Roux‐en‐Y gastric bypass is an effective bridge to kidney transplantation: Results from a single center

Abstract

Body mass index (BMI) > 35-40 kg/m is often a contraindication, while Roux-en-Y gastric bypass (RYGB) is performed to enable kidney transplantation. This single-center retrospective study evaluated pre- and post-transplant outcomes of 31 morbidly obese patients with end-stage renal disease having RYGB before kidney transplantation between July 2009 and June 2014. Fourteen RYGB patients were subsequently transplanted. Nineteen recipients not having GB with a BMI ≥ 36 kg/m at transplantation were used as historical controls. Mean BMI (±SE) before RYGB was 43.5 ± 0.7 kg/m (range: 35.4-50.5 kg/m ); 87.1% (27/31) achieved a BMI < 35 kg/m . The percentage having improved diabetes/hypertension control was 29.0% (9/31); 25.8% (8/31) had complications (mostly minor) after RYGB. Among transplanted patients, blacks/Hispanics comprised 78.6% (11/14) and 84.2% (16/19) of RYGB and controls; 57.1% (8/14) and 63.2% (12/19) had a (mostly long-standing) pretransplant history of diabetes. While biopsy-proven acute rejection (BPAR) occurred significantly higher among RYGB vs control patients (6/14 vs 3/19, P = .03), patients developing T-cell BPAR were also significantly more likely to have a tacrolimus (TAC) trough level < 4.0 ng/mL within 3 weeks of T-cell BPAR (P = .0007). In Cox's model, the impact of having a TAC level < 4.0 ng/mg remained significant (P = .007) while the effect of RYGB was no longer significant (P = .13). Infections, graft, and patient survival were not significantly different. Despite obvious effectiveness in achieving weight loss, RYGB will need more careful post-transplant monitoring given the observed higher BPAR rate.

Metabolic Surgery to Treat Obesity in Diabetic Kidney Disease, Chronic Kidney Disease, and End-Stage Kidney Disease; What Are the Unanswered Questions?

“…Figure 3 outlines the potential roles of metabolic surgery in facilitating access to kidney transplantation and improving allograft outcomes in people with obesity and ESKD. Table 2 provides an overview of studies which have assessed the impact of metabolic surgery on transplant candidacy in people with advanced non-dialysis dependent CKD or ESKD (145)(146)(147)(148)(149)(150)(151)(152)(153)(154)(155)(156). Most studies were small, single-centre retrospective reviews, and without control groups.…”

“…However, reports to date are limited and further study is warranted to determine surgical and dialysis complication rates in this population. in the post-transplant period (148). The higher biopsy-proven acute rejection rate in RYGB-operated people associated with subtherapeutic tacrolimus trough levels (<4 ng/mL), although several RYGB-operated people were also non-compliant with immunosuppressive medications (148).…”

Preventive Nephrology: The Role of Obesity in Different Stages of Chronic Kidney Disease

“…Bariatric surgery might become an option for this group of patients (summary in Hossain et al [35]). While gastric banding is no longer the method of choice to reduce body weight and metabolic complications in the long term, newer techniques like sleeve gastrectomy and intestinal bypass procedures are increasingly performed [36,37]. In view of the limited data, it seems to be premature to advocate routine bariatric surgery for obese kidney recipients.…”

Impaired dexamethasone resorption in two patients with pseudo‐Cushing after bariatric surgery: Implications for immunosuppressive treatment

“…Roux‐en‐Y gastric bypass has for example been suggested prior to kidney transplantation to improve renal outcomes 9 . In a single centre study, in which patients with RYBG received a kidney transplant, the rate of acute rejection was significantly increased 10 . In case there is doubt about adequate resorption, we believe that in severe clinical cases intravenous application may be prioritized in individuals after gastric bypass until further evidence on oral bioavailability is available.…”