Weight-loss surgery enhances kidney transplant eligibility in patients with chronic kidney disease and obesity
In the United States, an estimated 40% of individuals undergoing dialysis are classified as having clinical obesity. This has led to patients with obesity becoming the fastest-growing demographic within the population affected by advanced chronic kidney disease (CKD). Regrettably, many of these patients find themselves ineligible for kidney transplant listings due to their body mass index (BMI) exceeding the stringent criteria set for transplantation.
While the impact of weight-loss therapies on patients with CKD has not been thoroughly examined, there exists a prevailing belief that a higher BMI might offer a survival advantage, particularly among those receiving dialysis. However, this perspective presents a paradox, as patients who experience delays in kidney transplantation due to not meeting the BMI requirements face an increased risk of mortality.
Dr. Aleksandra Kukla, a transplant nephrologist at Mayo Clinic in Rochester, Minnesota, elaborates on this issue: “The aim of our retrospective study was to describe the outcomes in candidates for kidney transplantation with obesity who were undergoing sleeve gastrectomy (SG) to meet BMI criteria for kidney transplant.
“These patients were participants in the Transplant Metabolic (TRANSMET) Program between February 2020 and August 2023. We compared 54 patients who underwent SG with 50 patients who did not have surgery. The mean BMI was similar in both groups at 41.7 kg/m².”
The findings of the study revealed that patients on dialysis achieved comparable weight-loss results to those not on dialysis. Over a median follow-up period of 15.5 months, 37 out of 54 patients (69%) who underwent SG were successfully placed on the active transplant list, and 20 of those 54 patients (37%) received a kidney transplant within 20 months of their surgery. In stark contrast, among the nonsurgical group, only 14 out of 50 patients (28%) were actively listed for a transplant, and a mere 5 out of 50 patients (10%) ultimately received a transplant.
Dr. Meera Shah, from the Endocrinology, Diabetes, and Nutrition department at Mayo Clinic in Rochester, Minnesota, further explains the comprehensive approach of their programme: “The bariatric transplant programme consists of a multidisciplinary team that assesses candidates for weight-loss surgery to ensure minimal perioperative complications and optimal long-term outcomes.”
Interestingly, the study noted no significant differences in major health complications or hospitalisation rates between the surgical and nonsurgical groups. However, there was a noted trend in the surgical group towards a decline in physical performance and an increase in frailty scores following SG, a change that aligns with the recognised rise in sarcopenia—loss of muscle mass—commonly observed after bariatric surgery.
Dr. Kukla concludes with an important consideration: “The findings of this study support the role of SG in CKD patients with obesity awaiting kidney transplant. As we further develop treatment protocols for obesity in CKD patients, we should include interventions to preserve or improve physical functioning, including physical therapy or health and wellness coaching. Although SG can be safe and effective in this population, it is not recommended in all patients with CKD and obesity. Our patients are best served by the expertise of a multidisciplinary team to evaluate all treatment options and formulate a plan that meets their goals.”
This study underscores the potential of sleeve gastrectomy as a viable intervention for patients with CKD and obesity, aiding them in meeting the BMI criteria necessary for kidney transplantation. However, it also highlights the critical need for a balanced approach that addresses both weight loss and the preservation of physical function to optimise patient outcomes.
