Bariatric Surgery for Morbid Obesity in End-Stage Renal Disease

The effective and long-term sustained outcomes of bariatric surgery in the general population have led many to consider bariatric surgery in morbidly obese patients with chronic kidney disease (CKD). As most transplant centers have strict criteria for listing patients based on BMI, patients with BMI > 35 become ineligible for transplant. Hence, most series on CKD includes these patients who were subjected to bariatric surgery. Bariatric surgery with its effect on weight reduction and reduction of comorbidities could help these patients become eligible and also improve associated comorbidities. In a small series by Koshy et al. three patients with end- stage renal disease (ESRD) underwent adjustable gastric banding (AGB) to qualify for renal transplantation. All underwent uncomplicated kidney transplantations. There was no change in post-operative renal function. All 3 had an excess weight loss ranging from 35 to 41 %, at 12 and 15 months with resolution of co-morbidities later meeting the BMI criterion for transplantation allowing for renal transplantation. Long -term success was however not assessed [6]. In another series by Newcomb et al. three patients with end stage renal disease (ESRD) underwent AGB to qualify for renal transplantation. All underwent uncomplicated kidney transplantations. All lost weight at follow-up, meeting the BMI criterion for transplantation allowing for renal transplantation to proceed and in addition had resolution/improve- ment of obesity related co-morbidities with stable renal function. Again this series did not report long -term success [7]. In a series by Alexander et al. 30 morbidly obese patients with chronic renal failure/post-transplantation underwent gastric bypass. 19 patients had CRF at the time of Roux en Y gastric bypass (RYGB), eight had transplantation followed by RYGB, and three had RYGB and then transplantation. The reduction in excess BMI and resolution of co-morbid conditions was similar to patients without transplantation or chronic renal failure. The only perioperative complication among the group was a wound separation. No patients required blood transfusions in the perioperative period. One patient died 7.9 years after a RYGB and 6.1 years after transplantation from cardiovascular disease related to longstanding diabetes [8]. Takata et al. reported 7 morbidly obese patients with ESRD needing transplantation who underwent RYGB without morbidity and mortality with a mean percentage of excess weight loss at >9 months of 61 % with improvement or resolution obesity-associated co-morbidities in all patients. All eventually qualified for renal transplantation [9]. In a recent series by Lin et al. six pre-transplant patients with end-stage renal disease underwent sleeve gastrectomy (SG). All patients met the institution’s BMI cutoffs for transplantation by 12 months after the procedure. There were no deaths, and there was 1 temporary renal insufficiency. The mean percentage of excess weight loss was 50 % at 1 year. One patient’s renal function stabilized, and he was taken off the transplant list. One patient received a combined liver and kidney transplant and 1 received a kidney transplant [10].

Thus a SG or a RYGB can be performed safely in patients with CKD/ESRD. Also the risk of worsening renal function in the post-operative period is low with low morbidity. They achieve excellent weight loss and improvement in obesity-related co-morbidities with improved candidacy for renal transplantation.