In the Literature Bariatric Surgery: The Solution to a Big Problem? Commentary on Courcoulas AP, Christian NJ, Belle SH, et al. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013:310(22):2416-2425.
A
lthough behavioral and medical therapies for obesity management are both safe and effective, weight loss achieved with nonsurgical interventions is not adequate to prevent or reverse obesity-related comorbid conditions for the overwhelming majority of patients with body mass index (BMI) . 40 kg/m 2.1 During the 1960s and 1970s, jejunoileal bypass surgery revolutionized the treatment of morbid obesity. In this procedure, w1 ft of the proximal jejunum is anastomosed to the terminal part of the ileum. Patients generally lost 50-60 kg in the first year, but its use was limited by severe complications, including liver failure and malnutrition.1,2 The rapid increase in obesity prevalence between 1995 and 2005 drove the development of improved surgical techniques for managing morbid obesity, including the Roux-en-Y and gastric banding procedures, which now routinely are performed laparoscopically. 3 The efficacy and safety of these newer surgical procedures have been summarized previously, but most follow-up periods for studies are 2 years or less.4 Thus, long-term outcomes and safety of these procedures remain major questions, such that there is continuing hesitation to increase the use of bariatric surgery to manage morbidly obese patients with chronic kidney disease (CKD).
WHAT DOES THIS IMPORTANT STUDY SHOW? LABS (Longitudinal Assessment of Bariatric Surgery) is the first American, multicenter, longitudinal, observational cohort study that reports the long-term effects (.2 years) of modern bariatric surgery.5 Between 2006 and 2009, a total of 3,237 participants across 6 US centers were recruited and consented, and 2,467 were scheduled for surgery with a study-certified surgeon. After excluding 119 patients (110 had other procedures and 9 did not undergo surgery), 1,738 patients underwent Roux-en-Y gastric bypass (RYGB) and 610 underwent laparoscopic adjustable gastric banding (LAGB). Three-year follow-up data were available for 88% of patients with RYGB and 90% of patients with LAGB. The majority of patients were white (86%) and women (79%), with a median age of 46 (range, 18-78) years. Median BMI at the start of the study was 46 (range, 33-94) kg/m2. Prior to surgery, approximately one-third of patients had diabetes and 8.5% had CKD.6 Similar to previous studies,4,7,8 most participants’ weight loss occurred during the first year and then reached a plateau. After 3 years, median weight loss Am J Kidney Dis. 2014;-(-):---
was 41 kg for those in the RYGB group and 20 kg in the LAGB group. However, weight-loss trajectories were heterogeneous in both groups. Although all participants lost significant weight during the first 6 months, 36 participants in the RYGB group (2.1%) and 115 in the LAGB group (18.9%) showed weight gain after 6 months. By the end of the 3 years, participants who were weight gainers at 6 months had no significant change in weight (median weight loss of 0%-10%) compared to baseline weight. In the RYGB group, the overwhelming majority maintained weight loss of 20%-40% of baseline weight. In contrast, 62% in the LAGB group maintained 15% weight loss compared to baseline weight and another 19% maintained 30% weight loss compared to baseline weight at 3 years. Remission rates of both diabetes and hypertension were 2-fold higher in the RYGB compared to the LAGB group (Table 1), and both the RYGB and LAGB procedures surpassed medical treatment alone for both incidence and regression of diabetes, hypertension, and hypertriglyceridemia. Overall mortality rates were similar between the RYGB (n 5 16/1,738 [0.9%]) and the LAGB group (n 5 5/610 [0.8%]), but the need for additional procedures was lower in the RYGB group (4/1,738 [0.3%]) versus the LAGB group (77/610 [12.6%]). Additional procedures in the LAGB group included band replacement or removal, port revision, and revision to another bariatric procedure. Only 4 participants who underwent RYGB underwent a subsequent bariatric procedure.
HOW DOES THIS STUDY COMPARE WITH PRIOR STUDIES? LABS is now the most current cohort study of patients undergoing bariatric surgery, and this is important because outcomes after surgical procedures may change over time as techniques evolve and surgical expertise improves. However, in almost all studies of bariatric surgery,4 the weight-loss pattern after surgery shows several important characteristics: maximum weight loss 1 year after surgery, greater Address correspondence to Holly Kramer, MD, MPH, Loyola University Chicago Health Sciences Campus, 2160 S First Ave, Maguire Bldg, Rm 3380, Maywood, IL 60153. E-mail: hkramer@ lumc.edu Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc. This is a US Government Work. There are no restrictions on its use. 0272-6386/$0.00 http://dx.doi.org/10.1053/j.ajkd.2014.04.011 1
Alhosaini, Leehey, and Kramer Table 1. Recovery Rates of Diabetes and Hypertension After Bariatric Surgery Remission of Diabetes
Remission of HTN
New-Onset Diabetes
New-Onset HTN
LABS-25
RYGB, 68% at 3 y; LAGB, 29% at 3 y
RYGB, 38% at 3 y; LAGB, 17% at 3 y
RYGB, 0.9% at 3 y; LAGB, 3.2% at 3 y
RYGB, 2.5% at 3 y; LAGB, 13.7% at 3 y
SOS7 Adams et al8,a
72% at 2 y; 36% at 10 y 75% at 2 y; 62% at 6 y
34% at 2 y; 19% at 10 y 53% at 2 y; 42% at 6 y
1% at 2 y; 7% at 10 y 0% at 2 y; 2% at 6 y
24% at 2 y; 41% at 10 y 4% at 2 y; 16% at 6 y
Abbreviations: HTN, hypertension; LABS, Longitudinal Assessment of Bariatric Surgery Study; LAGB, laparoscopic adjustable gastric banding; RYGB, Roux-en-Y gastric bypass; SOS, Swedish Obesity Study. a All patients in the surgery group had gastric bypass.
weight loss in those treated with RYGB versus LAGB, and higher risk of complete weight regain in those treated with LAGB versus RYGB. Long-term outcomes after bariatric surgery have not been elucidated fully. In the Swedish Obesity Study, long-term outcomes of 2,010 patients who underwent bariatric surgery were compared to a matched group of 2,037 obese patients who were managed medically.7 In this study, the majority of bariatric surgery procedures were not done laparoscopically, and only 13% underwent RYGB, while 19% had LAGB and 68% had vertical gastric banding.7 After 10 years, w25% of the LAGB group basically maintained ,5% of their maximum weight loss compared to baseline weight. After 15 years, average weight loss compared to baseline weight was 27% 6 12%, 18% 6 11%, and 13% 6 14% in the RYGB, LAGB, and vertical gastric banding groups, respectively. However, only 32% of the original cohort participants were followed up for the 15-year period. LABS demonstrated higher rates of remission of obesity-related comorbid conditions among individuals who undergo RYGB versus those who undergo LAGB.5 This finding is supported by numerous other cohort studies and case series previously summarized.4 However, compared to medical treatment alone, both the RYGB and LAGB procedures are superior for remission of obesity-related comorbid conditions. It is important to know whether remission rates of these comorbid conditions are maintained over a 10- or 20-year period given the fairly young age of most individuals who are considered for bariatric surgery. Due to the different definitions of recovery and different severities of diseases at baseline, remission rates of hypertension and diabetes are not consistent across the most recent bariatric surgery cohort studies (Table 1). Nevertheless, even the lowest remission rates of obesity-related comorbid conditions after bariatric surgery are clinically relevant and impressive. However, studies with follow-up of 4 years or more suggest that diabetes and hypertension that rescind with bariatric surgery may recur within 10 years.7,8 Overall mortality rates and risks of cancer and cardiovascular disease previously have been reported 2
to be significantly lower over a 10-year follow-up period for patients who undergo bariatric surgery compared with age- and BMI-matched controls,7-9 but these findings have been questioned recently.10 Furthermore, overall long-term health care expenditures for an obese patient do not appear to be reduced with bariatric surgery.11,12
WHAT SHOULD CLINICIANS AND RESEARCHERS DO? Although this study provides important information about the impact of different types of bariatric surgery on obesity-related comorbid conditions over a 3-year period, the long-term impact ($10 years) of bariatric surgery for patients with CKD remains uncertain. In case series of patients with CKD, bariatric surgery resulted in significant remission of diabetes, hypertension, and hypertriglyceridemia after 1 year, but the likelihood of diabetes remission was lower for more severe stages of CKD.13,14 Slowing of CKD progression and reversal of CKD after bariatric surgery have been reported in small case series and case reports.15-18 Among 45 nontransplantation patients with various stages of CKD, 9 participants’ kidney function either improved or stabilized, including 2 patients with end-stage renal disease who discontinued dialysis therapy just a few months after bariatric surgery.13 However, bariatric surgery also has been associated with heightened risk of acute kidney injury, with postoperative risk ranging from 6%-8%.19,20 Patients with CKD may have a longer hospital stay and higher risk of postsurgical complications, including acute kidney injury, after bariatric surgery compared with patients without CKD.20,21 Both the RYGB and jejunoileal bypass procedures heighten risk for oxalate nephropathy and kidney stone disease, and patients with CKD are particularly susceptible and should be monitored closely.22,23 Patients with kidney failure treated by maintenance dialysis who undergo bariatric surgery for obesity management likely will experience weight loss similar to patients without kidney failure, but their postoperative mortality risk may be 3-fold higher.24 Because many transplant centers preclude transplantation for patients with morbid obesity and the Am J Kidney Dis. 2014;-(-):---
In the Literature
majority of these patients will never receive a kidney transplant,25 more studies are urgently needed to determine the safety and efficacy of bariatric surgery for morbidly obese dialysis patients who are precluded from transplantation due to their obesity. In summary, bariatric surgery effectively treats obesity-related comorbid conditions, at least over the short term. Regardless of the amount of scientific information justifying its safety and efficacy, one must remember that, just as politics is local, obesity management is local. The overall safety of bariatric surgery remains critically dependent on the skill set of the individual surgeon. More studies are needed to assess the safety and efficacy of bariatric surgery in higher risk populations, such as morbidly obese patients with all stages of CKD. Mohamad Alhosaini, MD David Leehey, MD Holly Kramer, MD, MPH Loyola University Medical Center Maywood, IL
ACKNOWLEDGEMENTS Support: None. Financial Disclosure: The authors declare that they have no relevant financial interests.
REFERENCES 1. Leblanc ES, O’Connor E, Whitlock EP, Patnode CD, Kapka T. Effectiveness of primary care-relevant treatments for obesity in adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155(7):434-447. 2. Singh D, Laya AS, Clarkston WK, Allen MJ. Jejunoileal bypass: a surgery of the past and a review of its complications. World J Gastroenterol. 2009;15(18):2277-2279. 3. Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y—500 patients: technique and results, with 3-60 month follow-up. Obes Surg. 2000;10(3):233-239. 4. Chang S, Stroll CRT, Song J, Varela E, Eagon CJ, Colditz GA. The effectiveness and risk of bariatric surgery: an updated systematic review and meta-analysis. JAMA Surg. 2014; 149(3):275-287. 5. Courcoulas AP, Christian NJ, Belle SH, et al. Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013;310(22):2416-2425. 6. Belle SH, Berk PD, Chapman WH, et al; for the LABS Consortium. Baseline characteristics of participants in the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) Study. Surg Obes Relat Dis. 2013;9:926-935. 7. Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357(8):741-752.
Am J Kidney Dis. 2014;-(-):---
8. Adams TD, Davidson LE, Litwin SE, et al. Health benefits of gastric bypass surgery after 6 years. JAMA. 2012;308(11): 1122-1131. 9. MacDonald KG Jr, Long SD, Swanson MS, et al. The gastric bypass operation reduces the progression and mortality of noninsulin-dependent diabetes mellitus. J Gastrointest Surg. 1997;1(3):213-220. 10. Maciejewski ML, Livingston EH, Smith VA, et al. Survival among high-risk patients after bariatric surgery. JAMA. 2011;305(23):2419-2426. 11. Maciejewski ML, Arterburn DE. Cost-effectiveness of bariatric surgery. JAMA. 2013;310(7):742-743. 12. Weiner JP, Goodwin SM, Chang HY, et al. Impact of bariatric surgery on health care costs of obese persons: a 6-year follow-up of surgical and comparison cohorts using health plan data. JAMA Surg. 2013;148(6):555-562. 13. Alexander JW, Goodman H. Gastric bypass in chronic renal failure and renal transplant. Nutr Clin Pract. 2007;22(1):16-21. 14. Hou CC, Shyu RS, Lee WJ, Ser KH, Lee YC, Chen SC. Improved renal function 12 months after bariatric surgery. Surg Obes Relat Dis. 2013;9(2):202-206. 15. Agnani S, Vachharajani VT, Gupta R, Atray NK, Vachharajani TJ. Does treating obesity stabilize chronic kidney disease? BMC Nephrol. 2005;6:7. 16. Izzedine H, Coupaye M, Reach I, Deray G. Gastric bypass and resolution of proteinuria in an obese diabetic patient. Diabet Med. 2005;22(12):1761-1762. 17. Soto FC, Higa-Sansone G, Copley JB, et al. Renal failure, glomerulonephritis and morbid obesity: improvement after rapid weight loss following laparoscopic gastric bypass. Obes Surg. 2005;15(1):137-140. 18. Tafti BA, Haghdoost M, Alvarez L, Curet M, Melcher ML. Recovery of renal function in a dialysis-dependent patient following gastric bypass surgery. Obes Surg. 2009;19(9):13351339. 19. Weingarten TN, Gurrieri C, McCaffrey JM, et al. Acute kidney injury following bariatric surgery. Obes Surg. 2013;23(1): 64-70. 20. Thakar CV, Kharat V, Blanck S, Leonard AC. Acute kidney injury after gastric bypass surgery. Clin J Am Soc Nephrol. 2007;2(3):426-430. 21. Turgeon NA, Perez S, Mondestin M, et al. The impact of renal function on outcomes of bariatric surgery. J Am Soc Nephrol. 2012;23(5):885-894. 22. Nasr SH, D’Agati VD, Said SM, et al. Oxalate nephropathy complicating Roux-en-Y gastric bypass: an underrecognized cause of irreversible renal failure. Clin J Am Soc Nephrol. 2008;3(6): 1676-1683. 23. Matlaga BR, Shore AD, Magnuson T, Clark JM, Johns R, Makary MA. Effect of gastric bypass surgery on kidney stone disease. J Urol. 2009;181(6):2573-2577. 24. Modanlou KA, Muthyala U, Xiao H, et al. Bariatric surgery among kidney transplant candidates and recipients: analysis of the United States Renal Data System and literature review. Transplantation. 2009;87(8):1167-1173. 25. Segev DL, Simpkins CE, Thompson RE, Locke JE, Warren DS, Montgomery RA. Obesity impacts access to kidney transplantation. J Am Soc Nephrol. 2008;19(2):349-355.
3
A
lthough behavioral and medical therapies for obesity management are both safe and effective, weight loss achieved with nonsurgical interventions is not adequate to prevent or reverse obesity-related comorbid conditions for the overwhelming majority of patients with body mass index (BMI) . 40 kg/m 2.1 During the 1960s and 1970s, jejunoileal bypass surgery revolutionized the treatment of morbid obesity. In this procedure, w1 ft of the proximal jejunum is anastomosed to the terminal part of the ileum. Patients generally lost 50-60 kg in the first year, but its use was limited by severe complications, including liver failure and malnutrition.1,2 The rapid increase in obesity prevalence between 1995 and 2005 drove the development of improved surgical techniques for managing morbid obesity, including the Roux-en-Y and gastric banding procedures, which now routinely are performed laparoscopically. 3 The efficacy and safety of these newer surgical procedures have been summarized previously, but most follow-up periods for studies are 2 years or less.4 Thus, long-term outcomes and safety of these procedures remain major questions, such that there is continuing hesitation to increase the use of bariatric surgery to manage morbidly obese patients with chronic kidney disease (CKD).
WHAT DOES THIS IMPORTANT STUDY SHOW? LABS (Longitudinal Assessment of Bariatric Surgery) is the first American, multicenter, longitudinal, observational cohort study that reports the long-term effects (.2 years) of modern bariatric surgery.5 Between 2006 and 2009, a total of 3,237 participants across 6 US centers were recruited and consented, and 2,467 were scheduled for surgery with a study-certified surgeon. After excluding 119 patients (110 had other procedures and 9 did not undergo surgery), 1,738 patients underwent Roux-en-Y gastric bypass (RYGB) and 610 underwent laparoscopic adjustable gastric banding (LAGB). Three-year follow-up data were available for 88% of patients with RYGB and 90% of patients with LAGB. The majority of patients were white (86%) and women (79%), with a median age of 46 (range, 18-78) years. Median BMI at the start of the study was 46 (range, 33-94) kg/m2. Prior to surgery, approximately one-third of patients had diabetes and 8.5% had CKD.6 Similar to previous studies,4,7,8 most participants’ weight loss occurred during the first year and then reached a plateau. After 3 years, median weight loss Am J Kidney Dis. 2014;-(-):---
was 41 kg for those in the RYGB group and 20 kg in the LAGB group. However, weight-loss trajectories were heterogeneous in both groups. Although all participants lost significant weight during the first 6 months, 36 participants in the RYGB group (2.1%) and 115 in the LAGB group (18.9%) showed weight gain after 6 months. By the end of the 3 years, participants who were weight gainers at 6 months had no significant change in weight (median weight loss of 0%-10%) compared to baseline weight. In the RYGB group, the overwhelming majority maintained weight loss of 20%-40% of baseline weight. In contrast, 62% in the LAGB group maintained 15% weight loss compared to baseline weight and another 19% maintained 30% weight loss compared to baseline weight at 3 years. Remission rates of both diabetes and hypertension were 2-fold higher in the RYGB compared to the LAGB group (Table 1), and both the RYGB and LAGB procedures surpassed medical treatment alone for both incidence and regression of diabetes, hypertension, and hypertriglyceridemia. Overall mortality rates were similar between the RYGB (n 5 16/1,738 [0.9%]) and the LAGB group (n 5 5/610 [0.8%]), but the need for additional procedures was lower in the RYGB group (4/1,738 [0.3%]) versus the LAGB group (77/610 [12.6%]). Additional procedures in the LAGB group included band replacement or removal, port revision, and revision to another bariatric procedure. Only 4 participants who underwent RYGB underwent a subsequent bariatric procedure.
HOW DOES THIS STUDY COMPARE WITH PRIOR STUDIES? LABS is now the most current cohort study of patients undergoing bariatric surgery, and this is important because outcomes after surgical procedures may change over time as techniques evolve and surgical expertise improves. However, in almost all studies of bariatric surgery,4 the weight-loss pattern after surgery shows several important characteristics: maximum weight loss 1 year after surgery, greater Address correspondence to Holly Kramer, MD, MPH, Loyola University Chicago Health Sciences Campus, 2160 S First Ave, Maguire Bldg, Rm 3380, Maywood, IL 60153. E-mail: hkramer@ lumc.edu Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc. This is a US Government Work. There are no restrictions on its use. 0272-6386/$0.00 http://dx.doi.org/10.1053/j.ajkd.2014.04.011 1
Alhosaini, Leehey, and Kramer Table 1. Recovery Rates of Diabetes and Hypertension After Bariatric Surgery Remission of Diabetes
Remission of HTN
New-Onset Diabetes
New-Onset HTN
LABS-25
RYGB, 68% at 3 y; LAGB, 29% at 3 y
RYGB, 38% at 3 y; LAGB, 17% at 3 y
RYGB, 0.9% at 3 y; LAGB, 3.2% at 3 y
RYGB, 2.5% at 3 y; LAGB, 13.7% at 3 y
SOS7 Adams et al8,a
72% at 2 y; 36% at 10 y 75% at 2 y; 62% at 6 y
34% at 2 y; 19% at 10 y 53% at 2 y; 42% at 6 y
1% at 2 y; 7% at 10 y 0% at 2 y; 2% at 6 y
24% at 2 y; 41% at 10 y 4% at 2 y; 16% at 6 y
Abbreviations: HTN, hypertension; LABS, Longitudinal Assessment of Bariatric Surgery Study; LAGB, laparoscopic adjustable gastric banding; RYGB, Roux-en-Y gastric bypass; SOS, Swedish Obesity Study. a All patients in the surgery group had gastric bypass.
weight loss in those treated with RYGB versus LAGB, and higher risk of complete weight regain in those treated with LAGB versus RYGB. Long-term outcomes after bariatric surgery have not been elucidated fully. In the Swedish Obesity Study, long-term outcomes of 2,010 patients who underwent bariatric surgery were compared to a matched group of 2,037 obese patients who were managed medically.7 In this study, the majority of bariatric surgery procedures were not done laparoscopically, and only 13% underwent RYGB, while 19% had LAGB and 68% had vertical gastric banding.7 After 10 years, w25% of the LAGB group basically maintained ,5% of their maximum weight loss compared to baseline weight. After 15 years, average weight loss compared to baseline weight was 27% 6 12%, 18% 6 11%, and 13% 6 14% in the RYGB, LAGB, and vertical gastric banding groups, respectively. However, only 32% of the original cohort participants were followed up for the 15-year period. LABS demonstrated higher rates of remission of obesity-related comorbid conditions among individuals who undergo RYGB versus those who undergo LAGB.5 This finding is supported by numerous other cohort studies and case series previously summarized.4 However, compared to medical treatment alone, both the RYGB and LAGB procedures are superior for remission of obesity-related comorbid conditions. It is important to know whether remission rates of these comorbid conditions are maintained over a 10- or 20-year period given the fairly young age of most individuals who are considered for bariatric surgery. Due to the different definitions of recovery and different severities of diseases at baseline, remission rates of hypertension and diabetes are not consistent across the most recent bariatric surgery cohort studies (Table 1). Nevertheless, even the lowest remission rates of obesity-related comorbid conditions after bariatric surgery are clinically relevant and impressive. However, studies with follow-up of 4 years or more suggest that diabetes and hypertension that rescind with bariatric surgery may recur within 10 years.7,8 Overall mortality rates and risks of cancer and cardiovascular disease previously have been reported 2
to be significantly lower over a 10-year follow-up period for patients who undergo bariatric surgery compared with age- and BMI-matched controls,7-9 but these findings have been questioned recently.10 Furthermore, overall long-term health care expenditures for an obese patient do not appear to be reduced with bariatric surgery.11,12
WHAT SHOULD CLINICIANS AND RESEARCHERS DO? Although this study provides important information about the impact of different types of bariatric surgery on obesity-related comorbid conditions over a 3-year period, the long-term impact ($10 years) of bariatric surgery for patients with CKD remains uncertain. In case series of patients with CKD, bariatric surgery resulted in significant remission of diabetes, hypertension, and hypertriglyceridemia after 1 year, but the likelihood of diabetes remission was lower for more severe stages of CKD.13,14 Slowing of CKD progression and reversal of CKD after bariatric surgery have been reported in small case series and case reports.15-18 Among 45 nontransplantation patients with various stages of CKD, 9 participants’ kidney function either improved or stabilized, including 2 patients with end-stage renal disease who discontinued dialysis therapy just a few months after bariatric surgery.13 However, bariatric surgery also has been associated with heightened risk of acute kidney injury, with postoperative risk ranging from 6%-8%.19,20 Patients with CKD may have a longer hospital stay and higher risk of postsurgical complications, including acute kidney injury, after bariatric surgery compared with patients without CKD.20,21 Both the RYGB and jejunoileal bypass procedures heighten risk for oxalate nephropathy and kidney stone disease, and patients with CKD are particularly susceptible and should be monitored closely.22,23 Patients with kidney failure treated by maintenance dialysis who undergo bariatric surgery for obesity management likely will experience weight loss similar to patients without kidney failure, but their postoperative mortality risk may be 3-fold higher.24 Because many transplant centers preclude transplantation for patients with morbid obesity and the Am J Kidney Dis. 2014;-(-):---
In the Literature
majority of these patients will never receive a kidney transplant,25 more studies are urgently needed to determine the safety and efficacy of bariatric surgery for morbidly obese dialysis patients who are precluded from transplantation due to their obesity. In summary, bariatric surgery effectively treats obesity-related comorbid conditions, at least over the short term. Regardless of the amount of scientific information justifying its safety and efficacy, one must remember that, just as politics is local, obesity management is local. The overall safety of bariatric surgery remains critically dependent on the skill set of the individual surgeon. More studies are needed to assess the safety and efficacy of bariatric surgery in higher risk populations, such as morbidly obese patients with all stages of CKD. Mohamad Alhosaini, MD David Leehey, MD Holly Kramer, MD, MPH Loyola University Medical Center Maywood, IL
ACKNOWLEDGEMENTS Support: None. Financial Disclosure: The authors declare that they have no relevant financial interests.
REFERENCES 1. Leblanc ES, O’Connor E, Whitlock EP, Patnode CD, Kapka T. Effectiveness of primary care-relevant treatments for obesity in adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155(7):434-447. 2. Singh D, Laya AS, Clarkston WK, Allen MJ. Jejunoileal bypass: a surgery of the past and a review of its complications. World J Gastroenterol. 2009;15(18):2277-2279. 3. Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y—500 patients: technique and results, with 3-60 month follow-up. Obes Surg. 2000;10(3):233-239. 4. Chang S, Stroll CRT, Song J, Varela E, Eagon CJ, Colditz GA. The effectiveness and risk of bariatric surgery: an updated systematic review and meta-analysis. JAMA Surg. 2014; 149(3):275-287. 5. Courcoulas AP, Christian NJ, Belle SH, et al. Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013;310(22):2416-2425. 6. Belle SH, Berk PD, Chapman WH, et al; for the LABS Consortium. Baseline characteristics of participants in the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) Study. Surg Obes Relat Dis. 2013;9:926-935. 7. Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357(8):741-752.
Am J Kidney Dis. 2014;-(-):---
8. Adams TD, Davidson LE, Litwin SE, et al. Health benefits of gastric bypass surgery after 6 years. JAMA. 2012;308(11): 1122-1131. 9. MacDonald KG Jr, Long SD, Swanson MS, et al. The gastric bypass operation reduces the progression and mortality of noninsulin-dependent diabetes mellitus. J Gastrointest Surg. 1997;1(3):213-220. 10. Maciejewski ML, Livingston EH, Smith VA, et al. Survival among high-risk patients after bariatric surgery. JAMA. 2011;305(23):2419-2426. 11. Maciejewski ML, Arterburn DE. Cost-effectiveness of bariatric surgery. JAMA. 2013;310(7):742-743. 12. Weiner JP, Goodwin SM, Chang HY, et al. Impact of bariatric surgery on health care costs of obese persons: a 6-year follow-up of surgical and comparison cohorts using health plan data. JAMA Surg. 2013;148(6):555-562. 13. Alexander JW, Goodman H. Gastric bypass in chronic renal failure and renal transplant. Nutr Clin Pract. 2007;22(1):16-21. 14. Hou CC, Shyu RS, Lee WJ, Ser KH, Lee YC, Chen SC. Improved renal function 12 months after bariatric surgery. Surg Obes Relat Dis. 2013;9(2):202-206. 15. Agnani S, Vachharajani VT, Gupta R, Atray NK, Vachharajani TJ. Does treating obesity stabilize chronic kidney disease? BMC Nephrol. 2005;6:7. 16. Izzedine H, Coupaye M, Reach I, Deray G. Gastric bypass and resolution of proteinuria in an obese diabetic patient. Diabet Med. 2005;22(12):1761-1762. 17. Soto FC, Higa-Sansone G, Copley JB, et al. Renal failure, glomerulonephritis and morbid obesity: improvement after rapid weight loss following laparoscopic gastric bypass. Obes Surg. 2005;15(1):137-140. 18. Tafti BA, Haghdoost M, Alvarez L, Curet M, Melcher ML. Recovery of renal function in a dialysis-dependent patient following gastric bypass surgery. Obes Surg. 2009;19(9):13351339. 19. Weingarten TN, Gurrieri C, McCaffrey JM, et al. Acute kidney injury following bariatric surgery. Obes Surg. 2013;23(1): 64-70. 20. Thakar CV, Kharat V, Blanck S, Leonard AC. Acute kidney injury after gastric bypass surgery. Clin J Am Soc Nephrol. 2007;2(3):426-430. 21. Turgeon NA, Perez S, Mondestin M, et al. The impact of renal function on outcomes of bariatric surgery. J Am Soc Nephrol. 2012;23(5):885-894. 22. Nasr SH, D’Agati VD, Said SM, et al. Oxalate nephropathy complicating Roux-en-Y gastric bypass: an underrecognized cause of irreversible renal failure. Clin J Am Soc Nephrol. 2008;3(6): 1676-1683. 23. Matlaga BR, Shore AD, Magnuson T, Clark JM, Johns R, Makary MA. Effect of gastric bypass surgery on kidney stone disease. J Urol. 2009;181(6):2573-2577. 24. Modanlou KA, Muthyala U, Xiao H, et al. Bariatric surgery among kidney transplant candidates and recipients: analysis of the United States Renal Data System and literature review. Transplantation. 2009;87(8):1167-1173. 25. Segev DL, Simpkins CE, Thompson RE, Locke JE, Warren DS, Montgomery RA. Obesity impacts access to kidney transplantation. J Am Soc Nephrol. 2008;19(2):349-355.
3
