Bariatric surgery prior to transplantation and risk of early hospital re-admission, graft failure, or death following kidney transplantation

Association between bariatric surgery after kidney transplantation and graft and survival outcomes

Bariatric surgery has been shown to be safe in chronic kidney disease and improves access of patients to transplantation. Whether bariatric surgery after kidney transplantation is associated with improved graft or patient survival has not been examined nationally. We included adults with obesity who received a first kidney transplant according to the US Renal Data System between 2003-2019. We matched 4 controls to each case of bariatric surgery based on age at transplantation, sex, donor type, diabetes, and body mass index at transplantation. We examined the association between bariatric surgery and graft failure or death using multivariable Cox proportional hazards models and Fine-Gray models accounting for death as a competing risk. We included 770 patients, of whom 155 (20%) received bariatric surgery. Median age was 45 years and 56% were women. Receipt of bariatric surgery was associated with improved graft survival (hazard ratio [HR], 0.57; 95% CI, 0.34-0.98) in fully adjusted models, although findings did not consistently maintain statistical significance in competing risk analyses (subHR, 0.60; 95% CI, 0.35-1.02). Receipt of bariatric surgery was associated with lower risk of death (HR, 0.45; 95% CI, 0.26-0.76). In conclusion, bariatric surgery is associated with improved patient survival and potentially graft survival after kidney transplantation.

Bariatric surgery prior to pancreas transplantation: a retrospective matched case-control study

BACKGROUND

The clinical impact of bariatric surgery (BS) prior to pancreas transplantation (PTx) is unclear.

SETTING

University of Minnesota Hospital, Minneapolis, MN.

METHODS

This was a single center retrospective case-controlled study of all patients January 1, 1998 and May 1, 2024 with a history of BS prior to PTx. Patients were matched (1:3) with control patients by recipient age, body mass index (BMI) at PTx, type of transplant, primary versus retransplant, and year of PTx.

RESULTS

Among 1542 transplants, 17 patients had a history of BS prior to PTx, with an overall incidence of 1.1%. Eleven patients underwent roux-en-y gastric bypass, 5 underwent sleeve gastrectomy (SG), and one underwent vertical-banded gastroplasty. Eleven underwent simultaneous pancreas kidney transplant, 5 underwent pancreas transplant alone, and one underwent pancreas after kidney transplant. The median time (interquartile range [IQR]) between BS and PTx was 2.9 yrs (4.6) and ranged from .7 to 20.6 yrs. Compared to the non-BS group, patients in the BS group had similar rates of graft thrombosis (5.9% versus 3.9%, P = .76) and rejection (29.4% versus 29.4%, P > .99). Length of stay following PTx (P = .22), number of 30-day readmissions (P = .24), and number of 1-year readmissions (P = .70) were not different between the two groups. Median death-censored graft survival (9.4 yrs versus median not reached, P = .23) and patient survival (9.4 yrs versus median not reached, P = .18) were similar between the BS and non-BS groups. Finally, six patients underwent BS with the specific intention of reaching the acceptable BMI threshold for PTx. Median BMI was reduced from 37.4 prior to BS to 26.4 at time of PTx. Median time from BS to PTx was 2.4 yrs. At 4 yr follow-up, graft and patient survival was 100%.

CONCLUSIONS

This represents the largest series of patients with BS prior to PTx. Perioperative complications are not increased in patients undergoing PTx with a history of prior BS and long-term outcomes are equivalent. Patients with a prohibitive BMI for PTx eligibility should be considered for BS without concern for detrimental effect on post-transplant outcomes.

Scientific Evidence for the Updated Guidelines on Indications for Metabolic and Bariatric Surgery (IFSO/ASMBS)

The 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for Metabolic and Bariatric Surgery (MBS), replacing the previous guidelines established by the NIH over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams, as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

Scientific evidence for the updated guidelines on indications for metabolic and bariatric surgery (IFSO/ASMBS)

The 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for metabolic and bariatric surgery (MBS), replacing the previous guidelines established by the National Institutes of Health (NIH) over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams (MDTs), as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

Obesity in Renal Transplantation

Obesity has surged as a formidable global public health concern, with its prevalence nearly tripling over the past 40 years. Concurrently, the burden of kidney disease remains substantial, with obesity emerging as a significant risk factor. Transplantation is a life-saving intervention for patients with end-stage kidney disease living with obesity. However, it introduces a dual-edged sword, decreasing the risk of mortality related to dialysis while still leaving cardiovascular disease as one of the leading causes of death in transplant recipients. The relationship between obesity and transplantation is a multifaceted challenge demanding concerted efforts from health-care providers, researchers, and policymakers to navigate. While transplantation offers hope and improved quality of life for many, the weight of obesity cannot be underestimated. This review provides a comprehensive assessment of the intricate interplay between obesity and transplantation, with a particular focus on kidney transplantation. Through this review article, we want to reiterate the critical role of weight management, lifestyle modifications, and medical interventions in optimizing transplantation outcomes for individuals with obesity. By comprehensively addressing these issues, we aim to contribute to the development of a holistic approach that minimizes the risks while maximizing the benefits of transplantation for this vulnerable population.

Safety outcomes of bariatric surgery in patients with advanced organ disease: the ONWARD study: a prospective cohort study

INTRODUCTION

Increasing numbers of patients with advanced organ disease are being considered for bariatric and metabolic surgery (BMS). There is no prospective study on the safety of BMS in these patients. This study aimed to capture outcomes for patients with advanced cardiac, renal, or liver disease undergoing BMS.

MATERIALS AND METHODS

This was a multinational, prospective cohort study on the safety of elective BMS in adults (≥18 years) with advanced disease of the heart, liver, or kidney.

RESULTS

Data on 177 patients with advanced diseases of heart, liver, or kidney were submitted by 75 centres in 33 countries. Mean age and BMI was 48.56±11.23 years and 45.55±7.35 kg/m 2 , respectively. Laparoscopic sleeve gastrectomy was performed in 124 patients (70%). The 30-day morbidity and mortality were 15.9% ( n =28) and 1.1% ( n =2), respectively. Thirty-day morbidity was 16.4%, 11.7%, 20.5%, and 50.0% in patients with advanced heart ( n =11/61), liver ( n =8/68), kidney ( n =9/44), and multi-organ disease ( n =2/4), respectively. Cardiac patients with left ventricular ejection fraction less than or equal to 35% and New York Heart Association classification 3 or 4, liver patients with model for end-stage liver disease score greater than or equal to 12, and patients with advanced renal disease not on dialysis were at increased risk of complications. Comparison with a propensity score-matched cohort found advanced disease of the heart, liver, or kidney to be significantly associated with higher 30-day morbidity.

CONCLUSION

Patients with advanced organ disease are at increased risk of 30-day morbidity following BMS. This prospective study quantifies that risk and identifies patients at the highest risk.

Combined Donor-Recipient Obesity and the Risk of Graft Loss After Kidney Transplantation

Background: As the prevalence of obesity increases globally, appreciating the effect of donor and recipient (DR) obesity on graft outcomes is of increasing importance. Methods: In a cohort of adult, kidney transplant recipients (2000-2017) identified using the SRTR, we used Cox proportional hazards models to examine the association between DR obesity pairing (body mass index (BMI) >30 kg/m2), and death-censored graft loss (DCGL) or all-cause graft loss, and logistic regression to examine risk of delayed graft function (DGF) and ≤30 days graft loss. We also explored the association of DR weight mismatch (>30 kg, 10-30 kg (D>R; D Collapse

Key Words

• body mass index
• graft loss
• kidney transplant outcomes
• obesity
• obesity pairing
• weight mismatch

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MESH Headings

• Adult
• Cohort Studies
• Graft Rejection/epidemiology
• Humans
• Kidney Transplantation/adverse effects
• Obesity/epidemiology
• Risk Factors
• Tissue Donors/statistics & numerical data
• Transplant Recipients/statistics & numerical data
• Treatment Outcome

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Affiliation(s)

Faisal Jarrar Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
Karthik K. Tennankore Faculty of Medicine, Dalhousie University, Halifax, NS, Canada Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, NS, Canada
Amanda J. Vinson Faculty of Medicine, Dalhousie University, Halifax, NS, Canada Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, NS, Canada

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Management of obesity in kidney transplant candidates and recipients: A clinical practice guideline by the DESCARTES Working Group of ERA

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.

The Impact of Recipient Demographics on Outcomes from Living Donor Kidneys: Systematic Review and Meta-Analysis

Background and Aims: Recipient demographics affect outcomes after kidney transplantation. The aim of this study was to assess, for kidneys retrieved from living donors, the effect of recipient sex, ethnicity, and body mass index (BMI) on delayed graft function (DGF) and one-year graft function, incidence of acute rejection (AR), and recipient and graft survivals. Methods: A systematic review and meta-analysis was performed. EMBASE and MEDLINE databases were searched using algorithms through Ovid. Web of Science collection, BIOSIS, CABI, Korean Journal database, Russian Science Citation Index, and SciELO were searched through Web of Science. Cochrane database was also searched. Risk of bias was assessed using the NHBLI tools. Data analysis was performed using Revman 5.4. Mean difference (MD) and risk ratio (RR) were used in analysis. Results: A total of 5129 studies were identified; 24 studies met the inclusion criteria and were analysed. Female recipients were found to have a significantly lower serum creatinine 1-year-post renal transplantation (MD: -0.24 mg/dL 95%CI: -0.18 to -0.29 p < 0.01) compared to male recipients. No significant difference in survival between male and female recipients nor between Caucasians and Africans was observed (p = 0.08). However, Caucasian recipients had a higher 1-year graft survival compared to African recipients (95% CI 0.52-0.98) with also a lower incidence of DGF (RR = 0.63 p < 0.01) and AR (RR = 0.55 p < 0.01). Recipient obesity (BMI > 30) was found to have no effect on 1-year recipient (p = 0.28) and graft survival (p = 0.93) compared to non-obese recipients although non-obese recipients had a lower rate of DGF (RR = 0.65 p < 0.01) and AR (RR = 0.81 p < 0.01) compared to obese recipients. Conclusions: Gender mismatch between male recipients and female donors has negative impact on graft survival. African ethnicity and obesity do not to influence recipient and graft survival but negatively affect DGF and AR rates.