| Abstract|| |
Obesity is an important risk factor for chronic kidney disease. Bariatric surgery (BS) may improve long-term kidney outcomes, but there is no agreement regarding the benefit and timing of BS in patients with end-stage renal disease. We present a 46-year-old male patient with type 2 diabetes mellitus, in hemodialysis (HD), and with a body mass index (BMI) of 39.79 kg/m2, who was submitted to laparoscopic one-anastomosis gastric bypass surgery. Eight months after surgery, and after a 40-kg weight loss, the patient showed signs of kidney function improvement and HD was discontinued. At this moment, one year after, the patient has an estimated glomerular filtration rate of 21.2 mL/min/1.73 m2 and a BMI of 25.61 kg/m2. To our knowledge, this case report seems to be the first one to talk about a HD patient that improved kidney function enough to stop dialysis.
|How to cite this article:|
Alves RV, Gonçalves H, Santos P, Lobos AV. Bariatric surgery and hemodialysis: A case report of a patient with less 40 kilograms and without dialysis. Saudi J Kidney Dis Transpl 2021;32:1485-8
|How to cite this URL:|
Alves RV, Gonçalves H, Santos P, Lobos AV. Bariatric surgery and hemodialysis: A case report of a patient with less 40 kilograms and without dialysis. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 Jun 28];32:1485-8. Available from: https://www.sjkdt.org/text.asp?2021/32/5/1485/344774
| Introduction|| |
There is evidence of a direct causal connection between a high body mass index (BMI) and chronic kidney disease (CKD), with more rapid progression to end-stage renal disease (ESRD) caused by the underlying renal hyperfiltration. This condition is termed obesity-related glomerulopathy.
Over the years, bariatric surgery (BS) has become an effective alternative to achieve a significant weight reduction. However, data regarding the impact and safety of BS in patients with CKD are lacking.
BS lowers glycated hemoglobin and fasting glucose, reduces the number of diabetes medicines, and improves diabetes mellitus (DM) remission rates in patients with type 2 DM much more than intensive medical therapy.
| Case Report|| |
We present a 46-year-old male patient with type 2 DM since he was 18 years old, with macro- and microvascular complications (peripheral neuropathy with left limb amputation, diabetic retinopathy, and diabetic nephropathy), obesity (BMI: 39.79 kg/m2–115 kg), obstructive sleep apnea, arterial hypertension, dyslipidemia, and sarcoidosis.
The patient was followed in nephrology since 2010 and at this time presented plasmatic creatinine (pCr) of 2.1 mg/dL [estimated glomerular filtration rate (eGFR): 39.3 mL/min/1.73 m2] with urinary 24-h protein of 3 g. The etiological investigation was innocent and diabetic nephropathy was assumed as CKD etiology. The patient started hemodialysis (HD) in September 2016. He maintained residual diuresis around 1.5 L.
Behavioral and nutritional measures were not sufficient for an adequate weight control, thus to allow access to a kidney transplant, a surgical approach was decided. A laparoscopic one-anastomosis gastric bypass surgery was performed in June 2018. There were not early or late postoperative complications.
On the initial dialysis sessions after surgery, due to rapid weight loss, the patient displayed cramps, dehydration, and hypotension, which required several adjustments of dry weight, almost every session at first, and weekly thereafter, in order to better define the optimal ultrafiltration rate and symptom resolution.
The patient achieved a BMI of 27.89 kg/m2 (80.6 kg), adequate blood pressure control, progressively reduced the insulin dose until total discontinuation, and reduced severity of sleep apnea.
The patient showed signs of renal function recovery, and on March 16, 2019, HD was discontinued. Since that time, the patient maintains regular follow-up in nephrology. The last laboratory results presented pCr of 3.3 mg/dL (eGFR: 21.2 mL/min/1.73 m2) and urea of 135 mg/dL and a BMI of 25.61 kg/m2 (74 kg). The patient is completing the evaluation procedures to access the kidney transplant active waiting list.
The authors obtained all appropriate consent forms from the patient for the publication of this case report.
| Discussion|| |
Obesity has been established as a barrier to access to transplantation of patients with ESRD. After having discussed eligibility and the waiting list, a complete evaluation of the extra burden faced by obese patients in need of a kidney transplant cannot avoid analysis of specific challenges. Transplant candidates with high BMI present anatomy and physiologic challenges, both in terms of surgical and medical management during and after the transplant.
The optimal management of obese and morbidly obese patients in need of a kidney transplant is largely controversial and unclear, and no guidelines have yet been developed to provide evidence-based indications.
Laparoscopic sleeve gastrectomy is an effective method of treatment for morbid obesity, especially in cases meeting criteria for metabolic syndrome, which provides a significant positive clinical outcome in obesity-related comorbidities. This also induces positive changes in biochemical markers, such as creatinine, that might be considered a good prognostic factor in the assessment of kidney function., However, the effect of gastric bypass in the treatment of CKD is unclear.
Another significant benefit of BS is the control of obesity-related comorbidities, most importantly DM, that has a major effect on overall patient survival.
In patients with CKD, the association between obesity, morbidity, and mortality is complex: the identification of obese patients who may profit from weight loss in this population is difficult., Clinicians must weigh the increased risks against the substantial benefits of surgically induced weight loss when counseling patients with CKD about BS.
In stable dialysis-dependent patients, who are not eligible for transplantation for other reasons, benefits of weight loss need to be individually assessed based on the patient’s comorbid conditions and nutritional status.
There are limiting factors in proposing weight loss to dialyzed patients. These patients frequently suffer from decreased exercise capacity and poor physical function. Second, calorie restriction, if not correctly prescribed and supervised, may be accompanied by insufficient protein intake, exposing the patients to protein–energy wasting. Lifestyle modifications are particularly challenging for obese patients treated by dialysis.
Lin et al demonstrated the beneficial effect of BS on the eGFR in obese patients at risk of CKD. BS improved the patient’s renal function, and the effect lasted for more than one year.
Schindel et al demonstrated an improvement in renal function among the patients in the BS group, while the patients in the control group experienced a worsening of their renal function.
A standard strategy when treating CKD is to target each risk factor individually. An alternative strategy appropriate for many patients that is not as commonly employed is to address them all by attacking the root cause–namely obesity– through a weight reduction intervention. Of all available weight reduction techniques, BS offers the largest and most durable effect. Ideally, any treatment of obesity should be initiated as early as possible before transplantation.
As the number of obese people in the general population is set to continue to increase, nephrologists and transplant surgeons need to be prepared to deal with the dilemma of managing obese renal patients more frequently.
Weight loss is an important treatment, however, that is even more complicated in dialysis population. Our patient presented decreased exercise capacity due to obesity but also due to the amputated limb, which were two important limiting factors to weight loss. This case report showed us that it should not be used only as bridge for transplantation but also as a tool for the partial recovery of renal function. It is important that the nephrologists have in mind that we need to insist on the patients to lose weight, even on those that will not be candidates for transplantation. An early referral to BS during the early stages of CKD could be beneficial to the patient and cost-effective, since we could delay or even stop the progression to ESRD.
Our patient didn’t have a kidney biopsy that confirmed the presumed kidney disease etiology. We admit that the lack of a kidney biopsy can be interpreted as a limitation of our case report since we did not document the histopathologic changes of the kidney.
To our knowledge, this case report seems to be the first one to talk about a HD patient that improved kidney function enough to stop dialysis.
Conflict of interest: None declared.
| References|| |
Câmara NO, Iseki K, Kramer H, Liu ZH, Sharma K. Kidney disease and obesity: Epidemiology, mechanisms and treatment. Nat Rev Nephrol 2017;13:181-90.
McIsaac M, Kaban G, Clay A, Berry W, Prasad B. Long-term impact of bariatric surgery on renal outcomes at a community-based publicly funded bariatric program: The Regina Bariatric Study. Can J Kidney Health Dis 2019;6: 2054358119884903.
Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes – 5-year outcomes. N Engl J Med 2017;376:641-51.
Kassam AF, Mirza A, Kim Y, et al. Long-term outcomes in patients with obesity and renal disease after sleeve gastrectomy. Am J Transplant 2020;20:422-9.
Bellini MI, Paoletti F, Herbert PE. Obesity and bariatric intervention in patients with chronic renal disease. J Int Med Res 2019;47:2326-41.
Wojciak PA, Pawluszewicz P, Diemieszczyk I, et al. Laparoscopic sleeve gastrectomy: A study of efficiency in treatment of metabolic syndrome components, comorbidities and influence on certain biochemical markers. WideochirInne Tech Maloinwazyjne 2020;15:136-47.
Bilha SC, Nistor I, Nedelcu A, et al. The effects of bariatric surgery on renal outcomes: A systematic review and meta-analysis. Obes Surg 2018;28:3815-33.
Alexander JW, Goodman HR, Hawver LR, Cardi MA. Improvement and stabilization of chronic kidney disease after gastric bypass. Surg Obes Relat Dis 2009;5:237-41.
Schindel H, Winkler J, Yemini R, Carmeli I, Nesher E, Keidar A. Survival benefit in bariatric surgery kidney recipients may be mediated through effects on kidney graft function and improvement of co-morbidities: A case-control study. Surg Obes Relat Dis 2019;15:621-7.
Teta D. Weight loss in obese patients with chronic kidney disease: Who and how? J Ren Care 2010;36 Suppl 1:163-71.
Turgeon NA, Perez S, Mondestin M, et al. The impact of renal function on outcomes of bariatric surgery. J Am Soc Nephrol 2012;23:885-94.
Lin YC, Lai YJ, Lin YC, et al. Effect of weight loss on the estimated glomerular filtration rates of obese patients at risk of chronic kidney disease: The RIGOR-TMU study. J Cachexia Sarcopenia Muscle 2019;10:756-66.
Friedman AN, Cohen RV. Bariatric surgery as a renoprotective intervention. Curr Opin Nephrol Hypertens2 019;28:537-44.
Camilleri B, Bridson JM, Sharma A, Halawa A. From chronic kidney disease to kidney transplantation: The impact of obesity and its treatment modalities. Transplant Rev (Orlando) 2016;30:203-11.
Rita Valério Alves
Department of Nephrology, Centro Hospitalar MédioTejo, Torres Novas
Source of Support: None, Conflict of Interest: None