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• W2581895415 abstract "The prevalence of severe obesity in both the general and the chronic kidney disease (CKD) populations continues to rise, with more than one-fifth of CKD patients in the United States having a body mass index of ≥35 kg/m2. Severe obesity has significant renal consequences, including increased risk of end-stage renal disease (ESRD) and nephrolithiasis. Bariatric surgery represents an effective method for achieving sustained weight loss, and evidence from randomized controlled trials suggests that bariatric surgery is also effective in improving blood pressure, reducing hyperglycemia, and even inducing diabetes remission. There is also observational evidence suggesting that bariatric surgery may diminish the long-term risk of kidney function decline and ESRD. Bariatric surgery appears to be relatively safe in patients with CKD, with postoperative complications only slightly higher than in the general bariatric surgery population. The use of bariatric surgery in patients with CKD might help prevent progression to ESRD or enable selected ESRD patients with severe obesity to become candidates for kidney transplantation. However, there are also renal risks in bariatric surgery, namely, acute kidney injury, nephrolithiasis, and, in rare cases, oxalate nephropathy, particularly in types of surgery involving higher degrees of malabsorption. Although bariatric surgery may improve long-term kidney outcomes, this potential benefit remains unproved and must be balanced with potential adverse events. The prevalence of severe obesity in both the general and the chronic kidney disease (CKD) populations continues to rise, with more than one-fifth of CKD patients in the United States having a body mass index of ≥35 kg/m2. Severe obesity has significant renal consequences, including increased risk of end-stage renal disease (ESRD) and nephrolithiasis. Bariatric surgery represents an effective method for achieving sustained weight loss, and evidence from randomized controlled trials suggests that bariatric surgery is also effective in improving blood pressure, reducing hyperglycemia, and even inducing diabetes remission. There is also observational evidence suggesting that bariatric surgery may diminish the long-term risk of kidney function decline and ESRD. Bariatric surgery appears to be relatively safe in patients with CKD, with postoperative complications only slightly higher than in the general bariatric surgery population. The use of bariatric surgery in patients with CKD might help prevent progression to ESRD or enable selected ESRD patients with severe obesity to become candidates for kidney transplantation. However, there are also renal risks in bariatric surgery, namely, acute kidney injury, nephrolithiasis, and, in rare cases, oxalate nephropathy, particularly in types of surgery involving higher degrees of malabsorption. Although bariatric surgery may improve long-term kidney outcomes, this potential benefit remains unproved and must be balanced with potential adverse events. Worldwide, the prevalence of obesity (body mass index [BMI] ≥ 30 kg/m2) in the general population has risen dramatically over the past few decades; this trend is paralleled in the chronic kidney disease (CKD) population.1Ng M. Fleming T. Robinson M. et al.Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013.Lancet. 2014; 384 (Erratum in: Lancet. 2014;384(9945):746): 766-881Abstract Full Text Full Text PDF PubMed Scopus (8055) Google Scholar, 2Chang A.R. Appel L.J. Grams M.E. Abstract MP95: Prevalence of general and abdominal obesity in adults with chronic kidney disease: results from NHANES 2007-2012.Circulation. 2015; 131: AMP95Google Scholar Among adults with CKD in the United States, for example, the prevalence of obesity increased from 38.1% in 1999 to 2002 to 44.1% in 2011 to 2014 (P = 0.004 for linear trend) (Figure 1).2Chang A.R. Appel L.J. Grams M.E. Abstract MP95: Prevalence of general and abdominal obesity in adults with chronic kidney disease: results from NHANES 2007-2012.Circulation. 2015; 131: AMP95Google Scholar The increase in obesity prevalence occurred primarily in World Health Organization (WHO) class II and III obesity3World Health OrganizationObesity: preventing and managing the global epidemic. Report of a WHO consultation.World Health Organ Tech Rep Ser. 2000; 894: 1-253Google Scholar (BMI ≥ 35 and ≥ 40 kg/m2, respectively), which increased from 17.2% in 1999 to 2002 to 22.2% in 2011 to 2014 (P = 0.01 for linear trend). An increasing prevalence of obesity in the CKD population is of particular concern due to evidence of associations between higher BMI and adverse renal outcomes. In observational studies, obesity has been associated with higher risk of incident CKD and end-stage renal disease (ESRD), as well as nephrolithiasis and renal cell cancer.4Wang Y. Chen X. Song Y. et al.Association between obesity and kidney disease: a systematic review and meta-analysis.Kidney Int. 2008; 73: 19-33Abstract Full Text Full Text PDF PubMed Scopus (443) Google Scholar, 5Hsu C.Y. McCulloch C.E. Iribarren C. et al.Body mass index and risk for end-stage renal disease.Ann Intern Med. 2006; 144: 21-28Crossref PubMed Scopus (1031) Google Scholar, 6Vivante A. Golan E. Tzur D. et al.Body mass index in 1.2 million adolescents and risk for end-stage renal disease.Arch Intern Med. 2012; 172: 1644-1650Crossref PubMed Scopus (193) Google Scholar, 7Fox C.S. Larson M.G. Leip E.P. et al.Predictors of new-onset kidney disease in a community-based population.JAMA. 2004; 291: 844-850Crossref PubMed Scopus (981) Google Scholar Potential mechanisms explaining the increased risk for CKD and ESRD include obesity-mediated hypertension, insulin resistance, glomerular hyperfiltration, activation of the renin−angiotensin−aldosterone system, inflammation, and adipocytokine dysregulation.8Bagby S.P. Obesity-initiated metabolic syndrome and the kidney: a recipe for chronic kidney disease?.J Am Soc Nephrol. 2004; 15: 2775-2791Crossref PubMed Scopus (224) Google Scholar, 9Griffin K.A. Kramer H. Bidani A.K. Adverse renal consequences of obesity.Am J Physiol Renal Physiol. 2008; 294: F685-F696Crossref PubMed Scopus (190) Google Scholar On the other hand, the risk associated with obesity may be reversible: a randomized controlled trial of patients with type 2 diabetes demonstrated that weight loss decreased the risk of adverse CKD outcomes.10Look AHEAD Research GroupEffect of a long-term behavioural weight loss intervention on nephropathy in overweight or obese adults with type 2 diabetes: a secondary analysis of the Look AHEAD randomised clinical trial.Lancet Diabetes Endocrinol. 2014; 2: 801-809Abstract Full Text Full Text PDF PubMed Scopus (194) Google Scholar However, achieving sustained weight loss through lifestyle modification is challenging. Bariatric surgery is a proven, effective method for sustained weight loss and is becoming more commonplace for patients with morbid or severe obesity. Consensus guidelines from a National Institutes of Health (NIH) conference include BMI ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with obesity-related comorbidity as approved clinical indications for bariatric surgery.11Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement.Am J Clin Nutr. 1992; 55: 615S-619SPubMed Google Scholar As a significant proportion of patients with CKD may qualify for bariatric surgery, it is increasingly important to understand the potential benefits and risks of bariatric surgery in regard to kidney function and other outcomes. Contemporary bariatric surgery techniques are very effective in achieving sustained weight loss, with total weight loss averaging 20% to 35% of total body weight.12O'Brien P.E. McPhail T. Chaston T.B. Dixon J.B. Systematic review of medium-term weight loss after bariatric operations.Obes Surg. 2006; 16: 1032-1040Crossref PubMed Scopus (377) Google Scholar, 13Brethauer S.A. Hammel J.P. Schauer P.R. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure.Surg Obes Relat Dis. 2009; 5: 469-475Abstract Full Text Full Text PDF PubMed Scopus (395) Google Scholar Several surgical procedures to promote weight loss have been developed over the past few decades. These procedures vary in terms of the amount of gastric surface area restriction, intended nutrient malabsorption, effects on gastrointestinal hormones, weight loss outcomes, and risk of complications (Table 1).14Miras A.D. le Roux C.W. Mechanisms underlying weight loss after bariatric surgery.Nat Rev Gastroenterol Hepatol. 2013; 10: 575-584Crossref PubMed Scopus (206) Google Scholar Initial efforts in bariatric surgery started in the 1970s with the jejunoileal bypass, which was a purely malabsorptive procedure, bypassing most of the small intestine.15Requarth J.A. Burchard K.W. Colacchio T.A. et al.Long-term morbidity following jejunoileal bypass. The continuing potential need for surgical reversal.Arch Surg. 1995; 130: 318-325Crossref PubMed Scopus (128) Google Scholar The jejunoileal bypass has since been abandoned due to the high rate of complications, which included deficiency of fat-soluble vitamins, bacterial overgrowth, calcium oxalate nephrolithiasis, and kidney and liver failure.Table 1Comparison of the most common surgical procedures for weight lossAdapted from previously published literature.14Miras A.D. le Roux C.W. Mechanisms underlying weight loss after bariatric surgery.Nat Rev Gastroenterol Hepatol. 2013; 10: 575-584Crossref PubMed Scopus (206) Google Scholar, 74Li J.F. Lai D.D. Ni B. Sun K.X. Comparison of laparoscopic Roux-en-Y gastric bypass with laparoscopic sleeve gastrectomy for morbid obesity or type 2 diabetes mellitus: a meta-analysis of randomized controlled trials.Can J Surg. 2013; 56: E158-E164Crossref PubMed Scopus (80) Google Scholar, 75Tice J.A. Karliner L. Walsh J. et al.Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures.Am J Med. 2008; 121: 885-893Abstract Full Text Full Text PDF PubMed Scopus (353) Google ScholarRYGBLSGLAGBWeight lossHighestModerateLowestGastric emptying↑ or ↓↑No changePlasma GLP-1 levels↑↑No changePlasma PYY levels↑↑No changePlasma ghrelin levelsVariable↑↓Plasma leptin levels↓↓↓Plasma bile acid levels↑↑No changeFat malabsorption/fat-soluble vitamin deficiency↑No changeNo changeNephrolithiasis risk↑No changeNo changeDiabetes remissionHighestModerateLowestShort-term complicationsHigherLowerLowerNeed for reoperationLowerLowerHigherGLP-1, glucagon-like peptide-1; LAGB, laparoscopic-assisted gastric banding; LSG, laparoscopic sleeve gastrectomy; PYY, peptide YY; RYGB, Roux-en-y gastric bypass. Open table in a new tab GLP-1, glucagon-like peptide-1; LAGB, laparoscopic-assisted gastric banding; LSG, laparoscopic sleeve gastrectomy; PYY, peptide YY; RYGB, Roux-en-y gastric bypass. Currently, the most common bariatric procedures performed worldwide are laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic vertical sleeve gastrectomy (LSG).16Angrisani L. Santonicola A. Iovino P. et al.Bariatric surgery worldwide 2013.Obes Surg. 2015; 25: 1822-1832Crossref PubMed Scopus (1063) Google Scholar, 17Esteban Varela J. Nguyen N.T. Laparoscopic sleeve gastrectomy leads the U.S. utilization of bariatric surgery at academic medical centers.Surg Obes Relat Dis. 2015; 11: 987-990Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar The RYGB surgery involves both malabsorption and restriction. First, the stomach is divided into an upper stomach pouch (15−30 ml) and a lower gastric remnant (Figure 2). The stomach pouch is then anastomosed to the mid-jejunum, and a jejuno-jejunal anastomosis is created to reconnect the biliopancreatic limb and the gastric remnant, thereby allowing gastric, pancreatic, and biliary secretions to mix with food in the jejuno-jejunal anastomosis.14Miras A.D. le Roux C.W. Mechanisms underlying weight loss after bariatric surgery.Nat Rev Gastroenterol Hepatol. 2013; 10: 575-584Crossref PubMed Scopus (206) Google Scholar LSG is a restrictive surgery that involves the removal of 70% to 80% of the lateral stomach. Due to its success in achieving weight loss and perhaps better safety profile compared to RYGB, LSG has become more common in the past few years and has eclipsed RYGB in the United States (Figure 3).18ASMBS. Estimate of Bariatric Surgery Numbers, 2011-2015. 2016. Available at: https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers. Accessed January 12, 2017.Google Scholar However, some patients who undergo LSG may require subsequent conversion to RYGB or duodenal switch surgery, in which biliopancreatic secretions are diverted from the food until the last portion of the small bowel to increase malabsorption. Reported reasons for conversion of LSG to RYGB or duodenal switch surgery include weight regain and intractable acid reflux.19Felsenreich D.M. Langer F.B. Kefurt R. et al.Weight loss, weight regain, and conversions to Roux-en-Y gastric bypass: 10-year results of laparoscopic sleeve gastrectomy.Surg Obes Relat Dis. 2016; 12: 1655-1662Abstract Full Text Full Text PDF PubMed Scopus (122) Google ScholarFigure 3Estimated number of surgical procedures for weight loss in the United States from 2011 to 2015.Adapted from the American Society of Metabolic Surgery (ASMBS) estimations.18ASMBS. Estimate of Bariatric Surgery Numbers, 2011-2015. 2016. Available at: https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers. Accessed January 12, 2017.Google Scholar BPD/DS, biliopancreatic diversion with duodenal switch; LAGB, laparoscopic-assisted gastric banding; LSG, laparoscopic sleeve gastrectomy; RYGB, Roux-en-y gastric bypass.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Laparoscopic adjustable gastric banding (LAGB) is another purely restrictive procedure that involves the insertion of an adjustable ring immediately below the gastroesophageal junction on the proximal stomach. Due to lower success in achieving weight loss and high risk of reoperation, LAGB has fallen out of favor during the past few years and is now much less commonly performed than RYGB or LSG. All 3 procedures are now almost exclusively done laparoscopically; the proportion of laparoscopic bariatric surgery procedures in a worldwide survey increased from 63% in 2003 to 96% in 2013.16Angrisani L. Santonicola A. Iovino P. et al.Bariatric surgery worldwide 2013.Obes Surg. 2015; 25: 1822-1832Crossref PubMed Scopus (1063) Google Scholar, 20Buchwald H. Oien D.M. Metabolic/bariatric surgery worldwide 2011.Obes Surg. 2013; 23: 427-436Crossref PubMed Scopus (1032) Google Scholar Unlike gastric banding, RYGB and LSG have favorable effects on various hormones linked to hunger, satiety, and food preferences (Table 1).14Miras A.D. le Roux C.W. Mechanisms underlying weight loss after bariatric surgery.Nat Rev Gastroenterol Hepatol. 2013; 10: 575-584Crossref PubMed Scopus (206) Google Scholar Other procedures that induce more weight loss by increased malabsorption are less commonly performed and include the biliopancreatic diversion with duodenal switch (Figure 2). A variation of the RYGB involves increasing the length of the Roux limb to upwards of 200 cm, resulting in increased malabsorption.21Lieske J.C. Kumar R. Collazo-Clavell M.L. Nephrolithiasis after bariatric surgery for obesity.Semin Nephrol. 2008; 28: 163-173Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar Although increasing malabsorption results in greater weight loss, risks of nephrolithiasis and oxalate nephropathy may be increased. Obesity greatly increases the risk of hypertension and diabetes, the 2 most common reported causes of ESRD.22U.S. Renal Data SystemUSRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2013Google Scholar A systematic review of bariatric surgery studies with long-term follow-up reported remission rates for type 2 diabetes of 66.7% and 28.6% for RYGB and LAGB, respectively.23Puzziferri N. Roshek 3rd, T.B. Mayo H.G. et al.Long-term follow-up after bariatric surgery: a systematic review.JAMA. 2014; 312: 934-942Crossref PubMed Scopus (535) Google Scholar In a randomized trial of obese patients with uncontrolled type 2 diabetes who were randomized to either bariatric surgery plus intensive medical therapy or intensive medical therapy alone, bariatric surgery resulted in better glycemic control, defined by achievement of glycated hemoglobin level of 6% or less after 3 years (RYGB, 38%; sleeve gastrectomy, 24%; medical therapy, 5%; P ≤ 0.01 for both comparisons).24Schauer P.R. Bhatt D.L. Kirwan J.P. et al.STAMPEDE InvestigatorsBariatric surgery versus intensive medical therapy for diabetes—3-year outcomes.N Engl J Med. 2014; 370: 2002-2013Crossref PubMed Scopus (1150) Google Scholar Bariatric surgery also reduced the number of glucose-lowering and antihypertensive medications, and improved quality of life compared to intensive medical therapy (P < 0.05 for all comparisons). Impressive effects on blood pressure have also been reported. Among adolescents undergoing bariatric surgery, elevated blood pressure remitted in 75% of patients.25Inge T.H. Courcoulas A.P. Jenkins T.M. et al.Weight loss and health status 3 years after bariatric surgery in adolescents.N Engl J Med. 2016; 374: 113-123Crossref PubMed Scopus (231) Google Scholar In the aforementioned systematic review of bariatric surgery studies with long-term follow-up, remission rates for hypertension were 60.4% for RYGB and 22.7% for LAGB.23Puzziferri N. Roshek 3rd, T.B. Mayo H.G. et al.Long-term follow-up after bariatric surgery: a systematic review.JAMA. 2014; 312: 934-942Crossref PubMed Scopus (535) Google Scholar Over the long-term, observational studies suggest that bariatric surgery is associated with a 30% to 45% lower risk of death compared to similar patients with severe obesity who did not undergo bariatric surgery.26Sjostrom L. Narbro K. Sjostrom C.D. et al.Effects of bariatric surgery on mortality in Swedish obese subjects.N Engl J Med. 2007; 357: 741-752Crossref PubMed Scopus (3561) Google Scholar, 27Adams T.D. Gress R.E. Smith S.C. et al.Long-term mortality after gastric bypass surgery.N Engl J Med. 2007; 357: 753-761Crossref PubMed Scopus (1995) Google Scholar, 28Arterburn D.E. Olsen M.K. Smith V.A. et al.Association between bariatric surgery and long-term survival.JAMA. 2015; 313: 62-70Crossref PubMed Scopus (305) Google Scholar Most of the observed reduction in mortality risk is due to lower risks of deaths from cardiovascular disease, diabetes, and cancer. However, caution should be advised in interpreting these observational findings, as they are subject to selection bias: patients who undergo bariatric surgery are likely healthier than their severely obese peers. Patients undergoing surgery go through a rigorous, multistep process that includes evaluations and multiple appointments with a multidisciplinary team, and require successful weight loss prior to bariatric surgery, thereby displaying their commitment and motivation. It is important to note that 1 study found a 58% higher rate of non−disease-related deaths (e.g., accidents, suicide) among patients who underwent bariatric surgery compared to matched controls.27Adams T.D. Gress R.E. Smith S.C. et al.Long-term mortality after gastric bypass surgery.N Engl J Med. 2007; 357: 753-761Crossref PubMed Scopus (1995) Google Scholar Further research from randomized trials, if possible, is needed to evaluate whether bariatric surgery provides a long-term mortality benefit as well as to elucidate the long-term risks of surgery. There are nontrivial perioperative and postoperative risks of bariatric surgery, including infection, respiratory failure, acute kidney injury (AKI), and death. Recent reports from a prospective observational cohort study in the United States and an Italian national registry found that modern bariatric surgery mortality rates were approximately 0.3%, similar to those for laparoscopic cholecystectomy.29Morino M. Toppino M. Forestieri P. et al.Mortality after bariatric surgery: analysis of 13,871 morbidly obese patients from a national registry.Ann Surg. 2007; 246 ([discussion: 1007–1009]): 1002-1007Crossref PubMed Scopus (206) Google Scholar, 30Smith M.D. Patterson E. Wahed A.S. et al.Thirty-day mortality after bariatric surgery: independently adjudicated causes of death in the longitudinal assessment of bariatric surgery.Obes Surg. 2011; 21: 1687-1692Crossref PubMed Scopus (93) Google Scholar In an analysis of 27,736 bariatric surgery patients from 2006 to 2008 in the American College of Surgeons National Surgical Quality Improvement Program, the risk of 30-day mortality was not significantly different across levels of estimated glomerular filtration rate (eGFR) (eGFR ≥ 90, 0.1%; eGFR 60−89, 0.2%; eGFR 30−59, 0.3%; eGFR <30, 0.0%; P = 0.2); however, postoperative complications were more common with lower levels of kidney function (4.6%, 6.1%, 7.7%, 7.5%, and 9.9%, respectively; P < 0.001 for linear trend).31Turgeon N.A. Perez S. Mondestin M. et al.The impact of renal function on outcomes of bariatric surgery.J Am Soc Nephrol. 2012; 23: 885-894Crossref PubMed Scopus (82) Google Scholar After multivariate adjustment, each increase in CKD stage was associated with an 18% higher odds of postoperative complications. Another American College of Surgeons National Surgical Quality Improvement Program study examined outcomes in 138 dialysis-dependent ESRD patients who underwent bariatric surgery betweeen 2006 and 2011 (34% LAGB, 49% RYGB, 17% LSG). Reassuringly, this study found that 30-day mortality was relatively low (0.7%) and noted a shift from LABG to LSG in more recent years, similar to overall trends in bariatric surgery.32Mozer A.B. Pender 4th, J.R. Chapman W.H. et al.Bariatric surgery in patients with dialysis-dependent renal failure.Obes Surg. 2015; 25: 2088-2092Crossref PubMed Scopus (19) Google Scholar Change in kidney function after bariatric surgery was first described in 1980 in a study in which 8 obese patients had GFR measured (mGFR) using [51Cr] ethylenediaminetetraacetic acid (EDTA) before and 12 months after jejunoileal bypass (Table 2).33Brochner-Mortensen J. Rickers H. Balslev I. Renal function and body composition before and after intestinal bypass operation in obese patients.Scand J Clin Lab Invest. 1980; 40: 695-702Crossref PubMed Scopus (63) Google Scholar Mean unindexed mGFR significantly decreased from 153 to 123 ml/min, but because body surface area (BSA) also decreased from 2.33 m2 to 1.93 m2, there was no change in mGFR indexed to BSA (114 to 110 ml/min/1.73 m2). Similar findings have been seen in other studies measuring GFR or creatinine clearance in individuals with preserved kidney function.34Chagnac A. Weinstein T. Herman M. et al.The effects of weight loss on renal function in patients with severe obesity.J Am Soc Nephrol. 2003; 14: 1480-1486Crossref PubMed Scopus (428) Google Scholar, 35Lieske J.C. Collazo-Clavell M.L. Sarr M.G. et al.Gastric bypass surgery and measured and estimated GFR in women.Am J Kidney Dis. 2014; 64: 663-665Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 36Friedman A.N. Moe S. Fadel W.F. et al.Predicting the glomerular filtration rate in bariatric surgery patients.Am J Nephrol. 2014; 39: 8-15Crossref PubMed Scopus (67) Google Scholar, 37Navarro-Diaz M. Serra A. Romero R. et al.Effect of drastic weight loss after bariatric surgery on renal parameters in extremely obese patients: long-term follow-up.J Am Soc Nephrol. 2006; 17: S213-S217Crossref PubMed Scopus (202) Google Scholar, 38Serpa Neto A. Bianco Rossi F.M. Dal Moro Amarante R. et al.Effect of weight loss after Roux-en-Y gastric bypass, on renal function and blood pressure in morbidly obese patients.J Nephrol. 2009; 22: 637-646PubMed Google Scholar, 39Saliba J. Kasim N.R. Tamboli R.A. et al.Roux-en-Y gastric bypass reverses renal glomerular but not tubular abnormalities in excessively obese diabetics.Surgery. 2010; 147: 282-287Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Since nephron number is fixed at birth, a decrease in unindexed GFR in this high range may be interpreted as improvement in single nephron glomerular hyperfiltration.34Chagnac A. Weinstein T. Herman M. et al.The effects of weight loss on renal function in patients with severe obesity.J Am Soc Nephrol. 2003; 14: 1480-1486Crossref PubMed Scopus (428) Google Scholar, 40Delanaye P. Radermecker R.P. Rorive M. et al.Indexing glomerular filtration rate for body surface area in obese patients is misleading: concept and example.Nephrol Dial Transplant. 2005; 20: 2024-2028Crossref PubMed Scopus (167) Google Scholar A meta-analysis of surgical weight loss studies found that bariatric surgery reduced unindexed mGFR in patients with normal GFR or high GFR by a mean of 25.6 ml/min.41Navaneethan S.D. Yehnert H. Moustarah F. et al.Weight loss interventions in chronic kidney disease: a systematic review and meta-analysis.Clin J Am Soc Nephrol. 2009; 4: 1565-1574Crossref PubMed Scopus (280) Google Scholar In support of a beneficial effect of bariatric surgery on future renal risk, a number of studies and meta-analyses have shown that albuminuria and proteinuria decrease after bariatric surgery, although it is unclear whether this is a direct effect of weight loss or mediated by improvements in blood pressure and insulin resistance.42Afshinnia F. Wilt T.J. Duval S. et al.Weight loss and proteinuria: systematic review of clinical trials and comparative cohorts.Nephrol Dial Transplant. 2010; 25: 1173-1183Crossref PubMed Scopus (172) Google Scholar, 43Li K. Zou J. Ye Z. et al.Effects of bariatric surgery on renal function in obese patients: a systematic review and meta analysis.PLoS One. 2016; 11: e0163907Google Scholar Two case reports observed complete resolution of proteinuria after bariatric surgery in patients with obesity-related FSGS.44Fowler S.M. Kon V. Ma L. et al.Obesity-related focal and segmental glomerulosclerosis: normalization of proteinuria in an adolescent after bariatric surgery.Pediatr Nephrol. 2009; 24: 851-855Crossref PubMed Scopus (59) Google Scholar, 45Huan Y. Tomaszewski J.E. Cohen D.L. Resolution of nephrotic syndrome after successful bariatric surgery in patient with biopsy-proven FSGS.Clin Nephrol. 2009; 71: 69-73Crossref PubMed Scopus (18) Google Scholar However, all of these studies were of short duration (1−2 years), and often lacked comparison groups.Table 2Short-term studies measuring glomerular filtration rate by exogenous filtration markers or creatinine clearance (24-h urine) before and after bariatric surgeryFirst author, yearnType of surgery (n)Follow-up (mo)GFR assessmentPresurgeryGFR, CrCl, albuminuriaFollow-upGFR, CrCl, albuminuriaPatients with normal or increased GFRBrochner, 19808Intestinal bypass12mGFR (EDTA)GFRunindexed 153 ml/minGFRindexed 114 ml/min/1.73 m2GFRunindexed 123 ml/minGFR 110indexed ml/min/1.73 m2Chagnac, 20048Gastroplasty12mGFR (inulin)GFRunindexed 145 ml/minUAE 16 μg/minGFRunindexed 110 ml/minUAE 5 μg/minNavarro-Diaz, 200661Gastric bypass2424-h CrClCrCl 140 ml/minUAE ≥ 30 mg/d 42.6%CrCl 118 ml/minUAE ≥ 30 mg/d 14.8%Serpa, 2009140RYGB8CrClCrCl 148 ml/minUAE ≥ 30 mg/d 43.6%CrCl 114 ml/minUAE ≥ 30 mg/d 21.4%Saliba, 201035RYGB12CrClDiabetic patients:CrCl 155 ml/minUAE 26 mg/dNondiabetic patients:CrCl 148 ml/minUAE 10 mg/dDiabetic patients:CrCl 132 ml/minUAE 15 mg/dNondiabetic patients:CrCl 117 ml/minUAE 14 mg/dLieske, 201411RYGB (9), BPD/DS (2)12mGFR (iothalamate), CrClGFRunindexed 121 ml/minGFRindexed 95 ml/min/1.73 m2CrCl 120 ml/minUAE 20.5 mg/dGFRunindexed 90 ml/minGFRindexed 85 ml/min/1.73 m2CrCl 98 ml/minUAE 17.1 mg/dFriedman, 201436Gastric bypassMean 10mGFR (iohexol)GFRunindexed 117 ml/minGFRindexed 87 ml/min/1.73 m2GFRunindexed 100 ml/minGFRindexed 87 ml/min/1.73 m2Patients with CKDNavaneethan, 201515RYGB (7), LAGB (3), LSG (3)12mGFR (iothalamate)GFRunindexed 82 ml/minGFRindexed 50 ml/min/1.73 m2Proteinuria 0.60 g/dGFRunindexed 81 ml/minGFRindexed 64 ml/min/1.73 m2Proteinuria 0.43 g/dBPD/DS, biliopancreatic diversion with duodenal switch; CKD, chronic kidney disease; CrCl, creatinine clearance; EDTA, ethylenediaminetetraacetic acid; GFR, glomerular filtration rate; LAGB, laparoscopic-assisted gastric banding; LSG, laparoscopic sleeve gastrectomy; mGFR, measured GFR; RYGB, Roux-en-y gastric bypass; UAE, urinary albumin excretion. Open table in a new tab BPD/DS, biliopancreatic diversion with duodenal switch; CKD, chronic kidney disease; CrCl, creatinine clearance; EDTA, ethylenediaminetetraacetic acid; GFR, glomerular filtration rate; LAGB, laparoscopic-assisted gastric banding; LSG, laparoscopic sleeve gastrectomy; mGFR, measured GFR; RYGB, Roux-en-y gastric bypass; UAE, urinary albumin excretion. A limited number of studies have examined the effect of bariatric surgery in patients with CKD. In a study led by Navaneethan et al., 13 patients with serum creatinine ≥ 1.3 mg/dl underwent measurement of GFR using iothalamate clearance before surgery and 3, 6, and 12 months after bariatric surgery (RYGB, 7; LAGB, 3; LSG, 3).47MacLaughlin H.L. Hall W.L. Patel A.G. et al.Weight loss, adipokines, and quality of life after sleeve gastrectomy in obese patients with stages 3-4 CKD: a randomized controlled pilot study.Am J Kidney Dis." @default.
• W2581895415 created "2017-02-03" @default.
• W2581895415 creator A5031574122 @default.
• W2581895415 creator A5033395115 @default.
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• W2581895415 date "2017-03-01" @default.
• W2581895415 modified "2023-10-16" @default.
• W2581895415 title "Bariatric Surgery and Kidney-Related Outcomes" @default.
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• W2581895415 doi "https://doi.org/10.1016/j.ekir.2017.01.010" @default.
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