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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 great interest the results of the randomized clinical trial conducted by Cohen et al1 demonstrating the superiority of Roux-en-Y gastric bypass (RYGB) compared with optimal medical treatment regarding remission of albuminuria in patients with type 2 diabetes mellitus, obesity, and early-stage chronic kidney disease (CKD), primarily driven by the significant reduction in body mass index.1 Marginally significant improvement in glycemic control, along with no difference in blood pressure reduction, were shown for RYGB-treated patients compared with those randomized to pharmacologic intervention only, underlining the significance of induced weight loss regarding the assessed kidney end point.1 A closer look at participants’ baseline characteristics reveals that there were almost twice as many patients receiving glucagon-like peptide-1 receptor agonist (GLP-1RA) treatment prior to randomization in the RYGB arm compared with the best medical treatment arm (23 vs 13 patients).1 Post hoc analyses of hallmark cardiovascular outcome trials have shown that liraglutide and dulaglutide decrease the risk for new-onset macroalbuminuria by 26% and 23%, respectively,2,3 while lixisenatide provides a significant reduction in urinary albumin-to-creatinine ratio by 39.18% in patients with macroalbuminuria at baseline, decreasing the corresponding risk for new onset macroalbuminuria by 19%.4 Despite the fact that GLP-1RA treatment before bariatric surgery does not predict the weight loss achieved following surgery in patients with diabetes,5 it would be interesting to know whether such a treatment option could enhance the odds for remission of albuminuria. A subanalysis of corresponding data concerning patients in the RYGB arm according to presurgery treatment with a GLP-1RA might provide further insights that will add value to the significant observations made by Cohen et al.1 Back to top Article Information Corresponding Author: Dimitrios Patoulias, MD, MSc, PhD(c), Second Propedeutic Department of Internal Medicine, General Hospital “Hippokration” Konstantinoupoleos 49, 54642, Thessaloniki, Greece (dipatoulias@gmail.com). Published Online: November 18, 2020. doi:10.1001/jamasurg.2020.5171 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 June 3, 2020. doi:10.1001/jamasurg.2020.0420PubMedGoogle Scholar 2. Mann JFE, Ørsted DD, Brown-Frandsen K, et al; LEADER Steering Committee and Investigators. Liraglutide and renal outcomes in type 2 diabetes.  N Engl J Med. 2017;377(9):839-848. doi:10.1056/NEJMoa1616011PubMedGoogle ScholarCrossref 3. Gerstein HC, Colhoun HM, Dagenais GR, et al; REWIND Investigators. Dulaglutide and renal outcomes in type 2 diabetes: an exploratory analysis of the REWIND randomised, placebo-controlled trial.  Lancet. 2019;394(10193):131-138. doi:10.1016/S0140-6736(19)31150-XPubMedGoogle ScholarCrossref 4. Muskiet MHA, Tonneijck L, Huang Y, et al. Lixisenatide and renal outcomes in patients with type 2 diabetes and acute coronary syndrome: an exploratory analysis of the ELIXA randomised, placebo-controlled trial.  Lancet Diabetes Endocrinol. 2018;6(11):859-869. doi:10.1016/S2213-8587(18)30268-7PubMedGoogle ScholarCrossref 5. Tang T, Abbott S, le Roux CW, et al. Preoperative weight loss with glucagon-like peptide-1 receptor agonist treatment predicts greater weight loss achieved by the combination of medical weight management and bariatric surgery in patients with type 2 diabetes: a longitudinal analysis.  Diabetes Obes Metab. 2018;20(3):745-748. doi:10.1111/dom.13131PubMedGoogle 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.2020.5171
Publisher site
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Abstract

To the Editor We read with great interest the results of the randomized clinical trial conducted by Cohen et al1 demonstrating the superiority of Roux-en-Y gastric bypass (RYGB) compared with optimal medical treatment regarding remission of albuminuria in patients with type 2 diabetes mellitus, obesity, and early-stage chronic kidney disease (CKD), primarily driven by the significant reduction in body mass index.1 Marginally significant improvement in glycemic control, along with no difference in blood pressure reduction, were shown for RYGB-treated patients compared with those randomized to pharmacologic intervention only, underlining the significance of induced weight loss regarding the assessed kidney end point.1 A closer look at participants’ baseline characteristics reveals that there were almost twice as many patients receiving glucagon-like peptide-1 receptor agonist (GLP-1RA) treatment prior to randomization in the RYGB arm compared with the best medical treatment arm (23 vs 13 patients).1 Post hoc analyses of hallmark cardiovascular outcome trials have shown that liraglutide and dulaglutide decrease the risk for new-onset macroalbuminuria by 26% and 23%, respectively,2,3 while lixisenatide provides a significant reduction in urinary albumin-to-creatinine ratio by 39.18% in patients with macroalbuminuria at baseline, decreasing the corresponding risk for new onset macroalbuminuria by 19%.4 Despite the fact that GLP-1RA treatment before bariatric surgery does not predict the weight loss achieved following surgery in patients with diabetes,5 it would be interesting to know whether such a treatment option could enhance the odds for remission of albuminuria. A subanalysis of corresponding data concerning patients in the RYGB arm according to presurgery treatment with a GLP-1RA might provide further insights that will add value to the significant observations made by Cohen et al.1 Back to top Article Information Corresponding Author: Dimitrios Patoulias, MD, MSc, PhD(c), Second Propedeutic Department of Internal Medicine, General Hospital “Hippokration” Konstantinoupoleos 49, 54642, Thessaloniki, Greece (dipatoulias@gmail.com). Published Online: November 18, 2020. doi:10.1001/jamasurg.2020.5171 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 June 3, 2020. doi:10.1001/jamasurg.2020.0420PubMedGoogle Scholar 2. Mann JFE, Ørsted DD, Brown-Frandsen K, et al; LEADER Steering Committee and Investigators. Liraglutide and renal outcomes in type 2 diabetes.  N Engl J Med. 2017;377(9):839-848. doi:10.1056/NEJMoa1616011PubMedGoogle ScholarCrossref 3. Gerstein HC, Colhoun HM, Dagenais GR, et al; REWIND Investigators. Dulaglutide and renal outcomes in type 2 diabetes: an exploratory analysis of the REWIND randomised, placebo-controlled trial.  Lancet. 2019;394(10193):131-138. doi:10.1016/S0140-6736(19)31150-XPubMedGoogle ScholarCrossref 4. Muskiet MHA, Tonneijck L, Huang Y, et al. Lixisenatide and renal outcomes in patients with type 2 diabetes and acute coronary syndrome: an exploratory analysis of the ELIXA randomised, placebo-controlled trial.  Lancet Diabetes Endocrinol. 2018;6(11):859-869. doi:10.1016/S2213-8587(18)30268-7PubMedGoogle ScholarCrossref 5. Tang T, Abbott S, le Roux CW, et al. Preoperative weight loss with glucagon-like peptide-1 receptor agonist treatment predicts greater weight loss achieved by the combination of medical weight management and bariatric surgery in patients with type 2 diabetes: a longitudinal analysis.  Diabetes Obes Metab. 2018;20(3):745-748. doi:10.1111/dom.13131PubMedGoogle ScholarCrossref

Journal

JAMA SurgeryAmerican Medical Association

Published: Feb 18, 2021

References