910.2011.00095.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Renal transplant is the only curative treatment for end-stage renal disease. As diabetes and obesity are the major causes of graft failure and post-transplant complication, it is important to manage obesity in patients with renal transplant. Herein, we report a case of a morbidly obese renal-transplant patient with poorly controlled diabetes who received bariatric surgery. A 34-year-old obese Taiwanese man with type 2 diabetes had end-stage renal disease that had progressed since 2008, when he had commenced hemodialysis (January 2008) and had a renal transplant (July 2008). Because of persistent obesity and poorly controlled diabetes, he received LRYGB at Chiayi Christian hospital on 18 August 2010. In the month that followed, he lost 10 kg. His serum creatinine decreased to 1.11 mg/dL (1.4 mg/dL, preoperative) and his hemoglobin A1c decreased to 8.5% (10.4%, preoperative). These results indicate that, in obese renal transplant patients, LRYGB may be employed to treat obesity, control diabetes and stabilize or improve the renal function.
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Affiliation(s)
- T C Sung
- Department of General Surgery, Chiayi Christian Hospital, Chiayi, Taiwan.
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Kaposztas Z, Gyurus E, Kahan BD. New-onset diabetes after renal transplantation: diagnosis, incidence, risk factors, impact on outcomes, and novel implications. Transplant Proc 2011; 43:1375-94. [PMID: 21693204 DOI: 10.1016/j.transproceed.2011.04.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE New-onset diabetes after transplantation (NODAT) is a multifactorial, complex metabolic disorder associated with impaired long-term graft function, reduced recipient survival, and increased risks of cardiovascular disease and infectious complications. The impact of NODAT is generally underestimated partly due to the inconsistent criteria that have been previously used for its diagnosis and to the generally short observation periods. The aim of this article was to review the recent literature on NODAT and to highlight the novel implications. FINDINGS The 2010 American Diabetes Association guidelines provide useful, simplified criteria to unify the diagnosis including application of hemoglobin A1C levels. We sought to establish the impact of various modifiable and nonmodifiable risk factors. A vast number of papers have examined the effects of immunosuppressive medications on the development of NODAT: Neither calcineurin inhibitor nor sirolimus (SRL) or steroids seems to be innocent of contributing to it. Immunosuppressants account for 74% of the occurrence of NODAT. Among modifiable risk factors, obesity is independent and significant, with great prevalence in the population. In additional to lifestyle modifications, the role of bariatric surgery (BS) either before or after transplantation is highlighted herein as a strategy to reduce disease in the view of the results among overweight, nontransplanted patients. SUMMARY Because of the strong association between high glucose values in the early posttransplant period and the development of NODAT, the condition must be recognized early after (or even before) transplantation by intensive screening. Patients at risk for NODAT must modify appropriate risk factors and particularly undergo pretransplant planning and/or posttransplant adjustment individualizing immunosuppressive therapy to mitigate the risk of this serious complication.
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Affiliation(s)
- Z Kaposztas
- Cardiff Transplant Unit, University Hospital of Wales, Cardiff, Wales
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