Abstract
Obesity is a major factor in contemporary clinical practice in nephrology. Obesity accelerates the progression of both diabetic and non-diabetic chronic kidney disease and, in renal transplantation, both recipient and donor obesity increase the risk of allograft complications. Obesity is thus a major driver of renal disease progression and a barrier to deceased and living donor kidney transplantation. Large observational studies have highlighted that metabolic surgery reduces the incidence of albuminuria, slows chronic kidney disease progression, and reduces the incidence of end-stage kidney disease over extended follow-up in people with and without type 2 diabetes. The surgical treatment of obesity and its metabolic sequelae has therefore the potential to improve management of diabetic and non-diabetic chronic kidney disease and aid in the slowing of renal decline toward end-stage kidney disease. In the context of patients with end-stage kidney disease, although complications of metabolic surgery are higher, absolute event rates are low and it remains a safe intervention in this population. Pre-transplant metabolic surgery increases access to kidney transplantation in people with obesity and end-stage kidney disease. Metabolic surgery also improves management of metabolic complications post-kidney transplantation, including new-onset diabetes. Procedure selection may be critical to mitigate the risks of oxalate nephropathy and disruption to immunosuppressant pharmacokinetics. Metabolic surgery may also have a role in the treatment of donor obesity, which could increase the living kidney donor pool with potential downstream impact on kidney paired exchange programmes. The present paper provides a comprehensive coverage of the literature concerning renal outcomes in clinical studies of metabolic surgery and integrates findings from relevant mechanistic pre-clinical studies. In so doing the key unanswered questions for the field are brought to the fore for discussion.
Highlights
Reviewed by: Bruno Ramos-Molina, Biomedical Research Institute of Murcia (IMIB), Spain Thomas Alexander Lutz, University of Zurich, Switzerland
Shulman et al demonstrated that metabolic surgery (n = 344) in the Swedish Obese Subjects (SOS) cohort reduced the incidence of a composite of chronic kidney disease (CKD) stage 4/end-stage kidney disease (ESKD) in those with baseline type 2 diabetes compared with usual care controls (n = 263) over median 18-year follow-up [73]
Metabolic surgery as an adjunct to medical therapy to slow the progression of diabetic kidney disease currently has the best evidence base and is closest to incorporation into clinical practice
Summary
Clinicians understand the risks of being obese and encourage patients to lose weight to prevent the complications of obesity. The obesity pandemic has contributed to an increased prevalence of type 2 diabetes and its attendant microvascular complications, including diabetic kidney disease (DKD) [4]. Compared with people with diabetes but no kidney disease, DKD [defined as eGFR ≤60 mL/min/BSA and/or urine albumin-to-creatinine ratio (uACR). The obesity pandemic has fueled an increased incidence of obesity-related glomerulopathy (ORG), a distinct cause of chronic kidney disease (CKD) characterized by sub-nephrotic range proteinuria, glomerulomegaly, and progressive renal functional loss [14]. Obesity increases afferent arteriolar ultrafiltration pressure to cause glomerular hyperfiltration [15]; as a result, many patients with ORG develop an adaptive form of focal segmental glomerulosclerosis (FSGS) [16].
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