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De Luca M, Zese M, Silverii GA, Ragghianti B, Bandini G, Forestieri P, Zappa MA, Navarra G, Foschi D, Musella M, Sarro G, Pilone V, Facchiano E, Foletto M, Olmi S, Raffelli M, Bellini R, Gentileschi P, Cerbone MR, Grandone I, Berardi G, Di Lorenzo N, Lucchese M, Piazza L, Casella G, Manno E, Zaccaroni A, Balani A, Mannucci E, Monami M. Bariatric Surgery for Patients with Overweight/Obesity. A Comprehensive Grading Methodology and Network Metanalysis of Randomized Controlled Trials on Weight Loss Outcomes and Adverse Events. Obes Surg 2023; 33:4147-4158. [PMID: 37917391 DOI: 10.1007/s11695-023-06909-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
This study aims to compare different types of metabolic bariatric surgery (MBS) with lifestyle intervention/medical therapy (LSI/MT) for the treatment of overweight/obesity. The present and network meta-analysis (NMA) includes randomized trials. MBS was associated with a reduction of BMI, body weight, and percent weight loss, when compared to LSI/MT, and also with a significant reduction of HbA1c and a higher remission of diabetes. Meta-regression analyses revealed that BMI, a higher proportion of women, and a longer duration of trial were associated with greater effects of MBS. The NMA showed that all surgical procedures included (except greater curvature plication) were associated with a reduction of BMI. MBS is an effective option for the treatment of obesity. The choice of BMI thresholds for eligibility for surgery of patients with different complications should be performed making an evaluation of risks and benefits in each BMI category.
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Affiliation(s)
- Maurizio De Luca
- Dipartimento di Chirurgia Generale e Metabolica, Azienda ULSS5 Polesana, Ospedale di Rovigo, 45010, Rovigo, Italia
| | - Monica Zese
- Dipartimento di Chirurgia Generale e Metabolica, Azienda ULSS5 Polesana, Ospedale di Rovigo, 45010, Rovigo, Italia.
| | | | - Benedetta Ragghianti
- Azienda Ospedaliero Universitaria Careggi e Università di Firenze, 50134, Firenze, Italia
| | - Giulia Bandini
- Azienda Ospedaliero Universitaria Careggi e Università di Firenze, 50134, Firenze, Italia
| | - Pietro Forestieri
- Dipartimento di Scienze Biochimiche Avanzate, Università Degli Studi Di Napoli "Federico II", 80138, Napoli, Italia
| | | | - Giuseppe Navarra
- Policlinico Universitario "G. Martino" Messina, 98124, Messina, Italia
| | | | - Mario Musella
- Dipartimento di Scienze Biochimiche Avanzate, Università Degli Studi Di Napoli "Federico II", 80138, Napoli, Italia
| | - Giuliano Sarro
- UOC Chirurgia Generale e Bariatrica, Istituto Clinico Alta Specialità' San Gaudenzio - Novara, Gruppo Policlinico di Monza, 28100, Novara, Italia
| | - Vincenzo Pilone
- Università degli Studi di Salerno A.O.U. San Giovanni di Dio e Ruggi D'Aragona Ospedale G. Fucito, 84131, Salerno, Italia
| | | | - Mirto Foletto
- Policlinico Universitario di Padova, 35128, Padova, Italia
| | - Stefano Olmi
- Policlinico San Marco, Bergamo, 24046, Bergamo, Italia
| | - Marco Raffelli
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, 00168, Italia
| | - Rosario Bellini
- Azienda Ospedaliero-Universitaria Pisana, 56126, Pisa, Italia
| | - Paolo Gentileschi
- Dipartimento di Chirurgia Bariatrica e Metabolica-Ospedale San Carlo di Nancy, Università di Roma Tor Vergata, Roma e Maria Cecilia Hospital, Cotignola, 00165, (Ravenna), Italia
| | | | - Ilenia Grandone
- SC Diabetologia Dietologia e Nutrizione Clinica, Azienda Ospedaliera Santa Maria di Terni, 05100, Terni, Italia
| | - Giovanna Berardi
- Dipartimento di Scienze Biochimiche Avanzate, Università Degli Studi Di Napoli "Federico II", 80138, Napoli, Italia
| | | | - Marcello Lucchese
- Ospedale Santa Maria Nuova-Chirurgia Generale e Bariatrica - Azienda Sanitaria Toscana Centro, 50122, Firenze, Italia
| | - Luigi Piazza
- UOC Chirurgia Generale e d'Urgenza, Arnas Garibaldi, 95123, Catania, Italia
| | - Giovanni Casella
- Dipartimento di Chirurgia, Università La Sapienza, AOU Policlinico Umberto I, 00161, Roma, Italia
| | - Emilio Manno
- AORN A. Cardarelli Napoli, UO Chirurgia Bariatrica e Metabolica, 80131, Napoli, Italia
| | - Alberto Zaccaroni
- Chirurgia Endocrina e Metabolica, Ospedale G.B.Morgagni, 47121, Forlì, Italia
| | - Alessandro Balani
- Dipartimento Chirurgico del Presidio Ospedaliero Gorizia-Monfalcone, ASS2 Isontina, 34170, Gorizia, Italia
| | - Edoardo Mannucci
- Azienda Ospedaliero Universitaria Careggi e Università di Firenze, 50134, Firenze, Italia
| | - Matteo Monami
- Azienda Ospedaliero Universitaria Careggi e Università di Firenze, 50134, Firenze, Italia
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Di Cocco P, Bencini G, Spaggiari M, Petrochenkov E, Akshelyan S, Fratti A, Zhang JC, Almario Alvarez J, Tzvetanov I, Benedetti E. Obesity and Kidney Transplantation-How to Evaluate, What to Do, and Outcomes. Transplantation 2023; 107:1903-1909. [PMID: 36855222 DOI: 10.1097/tp.0000000000004564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Obesity is a growing issue that is spreading worldwide; its prevalence is ever increasing in patients with end-stage renal disease and represents a potential barrier to transplantation. The lack of unanimous guidelines exacerbates the current disparity in treatment, which can affect outcomes, leading to a significantly longer time on the waiting list. Multidisciplinary and multimodal management (encompassing several healthcare professionals such as nephrologists, transplant physicians and surgeons, primary care providers, and nurses) is of paramount importance for the optimal management of this patient population in a continuum from waitlisting to transplantation. Development of this guideline followed a standardized protocol for evidence review. In this review, we report on our clinical experience in transplantation of obese patients; strategies to manage this condition, including bariatric surgery, suitable timing for transplantation among this patient population, and clinical experience in robotic sleeve gastrectomy; and simultaneous robotic kidney transplantation to achieve optimal outcomes.
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Affiliation(s)
- Pierpaolo Di Cocco
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Giulia Bencini
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Mario Spaggiari
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Egor Petrochenkov
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Stepan Akshelyan
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Alberto Fratti
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Jing Chen Zhang
- University of Illinois College of Medicine at Chicago, Chicago, IL
| | - Jorge Almario Alvarez
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Ivo Tzvetanov
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Enrico Benedetti
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
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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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Sarno G, Frias-Toral E, Ceriani F, Montalván M, Quintero B, Suárez R, García Velasquèz E, Muscogiuri G, Iannelli A, Pilone V, Schiavo L. The Impact and Effectiveness of Weight Loss on Kidney Transplant Outcomes: A Narrative Review. Nutrients 2023; 15:nu15112508. [PMID: 37299471 DOI: 10.3390/nu15112508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
Obesity is a worldwide epidemic that leads to several non-communicable illnesses, including chronic kidney disease (CKD). Diet and lifestyle modifications have shown a limited impact in the treatment of obesity. Because the group of end-stage renal disease (ESRD) patients examined in this study had limited access to kidney transplantation (KT), patients with obesity were thought to be at an increased risk of intraoperative and postoperative KT complications. Although bariatric surgery (BS) is now recognized as the gold standard treatment for morbid obesity, its role in ESRD or kidney transplant patients remains unknown. It is critical to know the correlation between weight loss and complications before and after KT, the impact of the overall graft, and patients' survival. Hence, this narrative review aims to present updated reports addressing when to perform surgery (before or after a KT), which surgical procedure to perform, and again, if strategies to avoid weight regain must be specific for these patients. It also analyzes the metabolic alterations produced by BS and studies its cost-effectiveness pre- and post-transplantation. Due to the better outcomes found in KT recipients, the authors consider it more convenient to perform BS before KT. However, more multicenter trials are required to provide a solid foundation for these recommendations in ERSD patients with obesity.
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Affiliation(s)
- Gerardo Sarno
- San Giovanni di Dio e Ruggi D'Aragona, University Hospital, Scuola Medica Salernitana, 84131 Salerno, Italy
| | - Evelyn Frias-Toral
- School of Medicine, Universidad Espìritu Santo, Samborondòn 091952, Ecuador
| | - Florencia Ceriani
- Nutrition School, Universidad de la República (UdelaR), Ricaldoni s/n, Montevideo 11300, Uruguay
| | - Martha Montalván
- School of Medicine, Universidad Catòlica Santiago de Guayaquil, Av. Pdte. Carlos Julio Arosemena Tola, Guayaquil 090615, Ecuador
| | - Beatriz Quintero
- School of Medicine, Universidad Técnica Particular de Loja, Calle París, San Cayetano Alto, Loja 110101, Ecuador
| | - Rosario Suárez
- School of Medicine, Universidad Técnica Particular de Loja, Calle París, San Cayetano Alto, Loja 110101, Ecuador
| | | | - Giovanna Muscogiuri
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Antonio Iannelli
- Department of Clinical Research and Innovation, University Hospital of Nice, Cimiez Hospital, 06000 Nice, France
- Digestive Surgery and Liver Transplantation Unit, University Hospital of Nice, Archet 2 Hospital, 06200 Nice, France
- Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", 06204 Nice, France
| | - Vincenzo Pilone
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081 Baronissi, Italy
| | - Luigi Schiavo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081 Baronissi, Italy
- National Biodiversiy Future Center, 90133 Palermo, Italy
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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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Bariatric surgery before and after kidney transplantation: a propensity score-matched analysis. Surg Obes Relat Dis 2022; 19:501-509. [PMID: 36572583 DOI: 10.1016/j.soard.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 09/27/2022] [Accepted: 11/13/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Obesity is becoming more prevalent in the end-stage renal disease population. Bariatric surgery (BS) is increasingly considered as an approach to become eligible for kidney transplant (KT) or reduce obesity-related morbidities. OBJECTIVES To assess the short- and long-term outcomes of patients who underwent both BS and KT and to determine the optimal timing of BS. METHODS Patients who underwent both KT and BS between January 2000 and December 2020 were included and stratified according to the sequence of the 2 operations. The primary outcomes were patient and graft survival. The secondary outcomes were postoperative complications and efficacy of weight loss. RESULTS Twenty-two patients were included in the KT first group and 34 in the BS first group. Death-uncensored graft survival in the KT first group was significantly higher than in the BS first group (90.9% versus 71.4%, P = .009), without significant difference in patient survival and death-censored graft survival (100% versus 90.5%, P = .082; 90.9% versus 81.0%, P = .058). There was no significant difference in 1-year total weight loss (1-yr TWL: median [interquartile range {IQR}], 36.0 [28.0-42.0] kg versus 29.6 [21.5-40.6] kg, P = .424), 1-year percentage of excess weight loss (1-yr %EWL: median [IQR], 74.9 [54.1-99.0] versus 57.9 [47.5-79.4], P = .155), and the incidence of postoperative complications (36.4% versus 50.0%, P = .316) between the KT first and BS first groups. CONCLUSION Both pre- and posttransplant BS are effective and safe. Different conditions of each transplant candidate should be considered in detail to determine the optimal timing of BS.
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Bariatric Surgery Outcomes in Patients with Kidney Transplantation. J Clin Med 2022; 11:jcm11206030. [PMID: 36294351 PMCID: PMC9604744 DOI: 10.3390/jcm11206030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/03/2022] [Accepted: 10/11/2022] [Indexed: 11/17/2022] Open
Abstract
Obesity and kidney transplantation (KTx) are closely related. Obesity increases the risk of chronic kidney disease and can be a relative contraindication for KTx. Besides, KTx recipients are predisposed to obesity and its comorbidities. Consequently, bariatric surgery (BS) emerges as a powerful therapeutic tool either before or after KTx. Since evidence regarding the best approach is still scarce, we aimed to describe renal and metabolic outcomes in a single centre with more than 15-year experience in both surgeries. Methods: A retrospective study including patients who had received a KTx either before or after BS. Usual metabolic and renal outcomes, but also new variables (as renal graft dysfunction) were collected for a minimum follow-up of 1-year post-BS. Results: A total of 11 patients were included: n = 6 (BS-post-KTx) and n = 5 (BS-pre-KTx). One patient was assessed in both groups. No differences in the main outcomes were identified, but BS-post-KTx group tended to gain more weight during the follow-up. The incidence of renal graft dysfunction was comparable (4/6 for BS-post-KTx, 3/5 for BS-pre-KTx) between groups. Conclusions: BS in patients with KTx appears to be safe and effective attending to metabolic and renal outcomes. These results seem irrespective of the time course, except for weight regain, which appears to be a common pattern in the BS-post-KTx group.
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Ross RC, Akinde YM, Schauer PR, le Roux CW, Brennan D, Jernigan AM, Bueter M, Albaugh VL. The role of bariatric and metabolic surgery in the development, diagnosis, and treatment of endometrial cancer. Front Surg 2022; 9:943544. [PMID: 36117808 PMCID: PMC9470773 DOI: 10.3389/fsurg.2022.943544] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/25/2022] [Indexed: 12/13/2022] Open
Abstract
The obesity pandemic continues to contribute to a worsening burden of disease worldwide. The link between obesity and diseases such as diabetes, cardiovascular disease, and cancer has been well established, yet most patients living with obesity remain untreated or undertreated. Metabolic and bariatric surgery is the most effective and durable treatment for obesity, is safe, and may have a protective benefit with respect to cancer incidence. In this review, an overview of the link between obesity, metabolic surgery, and cancer is discussed with emphasis on indications for endometrial cancer, the malignancy most strongly associated with obesity. Considerable evidence from retrospective and prospective cohort studies supports a decreased risk of endometrial cancer in patients with obesity who undergo bariatric surgery compared with nonsurgical controls. Survivors of endometrial cancer are at increased risk of poor health outcomes associated with obesity, and women with endometrial cancer are more likely to die of cardiovascular disease and other obesity-related illnesses than of the malignancy itself. Recent advances in anticancer drug therapies have targeted pathways that may also be therapeutically altered with metabolic surgery. Metabolic surgery has significant potential to enter the treatment paradigm for endometrial cancer, and gynecologic oncologist visits present an opportunity to identify patients who may benefit the most.
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Affiliation(s)
- Robert C. Ross
- Translational and Integrative Gastrointestinal and Endocrine Research Laboratory, Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, United States
| | - Yetunde M. Akinde
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, New Orleans, LA, United States
| | - Philip R. Schauer
- Metamor Institute, Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, United States
| | - Carel W. le Roux
- School of Medicine, St. Vincent's University Hospital and University College Dublin, Dublin, Ireland
| | - Donal Brennan
- UCD Gynecological Oncology Group, UCD School of Medicine, Catherine McAuley Research Centre, Mater Misericordiae University Hospital, Belfield, Dublin, Ireland
| | - Amelia M. Jernigan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, New Orleans, LA, United States
| | - Marco Bueter
- Department of Visceral and Transplantation Surgery, University Hospital of Zürich, Zürich, Switzerland
| | - Vance L. Albaugh
- Translational and Integrative Gastrointestinal and Endocrine Research Laboratory, Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, United States
- Metamor Institute, Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, United States
- Correspondence: Vance L. Albaugh
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Li Marzi V, Pecoraro A, Gallo ML, Caroti L, Peris A, Vignolini G, Serni S, Campi R. Robot-assisted kidney transplantation: Is it getting ready for prime time? World J Transplant 2022; 12:163-174. [PMID: 36051450 PMCID: PMC9331411 DOI: 10.5500/wjt.v12.i7.163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/08/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
Kidney transplantation (KT) is the treatment of choice for patients with end-stage renal disease, providing a better survival rate and quality of life compared to dialysis. Despite the progress in the medical management of KT patients, from a purely surgical standpoint, KT has resisted innovations during the last 50 years. Recently, robot-assisted KT (RAKT) has been proposed as an alternative approach to open surgery, especially due to its potential benefits for fragile and immunocompromised recipients. It was not until 2014 that the role of RAKT has found value thanks to the pioneering Vattikuti Urology Institute-Medanta collaboration that conceptualized and developed a new surgical technique for RAKT following the Idea, Development, Exploration, Assessment, Long-term follow-up recommendations for introducing surgical innovations into real-life practice. During the last years, mirroring the Vattikuti-Medanta technique, several centers developed RAKT program worldwide, providing strong evidence about the safety and the feasibility of this procedure. However, the majority of RAKT are still performed in the living donor setting, as an “eligible” procedure, while only a few centers have realized KT through a robotic approach in the challenging scenario of cadaver donation. In addition, despite the spread of minimally-invasive (predominantly robotic) surgery worldwide, many KTs are still performed in an open fashion. Regardless of the type of incision employed by surgeons, open KT may lead to non-negligible risks of wound complications, especially among obese patients. Particularly, the assessment for KT should consider not only the added surgical technical challenges but also the higher risk of postoperative complications. In this context, robotic surgery could offer several benefits, including providing a better exposure of the surgical field and better instrument maneuverability, as well as the possibility to integrate other technological nuances, such as the use of intraoperative fluorescence vascular imaging with indocyanine green to assess the ureteral vascularization before the uretero-vesical anastomosis. Therefore, our review aims to report the more significant experiences regarding RAKT, focusing on the results and future perspectives.
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Affiliation(s)
- Vincenzo Li Marzi
- Department of Minimally Invasive and Robotic Urologic Surgery, Careggi University Hospital, University of Florence, Florence 50134, Italy
| | - Alessio Pecoraro
- Department of Minimally Invasive and Robotic Urologic Surgery, Careggi University Hospital, University of Florence, Florence 50134, Italy
| | - Maria Lucia Gallo
- Department of Minimally Invasive and Robotic Urologic Surgery, Careggi University Hospital, University of Florence, Florence 50134, Italy
| | | | - Adriano Peris
- Intensive Care Unit and Regional ECMO Referral Centre, Careggi Hospital, Florence 50134, Italy
| | - Graziano Vignolini
- Department of Minimally Invasive and Robotic Urologic Surgery, Careggi University Hospital, University of Florence, Florence 50134, Italy
| | - Sergio Serni
- Department of Minimally Invasive and Robotic Urologic Surgery, University of Florence, Florence 50134, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Riccardo Campi
- Department of Minimally Invasive and Robotic Urologic Surgery, Careggi University Hospital, University of Florence, Florence 50134, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
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St Jules R, Blech D, Smith NK, Sakai T. Abdominal Organ Transplantation: Noteworthy Literature in 2021. Semin Cardiothorac Vasc Anesth 2022; 26:140-153. [PMID: 35608409 DOI: 10.1177/10892532221093955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This review highlights noteworthy literature pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. In 2021, we identified noteworthy papers from over 1,200 peer-reviewed publications on pancreatic transplantation, over 1,400 on intestinal transplantation, and over 9,000 on kidney transplantation. The liver transplantation section focuses on clinical trials and systematic reviews and meta-analyses published in 2021 and features 20 selected papers. COVID-19 and abdominal organ transplantation are featured in an independent section.
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Affiliation(s)
- Robert St Jules
- Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Daniel Blech
- Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Natalie K Smith
- Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA, USA
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Abstract
Since the mid 20th century, transplantation has been a fast-developing field of contemporary medicine. The technical aspects of transplant operations were developed in the 1950s, with little significant change for >50 y. Those techniques allowed completion of various organ transplants and successful patient outcomes, but they also carried the inherent disadvantages of open surgery, such as postoperative pain, wound complications and infections, and prolonged length of hospital stay. The introduction and adoption of minimally invasive surgical techniques in the early 1990s to various surgical specialties including general, gynecologic, and urologic surgery led to significant improvements in postoperative patient care and outcomes. Organ transplantation, with its precision demanding vascular anastomoses, initially had been considered infeasible to accomplish with conventional laparoscopic devices. The institution of robotic surgical technology in the late 1990s and its subsequent wide utilization in fields of surgery changed its accessibility and acceptance. With the steady camera, 3D views, and multidirectional wrist motions, surgical robotics opened new horizons for technically demanding surgeries such as transplantation to be completed in a minimally invasive fashion. Furthermore, the hope was this technique could find a niche to treat patients who otherwise are not deemed surgical candidates in many fields including transplantation. Here in, robotics in kidney transplantation and its ability to help provide equity through access to transplantation will be discussed.
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12
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Spiers HVM, Sharma V, Woywodt A, Sivaprakasam R, Augustine T. Robot-assisted kidney transplantation: an update. Clin Kidney J 2021; 15:635-643. [PMID: 35371439 PMCID: PMC8967665 DOI: 10.1093/ckj/sfab214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Indexed: 11/14/2022] Open
Abstract
Renal transplantation has become the gold-standard treatment for the majority of patients with established renal failure. Recent decades have seen significant progress in immunosuppressive therapies and advances in post-transplant management of recipients, resulting in improved graft and patient outcomes. However, the open technique of allograft implantation has stood the test of time, remaining largely unchanged. In a world where major advances in surgery have been facilitated by innovations in the fields of biotechnology and medical instrumentation, minimally invasive options have been introduced for the recipient undergoing kidney transplantation. In this review we present the evolution of minimally invasive kidney transplantation, with a specific focus on robot-assisted kidney transplant and the benefits it offers to specific patient groups. We also discuss the ethical concerns that must be addressed by transplant teams considering developing or referring to robotic programs.
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Affiliation(s)
- Harry V M Spiers
- Department of Transplantation, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Videha Sharma
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
- Faculty of Biology, Medicine and Health, Centre for Health Informatics, Division of Informatics, Imaging and Data Science, University of Manchester, Manchester, UK
| | - Alexander Woywodt
- Department of Renal Medicine, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Rajesh Sivaprakasam
- Department of Transplant and Robotic Surgery, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Titus Augustine
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
- Faculty of Biology, Medicine and Health, Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
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13
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Abstract
Obesity is one of the risk factors for the development and progression of chronic kidney disease (CKD). Several studies have shown the association between increased body mass index and kidney function decline. Obesity leads to CKD directly by acting as an independent risk factor and indirectly through increasing risks for diabetes, hypertension, and atherosclerosis, a group of well-established independent risk factors for CKD. Alterations in renal hemodynamics, inflammation, and in hormones and growth factors results in hyperfiltration injury and focal segmental glomerulosclerosis. In recent years, many studies have shown that the gut microbiome may play a role in the pathogenesis of obesity. Dysbiosis has been noted in obese subjects in both human and animal studies. Changes in the gut microbiome in obese patients promote weight gain by effectively extracting energy from diet, and induction of low-grade inflammation. Evidence also points to the role of inflammation within the adipose tissue in obesity as a key factor in the pathogenesis of obesity-related complications. Thus, obesity is the net result of complex interactions between behavioral, genetic, and environmental factors. In terms of management, conservative approaches are often the first option, but they often are unsuccessful in achieving and/or maintaining weight loss, particularly in severe obesity. Consequently, nonmedical management with bariatric surgery is the most effective treatment option for morbid obesity and has shown mitigation of multiple risk factors for the progression of CKD. The most frequently performed interventions are vertical sleeve gastrectomy and Roux-en-Y gastric bypass. Studies have shown that bariatric surgery is associated with beneficial effects on CKD by mitigating its risk factors by weight loss, reducing insulin resistance, hemoglobin A1c, and proteinuria, in addition to positive long-term outcomes. Because of the epidemic of obesity, the prevalence of obesity in kidney transplant recipients also is increasing. The maximal body mass index (BMI) threshold for kidney transplantation is not clear. The Organ Procurement Transplant Network/Scientific Registry of Transplant Recipients 2019 annual data report showed that the proportion of kidney transplant recipient candidates with a BMI of 30 kg/m2 or greater is increasing steadily. Morbid obesity is linked to adverse graft outcomes including delayed graft function, primary nonfunction, and decreased graft survival. Obesity is also an independent risk factor for cardiovascular death in kidney transplant recipients, suggesting that these patients should not be excluded from transplantation based on their BMI because transplantation is associated with lower mortality compared with dialysis. However, many centers exclude obese patients (with different BMI cut-off values) from transplantation to avoid postoperative complications. To minimize the surgical complications of kidney transplantation in obese patients, our center has adopted the robot-assisted kidney transplantation procedure. Our data show that this approach is comparable with historical nonobese controls in the United Network for Organ Sharing database in terms of patient and graft survival. Another surgical option for this group of patients at our center is a combined robotic sleeve gastrectomy and robotic-assisted kidney transplant. In a recent study, this approach showed promising results in terms of weight loss, patient survival, and graft survival, and might become more common in the future.
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Vranic G, Cooper M. But Why Weight: Understanding the Implications of Obesity in Kidney Transplant. Semin Nephrol 2021; 41:380-391. [PMID: 34715967 DOI: 10.1016/j.semnephrol.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Obesity is increasing in prevalence among candidates for kidney transplant. Understanding the influence of obesity on candidate evaluation, surgical risk, peritransplant management, and post-transplant outcomes is critical to ensuring equitable access to transplant for this growing population.
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Affiliation(s)
- Gayle Vranic
- MedStar Georgetown Transplant Institute, Georgetown University, Washington, DC.
| | - Matthew Cooper
- MedStar Georgetown Transplant Institute, Georgetown University, Washington, DC
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15
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Veroux M, Mattone E, Cavallo M, Gioco R, Corona D, Volpicelli A, Veroux P. Obesity and bariatric surgery in kidney transplantation: A clinical review. World J Diabetes 2021; 12:1563-1575. [PMID: 34630908 PMCID: PMC8472502 DOI: 10.4239/wjd.v12.i9.1563] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/30/2021] [Accepted: 08/09/2021] [Indexed: 02/06/2023] Open
Abstract
Obesity is increasing worldwide, and this has major implications in the setting of kidney transplantation. Patients with obesity may have limited access to transplantation and increased posttransplant morbidity and mortality. Most transplant centers incorporate interventions aiming to target obesity in kidney transplant candidates, including dietary education and lifestyle modifications. For those failing nutritional restriction and medical therapy, the use of bariatric surgery may increase the transplant candidacy of patients with obesity and end-stage renal disease (ESRD) and may potentially improve the immediate and late outcomes. Bariatric surgery in ESRD patients is associated with weight loss ranging from 29.8% to 72.8% excess weight loss, with reported mortality and morbidity rates of 2% and 7%, respectively. The most commonly performed bariatric surgical procedures in patients with ESRD and in transplant patients are laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass. However, the correct timing of bariatric surgery and the ideal type of surgery have yet to be determined, although pretransplant LSG seems to be associated with an acceptable risk-benefit profile. We review the impact of obesity on kidney transplant candidates and recipients and in potential living kidney donors, exploring the potential impact of bariatric surgery in addressing obesity in these populations, thereby potentially improving posttransplant outcomes.
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Affiliation(s)
- Massimiliano Veroux
- Department of Medical and Surgical Sciences and Advanced Technologies GF Ingrassia, University of Catania, Catania 95123, Italy
| | - Edoardo Mattone
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, Catania 95123, Italy
| | - Matteo Cavallo
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, Catania 95123, Italy
| | - Rossella Gioco
- General Surgery Unit, University Hospital of Catania, Catania 95123, Italy
| | - Daniela Corona
- General Surgery Unit, University Hospital of Catania, Catania 95123, Italy
| | - Alessio Volpicelli
- General Surgery Unit, University Hospital of Catania, Catania 95123, Italy
| | - Pierfrancesco Veroux
- Department of General Surgery and Medical Specialities, University of Catania, Catania 95123, Italy
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Conley MM, McFarlane CM, Johnson DW, Kelly JT, Campbell KL, MacLaughlin HL. Interventions for weight loss in people with chronic kidney disease who are overweight or obese. Cochrane Database Syst Rev 2021; 3:CD013119. [PMID: 33782940 PMCID: PMC8094234 DOI: 10.1002/14651858.cd013119.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Obesity and chronic kidney disease (CKD) are highly prevalent worldwide and result in substantial health care costs. Obesity is a predictor of incident CKD and progression to kidney failure. Whether weight loss interventions are safe and effective to impact on disease progression and clinical outcomes, such as death remains unclear. OBJECTIVES This review aimed to evaluate the safety and efficacy of intentional weight loss interventions in overweight and obese adults with CKD; including those with end-stage kidney disease (ESKD) being treated with dialysis, kidney transplantation, or supportive care. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 14 December 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs of more than four weeks duration, reporting on intentional weight loss interventions, in individuals with any stage of CKD, designed to promote weight loss as one of their primary stated goals, in any health care setting. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility and extracted data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess the certainty of evidence. We estimated treatment effects using random-effects meta-analysis. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardised mean difference (SMD) for continuous outcomes or in descriptive format when meta-analysis was not possible. MAIN RESULTS We included 17 RCTs enrolling 988 overweight or obese adults with CKD. The weight loss interventions and comparators across studies varied. We categorised comparisons into three groups: any weight loss intervention versus usual care or control; any weight loss intervention versus dietary intervention; and surgical intervention versus non-surgical intervention. Methodological quality was varied, with many studies providing insufficient information to accurately judge the risk of bias. Death (any cause), cardiovascular events, successful kidney transplantation, nutritional status, cost effectiveness and economic analysis were not measured in any of the included studies. Across all 17 studies many clinical parameters, patient-centred outcomes, and adverse events were not measured limiting comparisons for these outcomes. In studies comparing any weight loss intervention to usual care or control, weight loss interventions may lead to weight loss or reduction in body weight post intervention (6 studies, 180 participants: MD -3.69 kg, 95% CI -5.82 to -1.57; follow-up: 5 weeks to 12 months, very low-certainty evidence). In very low certainty evidence any weight loss intervention had uncertain effects on body mass index (BMI) (4 studies, 100 participants: MD -2.18 kg/m², 95% CI -4.90 to 0.54), waist circumference (2 studies, 53 participants: MD 0.68 cm, 95% CI -7.6 to 6.24), proteinuria (4 studies, 84 participants: 0.29 g/day, 95% CI -0.76 to 0.18), systolic (4 studies, 139 participants: -3.45 mmHg, 95% CI -9.99 to 3.09) and diastolic blood pressure (4 studies, 139 participants: -2.02 mmHg, 95% CI -3.79 to 0.24). Any weight loss intervention made little or no difference to total cholesterol, high density lipoprotein cholesterol, and inflammation, but may lower low density lipoprotein cholesterol. There was little or no difference between any weight loss interventions (lifestyle or pharmacological) compared to dietary-only weight loss interventions for weight loss, BMI, waist circumference, proteinuria, and systolic blood pressure, however diastolic blood pressure was probably reduced. Furthermore, studies comparing the efficacy of different types of dietary interventions failed to find a specific dietary intervention to be superior for weight loss or a reduction in BMI. Surgical interventions probably reduced body weight (1 study, 11 participants: MD -29.50 kg, 95% CI -36.4 to -23.35), BMI (2 studies, 17 participants: MD -10.43 kg/m², 95% CI -13.58 to -7.29), and waist circumference (MD -30.00 cm, 95% CI -39.93 to -20.07) when compared to non-surgical weight loss interventions after 12 months of follow-up. Proteinuria and blood pressure were not reported. All results across all comparators should be interpreted with caution due to the small number of studies, very low quality of evidence and heterogeneity across interventions and comparators. AUTHORS' CONCLUSIONS All types of weight loss interventions had uncertain effects on death and cardiovascular events among overweight and obese adults with CKD as no studies reported these outcome measures. Non-surgical weight loss interventions (predominately lifestyle) appear to be an effective treatment to reduce body weight, and LDL cholesterol. Surgical interventions probably reduce body weight, waist circumference, and fat mass. The current evidence is limited by the small number of included studies, as well as the significant heterogeneity and a high risk of bias in most studies.
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Affiliation(s)
- Marguerite M Conley
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Woolloongabba, Australia
- School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, Australia
| | | | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Jaimon T Kelly
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Nathan, Australia
| | - Katrina L Campbell
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Nathan, Australia
| | - Helen L MacLaughlin
- School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, Australia
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