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Bariatric Surgery

Bariatric surgery and chronic kidney disease: much hope, but proof is still awaited

International Journal of Obesity volume 42, pages 1532–1533 (2018)Cite this article

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People with severe or morbid obesity face a double threat when they also have chronic kidney disease (CKD). First, their rate of decline of glomerular filtration is worse than that of non-obese people, even after adjustment on other risk factors, like blood pressure or diabetes [1]. Second, obesity, especially when abdominally distributed, is often considered as a contra-indication to renal graft; in consequence, even young patients cannot escape dialysis. Reduction of weight is strongly recommended in people with severe obesity and CKD, but lifestyle changes have not proved to be very efficacious and sustainable. Hope came from bariatric surgery, but the higher the CKD stage, the higher the risk [2], and the balance between risk and benefit of the intervention requires proper evaluation. In that regard, Shulman et al. [3] provided valuable evidence from the well-documented Swedish Obese Subjects (SOS) study. They showed that people receiving bariatric surgery 18 years ago were less prone to develop end stage renal disease (ESRD) or CKD stage 4 than obese people not treated surgically for their condition.

However, several issues should have been addressed in the paper, in our opinion. As previously reported, already in 2007 by Sjöström et al., much more fatalities occurred during the follow-up than cases of ESRD: 230 deaths reported in the 2007 paper, whereas only 39 ESRD cases occurred, despite a much longer follow-up [4]. To develop ESRD, one needs to stay alive, so there is a competition between renal morbidity and mortality. It should be taken into account in the statistical analysis with techniques like competing risk regression analysis (Fine and Gray model) [5]. Moreover, the issue of ESRD is especially relevant in people with CKD stage 2 or even more stage 3, when the absolute risk of ESRD is high, but in the same time, there is still a delay of several years before ESRD, which can be used for protective intervention. Could the authors provide an exploratory subgroup analysis based on CKD stages? Finally, we think the manuscript is overconclusive. As stated in the Methods, the current analysis was not pre-specified, thus, results can only be seen as exploratory. This should be clear already from the abstract. Unfortunately, the wording often suggests causality; for instance, at the end of the manuscript “In conclusion, bariatric surgery reduced the long-term incidence of ESRD by over 70% compared to conventional obesity treatment.” This is no more than a hypothesis at this stage. A randomized trial comparing obesity surgery and medical therapy in people with CKD is currently conducted to support causality in that regard, with change of measured glomerular filtration as an outcome (NCT02612831).

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References

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Authors and Affiliations

  1. Department of Surgery, Hôpitaux Universitaires Paris-Nord Val de Seine, Hôpital Bichat-Claude-Bernard, 48, rue Henri Hussard, 75018, Paris, France

    Konstantinos Arapis

  2. Paris Diderot University-Sorbonne Paris Cité, Paris, France

    Konstantinos Arapis & Boris Hansel

  3. Department of Endocrinology, Diabetology, Nutrition, Hôpitaux Universitaires Paris-Nord Val de Seine, Hôpital Bichat-Claude-Bernard, 48, rue Henri Hussard, 75018, Paris, France

    Diana Kadouch, Ombeline Cailliéret, Ronan Roussel & Boris Hansel

  4. Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Paris, France

    Ronan Roussel

  5. Institut National de la Santé et de la Recherche Médicale, U1148, Paris, France

    Boris Hansel

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  1. Konstantinos Arapis
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  2. Diana Kadouch
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Correspondence to Konstantinos Arapis.

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Arapis, K., Kadouch, D., Cailliéret, O. et al. Bariatric surgery and chronic kidney disease: much hope, but proof is still awaited. Int J Obes 42, 1532–1533 (2018). https://doi.org/10.1038/s41366-018-0146-6

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