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Prabhahar A, Batta A, Hatwal J, Kumar V, Ramachandran R, Batta A. Endothelial dysfunction in the kidney transplant population: Current evidence and management strategies. World J Transplant 2025; 15:97458. [PMID: 40104196 PMCID: PMC11612885 DOI: 10.5500/wjt.v15.i1.97458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 09/04/2024] [Accepted: 11/04/2024] [Indexed: 11/26/2024] Open
Abstract
The endothelium modulates vascular homeostasis owing to a variety of vasoconstrictors and vasodilators. Endothelial dysfunction (ED), characterized by impaired vasodilation, inflammation, and thrombosis, triggers future cardiovascular (CV) diseases. Chronic kidney disease, a state of chronic inflammation caused by oxidative stress, metabolic abnormalities, infection, and uremic toxins damages the endothelium. ED is also associated with a decline in estimated glomerular filtration rate. After kidney transplantation, endothelial functions undergo immediate but partial restoration, promising graft longevity and enhanced CV health. However, the anticipated CV outcomes do not happen due to various transplant-related and unrelated risk factors for ED, culminating in poor CV health and graft survival. ED in kidney transplant recipients is an under-recognized and poorly studied entity. CV diseases are the leading cause of death among kidney transplant candidates with functioning grafts. ED contributes to the pathogenesis of many of the CV diseases. Various biomarkers and vasoreactivity tests are available to study endothelial functions. With an increasing number of transplants happening every year, and improved graft rejection rates due to the availability of effective immunosuppressants, the focus has now shifted to endothelial protection for the prevention, early recognition, and treatment of CV diseases.
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Affiliation(s)
- Arun Prabhahar
- Department of Telemedicine (Internal Medicine and Nephrology), Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Akshey Batta
- Department of Urology and Renal Transplant, Neelam Hospital, Rajpura 140401, Punjab, India
| | - Juniali Hatwal
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Vivek Kumar
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Raja Ramachandran
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Akash Batta
- Department of Cardiology, Dayanand Medical College and Hospital, Ludhiana 141001, Punjab, India
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Bosch KD, Harrington C, Sulutaura L, Lacea E, Burton K, Fernandez-Munoz N, Dugal N, Sufi P, Al Midani A, Parmar C. Bariatric Surgery as a Bridge to Facilitate Renal Transplantation in Patients with End-Stage Renal Disease. Obes Surg 2024; 34:355-362. [PMID: 38172424 DOI: 10.1007/s11695-023-06985-6] [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: 09/12/2023] [Revised: 11/28/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE Renal transplantation (RT) is not recommended above BMI 40 kg/m2 as post-operative risks (delayed graft function, wound complications) are increased. Bariatric surgery (BS) results in sustained long-term weight loss. However, renal failure (RF) patients are theoretically higher risk candidates. We aim to investigate the safety of BS in patients with RF and the effect of BS on access to renal transplantation. METHODS We reviewed data from 31 patients with RF referred for BS between 2013 and 2021. We compared the outcomes of patients with RF who underwent BS to those who were referred but did not undergo BS. Controls matched for age/BMI/comorbidity (MC) but without RF were used for comparison. RESULTS Of 31 patients referred, 19 proceeded with BS (68% female, median age 52 years, BMI 46.2 ± 4.9 kg/m2) and 12 did not (58% female, median age 58, mean BMI 41.5 ± 4.1). Excess body weight loss (EBWL) was 71.2% ± 20.2% at 2 years in RF patients versus 66.0% ± 28.0% in MC patients. In the operated group, 11/19 (58%) patients reached their treatment target (six transplanted, five placed on waiting list) versus 3/12 (25%) in unoperated patients (three transplanted). There was no difference in perioperative complications between RF and MC groups. Long-term, there were seven deaths amongst RF patients (two operated, five unoperated), none amongst the MC group. CONCLUSION BS in patients with RF increased access to RT and was safe and effective. We therefore recommend consideration of BS in patients with obesity and RF in specialised units.
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Affiliation(s)
- Karen D Bosch
- Department of Bariatric Surgery, Whittington Health NHS Trust, London, N19 5NF, UK.
| | - Cuan Harrington
- Department of Surgery, Royal London Hospital, Barts Health NHS Trust, London, E1 1FR, UK
| | - Liene Sulutaura
- Department of Bariatric Surgery, Whittington Health NHS Trust, London, N19 5NF, UK
| | - Emilane Lacea
- Department of Bariatric Surgery, Whittington Health NHS Trust, London, N19 5NF, UK
| | - Katarina Burton
- Department of Bariatric Surgery, Whittington Health NHS Trust, London, N19 5NF, UK
| | | | - Neal Dugal
- National Kidney Transplant Service, Beaumont Hospital, Dublin, D09V2N0, Ireland
| | - Pratik Sufi
- Department of Bariatric Surgery, Whittington Health NHS Trust, London, N19 5NF, UK
| | - Ammar Al Midani
- Department of Renal Transplantation, Royal Free Hospitals NHS Foundation Trust, London, NW3 2QG, UK
| | - Chetan Parmar
- Department of Surgery, Whittington Hospital, London, N19 5NF, UK
- University College London, London, WC1E 6BT, UK
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Walker RC, Abel S, Palmer SC, Walker C, Heays N, Tipene-Leach D. "We Need a System that's Not Designed to Fail Māori": Experiences of Racism Related to Kidney Transplantation in Aotearoa New Zealand. J Racial Ethn Health Disparities 2023; 10:219-227. [PMID: 35018578 PMCID: PMC8751454 DOI: 10.1007/s40615-021-01212-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/09/2021] [Accepted: 12/15/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Reported experiences of racism in Aotearoa New Zealand are consistently associated with negative measures of health, self-rated health, life satisfaction, and reduced access to high-quality healthcare with subsequent poor health outcomes. In this paper, we report on perceptions and experiences of prejudice and racism by Indigenous Māori with kidney disease and their family members and donors who took part in a wider study about experiences of kidney transplantation. METHODS We conducted semi-structured interviews with 40 Māori between September and December 2020. Participants included those with kidney disease who had considered, were being worked up for, or who had already received a kidney transplant as well as family members and potential or previous donors. We examined the data for experiences of racism using a theoretical framework for racism on three levels: institutionalised racism, personally mediated racism, and internalised racism. RESULTS We identified subthemes at each level of racism: institutional (excluded and devalued by health system; disease stigmatization; discriminatory body weight criteria, lack of power), personally mediated (experiencing racial profiling; explicit racism), and internalized racism (shame and unworthiness to receive a transplant). CONCLUSIONS The wide-reaching experiences and perceptions of racism described by participants with kidney disease and their families in this research point to an unfair health system and suggest that racism may be contributing to kidney transplantation inequity in Aotearoa New Zealand. Addressing racism at all levels is imperative if we are to address inequitable outcomes for Māori requiring kidney transplantation.
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Affiliation(s)
- Rachael C. Walker
- Eastern Institute of Technology, 501 Gloucester Street, Taradale, Napier, 4112 Hawke’s Bay New Zealand
| | - Sally Abel
- Kaupapa Consulting Ltd, Napier, 4110 New Zealand
| | - Suetonia C. Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, 8140 New Zealand ,Department of Nephrology, Canterbury District Health Board, Christchurch, New Zealand
| | - Curtis Walker
- Department of Medicine, Midcentral District Health Board, Palmerston North, 4442 New Zealand
| | - Nayda Heays
- Hawke’s Bay District Health Board, Hastings, New Zealand
| | - David Tipene-Leach
- Eastern Institute of Technology, 501 Gloucester Street, Taradale, Napier, 4112 Hawke’s Bay New Zealand
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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: 5] [Impact Index Per Article: 1.7] [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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Kukla A, Diwan T, Smith BH, Collazo-Clavell ML, Lorenz EC, Clark M, Grothe K, Denic A, Park WD, Sahi S, Schinstock CA, Amer H, Issa N, Bentall AJ, Dean PG, Kudva YC, Mundi M, Stegall MD. Guiding Kidney Transplantation Candidates for Effective Weight Loss: A Clinical Cohort Study. KIDNEY360 2022; 3:1411-1416. [PMID: 36176651 PMCID: PMC9416837 DOI: 10.34067/kid.0001682022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/13/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Obesity is increasingly common in kidney transplant candidates and may limit access to transplantation. Obesity and diabetes are associated with a high risk for post-transplant complications. The best approach to weight loss to facilitate active transplant listing is unknown, but bariatric surgery is rarely considered due to patient- and physician-related apprehension, among other factors. METHODS We aimed to determine the magnitude of weight loss, listing, and transplant rates in 28 candidates with a mean BMI of 44.4±4.6 kg/m2 and diabetes treated conservatively for 1 year post weight-loss consultations (group 1). Additionally, we evaluated 15 patients (group 2) who met the inclusion criteria but received bariatric intervention within the same time frame. All patients completed a multidisciplinary weight management consultation with at least 1 year of follow-up. RESULTS In the conservatively managed group (group 1), the mean weight at the time of initial consultation was 126.5±18.5 kg, and the mean BMI was 44.4±4.6 kg/m2. At 1 year post weight-loss consultation, the mean weight decreased by 4.4±8.2 kg to 122.9±17 kg, and the mean BMI was 43±4.8 kg/m2, with a total mean body weight decrease of 3% (P=0.01). Eighteen patients (64%) did not progress to become candidates for active listing/transplantation during the follow-up time of 4±2.9 years, with 15 (54%) subsequently developing renal failure/diabetes-related comorbidities prohibitive for transplantation. In contrast, mean total body weight decreased by 19% at 6 months post bariatric surgery, and the mean BMI was 34.2±4 and 32.5±3.7 kg/m2 at 6 and 12 months, respectively. Bariatric surgery was strongly associated with subsequent kidney transplantation (HR=8.39 [95% CI 1.71 to 41.19]; P=0.009). CONCLUSIONS A conservative weight-loss approach involving multidisciplinary consultation was ineffective in most kidney transplant candidates with diabetes, suggesting that a more proactive approach is needed.
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Affiliation(s)
- Aleksandra Kukla
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Tayyab Diwan
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
- Department of Surgery and Immunology, Mayo Clinic, Rochester, Minnesota
| | - Byron H. Smith
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Maria L. Collazo-Clavell
- Department of Medicine, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic Rochester, Minnesota
| | - Elizabeth C. Lorenz
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Matthew Clark
- Department of Medicine, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic Rochester, Minnesota
- Department of Psychiatry and Psychology, Mayo Clinic Rochester, Minnesota
| | - Karen Grothe
- Department of Medicine, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic Rochester, Minnesota
- Department of Psychiatry and Psychology, Mayo Clinic Rochester, Minnesota
| | - Aleksandar Denic
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Walter D. Park
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Sukhdeep Sahi
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Carrie A. Schinstock
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Hatem Amer
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Naim Issa
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Andrew J. Bentall
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Patrick G. Dean
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
- Department of Surgery and Immunology, Mayo Clinic, Rochester, Minnesota
| | - Yogish C. Kudva
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
- Department of Medicine, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic Rochester, Minnesota
| | - Manpreet Mundi
- Department of Medicine, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic Rochester, Minnesota
| | - Mark D. Stegall
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
- Department of Surgery and Immunology, Mayo Clinic, Rochester, Minnesota
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Misra J, Tripathi AK, Banerjee S. Laparoscopic Sleeve Gastrectomy: an Effective Weight Reduction Modality Prior to Kidney Transplantation in Patients with Extreme Obesity and Chronic Kidney Disease — Report of 4 Cases with Review of Literature. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03500-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Zharikov AA, Saydulaev DA, Sadovnikov SV, Miloserdov IA. Efficacy of surgical techniques for morbid obesity and their potentials in end-stage renal disease in preparation for kidney transplantation. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2022; 24:125-133. [DOI: 10.15825/1995-1191-2022-2-125-133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
Abstract
Obesity is a modern «epidemic» not only in the general population but also among patients with end-stage renal disease (ESRD) who require kidney transplantation (KTx). The objective of this literature review is to analyze global studies on surgical methods of treating morbid obesity and their potentials in ESRD patients in preparation for KTx.
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Affiliation(s)
- A. A. Zharikov
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - D. A. Saydulaev
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - S. V. Sadovnikov
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - I. A. Miloserdov
- Shumakov National Medical Research Center of Transplantology and Artificial Organs; Sechenov University
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Tzvetanov IG, Tulla KA, Di Cocco P, Spaggiari M, Benedetti E. Robotic Kidney Transplant: The Modern Era Technical Revolution. Transplantation 2022; 106:479-488. [PMID: 34288638 DOI: 10.1097/tp.0000000000003881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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Affiliation(s)
- Ivo G Tzvetanov
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
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Baker LA, March DS, Wilkinson TJ, Billany RE, Bishop NC, Castle EM, Chilcot J, Davies MD, Graham-Brown MPM, Greenwood SA, Junglee NA, Kanavaki AM, Lightfoot CJ, Macdonald JH, Rossetti GMK, Smith AC, Burton JO. Clinical practice guideline exercise and lifestyle in chronic kidney disease. BMC Nephrol 2022; 23:75. [PMID: 35193515 PMCID: PMC8862368 DOI: 10.1186/s12882-021-02618-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 11/22/2021] [Indexed: 12/13/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Mark D. Davies
- Betsi Cadwaladr University Health Board and Bangor University, Bangor, UK
| | | | | | | | | | | | - Jamie H. Macdonald
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
| | | | | | - James O. Burton
- University of Leicester and Leicester Hospitals NHS Trust, Leicester, UK
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11
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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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12
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Lee JH, McDonald EO, Harhay MN. Obesity Management in Kidney Transplant Candidates: Current Paradigms and Gaps in Knowledge. Adv Chronic Kidney Dis 2021; 28:528-541. [PMID: 35367021 DOI: 10.1053/j.ackd.2021.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 09/07/2021] [Accepted: 09/16/2021] [Indexed: 12/18/2022]
Abstract
In this review, we discuss the increasing prevalence of obesity among people with chronic and end-stage kidney disease (ESKD) and implications for kidney transplant (KT) candidate selection and management. Although people with obesity and ESKD receive survival and quality-of-life benefits from KT, most KT programs maintain strict body mass index (BMI) cutoffs to determine transplant eligibility. However, BMI does not distinguish between visceral adiposity, which confers higher cardiovascular risks and risks of perioperative and adverse posttransplant outcomes, and muscle mass, which is protective in ESKD. Furthermore, requirements for patients with obesity to lose weight before KT should be balanced with the findings of numerous studies that show weight loss is a risk factor for death among patients with ESKD, independent of starting BMI. Data suggest that KT is associated with survival benefits relative to remaining on dialysis for candidates with obesity although recipients without obesity have higher delayed graft function rates and longer transplant hospitalization durations. Research is needed to determine the optimal body composition metrics for KT candidacy assessments and risk stratification. In addition, ESKD-specific obesity management guidelines are needed that will address the neurologic, behavioral, socioeconomic, and physical underpinnings of this increasingly common disease.
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13
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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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14
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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: 16] [Impact Index Per Article: 4.0] [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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15
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Lee Y, Anvari S, Chu MM, Lovrics O, Khondker A, Malhan R, Aditya I, Doumouras AG, Walsh M, Hong D. Improvement of kidney function in patients with chronic kidney disease and severe obesity after bariatric surgery: A systematic review and meta-analysis. Nephrology (Carlton) 2021; 27:44-56. [PMID: 34375462 DOI: 10.1111/nep.13958] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/21/2021] [Accepted: 07/31/2021] [Indexed: 02/07/2023]
Abstract
The general management for chronic kidney disease (CKD) includes treating reversible causes, including obesity, which may be both a driver and comorbidity for CKD. Bariatric surgery has been shown to reduce the likelihood of CKD progression and improve kidney function in observational studies. We performed a systematic review and meta-analysis of patients with at least stage 3 CKD and obesity receiving bariatric surgery. We searched Embase, MEDLINE, CENTRAL and identified eligible studies reporting on kidney function outcomes in included patients before and after bariatric surgery with comparison to a medical intervention control if available. Risk of bias was assessed with the Newcastle-Ottawa Risk of Bias score. Nineteen studies were included for synthesis. Bariatric surgery showed improved eGFR with a mean difference (MD) of 11.64 (95%CI: 5.84 to 17.45, I2 = 66%) ml/min/1.73m2 and reduced SCr with MD of -0.24 (95%CI -0.21 to -0.39, I2 = 0%) mg/dl after bariatric surgery. There was no significant difference in the relative risk (RR) of having CKD stage 3 after bariatric surgery, with a RR of -1.13 (95%CI: -0.83 to -2.07, I2 = 13%), but there was reduced likelihood of having uACR >30 mg/g or above with a RR of -3.03 (95%CI: -1.44 to -6.40, I2 = 91%). Bariatric surgery may be associated with improved kidney function with the reduction of BMI and may be a safe treatment option for patients with CKD. Future studies with more robust reporting are required to determine the feasibility of bariatric surgery for the treatment of CKD.
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Affiliation(s)
- Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sama Anvari
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Megan M Chu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Olivia Lovrics
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Adree Khondker
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Roshan Malhan
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ishan Aditya
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Aristithes G Doumouras
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Michael Walsh
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute (PHRI), McMaster University, Hamilton, Ontario, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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16
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Hajjar R, Marcotte C, Chan G. Conservative Management of Obesity in Kidney Transplant Candidates. J Ren Nutr 2021; 32:347-353. [PMID: 33941439 DOI: 10.1053/j.jrn.2021.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 01/11/2021] [Accepted: 03/14/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Obesity is prevalent in patients with chronic kidney disease and is associated with increased complications after kidney transplantation (KT). A body mass index limit is used in most transplant programs, though few studies have focused on conservative weight loss in KT candidates. The objective of this retrospective study is to evaluate the efficacy of a basic conservative weight management program in morbidly obese KT candidates and to perform a comprehensive nutritional evaluation. METHODS This retrospective study included patients with a body mass index (BMI) >35 kg/m2, with grade IV or V chronic kidney disease. The conservative weight loss program consisted of anthropometric measurements every 3 months, consultation with a nutritionist, daily exercise, and counseling for healthier eating habits. Overall and quarterly BMI targets were defined. A subset of patients further underwent a comprehensive nutritional evaluation to measure socioeconomic characteristics, food intake behavior, motivation for change, and a 4-day food diary. RESULTS Eighty patients were observed for a mean of 24 months. Successful weight loss (BMI < 35 kg/m2) was achieved in 26.3%, associated with women and those already close to the limit. The mean 1-year excess body weight loss was 8.4%. No patient with a BMI >40 kg/m2 was successful. The comprehensive nutritional evaluation was performed with 44 patients and found that only 14.6% had previously received nutritional counseling for weight loss. Cognitive restraint scored highest in the food-intake behavior. Most patients were motivated to lose weight with 66% in the action phase. There was little evidence of overeating with a recommended mean calculated daily caloric intake of 82.9%. CONCLUSION The conservative weight loss program can have limited but non-negligible, success. Future successful nutritional interventions should take into consideration this surprising comprehensive profile of morbidly obese KT candidates.
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Affiliation(s)
- Roy Hajjar
- Department of Surgery, Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada; Division of General Surgery, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Cynthia Marcotte
- Department of Surgery, Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada; Department of Nutrition, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Gabriel Chan
- Department of Surgery, Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada; Division of General Surgery, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.
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Spaggiari M, Di Cocco P, Tulla K, Kaylan KB, Masrur MA, Hassan C, Alvarez JA, Benedetti E, Tzvetanov I. Simultaneous robotic kidney transplantation and bariatric surgery for morbidly obese patients with end-stage renal failure. Am J Transplant 2021; 21:1525-1534. [PMID: 32976702 DOI: 10.1111/ajt.16322] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/25/2020] [Accepted: 09/15/2020] [Indexed: 02/06/2023]
Abstract
Patients with obesity have limited access to kidney transplantation, mainly due to an increased incidence of surgical complications, which could be reduced with selective use of robotic-assisted surgery. This prospective randomized controlled trial compares the safety and efficacy of combining robotic sleeve gastrectomy and robotic-assisted kidney transplant to robotic kidney transplant alone in candidates with class II or III obesity. Twenty candidates were recruited, 11 were randomized to the robotic sleeve gastrectomy and robotic-assisted kidney transplant group and 9 to the robotic kidney transplant group. At 12-month follow-up, change in body mass index was -8.76 ± 1.82 in the robotic sleeve gastrectomy and robotic-assisted kidney transplant group compared to 1.70 ± 2.30 in the robotic kidney transplant group (P = .0041). Estimated glomerular filtration rate, serum creatinine, readmission rates, and graft failure rates up to 12 months were not different between the two groups. Length of surgery was longer in the robotic sleeve gastrectomy and robotic-assisted kidney transplant group (405 minutes vs. 269 minutes, p = .00304) without increase in estimated blood loss (120 ml vs. 117 ml, p = .908) or incidence of surgical complications. Combined robotic-assisted kidney transplant and sleeve gastrectomy is safe and effective compared to robotic-assisted kidney transplant alone.
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Affiliation(s)
- Mario Spaggiari
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Pierpaolo Di Cocco
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Kiara Tulla
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Kerim B Kaylan
- College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Mario A Masrur
- Division of General, Minimally Invasive, & Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Chandra Hassan
- Division of General, Minimally Invasive, & Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Jorge A Alvarez
- 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
| | - Ivo Tzvetanov
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL
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Hajjar R, Lafrance JP, Tchervenkov J, Gingras S, Boutin L, Elftouh N, Andalib A, Pescarus R, Garneau PY, Chan G. Successful surgical weight loss with laparoscopic sleeve gastrectomy for morbid obesity prior to kidney transplantation. Transpl Int 2021; 34:964-973. [PMID: 33630394 DOI: 10.1111/tri.13855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/18/2021] [Accepted: 02/23/2021] [Indexed: 01/07/2023]
Abstract
Morbid obesity in kidney transplant (KT) candidates is associated with increased complications and graft failure. Multiple series have demonstrated rapid and significant weight loss after laparoscopic sleeve gastrectomy (LSG) in this population. Long-term and post-transplant weight evolutions are still largely unknown. A retrospective review was performed in eighty patients with end-stage kidney disease (ESKD) who underwent LSG in preparation for KT. From a median initial BMI of 43.7 kg/m2 , the median change at 1-year was -10.0 kg/m2 . Successful surgical weight loss (achieving a BMI < 35 kg/m2 or an excess body weight loss >50%) was attained in 76.3% and was associated with male gender, predialysis status, lower obesity class and lack of coronary artery disease. Thirty-one patients subsequently received a KT with a median delay of 16.7 months. Weight regain (increase in BMI of 5 kg/m2 postnadir) and recurrent obesity (weight regain + BMI > 35) remain a concern, occurring post-KT in 35.7% and 17.9%, respectively. Early LSG should be considered for morbidly obese patients with ESKD for improved weight loss outcomes. Early KT after LSG does not appear to affect short-term surgical weight loss. Candidates with a BMI of up to 45 kg/m2 can have a reasonable expectation to achieve the limit within 1 year.
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Affiliation(s)
- Roy Hajjar
- General Surgery Service, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, QC, Canada.,Division of General Surgery, Department of Surgery, Université de Montréal, Montréal, QC, Canada
| | - Jean-Philippe Lafrance
- Nephrology Service, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, QC, Canada.,Centre de Recherche de l'Hôpital Maisonneuve-Rosemont, Montréal, QC, Canada.,Département de Pharmacologie et Physiologie, Université de Montréal, Montréal, QC, Canada
| | - Jean Tchervenkov
- Department of Surgery, Royal Victoria Hospital, McGill University, Montréal, QC, Canada
| | - Sébastien Gingras
- General Surgery Service, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, QC, Canada
| | - Lucie Boutin
- Nephrology Service, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, QC, Canada
| | - Naoual Elftouh
- Nephrology Service, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, QC, Canada
| | - Amin Andalib
- Department of Surgery, Centre for Bariatric Surgery, McGill University, Montréal, QC, Canada
| | - Radu Pescarus
- Hôpital Sacré-Cœur de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Pierre Y Garneau
- Hôpital Sacré-Cœur de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Gabriel Chan
- General Surgery Service, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, QC, Canada.,Division of General Surgery, Department of Surgery, Université de Montréal, Montréal, QC, Canada
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19
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Chintam K, Chang AR. Strategies to Treat Obesity in Patients With CKD. Am J Kidney Dis 2021; 77:427-439. [PMID: 33075388 PMCID: PMC7904606 DOI: 10.1053/j.ajkd.2020.08.016] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/11/2020] [Indexed: 12/17/2022]
Abstract
Obesity prevalence continues to increase worldwide, accompanied by a rising tide of hypertension, diabetes, and chronic kidney disease (CKD). Although body mass index is typically used to assess obesity in clinical practice, altered body composition (eg, reduced muscle mass and increased visceral adiposity) are common among patients with CKD. Weight loss achieved through behavioral modification or medications reduces albuminuria and in some cases slows the decline in estimated glomerular filtration rate. Use of medications that promote weight loss with favorable cardiovascular risk profiles should be promoted, particularly in patients with type 2 diabetes, obesity, and CKD. For those who fail to achieve weight loss through lifestyle modification, bariatric surgery should be considered because observational studies have shown reductions in risk for estimated glomerular filtration rate decline and kidney failure. Uncertainty persists on the risk to benefit ratio of intentional weight loss in patients with kidney failure due to the lack of prospective trials and limitations of observational data. Regardless, sleeve gastrectomy is increasingly being used for patients with kidney failure and severe obesity, with success in achieving sustained weight loss, improved access to kidney transplantation, and favorable posttransplantation outcomes. More research is needed assessing long-term cardiovascular and kidney outcomes of most weight loss medications.
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Affiliation(s)
| | - Alex R Chang
- Department of Population of Health Sciences, Geisinger, Danville, PA; Kidney Health Research Institute, Geisinger, Danville, PA; Department of Nephrology, Geisinger, Danville, PA.
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20
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Prudhomme T, Lesourd M, Roumiguié M, Gamé X, Soulié M, Del Bello A, Kamar N, Sallusto F, Doumerc N. [Living-donor robotic-assisted kidney transplantation: French academic center experience]. Prog Urol 2021; 31:539-554. [PMID: 33612444 DOI: 10.1016/j.purol.2020.09.016] [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: 06/13/2020] [Revised: 09/03/2020] [Accepted: 09/10/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The main objective was to report the intra-, post-operative and functional outcomes of living-donor robotic-assisted kidney transplantation (RAKT), performed by a surgeon skilled in robotic surgery. The secondary objective was to compare the results of RAKT, based on the surgeon's experience. METHODS For this retrospective cohort study, we analyzed data from consecutive patients who underwent living-donor RAKT from July 2015 to March 2020 and compared the results of RAKT according to the surgeon's experience (group 1: 1-14th RAKT versus group 2: 15-29th RAKT). RESULTS Twenty-nine living-donor RAKT were performed. The median age and BMI of the recipients were: 57.0 (44.0-66.0) years and 32.7 (23.5-39.6)kg/m2. The median overall operative time and median console time were: 140.0 (122.5-165.0) and 120.0 (107.5-137.5) minutes. The median rewarming time, arterial, venous and urinary anastomoses durations were: 35.0 (27.5-45.0), 15.0 (11.0-20.0), 12.0 (10.0-16.0), 20.0 (16.0-23.0) minutes. Two (6.9%) minor and 5 (17.2%) major (Clavien-Dindo≥III) postoperative complications occurred. At 2 years of follow-up, patient and transplant survival was 100% (n=29) and 93.1% (n=27). After the 14th RAKT, the rewarming time (P=0.01) and venous anastomosis duration (P=0.004) were statistically shorter. CONCLUSION Living-donor robotic-assisted kidney transplantation, performed by a surgeon skilled robotic surgery, ensures good functional results in the medium term. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- T Prudhomme
- Département d'urologie, de transplantation rénale et d'andrologie, centre hospitalier universitaire de Toulouse, Toulouse, France
| | - M Lesourd
- Département d'urologie, de transplantation rénale et d'andrologie, centre hospitalier universitaire de Toulouse, Toulouse, France
| | - M Roumiguié
- Département d'urologie, de transplantation rénale et d'andrologie, centre hospitalier universitaire de Toulouse, Toulouse, France
| | - X Gamé
- Département d'urologie, de transplantation rénale et d'andrologie, centre hospitalier universitaire de Toulouse, Toulouse, France
| | - M Soulié
- Département d'urologie, de transplantation rénale et d'andrologie, centre hospitalier universitaire de Toulouse, Toulouse, France
| | - A Del Bello
- Département de néphrologie et de transplantation d'organe, centre hospitalier universitaire de Toulouse, Toulouse, France
| | - N Kamar
- Département de néphrologie et de transplantation d'organe, centre hospitalier universitaire de Toulouse, Toulouse, France
| | - F Sallusto
- Département d'urologie, de transplantation rénale et d'andrologie, centre hospitalier universitaire de Toulouse, Toulouse, France
| | - N Doumerc
- Département d'urologie, de transplantation rénale et d'andrologie, centre hospitalier universitaire de Toulouse, Toulouse, France.
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21
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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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Liakh I, Sledzinski T, Kaska L, Mozolewska P, Mika A. Sample Preparation Methods for Lipidomics Approaches Used in Studies of Obesity. Molecules 2020; 25:E5307. [PMID: 33203044 PMCID: PMC7696154 DOI: 10.3390/molecules25225307] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 02/06/2023] Open
Abstract
Obesity is associated with alterations in the composition and amounts of lipids. Lipids have over 1.7 million representatives. Most lipid groups differ in composition, properties and chemical structure. These small molecules control various metabolic pathways, determine the metabolism of other compounds and are substrates for the syntheses of different derivatives. Recently, lipidomics has become an important branch of medical/clinical sciences similar to proteomics and genomics. Due to the much higher lipid accumulation in obese patients and many alterations in the compositions of various groups of lipids, the methods used for sample preparations for lipidomic studies of samples from obese subjects sometimes have to be modified. Appropriate sample preparation methods allow for the identification of a wide range of analytes by advanced analytical methods, including mass spectrometry. This is especially the case in studies with obese subjects, as the amounts of some lipids are much higher, others are present in trace amounts, and obese subjects have some specific alterations of the lipid profile. As a result, it is best to use a method previously tested on samples from obese subjects. However, most of these methods can be also used in healthy, nonobese subjects or patients with other dyslipidemias. This review is an overview of sample preparation methods for analysis as one of the major critical steps in the overall analytical procedure.
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Affiliation(s)
- Ivan Liakh
- Department of Pharmaceutical Biochemistry, Medical University of Gdansk, Debinki 1, 80-211 Gdansk, Poland; (I.L.); (T.S.); (P.M.)
- Department of Toxicology, Medical University of Gdańsk, Al. Gen. Hallera 107, 80-416 Gdańsk, Poland
| | - Tomasz Sledzinski
- Department of Pharmaceutical Biochemistry, Medical University of Gdansk, Debinki 1, 80-211 Gdansk, Poland; (I.L.); (T.S.); (P.M.)
| | - Lukasz Kaska
- Department of General, Endocrine and Transplant Surgery, Faculty of Medicine, Medical University of Gdansk, Smoluchowskiego 17, 80-214 Gdansk, Poland;
| | - Paulina Mozolewska
- Department of Pharmaceutical Biochemistry, Medical University of Gdansk, Debinki 1, 80-211 Gdansk, Poland; (I.L.); (T.S.); (P.M.)
| | - Adriana Mika
- Department of Pharmaceutical Biochemistry, Medical University of Gdansk, Debinki 1, 80-211 Gdansk, Poland; (I.L.); (T.S.); (P.M.)
- Department of Environmental Analysis, Faculty of Chemistry, University of Gdansk, Wita Stwosza 63, 80-308 Gdansk, Poland
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Diwan TS, Lee TC, Nagai S, Benedetti E, Posselt A, Bumgardner G, Noria S, Whitson BA, Ratner L, Mason D, Friedman J, Woodside KJ, Heimbach J. Obesity, transplantation, and bariatric surgery: An evolving solution for a growing epidemic. Am J Transplant 2020; 20:2143-2155. [PMID: 31965711 DOI: 10.1111/ajt.15784] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 01/05/2020] [Accepted: 01/08/2020] [Indexed: 01/25/2023]
Abstract
The increasing obesity epidemic has major implications in the realm of transplantation. Patients with obesity face barriers in access to transplant and unique challenges in perioperative and postoperative outcomes. Because of comorbidities associated with obesity, along with the underlying end-stage organ disease leading to transplant candidacy, these patients may not even be referred for transplant evaluation, much less be waitlisted or actually undergo transplant. However, the use of bariatric surgery in this population can help optimize the transplant candidacy of patients with obesity and end-stage organ disease and improve perioperative and postoperative outcomes. We review the impact of obesity on kidney, liver, and cardiothoracic transplant candidates and recipients and explore potential interventions to address obesity in these populations.
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Affiliation(s)
| | | | | | | | - Andrew Posselt
- University of California at San Francisco, San Francisco, California, USA
| | | | | | | | - Lloyd Ratner
- Columbia University Medical Center, New York, New York, USA
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Choudhury RA, Yoeli D, Moore HB, Yaffe H, Hoeltzel GD, Dumon KR, Williams NN, Abt PL, Conzen KD, Nydam TL. Reverse epidemiology and the obesity paradox for patients with chronic kidney disease: a Markov decision model. Surg Obes Relat Dis 2020; 16:948-954. [DOI: 10.1016/j.soard.2020.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/14/2020] [Accepted: 02/22/2020] [Indexed: 02/08/2023]
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Robotic-assisted kidney transplantation in obese recipients compared to non-obese recipients: the European experience. World J Urol 2020; 39:1287-1298. [PMID: 32562044 DOI: 10.1007/s00345-020-03309-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 06/11/2020] [Indexed: 12/16/2022] Open
Abstract
PURPOSE The main objective was to compare minor (Clavien I-II) and major (Clavien ≥ III) intra- and postoperative complications of living donor robotic assisted kidney transplantation (RAKT) in obese (≥ 30 kg/m2 BMI), overweight (< 30/ ≥ 25 kg/m2 BMI) and non-overweight recipients (< 25 kg/m2 BMI). METHODS For the present retrospective study, we reviewed the multi-institutional ERUS-RAKT database to select consecutive living donor RAKT recipients. Functional outcomes, intra- and postoperative complications were compared between obese, overweight and non-overweight recipients. RESULTS 169 living donor RAKTs were performed, by 10 surgeons, from July 2015 to September 2018 in the 8 European centers. 32 (18.9%) recipients were obese, 66 (39.1%) were overweight and 71 (42.0%) were non-overweight. Mean follow-up was 1.2 years. There were no major intra-operative complications in either study group. Conversion to open surgery occurred in 1 obese recipient, in 2 overweight recipients and no conversion occurred in non-overweight recipients (p = 0.3). Minor and major postoperative complications rates were similar in the 3 groups. At one-year of follow-up, median eGFR was similar in all groups [54 (45-60) versus 57 (46-70) versus 63 (49-78) ml/min/1.73 m2 in obese, overweight and non-overweight recipient groups, respectively, p = 0.5]. Delayed graft function rate was similar in the 3 groups. Only the number of arteries was an independent predictive factor of suboptimal renal function at post-operative day 30 in the multivariate analysis. CONCLUSION RAKT in obese recipients is safe, compared to non-overweight recipients and yields very good function, when it performed at high-volume referral centers by highly trained transplant teams.
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Di Cocco P, Okoye O, Almario J, Benedetti E, Tzvetanov IG, Spaggiari M. Obesity in kidney transplantation. Transpl Int 2020; 33:581-589. [PMID: 31667905 DOI: 10.1111/tri.13547] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/03/2019] [Accepted: 10/28/2019] [Indexed: 12/14/2022]
Abstract
The prevalence of obesity among patients with chronic kidney disease continues to increase as a reflection of the trend observed in the general population. Factors affecting the access to the waiting list and the transplantability of this specific population will be analysed. From observational studies, kidney transplantation in obese patients carries an increased risk of surgical complications compared to the nonobese population; therefore, many centres have been reluctant to proceed with transplantation, despite this treatment modality confers a survival advantage over dialysis. As a consequence, obese patients continue to face decreased access to the waiting list, with a lower likelihood of being transplanted and higher waiting times when compared to the nonobese candidates. In this review will be described the current strategies for treatment of obesity in different settings (pretransplant, at transplant and post-transplant). Obesity represents a risk factor for surgical complications but not a contraindication for kidney transplantation; outcomes could be greatly improved with its multidisciplinary and multimodal treatment. The modern technology with minimally invasive techniques, mainly using robotic platform, allows a reduction in the surgical complications rate, with graft and patient survival rates comparable to the nonobese counterpart.
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Affiliation(s)
- Pierpaolo Di Cocco
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Obi Okoye
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Jorge Almario
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Enrico Benedetti
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Ivo G Tzvetanov
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Mario Spaggiari
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
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Cohen E, Korah M, Callender G, Belfort de Aguiar R, Haakinson D. Metabolic Disorders with Kidney Transplant. Clin J Am Soc Nephrol 2020; 15:732-742. [PMID: 32284323 PMCID: PMC7269213 DOI: 10.2215/cjn.09310819] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Metabolic disorders are highly prevalent in kidney transplant candidates and recipients and can adversely affect post-transplant graft outcomes. Management of diabetes, hyperparathyroidism, and obesity presents distinct opportunities to optimize patients both before and after transplant as well as the ability to track objective data over time to assess a patient's ability to partner effectively with the health care team and adhere to complex treatment regimens. Optimization of these particular disorders can most dramatically decrease the risk of surgical and cardiovascular complications post-transplant. Approximately 60% of nondiabetic patients experience hyperglycemia in the immediate post-transplant phase. Multiple risk factors have been identified related to development of new onset diabetes after transplant, and it is estimated that upward of 7%-30% of patients will develop new onset diabetes within the first year post-transplant. There are a number of medications studied in the kidney transplant population for diabetes management, and recent data and the risks and benefits of each regimen should be optimized. Secondary hyperparathyroidism occurs in most patients with CKD and can persist after kidney transplant in up to 66% of patients, despite an initial decrease in parathyroid hormone levels. Parathyroidectomy and medical management are the options for treatment of secondary hyperparathyroidism, but there is no randomized, controlled trial providing clear recommendations for optimal management, and patient-specific factors should be considered. Obesity is the most common metabolic disorder affecting the transplant population in both the pre- and post-transplant phases of care. Not only does obesity have associations and interactions with comorbid illnesses, such as diabetes, dyslipidemia, and cardiovascular disease, all of which increase morbidity and mortality post-transplant, but it also is intimately inter-related with access to transplantation for patients with kidney failure. We review these metabolic disorders and their management, including data in patients with kidney transplants.
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Affiliation(s)
- Elizabeth Cohen
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, Connecticut
| | - Maria Korah
- Yale University School of Medicine, New Haven, Connecticut
| | - Glenda Callender
- Department of Surgery, Section of Endocrine Surgery, Yale University, New Haven, Connecticut
| | | | - Danielle Haakinson
- Department of Surgery, Section of Transplant, Yale University, New Haven, Connecticut
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28
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Yemini R, Nesher E, Carmeli I, Winkler J, Rahamimov R, Mor E, Keidar A. Bariatric Surgery Is Efficacious and Improves Access to Transplantation for Morbidly Obese Renal Transplant Candidates. Obes Surg 2020; 29:2373-2380. [PMID: 31134476 DOI: 10.1007/s11695-019-03925-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The surgical risk of morbidly obese patients is high and even higher for kidney transplant candidates. A BMI > 35-40 kg/m2 is often a contraindication for that surgery. The safety, feasibility, and outcome of bariatric surgery for those patients are inconclusive. METHODS We conducted a retrospective chart review of prospectively collected data on morbidly obese renal transplant candidates who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) in our institution between January 2009 and September 2017. The reported outcome included body weight and graft status after a mean follow-up of 47 months (range 0.5-5 years). RESULTS Twenty-four patients (8 females, 16 males, average age 54 years, average preoperative BMI 41 kg/m2 [range 35-51]) underwent LSG (n = 17) or LRYGB (n = 7). Sixteen of them (67%) proceeded to kidney transplantation. Of the 8 pre-transplant and post-bariatric surgery patients, 5 are on the waitlist, and 2 patients died (one of staple line leakage, and one from sepsis unrelated to the bariatric surgery). The average time from bariatric surgery to transplantation was 1.5 years (range 1 month to 4.3 years). The average pre-transplantation BMI was 28 kg/m2 (range 19-36). The mean percentage of excess weight loss was 66% (n = 21), and the total percentage of weight loss was 29% (n = 21). Comorbidities (type 2 diabetes, hypertension, and dyslipidemia) improved significantly following both surgical approaches. CONCLUSIONS LSG and LRYGB appear to effectively address obesity issues before kidney transplantation and improve surgical access. Morbidly obese transplant candidates would benefit from prior bariatric surgery.
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Affiliation(s)
- Renana Yemini
- Department of Surgery, Assuta Ashdod Medical Center, Ashdod, Israel. .,Ben-Gurion University, Beer-Sheva, Israel.
| | - Eviatar Nesher
- Departments of Transplant Surgery, Beilinson Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Idan Carmeli
- Department of Surgery, Assuta Ashdod Medical Center, Ashdod, Israel.,Ben-Gurion University, Beer-Sheva, Israel
| | - Janos Winkler
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Departments of Nephrology, Beilinson Medical Center, Petach-Tikva, Israel
| | - Ruth Rahamimov
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Departments of Nephrology, Beilinson Medical Center, Petach-Tikva, Israel
| | - Eytan Mor
- Departments of Transplant Surgery, Beilinson Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Andrei Keidar
- Department of Surgery, Assuta Ashdod Medical Center, Ashdod, Israel.,Ben-Gurion University, Beer-Sheva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Bariatric Clinic, Department of Surgery, Beilinson Medical Center, Petach-Tikva, Israel
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29
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Diwan TS, Cuffy MC, Linares-Cervantes I, Govil A. Impact of obesity on dialysis and transplant and its management. Semin Dial 2020; 33:279-285. [PMID: 32277512 DOI: 10.1111/sdi.12876] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Obesity is increasing to unprecedented levels, including in the end-stage kidney disease population, where upwards of 60% of kidney transplant patients are overweight or obese. Obesity poses additional challenges to the care of the dialysis patient, including difficulties in creating vascular access and inserting Tenckhoff catheters, higher rates of catheter malfunction and peritonitis, the need for longer and/or more frequent dialysis (or peritoneal dialysis [PD] exchanges) to achieve adequate clearance, increased metabolic complications particularly with PD, and obesity is a barrier to kidney transplantation. In this article, we review special considerations in performing PD, hemodialysis and transplant in the obese patient, as well as the evidence behind medical and surgical management of obesity in dialysis patients.
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Affiliation(s)
- Tayyab S Diwan
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Madison C Cuffy
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Ivan Linares-Cervantes
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Amit Govil
- Division of Nephrology, Department of Medicine, University of Cincinnati, Cincinnati, OH, USA
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30
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Choudhury RA, Hoeltzel G, Prins K, Chow E, Moore HB, Lawson PJ, Yoeli D, Pratap A, Abt PL, Dumon KR, Conzen KD, Nydam TL. Sleeve Gastrectomy Compared with Gastric Bypass for Morbidly Obese Patients with End Stage Renal Disease: a Decision Analysis. J Gastrointest Surg 2020; 24:756-763. [PMID: 31044345 DOI: 10.1007/s11605-019-04225-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/29/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The use of bariatric surgery has increased for morbidly obese patients with end stage renal disease (ESRD) for whom listing on the waitlist is often restricted until a certain BMI threshold is achieved. Effective weight loss for this population improves access to life-saving renal transplantation. However, it is unclear whether sleeve gastrectomy (SG) vs Roux-en-Y gastric bypass (RYGB) is a more effective therapy for these patients. METHODS A decision analytic Markov state transition model was created to simulate the life of morbidly obese patients with ESRD who were deemed ineligible to be waitlisted for renal transplantation unless they achieved a BMI less than 35 kg/m2. Life expectancy following weight management (MWM), RYGB, and SG were estimated. Base case patients were defined as having a pre-intervention BMI of 45 kg/m2. Sensitivity analysis of initial BMI was performed. Markov parameters were extracted from literature review. RESULTS RYGB improved survival compared with SG and MWM. RYGB patients had higher rates of transplantation, leading to improved mean long-term survival. Base case patients who underwent RYGB gained 1.3 additional years of life compared with patient's who underwent SG and 2.6 additional years of life compared with MWM. CONCLUSIONS RYGB improves access to renal transplantation and thereby increases long-term survival compared with SG and MWM. The use of SG may be incongruent with the goal of improving access to renal transplantation for morbidly obese patients.
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Affiliation(s)
- Rashikh A Choudhury
- Department of Surgery, Division of Transplant Surgery, University of Colorado Hospital, Aurora, CO, USA.
| | - Gerard Hoeltzel
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Kas Prins
- Department of Surgery, Division of Transplant Surgery, University of Colorado Hospital, Aurora, CO, USA
| | - Eric Chow
- Department of Medicine- Quantitative Sciences Unit, Stanford University Medical Center, Palo Alto, CA, USA
| | - Hunter B Moore
- Department of Surgery, Division of Transplant Surgery, University of Colorado Hospital, Aurora, CO, USA
| | - Peter J Lawson
- Department of Surgery, Division of Transplant Surgery, University of Colorado Hospital, Aurora, CO, USA
| | - Dor Yoeli
- Department of Surgery, Division of Transplant Surgery, University of Colorado Hospital, Aurora, CO, USA
| | - Akshay Pratap
- Department Surgery, Division of MIS/Bariatric Surgery, University of Colorado Hospital, Aurora, CO, USA
| | - Peter L Abt
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Kristoffel R Dumon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Kendra D Conzen
- Department of Surgery, Division of Transplant Surgery, University of Colorado Hospital, Aurora, CO, USA
| | - Trevor L Nydam
- Department of Surgery, Division of Transplant Surgery, University of Colorado Hospital, Aurora, CO, USA
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31
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Rangaswami J, Mathew RO, Parasuraman R, Tantisattamo E, Lubetzky M, Rao S, Yaqub MS, Birdwell KA, Bennett W, Dalal P, Kapoor R, Lerma EV, Lerman M, McCormick N, Bangalore S, McCullough PA, Dadhania DM. Cardiovascular disease in the kidney transplant recipient: epidemiology, diagnosis and management strategies. Nephrol Dial Transplant 2020; 34:760-773. [PMID: 30984976 DOI: 10.1093/ndt/gfz053] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Indexed: 12/19/2022] Open
Abstract
Kidney transplantation (KT) is the optimal therapy for end-stage kidney disease (ESKD), resulting in significant improvement in survival as well as quality of life when compared with maintenance dialysis. The burden of cardiovascular disease (CVD) in ESKD is reduced after KT; however, it still remains the leading cause of premature patient and allograft loss, as well as a source of significant morbidity and healthcare costs. All major phenotypes of CVD including coronary artery disease, heart failure, valvular heart disease, arrhythmias and pulmonary hypertension are represented in the KT recipient population. Pre-existing risk factors for CVD in the KT recipient are amplified by superimposed cardio-metabolic derangements after transplantation such as the metabolic effects of immunosuppressive regimens, obesity, posttransplant diabetes, hypertension, dyslipidemia and allograft dysfunction. This review summarizes the major risk factors for CVD in KT recipients and describes the individual phenotypes of overt CVD in this population. It highlights gaps in the existing literature to emphasize the need for future studies in those areas and optimize cardiovascular outcomes after KT. Finally, it outlines the need for a joint 'cardio-nephrology' clinical care model to ensure continuity, multidisciplinary collaboration and implementation of best clinical practices toward reducing CVD after KT.
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Affiliation(s)
- Janani Rangaswami
- Einstein Medical Center, Philadelphia, PA, USA.,Sidney Kimmel College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Roy O Mathew
- Columbia Veterans Affairs Health Care System, Columbia, SC, USA
| | | | | | - Michelle Lubetzky
- Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY, USA
| | - Swati Rao
- University of Virginia, Charlottesville, VA, USA
| | | | | | | | | | - Rajan Kapoor
- Augusta University Medical Center, Augusta, GA, USA
| | - Edgar V Lerma
- UIC/Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Mark Lerman
- Medical City Dallas Hospital, Dallas, TX, USA
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Chan G, Hajjar R, Boutin L, Garneau PY, Pichette V, Lafrance JP, Elftouh N, Michaud J, du Souich P. Prospective study of the changes in pharmacokinetics of immunosuppressive medications after laparoscopic sleeve gastrectomy. Am J Transplant 2020; 20:582-588. [PMID: 31529773 DOI: 10.1111/ajt.15602] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/08/2019] [Accepted: 09/10/2019] [Indexed: 02/06/2023]
Abstract
Laparoscopic sleeve gastrectomy induces weight loss via the creation of a restrictive gastric tube for early satiety and is associated with an accelerated gastric transit time. A prospective, single-dose pharmacokinetic study was performed, prior to and after laparoscopic sleeve gastrectomy, for tacrolimus, extended-release tacrolimus, mycophenolate mofetil, and enteric-coated mycophenolate sodium. The study included 12 morbidly obese patients in chronic renal failure. The median decrease in body mass index was 8.8 kg/m2 with an excess body weight loss of 54.9%. The AUC24 of all drugs were increased after laparoscopic sleeve gastrectomy by 46%, 55%, 77%, and 74%, respectively. The maximum concentrations were increased for tacrolimus, extended-release tacrolimus, and mycophenolate mofetil by 43%, 46%, and 65%. The apparent total clearances were decreased for tacrolimus, mycophenolate mofetil, and enteric-coated mycophenolate sodium by 36%, 57%, and 38%. Laparoscopic sleeve gastrectomy can be associated with significant changes in pharmacokinetics of the drugs evaluated. The mechanism is likely decreased apparent drug clearance due to an increased drug exposure (from a more distal site of intestinal absorption with decreased intestinal metabolism), or decreased clearance (liver metabolism). Adapting the monitoring of immunosuppression will be important to avoid overdosing and potential side effects.
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Affiliation(s)
- Gabriel Chan
- Department of Surgery, University of Montréal, Montréal, Québec, Canada.,Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada
| | - Roy Hajjar
- Department of Surgery, University of Montréal, Montréal, Québec, Canada.,Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada
| | - Lucie Boutin
- Service de Néphrologie, Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada
| | - Pierre Y Garneau
- Department of Surgery, University of Montréal, Montréal, Québec, Canada.,Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada
| | - Vincent Pichette
- Service de Néphrologie, Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada.,Department of Medicine, University of Montréal, Montréal, Québec, Canada.,Department of Pharmacology, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada
| | - Jean-Philippe Lafrance
- Service de Néphrologie, Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada.,Department of Pharmacology, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada
| | | | - Josée Michaud
- Department of Medicine, University of Montréal, Montréal, Québec, Canada
| | - Patrick du Souich
- Department of Pharmacology, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada
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Kassam AF, Mirza A, Kim Y, Hanseman D, Woodle ES, Quillin RC, Johnson BL, Govil A, Cardi M, Schauer DP, Smith EP, Diwan TS. Long-term outcomes in patients with obesity and renal disease after sleeve gastrectomy. Am J Transplant 2020; 20:422-429. [PMID: 31605562 DOI: 10.1111/ajt.15650] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/06/2019] [Accepted: 10/03/2019] [Indexed: 01/25/2023]
Abstract
Morbid obesity is a barrier to kidney transplant in patients with end-stage renal disease (ESRD). Laparoscopic sleeve gastrectomy (SG) is an increasingly considered intervention, but the safety and long-term outcomes are uncertain. We reviewed prospectively collected data on patients with ESRD and chronic kidney disease (CKD) undergoing SG from 2011 to 2018. There were 198 patients with ESRD and 45 patients with CKD (stages 1-4) who met National Institutes of Health guidelines for bariatric surgery and underwent SG; 72% and 48% achieved a body mass index of ≤ 40 and ≤ 35 kg/m2 , respectively. The mean percentages of total weight loss and excess weight loss were 18.9 ± 10.8% and 38.2 ± 20.3%, respectively. SG reduced hypertension (85.8% vs 52.1%), decreased antihypertensive medication use (1.6 vs 1.0) (P < .01 each), and reduced incidence of diabetes (59.6% vs 32.5%, P < .01). Of the 71 patients with ESRD who achieved a body mass index of ≤ 40 kg/m2 , 45 were waitlisted and received a kidney transplant, whereas 10 remain on the waitlist. Mortality rate after SG was 1.8 per 100 patient-years, compared with 7.3 for non-SG. Patients with stage 3a or 3b CKD exhibited improved glomerular filtration rate (43.5 vs 58.4 mL/min, P = .01). In conclusion, SG safely improves transplant candidacy while providing significant, sustainable effects on weight loss, reducing medical comorbidities, and possibly improving renal function in stage 3 patients.
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Affiliation(s)
- Al-Faraaz Kassam
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Ahmad Mirza
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Young Kim
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Dennis Hanseman
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - E Steve Woodle
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Ralph C Quillin
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Bobby L Johnson
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amit Govil
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Michael Cardi
- Department of Internal Medicine, The Christ Hospital, Cincinnati, Ohio
| | - Daniel P Schauer
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Eric P Smith
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Tayyab S Diwan
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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34
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Kassam AF, Taylor ME, Morris MC, Watkins BM, Thompson JR, Schauer DP, Smith EP, Diwan TS. The impact of sleeve gastrectomy on renal function in patients with chronic kidney disease varies with severity of renal insufficiency. Surg Obes Relat Dis 2020; 16:607-613. [PMID: 32093996 DOI: 10.1016/j.soard.2020.01.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although laparoscopic sleeve gastrectomy is known, in general, to improve renal function in patients with obesity and chronic kidney disease (CKD), its effect on estimated glomerular filtration rate (eGFR) stratified by the stage of CKD is less clear. OBJECTIVES We aimed to evaluate the impact of sleeve gastrectomy on renal function in a stratified cohort of patients with CKD. SETTING University Hospital. METHODS We performed a retrospective review of 1932 patients who met National Institutes of Health's guidelines for metabolic surgery and underwent laparoscopic sleeve gastrectomy performed by 1 of 3 surgeons. One hundred sixty-four patients with CKD stages 1 through 4 were identified. RESULTS Mean follow-up period was 1.57 ± 1.0 years. Mean age was 56.4 ± 9.9 years with a preoperative body mass index of 47 ± 9 kg/m2, which decreased to 38.9 ± 8.7 kg/m2 at most recent follow-up (P < .001). In the cohort of patients with diabetes, significant decreases were observed in mean glycated hemoglobin level, daily number of oral hypoglycemics, and daily long acting insulin use (P < .001 each). Of 67 patients with diabetes, 34.3% (n = 24) achieved complete remission. In patients with hypertension, average daily number of antihypertensives decreased (P < .001) and 22.3% (n = 31) of 133 patients with hypertension discontinued all antihypertensives. Patients with CKD stages 2, 3a, and 3b showed significant improvement in eGFR. Reinforcing this evidence of improvement, patients with CKD 3a and 3b were more likely to downstage disease compared with those with CKD 4 (58.1% versus 73.1% versus 22.7%, respectively) (P < .001). CONCLUSION Renal function, as measured by eGFR, in patients with stages 1 and 4 CKD did not improve after laparoscopic sleeve gastrectomy; in contrast, eGFR in patients with CKD stages 2 and 3 significantly improved. Early surgical referral and intervention may be important in achieving the greatest improvement in eGFR and possibly delaying or reversing progression to end-stage renal disease.
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Affiliation(s)
- Al-Faraaz Kassam
- University of Cincinnati, Department of Surgery, Cincinnati, Ohio
| | | | | | - Brad M Watkins
- University of Cincinnati, Department of Surgery, Cincinnati, Ohio
| | | | - Daniel P Schauer
- University of Cincinnati, Department of Internal Medicine, Cincinnati, Ohio
| | - Eric P Smith
- University of Cincinnati, Department of Internal Medicine, Cincinnati, Ohio
| | - Tayyab S Diwan
- University of Cincinnati, Department of Surgery, Cincinnati, Ohio.
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35
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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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Neff KJ, Le Roux CW. The Effect of Metabolic Surgery on the Complications of Diabetes: What Are the Unanswered Questions? Front Endocrinol (Lausanne) 2020; 11:304. [PMID: 32547487 PMCID: PMC7272689 DOI: 10.3389/fendo.2020.00304] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/21/2020] [Indexed: 01/06/2023] Open
Abstract
It is now established that metabolic surgery (also known as bariatric surgery or obesity surgery) is an effective treatment for type 2 diabetes. Data from several randomized controlled trials have shown that surgery, when used as an adjunct to best medical therapy, is superior to medical therapy alone in achieving glycaemic and metabolic treatment targets in diabetes care. This has resulting in metabolic surgery being recommended as a treatment option for obesity-associated type 2 diabetes in national and international diabetes care guidelines. While the superior glycaemic effect of surgery is clear, the effect of surgery on the complications of diabetes is not fully understood. There are observational and epidemiological data that indicate a preventative effect in cohorts who do not have complications at baseline, as well as a positive effect on those with established diabetic kidney disease. However, there is a dearth of randomized controlled studies that specifically examine the effect of surgery on the complications of diabetes. Therefore, we should remain cautious in some cases, especially in those with retinopathy or neuropathy, as there is potential for deterioration of disease post-operatively. Further study is needed on this important topic. A lot is known, but there remain several unanswered questions. This article summarizes what we know about the effect of metabolic surgery on the complications of diabetes, poses some unanswered questions, and suggests how we could answer them.
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Affiliation(s)
- Karl J. Neff
- Diabetes Complications Research Centre, Conway Institute, University College Dublin, Dublin, Ireland
- *Correspondence: Karl J. Neff
| | - Carel W. Le Roux
- Diabetes Complications Research Centre, Conway Institute, University College Dublin, Dublin, Ireland
- Metabolic Medicine, Imperial College London, London, United Kingdom
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Morris MC, Jung AD, Kim Y, Lee TC, Kaiser TE, Thompson JR, Bari K, Shah SA, Cohen RM, Schauer DP, Smith EP, Diwan TS. Delayed Sleeve Gastrectomy Following Liver Transplantation: A 5-Year Experience. Liver Transpl 2019; 25:1673-1681. [PMID: 31518478 DOI: 10.1002/lt.25637] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/02/2019] [Indexed: 12/31/2022]
Abstract
Obesity has become an epidemic in the United States over the past decade, and recent studies have shown this trend in the liver transplantation (LT) population. These patients may be candidates for laparoscopic sleeve gastrectomy (LSG) to promote significant and sustained weight loss to prevent recurrence of nonalcoholic steatohepatitis. However, safety remains a concern, and efficacy in this setting is uncertain. A single-institution database from 2014 to 2018 was queried for patients undergoing LSG following LT. The selection criteria for surgery were consistent with National Institutes of Health guidelines, and patients were at least 6 months after LT. A total of 15 patients (median age, 59.0 years; Caucasian, 86.7%; and female, 60%) underwent LSG following LT. Median time from LT to LSG was 2.2 years with a median follow-up period of 2.6 years. The median hospital length of stay (LOS) was 2 days after LSG. Mortality and rate of liver allograft rejection was 0, and there was 1 postoperative complication (a surgical site infection). Following LSG, body mass index (BMI) decreased from 42.7 to 35.9 kg/m2 (P < 0.01), and in 12 patients with at least 1 year of follow-up, the total body weight loss was 20.6%. Following LSG in patients with diabetes, the median daily insulin requirements decreased from 98 (49-118) to 0 (0-29) units/day (P = 0.02), and 60% discontinued insulin. Post-LT patients had a similar decrease in BMI and reduction in comorbidities at 1 year compared with a matched non-LT patient cohort. In the largest patient series to date, we show that LSG following LT is safe, effective, and does not increase the incidence of liver allograft rejection. Larger longer-term studies are needed to confirm underlying metabolic changes following LSG.
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Affiliation(s)
- Mackenzie C Morris
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Andrew D Jung
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Young Kim
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Tiffany C Lee
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Tiffany E Kaiser
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Jonathan R Thompson
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Khurram Bari
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Robert M Cohen
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Daniel P Schauer
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Eric P Smith
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Tayyab S Diwan
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
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38
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Kim Y, Bailey AJ, Morris MC, Kassam AF, Shah SA, Diwan TS. Kidney transplantation after sleeve gastrectomy in the morbidly obese candidate: results of a 2-year experience. Surg Obes Relat Dis 2019; 16:10-14. [PMID: 31668565 DOI: 10.1016/j.soard.2019.09.069] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/24/2019] [Accepted: 09/13/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Morbid obesity serves as a barrier to kidney transplantation (KT) due to potential suboptimal posttransplant outcomes. Laparoscopic sleeve gastrectomy (LSG) has previously been shown to improve transplant eligibility through weight loss. OBJECTIVES We aimed to examine the role LSG plays in improving patient outcomes postrenal transplantation, including possible impact on new-onset diabetes after transplant (NODAT). SETTING University Hospital. METHODS A single-center analysis was performed identifying all patients who underwent KT after LSG from 2011 to 2017 (n = 41). Exclusion criteria included type I diabetes and previous pancreas transplantation. NODAT was defined as a new insulin requirement after KT. Delayed graft function was defined as need for dialysis within the first week after KT. Mean posttransplant follow-up period was 22 months. RESULTS Forty-one patients underwent KT after LSG after median time of 16 months. Median age of postLSG patients undergoing KT was 56.0 years at time of KT. Average body mass index decreased by 9 from the time of LSG to KT, and no patients regained weight at 1-year follow-up. After LSG, the number of patients with hypertension (85.4% versus 48.5%) and the number of antihypertensive medications used decreased significantly (1.6 versus .6) at time of KT (P < .001 each). At 1-year follow-up, the improvement in hypertension persisted (51.2% versus 48.5%, P = nonsignificant). The average insulin regimen decreased from 33.0 ± 51.6 to 11.7 ± 21.5 units at KT (P < .001). This improvement also persisted at 1-year follow-up (11.9 versus 11.7 units, P = nonsignificant). Zero patients suffered NODAT over the follow-up period (versus institutional rate of NODAT at 15.8%). One patient developed delayed graft function (2.4%, versus institutional rate of 13.3%). After 1 year postKT, there was 1 graft loss (2.4%) and no mortality. CONCLUSION This is the largest reported series of KT after planned LSG in morbidly obese patients. Our results confirm excellent posttransplant outcomes among patients who otherwise would have been denied KT eligibility.
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Affiliation(s)
- Young Kim
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amanda J Bailey
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mackenzie C Morris
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Al-Faraaz Kassam
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shimul A Shah
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Tayyab S Diwan
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Safety and efficacy of the sleeve gastrectomy as a strategy towards kidney transplantation. Surg Endosc 2019; 34:2657-2664. [DOI: 10.1007/s00464-019-07042-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/24/2019] [Indexed: 12/14/2022]
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40
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Bellini MI, Paoletti F, Herbert PE. Obesity and bariatric intervention in patients with chronic renal disease. J Int Med Res 2019; 47:2326-2341. [PMID: 31006298 PMCID: PMC6567693 DOI: 10.1177/0300060519843755] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 03/23/2019] [Indexed: 12/25/2022] Open
Abstract
Obesity is associated with chronic metabolic conditions that directly and indirectly cause kidney parenchymal damage. A review of the literature was conducted to explore existing evidence of the relationship between obesity and chronic kidney disease as well as the role of bariatric surgery in improving access to kidney transplantation for patients with a high body mass index. The review showed no definitive evidence to support the use of a transplant eligibility cut-off parameter based solely on the body mass index. Moreover, in the pre-transplant scenario, the obesity paradox is associated with better patient survival among obese than non-obese patients, although promising results of bariatric surgery are emerging. However, until more information regarding improvement in outcomes for obese kidney transplant candidates is available, clinicians should focus on screening of the overall frailty condition of transplant candidates to ensure their eligibility and addition to the wait list.
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Affiliation(s)
- Maria Irene Bellini
- Renal and Transplant Directorate, Hammersmith Hospital, Imperial College NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | | | - Paul Elliot Herbert
- Renal and Transplant Directorate, Hammersmith Hospital, Imperial College NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
- Imperial College, London, United Kingdom
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41
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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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42
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The Evolution of Kidney Transplantation Surgery Into the Robotic Era and Its Prospects for Obese Recipients. Transplantation 2019; 102:1650-1665. [PMID: 29916987 DOI: 10.1097/tp.0000000000002328] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Robotic-assisted kidney transplantation (RAKT) represents the most recent innovation in the evolution of kidney transplantation surgery. Vascular techniques enabling kidney transplantation have existed since the early 20th century and contributed to the first successful open kidney transplant procedure in 1954. Technical advances have since facilitated minimally invasive laparoscopic and robotic techniques in live-donor surgery, and subsequently for the recipient procedure. This review follows the development of surgical techniques for kidney transplantation, with a special focus on the advent of robotic-assisted transplantation because of its potential to facilitate transplantation of those deemed previously too obese to transplant by standard means. The different techniques, indications, advantages, disadvantages, and future directions of this approach will be explored in detail. Robot-assisted kidney transplantation may become the preferred means of transplanting morbidly obese recipients, although its availability to such recipients remains extremely limited and strategies targeting weight loss pretransplantation should never be abandoned in favor of a "RAKT-first" approach.
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MacLaughlin HL, Campbell KL. Obesity as a barrier to kidney transplantation: Time to eliminate the body weight bias? Semin Dial 2019; 32:219-222. [PMID: 30941820 DOI: 10.1111/sdi.12783] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
There is clear evidence that survival rates following transplantation far exceed those for remaining on dialysis, regardless of body size measured by body mass index (BMI). Studies over the past 15 years also suggest little to no difference in long-term outcomes, including graft survival and mortality, irrespective of BMI, in contrast to earlier evidence. However, weight bias still exists, as access to kidney transplantation remains inequitable in centers using arbitrary BMI limits. Clinicians faced with the decision regarding listing based on body size are not helped by conflicting recommendations in national and international guidelines. Therefore, in clinical practice, obesity, and recommendations for weight loss, remain a controversial issue when assessing suitability for kidney transplantation. Obesity management interventions in end-stage kidney disease (ESKD), whether for weight loss for transplantation listing or for slowing kidney disease progression, are under-explored in trial settings. Bariatric surgery is the most successful treatment for obesity, but carries increased risk in the ESKD population, and the desired outcome of kidney transplant listing is not guaranteed. Centers that limit transplants to those meeting arbitrary levels of body mass, rather than adopting an individualized assessment approach, may be unfairly depriving many ESKD patients of the survival and quality of life benefits derived from kidney transplantation. However, robotic kidney transplantation surgery holds promise for reducing perioperative risks related to obesity, and may therefore represent an opportunity to remove listing criteria based on size.
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Affiliation(s)
- Helen L MacLaughlin
- Department of Nutrition and Dietetics, King's College Hospital, London, UK.,Bond University Nutrition and Dietetics Research Group, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Katrina L Campbell
- Allied Health Services, Metro North Hospital and Health Services, Herston, QLD, Australia.,Centre for Applied Health Economics, Menzies Health Institute, Griffith University, Brisbane, QLD, Australia
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44
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Lambert K, Beer J, Dumont R, Hewitt K, Manley K, Meade A, Salamon K, Campbell K. Weight management strategies for those with chronic kidney disease: A consensus report from the Asia Pacific Society of Nephrology and Australia and New Zealand Society of Nephrology 2016 renal dietitians meeting. Nephrology (Carlton) 2019; 23:912-920. [PMID: 28742255 DOI: 10.1111/nep.13118] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2017] [Indexed: 12/14/2022]
Abstract
AIM The aim of the present study was to develop a consensus report to guide dietetic management of overweight or obese individuals with chronic kidney disease (CKD). METHODS Six statements relating to weight management in CKD guided a comprehensive review of the literature. A summary of the evidence was then presented at the renal nutrition meeting of the 2016 Asia Pacific Society of Nephrology and Australia and New Zealand Society of Nephrology. Majority agreement was defined as group agreement on a statement of between 50-74%, and consensus was considered ≥75% agreement. The recommendations were developed via a mini Delphi process. RESULTS Two statements achieved group consensus: the current guidelines used by dietitians to estimate energy requirements for overweight and obese people with CKD are not relevant and weight loss medications may be unsafe or ineffective in isolation for those with CKD. One statement achieved group agreement: Meal replacement formulas are safe and efficacious in those with CKD. No agreement was achieved on the statements of whether there is strong evidence of benefit for weight loss prior to kidney transplantation; whether traditional weight loss strategies can be used in those with CKD and if bariatric surgery in those with end stage kidney disease is feasible and effective. CONCLUSION There is a limited evidence base to guide the dietetic management of overweight and obese individuals with CKD. Medical or surgical strategies to facilitate weight loss are not recommended in isolation and require a multidisciplinary approach with the involvement of a skilled renal dietitian.
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Affiliation(s)
- Kelly Lambert
- Department of Clinical Nutrition, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Jo Beer
- Younger Adult Rehabilitation Department, Osborne Park Hospital, Stirling, Western Australia, Australia
| | - Ruth Dumont
- Dietetics Department, Dietetics, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - Katie Hewitt
- Dietetics Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Karen Manley
- Dietetics Department, Austin Health, Heidelberg, Victoria, Australia
| | - Anthony Meade
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Karen Salamon
- Nutrition and Dietetics Department, Nutrition and Dietetics, Monash Medical Centre, Clayton, Victoria, Australia
| | - Katrina Campbell
- Nutrition and Dietetics, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
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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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Ben-Porat T, Weiss-Sadan A, Rottenstreich A, Sherf-Dagan S, Schweiger C, Yosef-Levi IM, Weiner D, Azulay O, Sakran N, Harari R, Elazary R. Nutritional Management for Chronic Kidney Disease Patients who Undergo Bariatric Surgery: A Narrative Review. Adv Nutr 2019; 10:122-132. [PMID: 30753268 PMCID: PMC6370259 DOI: 10.1093/advances/nmy112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 10/19/2018] [Accepted: 11/12/2018] [Indexed: 12/14/2022] Open
Abstract
Bariatric surgery (BS) may be effective for chronic kidney disease (CKD) patients by reducing microalbuminuria and proteinuria, and by facilitating their meeting inclusion criteria for kidney transplantation. However, nutritional management for this population is complex and specific guidelines are scarce. A literature search was performed to create dietetic practice for these patients based on the most recent evidence. For the purposes of nutritional recommendations, we divided the patients into 2 subgroups: 1) patients with CKD and dialysis, and 2) patients after kidney transplantation. Before surgery, nutritional care includes nutritional status evaluation and adjusting doses of supplements to treat deficiencies and daily nutrient intake according to the dietary restrictions derived from kidney disease, including quantities of fluids, protein, phosphorus, potassium, and vitamins. After BS, these patients are at major risk for lean body mass loss, malnutrition and dehydration because of fluid restriction and diuretics. Postoperative nutritional recommendations should be carefully tailored according to CKD nutritional limitations and include specific considerations regarding protein, fluids, and supplementation, in particular calcium, vitamin A, and vitamin D. Nutritional management of CKD and kidney transplant patients undergoing BS is challenging and future studies are required to establish uniform high-level evidence-based guidelines.
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Affiliation(s)
- Tair Ben-Porat
- The Israeli Dietetic Association, Herzliya, Israel
- Department of Nutrition, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Anat Weiss-Sadan
- The Israeli Dietetic Association, Herzliya, Israel
- Department of Nutrition, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Shiri Sherf-Dagan
- The Israeli Dietetic Association, Herzliya, Israel
- Department of Nutrition, Assuta Medical Center, Tel Aviv, Israel
| | - Chaya Schweiger
- The Israeli Dietetic Association, Herzliya, Israel
- Department of Nutrition, Rabin Medical Center, Petach Tiqva, Israel
| | - Irit Mor Yosef-Levi
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Dana Weiner
- The Israeli Dietetic Association, Herzliya, Israel
- Department of Nutrition, Sheba Medical Center, Tel Aviv, Israel
| | - Odile Azulay
- The Israeli Dietetic Association, Herzliya, Israel
- Department of Nutrition, Rabin Medical Center, Petach Tiqva, Israel
| | - Nasser Sakran
- Department of Surgery A, Emek Medical Center, Afula, affiliated with Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Rivki Harari
- The Israeli Dietetic Association, Herzliya, Israel
- Department of Nutrition, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ram Elazary
- Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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47
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Bobkova IN, Gussaova SS, Stavrovskaya EV, Struve AV. Nephrological aspects of surgical weight correction in morbid obesity. TERAPEVT ARKH 2018; 90:98-104. [PMID: 30701912 DOI: 10.26442/terarkh201890698-104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Obesity, including morbid obesity, is a growing worldwide problem. The adverse effect of obesity on the kidneys is associated with the development of comorbid conditions, such as insulin resistance (IR), metabolic syndrome (MS), diabetes mellitus (DM), arterial hypertension (AH), which are the recognized risk factors of chronic kidney disease (СKD). Obesity also causes direct kidney damage with the development of non-immune focal segmental glomerulosclerosis. The leading pathophysiological mechanisms of kidney damage in obesity are intrarenal hemodynamic disorders with the formation of hyperfiltration and damaging effects of adipokines produced by adipose tissue. Bariatric surgery (BS) has taken a leading position in the treatment of morbid obesity, demonstrating its effectiveness not only in long-term weight loss, but also in the correction of IR, MS, DM, AH. Nephroprotective effect of significant and persistent weight loss is caused by the elimination of hyperfiltration and damaging effect of adipokines. Results of the observational studies of the immediate and long-term effects of BS have demonstrated positive renal outcomes, in particular, the decrease in albuminuria/proteinuria, the improvement or stabilization of glomerular filtration rate, the delay of end-stage renal failure development; surgical correction of body weight in dialysis patients with morbid obesity lets them realize subsequent kidney transplantation. Large, randomized prospective studies with a longer follow-up are needed; analysis of the long-term renal consequences of BS in obesity patients with pre-existing renal impairment, including dialysis patients, is required; stratification of the BS risk of renal complications (acute kidney damage, nephrolithiasis, nephrocalcinosis) and effective strategy for managing these risks need to be developed.
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48
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Piotti G, Gandolfini I, Palmisano A, Maggiore U. Metabolic risk profile in kidney transplant candidates and recipients. Nephrol Dial Transplant 2018; 34:388-400. [DOI: 10.1093/ndt/gfy151] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 05/01/2018] [Indexed: 12/30/2022] Open
Affiliation(s)
- Giovanni Piotti
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Ilaria Gandolfini
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Alessandra Palmisano
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Umberto Maggiore
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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49
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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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Carandina S, Genser L, Bossi M, Montana L, Cortes A, Seman M, Danan M, Barrat C. Laparoscopic Sleeve Gastrectomy in Kidney Transplant Candidates: a Case Series. Obes Surg 2018; 27:2613-2618. [PMID: 28405876 DOI: 10.1007/s11695-017-2679-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with a body mass index (BMI) >35 kg/m2 who need kidney transplant present with increased postoperative mortality and reduced kidney graft survival compared to patients with a lower BMI. For this reason, obese patients are often excluded from the transplantation waiting list. The aim of this study was to evaluate the feasibility and the results of laparoscopic sleeve gastrectomy (LSG) for obese patients awaiting a kidney transplant. METHODS This was a retrospective study on patients with dialysis-dependent renal failure (DDRF) operated on at two first-level bariatric centers in Paris (France). All the patients were contraindicated for kidney transplantation due to the presence of morbid obesity. RESULTS Nine DDFR patients with a mean BMI of 45.9 kg/m2 underwent LSG for the treatment of obesity. Furthermore, all patients presented with hypertension and sleep apnea and six out nine were diabetics. In the immediate postoperative period, all patients were transferred to the intensive care unit (mean stay of 2.1 days). The only major adverse event was a delayed weaning from mechanical ventilation in one patient. The mean hospital stay was 5.5 days (3-12). The total weight loss (TWL) was 27.1, 33.6, and 39.5 kg at 6, 12, and 18 months, respectively. One patient underwent renal transplantation 18 months after LSG, and the other five patients were actively listed for kidney transplantation. CONCLUSIONS According to the results of this small sample series, LSG seems to be an effective and safe procedure in DDRF patients with concomitant obesity and can increase access to transplantation.
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Affiliation(s)
- Sergio Carandina
- Department of Digestive and Metabolic Surgery, Avicenne University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre Intégré Nord Francilien de la prise en charge de l'Obésité (CINFO), Université Paris XIII-UFR SMBH "Léonard de Vinci", AP-HP, route de Stalingrad, Bobigny, France. .,Department of Digestive and Bariatric Surgery, Clinique Saint Michel, 4, Place du 4 Septembre, 83100, Toulon, France.
| | - Laurent Genser
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Liver Transplantation, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Pierre & Marie Curie University, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Manuela Bossi
- Department of Digestive and Metabolic Surgery, Avicenne University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre Intégré Nord Francilien de la prise en charge de l'Obésité (CINFO), Université Paris XIII-UFR SMBH "Léonard de Vinci", AP-HP, route de Stalingrad, Bobigny, France
| | - Laura Montana
- Department of Digestive and Metabolic Surgery, Avicenne University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre Intégré Nord Francilien de la prise en charge de l'Obésité (CINFO), Université Paris XIII-UFR SMBH "Léonard de Vinci", AP-HP, route de Stalingrad, Bobigny, France
| | - Alexandre Cortes
- Department of Digestive and Metabolic Surgery, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre Hospitalier Marne-la-Vallée, 77600, Jossigny, France
| | - Marie Seman
- Department of Digestive and Metabolic Surgery, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre Hospitalier Marne-la-Vallée, 77600, Jossigny, France
| | - Marc Danan
- Department of Digestive and Bariatric Surgery, Clinique Saint Michel, 4, Place du 4 Septembre, 83100, Toulon, France
| | - Christophe Barrat
- Department of Digestive and Metabolic Surgery, Avicenne University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre Intégré Nord Francilien de la prise en charge de l'Obésité (CINFO), Université Paris XIII-UFR SMBH "Léonard de Vinci", AP-HP, route de Stalingrad, Bobigny, France
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