Bariatric surgery before kidney transplantation

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Abstract

BACKGROUND: Patients with obesity and with the terminal stage of chronic kidney disease face difficulties when undergoing transplantation due to their body weight, however, the most efficient method of decreasing the body weight, which is the bariatric surgery, according to the current clinical recommendations, is contraindicated in cases of severe irreversible changes in the kidneys. CLINICAL CASE DESCRIPTION: The article provides the description of two clinical cases. In the first one, the patient aged 33 years (heavy smoker) with the body mass index of 44 kg/m2 and with severe manifestations of the diseases related to the obesity, having received programmed hemodialysis for 3 years, and after the preoperative preparation, he underwent the laparoscopic longitudinal gastric resection. In 13 months, with the decrease of the body mass index down to 25.3 kg/m2, he underwent a successful cadaveric kidney transplantation. Another patient aged 30 years with the body mass index of 40.6 kg/m2 and with 8 years programmed hemodialysis, also underwent the laparoscopic longitudinal gastric resection, and in 12 months, having the body mass index of 30 kg/m2 — a successful cadaveric kidney transplantation was carried out. In both patients, six months after the transplantation, the renal function has restored, with no decrease in the blood concentration of immunosuppressive drugs being observed. CONCLUSION: At the present moment in Russia, despite the existing discrepancies in the national clinical recommendations on kidney transplantation and in the clinical recommendations on the treatment of obesity in terms of bariatric surgery, the longitudinal gastric resection among the patients with the terminal stage of chronic kidney disease and morbid obesity can provide the possibility of transplanting the donor kidney with the minimal risk of transplant failure.

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BACKGROUND

Obesity results in the development of non-adaptive stable low-rate inflammation, oxidative stress and cellular damage of peripheral tissues, including the kidneys [1]. Among the morbid obesity patients, the renal function is characterized by increased glomerular filtration, which leads to albuminuria and glomerulosclerosis [2]. The arterial hypertension and type 2 diabetes, associated with obesity, also increase the risk of developing the nephropathy [3]. The result can be the chronic kidney disease, requiring an organ transplantation.

According to the data from the National Health and Nutrition Examination Survey in the USA (NHANES), chronic kidney disease is statistically significantly more widespread among the obese individuals comparing to the ones having a normal body weight (33.2% versus 24.4%) [4].

In many countries, obesity is the contraindication to kidney transplantation, and the chances for organ survival decrease with increasing the body mass index (BMI) [5]. Thus, in 84 out of 113 centers in the USA, carrying out the kidney transplantation, the BMI threshold values are implemented for the inclusion of patients into the waiting list (in the majority of cases the value is 40 kg/m2) [6]. According to the recommendations from the European Renal Association, (ERA), patients with the BMI >30 kg/m2 before kidney transplantation need to decrease the body weight [7].

According to the Russian clinical recommendations on kidney transplantation [8], obesity is not an absolute contraindication to kidney transplantation, and the exclusion of candidates for transplantation for the reason of obesity is not recommended. Patients with grade II or III obesity (BMI ≥35 kg/m2) are recommended to receive a consultation by the Nutritionist or to undergo the bariatric surgery. There is no strict BMI-related limitation on including into the waiting list. It is recommended to implement the measures on decreasing the body weight among the obese candidates before kidney transplantation.

In a large meta-analysis (more than 200 000 recipients), in which an evaluation was carried out of the treatment results among the patients depending on the presence of obesity, it was demonstrated that the BMI of >30 kg/m2 increases the risk of fatal outcome (relative risk 1.52), of the delayed transplant functioning (relative risk 1.52), of the acute failure (relative risk 1.17), of the wound infection (relative risk 3.13), as well as the duration of hospitalization [9].

When using the conservative methods of loosing weight (correct nutrition, physical exercises and medication therapy), the decrease in the body weight shows an average of 5–10% of the initial one [10, 11]. Generally, such an insignificant body weight decrease is insufficient for the safe kidney transplantation in patients with class II–III obesity, in which the BMI exceeds 35 kg/m2.

The possibility of conducting the bariatric surgery before kidney transplantation is not investigated at the sufficient degree. According to the Russian clinical recommendations on the treatment of obesity in adults, surgical intervention is not recommended in cases of severe irreversible changes in the vital organs (including the renal insufficiency) [11]. Besides, the type of bariatric surgery in the settings of forthcoming kidney transplantation also has the substantial significance, for performing the bypassing bariatric interventions can impair the absorption of immunosuppressive drugs [12, 13]. Performing the Roux-en-Y gastric bypass (RYGB), the mini gastric bypass / one anastomosis gastric bypass (MGB/OAGB) and the Single Anastomosis Duodeno-Ileal-Sleeve (SADI-S) potentially can be associated with the elevated risk of surgical complications, as well as by the formation of kidney stones and by the development of oxalate nephropathy [14]. In such a situation, the majority of investigators recommend to limit the extent of surgical intervention to the level of the longitudinal gastric resection [15].

In our article, a series of clinical cases has demonstrated the safety of bariatric surgery in patients with the terminal stage of chronic kidney disease and with morbid obesity, also showing the treatment staging procedure in this category of patients.

DESCRIPTION OF CASES

Clinical case 1

Patient information. The patient V., 33 years, was admitted for examination purposes and for discussing the issue of the possibility of arranging the bariatric surgery before kidney transplantation due to having a chronic kidney disease stage V and morbid obesity.

Case history. Long-term history of excessive body weight. The diets were ineffective. During the past year, the weight of the patient has increased by 20 kg. Height 172 cm, body weight 132 kg. BMI 44 kg/m2. Heavy smoker (smoking from the age of 16 years — 20 cigarettes a day). Using the programmed hemodialysis for 3 years.

Laboratory and instrumental diagnosis. According to the laboratory testing data, the following abnormalities were detected: С-peptide — 15 ng/ml (ref. range: 1.09–5); blood urea nitrogen 12.8 mmol/l; creatinine 742.8 µmol/l; triglycerides (blood biochemistry panel) 7.19 mmol/l; cholesterol 4.58 mmol/l; iron 6.8 µmol/l; transferrin 3.29 g/l; potassium 4.6 mmol/l; glucose 13.04 mmol/l; parathyroid hormone 571 pg/ml (ref. range: 10–69); WBC 7.36×109/l; hemoglobin 82 g/l; platelets 187×109/l.

According to the data from instrumental examinations, several changes were revealed. Pulmonary function test (spirography): significant decrease of the forced vital capacity (63%); decreased forced expiratory volume in 1 second (60%); the Gaenslar’s Index (modified Tiffeneau index) was normal (78%). Restrictive abnormalities were suspected.

Interpretation of the electrocardiogram: sinus rhythm with a rate of cardiac contractions of 85 bpm; electric axis of the heart — normal; atrioventricular block grade I, PQ interval — 0.22 seconds; early repolarization phenomenon; impaired repolarization of the lateral area; the T peak is smoothened, weakly negative; borderline elongation of the QT interval: QT — 0.38 seconds, QTc (corrected) 0.45 seconds.

Echocardiography (ultrasound examination of the heart): mitral regurgitation grade I–II; tricuspid regurgitation grade I–II; pulmonary valve regurgitation grade I; moderate concentric myocardial hypertrophy in the left ventricle; enlarged cavities of both atriums (Vla 124 ml; Vra 92 ml) and of the right ventricle cavity as measured from the parasternal position (3.2 cm); dilation of the pulmonary artery trunk up to 3.2 cm; pulmonary hypertension grade I; systolic pressure in the pulmonary artery — 36 mm.Hg.; no data obtained that are confirming the presence of zones of local contractility abnormalities in the left ventricle; the global contractility of the myocardium in the left ventricle is normal; ejection fraction of the left ventricle — 56%.

Diagnosis. As a result of conducted examination, the following diagnosis was set to the patient: «Morbid obesity (BMI 44 kg/m2). Chronic mixed tubulointerstitial nephritis (gouty, infectious). Kidney stone disease (anamnestic data). Chronic kidney disease, stage V. Programmed hemodialysis from March 2020. Bone tissue mineral density abnormalities. Secondary hyperparathyroidism. Arterial-venous fistula in the left forearm. Arterial hypertension grade III, risk 4. Iron-deficient anemia of moderate degree of severity. Type 2 diabetes, newly diagnosed. Target level of glycosylated hemoglobin (HbA1c) — up to 6.5%. Mucopurulent chronic bronchitis, outside the exacerbation. Respiratory insufficiency grade II acc. to the modified Medical Research Council Dyspnea Scale (mMRC). Obstructive sleep apnoea syndrome».

Treatment. A consilium was held with the participation of the endocrinologist, the nephrologist, the cardiologist, the psychiatrist, the bariatric surgery specialist and the pulmonologist, during which, the possibility of performing the resection-type bariatric surgery was determined after the correction of glycemia level with short-acting insulin (fasting glucose less than 10 g/l), of blood hemoglobin (not less than 120 g/l) and of the blood pressure, after conducting the therapy with Continuous Positive Airway Pressure (СРАР), as well as after quitting smoking and after decreasing the body weight by 5–7% of the excess body weight (5–6 kg) with further evaluation of the compliance.

The patient was discharged with the recommendations on the preparation for surgical treatment. Upon the control laboratory tests in 4 weeks: glucose 7.1 mmol/l; hemoglobin 121 g/l. According to the oral information provided by the patient, during the last three weeks he completely quit smoking. Other findings included a decrease in the body weight of the patient with a background of low-carb diet by 10 kg. The BMI to the moment of surgery was 40.6 kg/m2. Due to high treatment compliance, the decision was to carry out the bariatric surgery for this patient at the extent of longitudinal gastric resection.

In the settings of the combined multimodal anesthesia, a laparoscopic longitudinal gastric resection was performed. Then followed the smooth course of the early postoperative period. On Days 2 and 4 after surgery, sessions of hemodialysis were arranged. The patient was adapted to the intake of liquid foods and discharged in generally satisfactory status on Day 5.

During the postoperative period, the patient was under the supervision of the abovementioned specialists. Ten months after surgery, the body weight of the patient has decreased by 56 kg comparing to the initial and equaled 76 kg. The BMI was 25.3 kg/m2. The glycemia values were within the normal ranges (4.3 mmol/l). The obstructive sleep apnoea symptoms have regressed.

Thirteen months after the bariatric surgery, further procedures included the cadaveric heterotopic transplantation on the left side (left kidney with stenting the urinary duct) along with the draining of retroperitoneal space.

Follow-up and outcomes. Smooth course was shown for the early postoperative period, with positive dynamic changes in the clinical-laboratory findings. According to the data from ultrasound examination, the circulation in the transplant is intact, the velocity characteristics are satisfactory. The postoperative wound had no signs of inflammation, healing by primary adhesion. Clinically, the status of the patient shows positive changes. A tendency was noted towards decreasing the levels of nitrogenous bases (creatinine 381 µmol/l, blood urea nitrogen 22 mmol/l). The diuresis is adequate, corresponding to the fluid intake.

The patient was discharged with the recommendations to continue the intake of Tacrolimus, mycophenolic acid and methylprednisolone during the out-patient phase.

Upon examining the patient in 6 months after the heterotopic transplantation of the cadaveric kidney, normalization was reported in the renal functions (creatinine 90 µmol/l, blood urea nitrogen 8 mmol/l), while the concentration of Tacrolimus was 10.2 ng/ml.

Clinical case 2

Patient information. The patient G., aged 30 years, was admitted for examination purposes and for discussing the possibility of arranging the bariatric surgery before kidney transplantation due to the chronic kidney disease stage V and morbid obesity.

Case history. The patient has a long-term history of excessive body weight. The diets were ineffective. Height 189 cm, body weight 145 kg. BMI 40.6 kg/m2. Using the programmed hemodialysis for 8 years.

Laboratory and instrumental diagnosis. According to the data from laboratory testing, the following abnormalities were detected: blood urea nitrogen 14.3 mmol/l; creatinine 930 µmol/l; potassium 5.8 mmol/l; glucose 4.2 mmol/l; parathyroid hormone 571 pg/ml (ref. range: 10–69); leucocytes 7.54×109/l; hemoglobin 97 g/l; platelets 230×109/l.

According to the data from the instrumental examination, no other pathological changes were detected.

Diagnosis. As a result of the conducted examination, the following diagnosis was set to the patient: «Morbid obesity (BMI 40.6 kg/m2); chronic glomerulonephritis with an outcome of the chronic kidney disease stage V (currently on dialysis); programmed hemodialysis for 8 years; nephrogenic mild anemia; secondary hyperparathyroidism.

Treatment. A consilium was arranged with the participation of the endocrinologist, the nephrologist, the internist, the psychiatrist and the bariatric surgery specialist, which has defined the possibility of arranging the resection-type bariatric surgery after the correction of blood hemoglobin level (not less than 120 g/l) and after decreasing the body weight by 5–7% of the excess (5–6 kg).

In 4 weeks (after achieving the target levels of blood hemoglobin and of the body weight) the patient was operated. Under the combined multimodal anesthesia, a laparoscopic longitudinal gastric resection was conducted. Smooth course of the early postoperative period followed. On Days 2 and 4 after surgery, hemodialysis sessions were carried out. The patient was adapted to the intake of liquid foods and was discharged in generally satisfactory status on Day 5.

During the postoperative period, the patient was under the supervision by a team of specialists. Nine months after surgery, the weight of the patient has decreased by 48 kg from the initial and equaled 97 kg. The BMI was 30 kg/m2.

In 12 months after the bariatric surgery, the cadaveric heterotopic transplantation was done on the left side (left kidney with stenting the urinary duct) along with the draining of retroperitoneal space.

Follow-up and outcome. Smooth course of the early postoperative period was reported with positive dynamic changes in the clinical-laboratory findings. According to the data from ultrasound examination, the circulation in the transplant is intact, the velocity characteristics are satisfactory. The postoperative wound had no signs of inflammation, healing by primary adhesion. Clinically, the status of the patient shows positive changes. A tendency was noted to decreasing the level of nitrogenous bases (creatinine 325 µmol/l, blood urea nitrogen 21 mmol/l). The diuresis is adequate, corresponding to the fluid intake.

The patient was discharged with the recommendations to continue the intake of Tacrolimus, mycophenolic acid and methylprednisolone at the out-patient phase.

Upon examining the patient in 6 months after the heterotopic transplantation of the cadaveric kidney, normalization was reported in the renal functions (creatinine 84 µmol/l, blood urea nitrogen 7.3 mmol/l), while the concentration of Tacrolimus was 10.4 ng/ml.

DISCUSSION

According to the data from the meta-analysis by N. Pencovich et al. [16], in four research works, which have compared the results of kidney transplantation in patients with obesity and with previously conducted bariatric surgery and without it, no differences were observed in the results, due to which it can be concluded that pre-transplantation surgical intervention, aimed at the decrease of the body weight, had no significant influence on the results after kidney transplantation. However, from our point of view, such a phrasing is erroneous, for only 1/4 of the transplantation centers in the USA technically accept the patients with obesity for further treatment.

The meta-analysis by S. Fernando et al. [17], including a total of 2297 patients after the bariatric surgery and kidney transplantation, has shown the safety and the high efficiency of surgical correction of body weight in this category of patients. The authors emphasize that bariatry allows the obese recipients, initially not subject to the inclusion into the waiting list, to pass the selection and to receive the kidney transplantation.

The conducted research works on the role of bariatric surgery are very different by their design, being retrospective and having a high probability of systematic bias, while the patient follow-up time rarely reaches five years, which is why, as of today, there is no clear answer to the important questions, such as the optimal time and the approach to surgical intervention, how long does the weight persists, the tactics of managing the patient in case of repeated weight gain, there are also no data on the remote survival rate.

The medication therapy of obesity with modern highly effective drugs — the glucagon-like peptide-1 receptor agonists — in patients before and after kidney transplantation at the present moment is poorly investigated. In the recent retrospective research conducted at the Mayo clinic (USA) and including 77 patients, it was shown that the usage of this group of drugs after kidney transplantation was associated with an increase in life duration (р=0.049), with a decreased albumin /creatinine ration in urine (clean decrease by 10.62 mg/g a year, р=0.003), with a slower decrease in the estimated glomerular filtration rate (1.04 versus 1.56 ml/1.73 m2 per minute a year, p=0.04) [18]. No other studies on this topic were found by us.

Despite the absence of clear adverse effects, widely recommending the therapy with glucagon-like peptide-1 agonists, from our point of view, is too early due to the small number of observations. Besides, after the transplantation, most probably, long-term continuation of treatment would be needed, for in case of therapy cancellation, re-gaining of the body weight is expected.

At the present moment in Russia, despite the existing discrepancies in the national clinical recommendations on kidney transplantation and the clinical recommendations on the treatment of obesity in the part regarding the bariatric surgery, longitudinal gastric resection for patients with terminal stage of chronic kidney disease and morbid obesity can become a good possibility to receive the donor kidney with the minimal risk of transplant rejection.

CONCLUSION

Patients with obesity and with the terminal stage of chronic kidney disease face obstacles during the transplantation due to their body weight. With the values of the body mass index being over 40 kg/m2, the most effective treatment strategy at the first stage would be the laparoscopic longitudinal gastric resection and further kidney transplantation in 12 months. Our observations demonstrate that bariatric surgery is safe in the given category of patients with the adequate preoperative preparation under the control from a team of specialists and with the compliance of the patient. The treatment of such patients should be carried out at the multi-profile clinics with the possibility of arranging the extracorporal detoxication methods.

ADDITIONAL INFORMATION

Author contributions: A.R. Akhmedianov, E.S. Danilina, V.I. Sychev, conducting the surgeries, A.V. Smirnov, E.M. Voronets, V.I. Sharobaro, collecting and analyzing the material, drafting the manuscript; V.R. Stankevich, performing operations, collecting and analyzing material, writing an article; N.A. Soloviev, Yu.V. Ivanov, editing, general guidance. Thereby, all authors provided approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Consent for publication: The authors received written informed voluntary consent from the patients’ to publish personal data, including photographs (with the face covered), in a scientific journal, including its electronic version (signed on 13 July 2023 and 27 March 2024 respectively). The volume of published data was agreed upon with the patient.

Funding sources: The study was carried out without attracting external funding.

Disclosure of interests: The authors declare no conflict of interests.

Statement of originality: The authors did not utilize previously published information (text, illustrations, data) in conducting the research and creating this paper.

Data availability statement: The editorial policy regarding data sharing does not apply to this work, data can be published as open access.

Generative AI: Generative AI technologies were not used for this article creation.

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About the authors

Vladimir R. Stankevich

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: v-stankevich@yandex.ru
ORCID iD: 0000-0002-8620-8755
SPIN-code: 5126-6092

MD, PhD

Russian Federation, Moscow

Alexander V. Smirnov

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Author for correspondence.
Email: alvsmirnov@mail.ru
ORCID iD: 0000-0003-3897-8306
SPIN-code: 5619-1151

MD, PhD, Assistant Professor

Russian Federation, Moscow

Artur R. Akhmedianov

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: rbertvich-artur@rambler.ru
ORCID iD: 0000-0003-2099-9344
Russian Federation, Moscow

Ekaterina S. Danilina

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: danilina.katja@bk.ru
ORCID iD: 0000-0002-2466-3795
Russian Federation, Moscow

Evgenia M. Voronets

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: Zhenuaria@list.ru
ORCID iD: 0009-0003-5546-8671
Russian Federation, Moscow

Vladislav I. Sychev

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: vladsychev@mail.ru
ORCID iD: 0000-0003-0460-3602
SPIN-code: 5988-8782
Russian Federation, Moscow

Vladimir I. Sharobaro

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: sharobarovi1@mail.ru
ORCID iD: 0000-0003-1501-706X
SPIN-code: 8529-5855

MD, PhD

Russian Federation, Moscow

Nikolay A. Solovyev

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: my_docs@mail.ru
ORCID iD: 0000-0001-9760-289X
SPIN-code: 8024-7220

MD, PhD

Russian Federation, Moscow

Yury V. Ivanov

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: ivanovkb83@yandex.ru
ORCID iD: 0000-0001-6209-4194
SPIN-code: 3240-4335

MD, PhD, Professor

Russian Federation, Moscow

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