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Introduction:
According to the Chronic Kidney Disease Prognosis Consortium (CKD-PC), 1 in 4 patients age ≥ 65 in North America has some form of chronic kidney disease (CKD), while 3 in 100 will progress to kidney failure. The aim of this study was to evaluate whether bariatric surgery alters the progression of CKD to kidney failure in patients who...
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Context 1
... the preoperative (5.68%) and postoperative (1.71%) risk of kidney failure in this population, the ARR and RRR were 4.0% and 68.7% at 2 years, and 5.8% and 60.5% at 5 years (Figs. 1 and 2). When further subdivided into stage A2 versus A3 (Table 5), once again statistically significant and clinically marked reductions in uACR were evident, with 98.8 and 96.6% RRRs in 2-and 5-year risk estimates, respectively, among the 27 stage A2 patients (P ¼ 0.04 and 0.03), and corresponding RRRs of 66.6 and 54.3% (both P ¼ 0.04) in the 10 stage A3 patients. When assessing the changes in eGFR and uACR in patients with stage A1 (<30 mg/g) of albuminuria and CKD-EPI stage 1 (>90 mL/min/1.73 ...Similar publications
Background:
Glycemic variability is associated with higher risk of microvascular complications in patients with type 2 diabetes.
Aim:
To test the hypothesis that glycemic variability can contribute to progression to macroalbuminuria in normal or microalbuminuria in patients with type 2 diabetes.
Design:
This prospective study enrolled 193 pati...
Background: Data on the association between suicide and kidney function in the general population are scarce. This study evaluated albuminuria across suicidal ideation in Korean adults.
Methods: We performed a cross-sectional study using data from the 2011 to 2013 Korean National Health and Nutrition Examination Survey. Overall, 14,101 adults were...
Objectives
To analyze the associations of serum uric acid (SUA) level with diabetic microvascular complications, including diabetic retinopathy (DR) and diabetic nephropathy (DN), in patients with type 2 diabetes mellitus (DM).
Methods
Three hundred eighty-nine inpatients with type 2 DM were included in this retrospective analysis. Nonmydriatic fu...
Citations
... Bariatric surgery and its metabolic effect has been described as an effective treatment for obesity resulting not only in significant weight loss, but also improvement and resolution of serious diseases [2,3]. ...
... Our previous work demonstrated a significant improvement in kidney function and a regression of glomerular injury in patients with obesity following metabolic surgery. Our findings suggested that bariatric surgery halts the progression of chronic kidney disease to kidney failure [3]. However, the effects of weight loss following bariatric interventions in patients with obesity and non-associated renal diseases have been poorly evaluated. ...
Background:
Acute kidney injury (AKI) after surgery increases long-term risk of kidney dysfunction. The major risk factor for AKI after bariatric surgery is having preoperative renal insufficiency. Little is known about the outcomes and risk factors for developing AKI in patients undergoing bariatric surgery with normal renal function.
Objective:
We aimed to describe factors that may increase risk of AKI after primary bariatric surgery in patients without history of kidney disease.
Setting:
Academic hospital, United States.
Methods:
We performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry for patients aged ≥18 years undergoing laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2015 to 2019. Patients with diagnosis of chronic kidney disease were excluded. The primary outcome was incidence of AKI. Secondary outcomes included 30-day complications, readmissions, reoperations, and mortality. Univariate and multivariate analyses were performed to identify differences between patients with and without AKI.
Results:
A total of 747,926 patients were included in our analysis (laparoscopic sleeve gastrectomy = 73.1%, LRYGB = 26.8%). Mean age was 44.40 ± 11.94 years, with female predominance (79.7%). AKI occurred in 446 patients (.05%). Patients with postoperative AKI had higher rates of complications, readmissions, reoperations, and mortality. Significant predictors of AKI were male sex, history of venous thromboembolism, hypertension, limitation for ambulation, and LRYGB. High albumin levels and White race were protective factors.
Conclusions:
New-onset AKI was associated with adverse 30-day outcomes in patients undergoing bariatric surgery. Male sex, venous thromboembolism, hypertension, limited ambulation, and LRYGB were independent predictors of AKI. Prospective studies are needed to better describe these results.
... After the one-year follow up, in 54% of patients with moderately or severely increased albuminuria, the median urinary albumin to creatinine ratio (uACR) decreased from 80 to 46 mg/g. In 29% of individuals with CKD stage ≥ 3, the median uACR decreased from 66.5 to 47 mg/g at one year, and the relative risk of progression to ESKD was reduced by 70% at 2 years and by 60% at 5 years [51]. ...
Obesity represents an independent risk factor for the development of chronic kidney disease (CKD), leading to specific histopathological alterations, known as obesity-related glomerulopathy. Bariatric surgery is the most effective means of inducing and maintaining sustained weight loss. Furthermore, in the context of bariatric-surgery-induced weight loss, a reduction in the proinflammatory state and an improvement in the adipokine profile occur, which may also contribute to the improvement of renal function following bariatric surgery. However, the assessment of renal function in the context of obesity and following marked weight loss is difficult, since the formulas adopted to estimate glomerular function use biomarkers whose production is dependent on muscle mass (creatinine) or adipose tissue mass and inflammation (cystatin-c). Thus, following bariatric surgery, the extent to which reductions in plasma concentrations reflect the actual improvement in renal function is not clear. Despite this limitation, the available literature suggests that in patients with hyperfiltration at baseline, GFR is reduced following bariatric surgery, whereas GFR is increased in patients with decreased GFR at baseline. These findings are also confirmed in the few studies that have used measured rather than estimated GFR. Albuminuria is also decreased following bariatric surgery. Moreover, bariatric surgery seems superior in achieving the remission of albuminuria and early CKD than the best medical treatment. In this article, we discuss the pathophysiology of renal complications in obesity, review the mechanisms through which weight loss induces improvements in renal function, and provide an overview of the renal outcomes following bariatric surgery.
... In nondiabetic subjects, randomized studies are not available, but many observational studies have demonstrated the beneficial impact in reducing incidence of albuminuria and the risk for ESKD after an 18 year follow-up [107]. In CKD patients, at the end of the first year post-surgery [108] and after 7 years of follow-up, improvement in the categories of CKD were observed in around half of the patients, and even in patients with very high risk at baseline a quarter of them improved [109]. ...
The clinical consequences of obesity on the kidneys, with or without metabolic abnormalities, involve both renal function and structures. The mechanisms linking obesity and renal damage are well understood, including several effector mechanisms with interconnected pathways. Higher prevalence of urinary albumin excretion, sub-nephrotic syndrome, nephrolithiasis, increased risk of developing CKD, and progression to ESKD have been identified as being associated with obesity and having a relevant clinical impact. Moreover, renal replacement therapy and kidney transplantation are also influenced by obesity. Losing weight is key in limiting the impact that obesity produces on the kidneys by reducing albuminuria/proteinuria, declining rate of eGFR deterioration, delaying the development of CKD and ESKD, and improving the outcome of a renal transplant. Weight reduction may also contribute to appropriate control of cardiometabolic risk factors such as hypertension, metabolic syndrome, diabetes, and dyslipidemia which may be protective not only in renal damage but also cardiovascular disease. Lifestyle changes, some drugs, and bariatric surgery have demonstrated the benefits.
... LSG (13 studies), RYGB (12 studies), LAGB (7 studies), and DS (1 studies) [26] were conducted in these studies. In ten studies [24,25,37,[29][30][31][32][33][34][35][36], CKD stage at baseline was provided for 2083 patients of which 232 had CKD stage 3 or above. In the five studies that compared surgery to non-surgical management of obesity in patients with CKD, there were 3304 patients with CKD that received bariatric surgery and 6539 with CKD that did not receive bariatric surgery [22][23][24][25][26]. ...
... Kidney function was primarily assessed via change in CKD stage and change in eGFR as described in Table 2. The definitions used for CKD in each study is provided in supplementary table 2. Seven studies were eligible for inclusion of analysis of change in eGFR, with initial eGFR <60 mL/min/1.73m 2 [25,28,30,33,36, 37]. ...
... I 2 =0%) as shown in Figure 2B [28,30,36]. Change in CKD stage was identified in three studies; 45 patients were classified as stage 3 or above CKD prior to bariatric surgery [31][32][33]. Following surgery, 12 of those patients had improvements of kidney function corresponding to a CKD stage below 3, and only 33 remained at stage 3 (RR 1.31; 95%CI 0.83 to 2.07; P=0.001; ...
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. This article is protected by copyright. All rights reserved.
... The benefits of bariatric surgery in patients with CKD are likely to outweigh the risks associated with the procedures [24], but intervening earlier in the natural history of the disease is recommended [25]. CKD does not appear to play a major role in short-term complications after bariatric surgery. ...
Background
Twenty percent of patients with CKD in the United States have a body mass index (BMI) ≥35 kg/m ² . Bariatric surgery reduces progression of CKD to ESKD, but the risk of perioperative complications remains a concern.
Methods
The 24-month data spanning 2017–2018 were obtained from the Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) database and analyzed. Surgical complications were assessed on the basis of the length of hospital stay, mortality, reoperation, readmission, surgical site infection (SSI), and worsening of kidney function during the first 30 days after surgery.
Results
The 277,948 patients who had primary bariatric procedures were 44±11.9 (mean ± SD) years old, 79.6% were women, and 71.2% were White. Mean BMI was 45.7±7.6 kg/m ² . Compared with patients with an eGFR≥90 ml/min per BSA, those with stage 5 CKD/ESKD were 1.91 times more likely to be readmitted within 30 days of a bariatric procedure (95% CI, 1.37 to 2.67; P <0.001). Similarly, length of hospital stay beyond 2 days was 2.05-fold (95% CI, 1.64 to 2.56; P <0.001) higher and risk of deep incisional SSI was 6.92-fold (95% CI, 1.62 to 29.52; P =0.009) higher for those with stage 5 CKD/ESKD. Risk of early postoperative mortality increased with declining preoperative eGFR, such that patients with stage 3b CKD were 3.27 (95% CI, 1.82 to 5.89; P <0.001) times more likely to die compared with those with normal kidney function. However, absolute mortality rates remained relatively low at 0.53% in those with stage 3b CKD. Furthermore, absolute mortality rates were <0.5% in those with stages 4 and 5 CKD, and these advanced CKD stages were not independently associated with an increased risk of early postoperative mortality.
Conclusions
Increased severity of kidney disease was associated with increased complications after bariatric surgery. However, even for the population with advanced CKD, the absolute rates of postoperative complications were low. The mounting evidence for bariatric surgery as a renoprotective intervention in people with and without established kidney disease suggests that bariatric surgery should be considered a safe and effective option for patients with CKD.
... Likewise, a prospective study analyzing 50 morbidly obese patients over 40 years of age that underwent SG revealed significant improvements of estimated GFR (62.5 mL/min/ m 2 preoperatively versus 77 mL/min/m 2 postoperatively) and serum creatinine (.9 mg/dL versus .7 mg/dL, respectively) at the 12-month follow-up [25]. Furthermore, a previous study from our team showed marked 2-and 5-year risk reductions in the progression from CKD to kidney failure after bariatric surgery [26]. ...
Background
Sleeve gastrectomy (SG) has become the most prevalent bariatric-metabolic surgical approach in the United States. Its popularity among surgeons and patients is mainly due to a better safety profile and less overall morbidity, with broad benefits from a systemic and metabolic perspective.
Objective
Comprehensively describe the short-term multiorgan metabolic effects of rapid weight loss after SG.
Setting
Academic hospital, United States.
Methods
We retrospectively reviewed the charts of patients that underwent SG at our institution between 2012 and 2016. We analyzed the required variables to calculate multiple risk scores, such as cardiovascular, hypertension, and diabetes risk scores. Furthermore, the renal and hepatic functions and the metabolic and hematologic profiles were assessed at 12 months of follow-up.
Results
A total of 1002 patients were included in the analysis. The percentage of excess body mass index loss was, on average, 65% at 12 months of follow-up. We observed a positive cardio-renal-hepatic improvement, demonstrated by a substantial reduction of the 10-year cardiovascular risk. We noticed an improvement of renal function, which was more significant in chronic kidney disease (stage ≥2), and a significant improvement on liver function tests (measured by decreased aspartate aminotransferase and alanine transaminase) at 12 months of follow-up. Our data also show a positive impact on decreasing the risk of developing hypertension and type 2 diabetes. There was a positive impact on the lipid profile, with the exception of low-density lipoprotein.
Conclusion
There are significant short-term benefits on multiorgan metabolic parameters after rapid weight loss in severely obese patients undergoing sleeve gastrectomy.
... Romero-Funes et al. studied changes in CKD-EPI creatinine eGFR, albuminuria, and kidney failure risk before and at 12 months after metabolic surgery in n = 69 people (VSG 61%, RYGB 39%; 93% diabetes) at Cleveland Clinic, Florida, United States (82). In n = 20 (29%) people with CKD stage 3 or greater, uACR decreased from 66.5 [35.1-465.4] to 47 [25.1-66] mg/g at 12-month follow-up. ...
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.
... To begin with, all of our patients were obese, and the majority were morbidly obese, and obesity, in itself, has been shown to cause chronic kidney disease that could have altered the kidneys' ability to concentrate urine. 24 In addition, the vast majority of our patients had diabetes mellitus, and their serum glucose levels may have spiked during the stress of surgery, causing urine to dilute. Another potential explanation is fluid overload from anesthesia upon induction. ...
Background:
Abdominal compartment syndrome has been linked to detrimental hemodynamic side effects that include increased intracranial pressure and diminished renal function, but the mechanisms behind this continue to be elucidated. In this study, we sought to investigate any direct association between acute elevations in intra-abdominal pressure and intracranial hypertension during experimentally induced abdominal compartment syndrome and between acutely elevated intracranial pressure and the hemodynamic response that might be elicited by a vasopressin-induced Cushing reflex affecting urine osmolality and urine output. The aim of this study is to explain the Cushing reflex and the vasopressin-mediated hemodynamic response to intracranial pressure during acute elevations in intra-abdominal pressure.
Methods:
We measured intra-abdominal pressure, intrathoracic pressure, optic nerve sheath diameter as an indirect sign of intracranial pressure, vasopressin levels in blood, urine osmolality, and urine output at 4 time points during surgery in 16 patients undergoing sleeve gastrectomy for morbid obesity. Values for the 4 time points were compared by repeated-measures analysis of variance.
Results:
More than 50-fold elevations in serum vasopressin paralleled increases in optic nerve sheath diameter, rising throughout prepneumoperitoneum and tapering off afterward, in conjunction with a marked decrease in urine but not serum osmolality. Mean arterial pressure rose transiently during pneumoperitoneum without elevated positive end-expiratory pressure but was not significantly elevated thereafter.
Conclusions:
These findings support our hypothesis that the oliguric response observed in abdominal compartment syndrome might be the result of the acutely elevated intra-abdominal pressure triggering increased intrathoracic pressure, decreased venous outflow from the central nervous system, increased intracranial pressure, and resultant vasopressin release via a Cushing reflex.
Bariatric surgery in people with obesity can lead to long-term remission of type 2 diabetes mellitus (T2DM) and a reduction in the incidence of macrovascular complications. The impact of bariatric surgery on microvascular complications is less clear. In this narrative review, we sought to evaluate the effect of bariatric surgery on microvascular complications in patients with and without diabetes. The risk of developing microvascular complications is increased in people with obesity, and this is amplified in those with T2DM. The impact of metabolic surgery on microvascular complications is limited to a subgroup analysis of studies or statistical modeling to predict the glycemia-independent effect of bariatric surgery. While bariatric surgery halts the progression of retinopathy in those with minimal retinopathy, it may worsen in those with advanced retinopathy. Bariatric surgery improves proteinuria and major renal outcomes, regardless of the severity of renal impairment. Bariatric surgery in patients with obesity with or without diabetes is associated with an improvement in neuropathic symptoms and regeneration of small nerve fibers. In conclusion, bariatric surgery is associated with an improvement in microvascular complications. Further studies are needed to elucidate the underlying mechanisms for the favorable effect of bariatric surgery on microvascular outcomes.
