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ABSTRACT
Year : 2018  |  Volume : 4  |  Issue : 4  |  Page : 107-108

Bariatric surgery for obese patients with kidney disease


1 Head, Department of Minimal Access and Bariatric Surgery, Saifee Hospital, Mumbai, Maharashtra, India
2 Group Manager Clinical Practice, Nutrition and Patient Care, Dr. Muffi's Digestive Health Institute, Mumbai, Maharashtra, India

Date of Web Publication19-Sep-2019

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrnm.jrnm_22_19

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How to cite this article:
Lakdawala M, Remedios C. Bariatric surgery for obese patients with kidney disease. J Renal Nutr Metab 2018;4:107-8

How to cite this URL:
Lakdawala M, Remedios C. Bariatric surgery for obese patients with kidney disease. J Renal Nutr Metab [serial online] 2018 [cited 2019 Oct 21];4:107-8. Available from: http://www.jrnm.in/text.asp?2018/4/4/107/267192



Chronic renal disease (CKD), commonly defined as abnormal structure/function and/or reduced glomerular filtration rate (GFR) for at least 3 months and with implications to health, has a plethora of causes.[1]

The most common among these are obesity, diabetes mellitus, and hypertension.[2]

Obesity by itself leads to afferent arteriole dilation augment GFR. Glomerular capillary dilation (with loss of auto-regulation) leads to barotrauma, with podocytes required to cover a larger surface area. The inability for the podocytes to do so can lead to proteinuria.[2] That bariatric surgery causes weight loss and improves metabolic parameters is a well-known fact. However, the exact reasons for the improvement in renal function have been inferred by multiple publications from across the globe.

A meta-analysis of observational studies was performed by a group from Romania, Bilha et al.[3] The findings of this meta-analysis was that most surgeons preferred a laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass to a malabsorptive procedure in patients with chronic kidney disease. The meta-analysis of studies inferred that the reduction in estimated GFR was weight and Body Mass Index (BMI) independent, rather it was dependent on adequate control of blood pressure and blood glucose levels, whereas a reduction in albuminuria was influenced by baseline albuminuria, insulin sensitivity/change in Hemoglobin A1c levels and adiponectin levels.[3]

Bariatric surgery causes improvement or even reversal of diabetes mellitus and hypertension (two of the leading causes of CKD), which is proven by scientific evidence. This suggests that if proper selection criteria are applied, bariatric surgery in patients with chronic kidney disease can benefit patients extensively. Another meta-analysis conducted by Li et al.[4] has inferred that weight loss following bariatric surgery results in significant improvement by reducing proteinuria, albuminuria, and reducing glomerular hyperfiltration. They concluded, however, that it is not possible to state that bariatric surgery reverses CKD or delays end-stage renal disease (ESRD) progression.[4]

There is robust evidence in favor of bariatric surgery and its benefits in pre-CKD and stages 1 and 2 CKD, but evidence is still lacking regarding the role of bariatric surgery in ESRD patients. A Japanese study by Wakamatsu et al.[5] recently concluded that for patients with eGFRcys values <60 ml/min/1.72 m2 the likelihood of improvement was lesser than those with values over 60. This was a single-center data and specific for the Japanese population with an average preoperative weight of 109 kg and BMI of 39.5 kg/m2.[5]

However, bariatric surgery has its own pitfalls. Acute on chronic renal injury postoperatively, especially in patients with ESRD, is the most common problem, followed by the development of nephrolithiasis (3%). This can add to the morbidity or even mortality postsurgery in CKD patients.[3] The mortality in CKD patients post bariatric surgery, though, is 0.12% which is comparable to that of bariatric patients without CKD.[3]


  Bariatric Surgery in End-stage Renal Disease/renal Transplant Recipients Top


Obesity in ESRD patients and postrenal transplant patients does lead to worsening of renal function owing to the aforementioned factors. Weight loss is essential in obese patients with ESRD/postrenal transplant recipients. Alternate ways of achieving this is by the means of dieting and exercising. This cohort of patients are usually not fit enough to exercise vigorously, and the diet recommended for weight loss (low carbohydrate, low fat and high-protein diet) can worsen ESRD.[6] Weight loss medication, too have little evidence to support its use in this population.[7] Bariatric surgery is a promising option for these patients.

Longer term studies to evaluate the effect of BS on ESRD patients on dialysis or postrenal transplant patients are required to support its use in this subset.

However, the general rule of the thumb is, the earlier we treat CKD in the disease process with bariatric surgery, the better will be the long-term results.



 
  References Top

1.
Polzin DJ. Chronic kidney disease. In: Nephrology and Urology of Small Animals. West Sussex, UK: John Wiley & Sons, Ltd.; 2014. p. 431-71.  Back to cited text no. 1
    
2.
Levey AS, Coresh J. Chronic kidney disease. Lancet 2012;379:165-80.  Back to cited text no. 2
    
3.
Bilha SC, Nistor I, Nedelcu A, Kanbay M, Scripcariu V, Timofte D, et al. The effects of bariatric surgery on renal outcomes: A systematic review and meta-analysis. Obes Surg 2018;28:3815-33.  Back to cited text no. 3
    
4.
Li K, Zou J, Ye Z, Di J, Han X, Zhang H, et al. Effects of bariatric surgery on renal function in obese patients: A systematic review and meta analysis. PLoS One 2016;11:e0163907.  Back to cited text no. 4
    
5.
Wakamatsu K, Seki Y, Kasama K, Uno K, Hashimoto K, Seto Y, et al. Prevalence of chronic kidney disease in morbidly obese Japanese and the impact of bariatric surgery on disease progression. Obes Surg 2018;28:489-96.  Back to cited text no. 5
    
6.
Knight EL, Stampfer MJ, Hankinson SE, Spiegelman D, Curhan GC. The impact of protein intake on renal function decline in women with normal renal function or mild renal insufficiency. Ann Intern Med 2003;138:460-7.  Back to cited text no. 6
    
7.
Kang JG, Park CY. Anti-obesity drugs: A review about their effects and safety. Diabetes Metab J 2012;36:13-25.  Back to cited text no. 7
    




 

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