Bariatric Surgery Can Benefit Patients With End-Stage Renal Disease

By Marilynn Larkin

October 07, 2019

NEW YORK (Reuters Health) - Despite increased complication rates, patients with end-stage renal disease (ESRD) can benefit from bariatric surgery, including becoming eligible for transplant, researchers say.

"There has been hesitancy towards offering patients with ESRD bariatric surgery due to concerns of prohibitive risk of complications," Dr. Dana Telem of the University of Michigan in Ann Arbor told Reuters Health by email. "This study demonstrates the perioperative safety of bariatric surgery in this patient population. Consideration for bariatric referral, particularly for patients who are candidates for organ transplant, is recommended."

"There are two main issues here," she noted. "First, the obesity paradox, where data support a protective effect of obesity on renal disease. Thus, there may be hesitancy to refer patients for surgery to reduce obesity."

"Second is the stigma, in general against bariatric surgery and obesity," she said. "Education and information dissemination - particularly around the safety and efficacy of the operation and potential benefits for those who are candidates for transplant - are needed."

Dr. Telem and colleagues used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database to study patients who underwent primary laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between 2015 and 2017.

As reported online September 25 in JAMA Surgery, 1,244 had ESRD (median age, 49; 44% men; 43% black/African American) and 417,403 had normal kidney function (median age, 44; 20% men; 64% white).

Patients with ESRD were more likely to be older, male, of black race/ethnicity, fully or partially dependent, and have more medical comorbidities and lower preoperative hematocrit levels.

On multivariable analysis, ESRD was associated with higher rates of all primary outcomes, e.g., surgical complications, medical complications, unplanned reoperation, unplanned ICU stay, transfusion, and endoscopic intervention.

Differences in surgical complications were driven by increased rates of unplanned reoperation (3.1% vs. 1.1%;), endoscopic intervention (1.6% vs. 0.9%;), transfusion (1.5% vs. 0.7%), and sepsis (0.4% vs. 0.2%).

Differences in medical complications were driven by increased rates of unplanned ICU stays (1.5% vs. 0.7%) and pneumonia (0.6% vs. 0.2%).

Nonetheless, the absolute rate differences did not exceed 4% for any individual or composite outcome.

The authors conclude, "...the common misperception that patients with ESRD have prohibitively high perioperative risks to undergo bariatric surgery is not justified and should not preclude obese patients with ESRD from operative consideration."

The group's research comparing sleeve versus gastric bypass in this patient population is in press, Dr. Telem said.

Dr. Eduardo Grunvald, Medical Director, UC San Diego Weight Management Program, commented by email, "This is an observational analysis, which has limitations... However, as the authors noted, the absolute increased risk of complications was low."

"Another way to think about this problem is as follows," he told Reuters Health. "Patients with severe obesity are not candidates for kidney transplantation. Medical weight loss to the degree often needed in these patients is usually ineffective, so they do not have a lot of great options. We have treated many patients under these conditions in our center, and many have become active on the transplant list."


JAMA Surg 2019.