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The Role of Bariatric Surgery in Prevention of Kidney Disease Progression in Moderately Obese Patients With Type 2 Diabetes

The Role of Bariatric Surgery in Prevention of Kidney Disease Progression in Moderately Obese... To the Editor We read with interest the study published by Cohen et al.1 This was a randomized clinical trial comparing the benefits of Roux-en-Y gastric bypass (RYGB) with best medical treatment (BMT) for chronic kidney disease in patients with type 2 diabetes and grade 1 obesity (body mass index of 30-35; calculated as weight in kilograms divided by height in meters squared).1 The authors concluded that RYGB is more effective at achieving microalbuminuria remission after 24 months and demonstrated it is a safe procedure with similar adverse effects to medical management. However, this conclusion lacks external validity. The operations performed in this study were undertaken by a solitary, highly experienced surgeon in a single center.2 As such, these results may be difficult to replicate among the broader community. In this study, potentially long-term adverse effects tended toward significance in RYGB compared with BMT. These included dumping syndrome, vitamin B12 deficiency, and anemia. By contrast, previous reports noted rates of dumping syndrome post–bariatric surgery up to 18%, and hypoferritinaemia in 66% of severely obese adolescents who underwent the procedure.3,4 It is unclear whether these long-term adverse effects will be seen in the cohort of patients with a longer duration of follow-up. In particular, CKD itself can be associated with anemia; thus, it would be of interest to follow up how these complications were managed to determine whether long-term postsurgical complications affect their morbidity and mortality. This study included newer antiglycemics (sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor antagonists) that offer a more weight-centric approach in diabetes management. These drugs are associated with reduced progression of kidney disease in patients with diabetes5 and were significantly different between the 2 groups. However, diuretic use was significantly higher in the BMT group and different diuretics have differential effects on proteinuria. It is important that the type of diuretics and adherence to all medications are documented to avoid misjudging the effects of best antidiabetic medical therapy on albuminuria. Finally, the mean urinary albumin-creatinine ratio in BMT group was less than 23.6 mg/g, and more than 50% achieved remission. Given that follow-up was only 24 months, it is unclear whether this outcome will translate into long-term improvement in clinically meaningful kidney outcomes. However, because this study will expand the indication of bariatric surgery in even moderately obese patients, future work should aim to assess the financial implications of integrating bariatric surgery into treatment algorithms for a wider patient range. Back to top Article Information Corresponding Author: ChunHei Li, BSc(Hons), University Hospital of Wales, Cardiff University School of Medicine, Heath Park, Cardiff CF14 4XN, England (lich1@cardiff.ac.uk). Published Online: November 18, 2020. doi:10.1001/jamasurg.2020.5177 Conflict of Interest Disclosures: None reported. References 1. Cohen RV, Pereira TV, Aboud CM, et al. Effect of gastric bypass vs best medical treatment on early-stage chronic kidney disease in patients with type 2 diabetes and obesity: a randomized clinical trial.  JAMA Surg. Published online June 3, 2020. doi:10.1001/jamasurg.2020.0420PubMedGoogle Scholar 2. Nguyen N, Paya M, Stevens C, Mavandadi S, Zainabadi K, Wilson S. The relationship between hospital volume and outcome in bariatric surgery at academic medical centers. Transactions of the Meeting of the American Surgical Association. 2004;CXXII(&NA;):184-192. 3. Emous M, Wolffenbuttel BHR, Totté E, van Beek AP. The short- to mid-term symptom prevalence of dumping syndrome after primary gastric-bypass surgery and its impact on health-related quality of life.  Surg Obes Relat Dis. 2017;13(9):1489-1500. doi:10.1016/j.soard.2017.04.028PubMedGoogle ScholarCrossref 4. Inge TH, Courcoulas AP, Jenkins TM, et al; Teen-LABS Consortium. Weight loss and health status 3 years after bariatric surgery in adolescents.  N Engl J Med. 2016;374(2):113-123. doi:10.1056/NEJMoa1506699PubMedGoogle ScholarCrossref 5. Heerspink HJ, Desai M, Jardine M, Balis D, Meininger G, Perkovic V. Canagliflozin slows progression of renal function decline independently of glycemic effects.  J Am Soc Nephrol. 2017;28(1):368-375. doi:10.1681/ASN.2016030278PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

The Role of Bariatric Surgery in Prevention of Kidney Disease Progression in Moderately Obese Patients With Type 2 Diabetes

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Publisher
American Medical Association
Copyright
Copyright 2020 American Medical Association. All Rights Reserved.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/jamasurg.2020.5177
Publisher site
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Abstract

To the Editor We read with interest the study published by Cohen et al.1 This was a randomized clinical trial comparing the benefits of Roux-en-Y gastric bypass (RYGB) with best medical treatment (BMT) for chronic kidney disease in patients with type 2 diabetes and grade 1 obesity (body mass index of 30-35; calculated as weight in kilograms divided by height in meters squared).1 The authors concluded that RYGB is more effective at achieving microalbuminuria remission after 24 months and demonstrated it is a safe procedure with similar adverse effects to medical management. However, this conclusion lacks external validity. The operations performed in this study were undertaken by a solitary, highly experienced surgeon in a single center.2 As such, these results may be difficult to replicate among the broader community. In this study, potentially long-term adverse effects tended toward significance in RYGB compared with BMT. These included dumping syndrome, vitamin B12 deficiency, and anemia. By contrast, previous reports noted rates of dumping syndrome post–bariatric surgery up to 18%, and hypoferritinaemia in 66% of severely obese adolescents who underwent the procedure.3,4 It is unclear whether these long-term adverse effects will be seen in the cohort of patients with a longer duration of follow-up. In particular, CKD itself can be associated with anemia; thus, it would be of interest to follow up how these complications were managed to determine whether long-term postsurgical complications affect their morbidity and mortality. This study included newer antiglycemics (sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor antagonists) that offer a more weight-centric approach in diabetes management. These drugs are associated with reduced progression of kidney disease in patients with diabetes5 and were significantly different between the 2 groups. However, diuretic use was significantly higher in the BMT group and different diuretics have differential effects on proteinuria. It is important that the type of diuretics and adherence to all medications are documented to avoid misjudging the effects of best antidiabetic medical therapy on albuminuria. Finally, the mean urinary albumin-creatinine ratio in BMT group was less than 23.6 mg/g, and more than 50% achieved remission. Given that follow-up was only 24 months, it is unclear whether this outcome will translate into long-term improvement in clinically meaningful kidney outcomes. However, because this study will expand the indication of bariatric surgery in even moderately obese patients, future work should aim to assess the financial implications of integrating bariatric surgery into treatment algorithms for a wider patient range. Back to top Article Information Corresponding Author: ChunHei Li, BSc(Hons), University Hospital of Wales, Cardiff University School of Medicine, Heath Park, Cardiff CF14 4XN, England (lich1@cardiff.ac.uk). Published Online: November 18, 2020. doi:10.1001/jamasurg.2020.5177 Conflict of Interest Disclosures: None reported. References 1. Cohen RV, Pereira TV, Aboud CM, et al. Effect of gastric bypass vs best medical treatment on early-stage chronic kidney disease in patients with type 2 diabetes and obesity: a randomized clinical trial.  JAMA Surg. Published online June 3, 2020. doi:10.1001/jamasurg.2020.0420PubMedGoogle Scholar 2. Nguyen N, Paya M, Stevens C, Mavandadi S, Zainabadi K, Wilson S. The relationship between hospital volume and outcome in bariatric surgery at academic medical centers. Transactions of the Meeting of the American Surgical Association. 2004;CXXII(&NA;):184-192. 3. Emous M, Wolffenbuttel BHR, Totté E, van Beek AP. The short- to mid-term symptom prevalence of dumping syndrome after primary gastric-bypass surgery and its impact on health-related quality of life.  Surg Obes Relat Dis. 2017;13(9):1489-1500. doi:10.1016/j.soard.2017.04.028PubMedGoogle ScholarCrossref 4. Inge TH, Courcoulas AP, Jenkins TM, et al; Teen-LABS Consortium. Weight loss and health status 3 years after bariatric surgery in adolescents.  N Engl J Med. 2016;374(2):113-123. doi:10.1056/NEJMoa1506699PubMedGoogle ScholarCrossref 5. Heerspink HJ, Desai M, Jardine M, Balis D, Meininger G, Perkovic V. Canagliflozin slows progression of renal function decline independently of glycemic effects.  J Am Soc Nephrol. 2017;28(1):368-375. doi:10.1681/ASN.2016030278PubMedGoogle ScholarCrossref

Journal

JAMA SurgeryAmerican Medical Association

Published: Feb 18, 2021

References