Gastric bypass versus best medical treatment for diabetic kidney disease: 5 years follow up of a single-centre open label randomised controlled trial.

Abstract

We compared the albuminuria-lowering effects of Roux-en-Y gastric bypass (RYGB) to best medical treatment in patients with diabetic kidney disease and obesity to determine which treatment is better. A 5 year, open-label, single-centre, randomised trial studied patients with diabetic kidney disease and class I obesity after 1:1 randomization to best medical treatment (n=49) or RYGB (n=51). The primary outcome was the proportion of patients achieving remission of microalbuminuria after 5 years. Secondary outcomes included improvements in diabetic kidney disease, glycemic control, quality of life, and safety. For efficacy outcomes, we performed an intention-to-treat (ITT) analysis. This study was registered with ClinicalTrials.gov, NCT01821508. 88% of patients (44 per arm) completed 5-year follow-up. Remission of albuminuria occurred in 59.6% (95% CI=45.5-73.8) after best medical treatment and 69.7% (95% CI=59.6-79.8) after RYGB (risk difference: 10%, 95% CI,-7 to 27, P=0.25). Patients after RYGB were twice as likely to achieve an HbA1c≤6.5% (60.2% versus 25.4%, risk difference, 34.9%; 95% CI=15.8-53.9, P<0.001). Quality of life after five years measured by the 36-Item Short Form Survey questionnaire (standardized to a 0-to-100 scale) was higher in the RYGB group than in the best medical treatment group for several domains. The mean differences were 13.5 (95% CI, 5.5-21.6, P=0.001) for general health, 19.7 (95% CI, 9.1-30.3, P<0.001) for pain, 6.1 (95% CI,-4.8 to 17.0, P=0.27) for social functioning, 8.3 (95% CI, 0.23 to 16.3, P=0.04) for emotional well-being, 12.2 (95% CI, 3.9-20.4, P=0.004) for vitality, 16.8 (95% CI,-0.75 to 34.4, P=0.06) for mental health, 21.8 (95% CI, 4.8-38.7, P=0.01) for physical health and 11.1 (95% CI, 2.24-19.9, P=0.01) for physical functioning. Serious adverse events were experienced in 7/46 (15.2%) after best medical treatment and 11/46 patients (24%) after RYGB (P=0.80). Albuminuria remission was not statistically different between best medical treatment and RYGB after 5 years in participants with diabetic kidney disease and class 1 obesity, with 6-7 in ten patients achieving remission of microalbuminuria (uACR <30mg/g) in both groups. RYGB was superior in improving glycemia, diastolic blood pressure, lipids, body weight, and quality of life. The study was supported by research grants from Johnson & Johnson Brasil, Oswaldo Cruz German Hospital, and by grant 12/YI/B2480 from Science Foundation Ireland (Dr le Roux) and grant 2015-02733 from the Swedish Medical Research Council (Dr le Roux). Dr Pereira was funded by the Chevening Scholarship Programme (Foreignand Commonwealth Office, UK).