Sleeve Gastrectomy Compared with Gastric Bypass for Morbidly Obese Patients with End Stage Renal Disease: a Decision Analysis

Abstract

Introduction

The use of bariatric surgery has increased for morbidly obese patients with end stage renal disease (ESRD) for whom listing on the waitlist is often restricted until a certain BMI threshold is achieved. Effective weight loss for this population improves access to life-saving renal transplantation. However, it is unclear whether sleeve gastrectomy (SG) vs Roux-en-Y gastric bypass (RYGB) is a more effective therapy for these patients.

Methods

A decision analytic Markov state transition model was created to simulate the life of morbidly obese patients with ESRD who were deemed ineligible to be waitlisted for renal transplantation unless they achieved a BMI less than 35 kg/m2. Life expectancy following weight management (MWM), RYGB, and SG were estimated. Base case patients were defined as having a pre-intervention BMI of 45 kg/m2. Sensitivity analysis of initial BMI was performed. Markov parameters were extracted from literature review.

Results

RYGB improved survival compared with SG and MWM. RYGB patients had higher rates of transplantation, leading to improved mean long-term survival. Base case patients who underwent RYGB gained 1.3 additional years of life compared with patient’s who underwent SG and 2.6 additional years of life compared with MWM.

Conclusions

RYGB improves access to renal transplantation and thereby increases long-term survival compared with SG and MWM. The use of SG may be incongruent with the goal of improving access to renal transplantation for morbidly obese patients.

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References

  1. 1.

    Finkelstein, E.A., et al., Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Affairs, 2009. 28(5): p. w822-w831.

    PubMed  Google Scholar 

  2. 2.

    Kramer, H.J., et al., Increasing Body Mass Index and Obesity in the Incident ESRD Population. Journal of the American Society of Nephrology, 2006. 17(5): p. 1453.

    PubMed  Google Scholar 

  3. 3.

    Kovesdy, C.P., et al., Obesity and Kidney Disease: Hidden Consequences of the Epidemic. Canadian Journal of Kidney Health and Disease, 2017. 4: p. 2054358117698669.

  4. 4.

    Srinivas, T.R. and H.-U. Meier-Kriesche, Obesity and Kidney Transplantation. Seminars in Nephrology, 2013. 33(1): p. 34–43.

    PubMed  Google Scholar 

  5. 5.

    Segev, D.L., et al., Obesity Impacts Access to Kidney Transplantation. Journal of the American Society of Nephrology : JASN, 2008. 19(2): p. 349–355.

    PubMed  Google Scholar 

  6. 6.

    Kieszek, R., et al., Impact of Pretransplant Body Mass Index on Early Kidney Graft Function. Transplantation Proceedings, 2014. 46(8): p. 2689–2691.

    PubMed  CAS  Google Scholar 

  7. 7.

    Fockens, M.M., et al., Wound Morbidity after Kidney Transplant. Progress in Transplantation, 2015. 25(1): p. 45–48.

    PubMed  Google Scholar 

  8. 8.

    Hill, C.J., et al., Recipient obesity and outcomes after kidney transplantation: a systematic review and meta-analysis. Nephrology Dialysis Transplantation, 2015. 30(8): p. 1403–1411.

    Google Scholar 

  9. 9.

    Moreira, T.R., et al., Obesity in kidney transplant recipients: association with decline in glomerular filtration rate. Renal Failure, 2013. 35(9): p. 1199–1203.

    PubMed  Google Scholar 

  10. 10.

    Kovesdy, C.P. and M.Z. Molnar, Restricting Kidney Transplant Wait-Listing for Obese Patients: Let's Stop Defending the Indefensible. Seminars in Dialysis, 2014. 27(1): p. 1–3.

    PubMed  Google Scholar 

  11. 11.

    Pham, P.-T.T., G.M. Danovitch, and P.-C.T. Pham, Kidney Transplantation in the Obese Transplant Candidates: To Transplant or Not To Transplant? Seminars in Dialysis, 2013. 26(5): p. 568–577.

    PubMed  Google Scholar 

  12. 12.

    Lentine, K.L., et al., Obesity and Kidney Transplant Candidates: How Big Is Too Big for Transplantation? American Journal of Nephrology, 2012. 36(6): p. 575–586.

    PubMed  CAS  Google Scholar 

  13. 13.

    Tariq, N., L.W. Moore, and V. Sherman, Bariatric Surgery and End-Stage Organ Failure. Surgical Clinics of North America, 2013. 93(6): p. 1359–1371.

    PubMed  Google Scholar 

  14. 14.

    Mozer, A.B., et al., Bariatric Surgery in Patients with Dialysis-Dependent Renal Failure. Obesity Surgery, 2015. 25(11): p. 2088–2092.

    PubMed  Google Scholar 

  15. 15.

    Li, K., et al., Effects of Bariatric Surgery on Renal Function in Obese Patients: A Systematic Review and Meta Analysis. PLoS ONE, 2016. 11(10): p. e0163907.

  16. 16.

    Neovius, M., et al., Mortality in chronic kidney disease and renal replacement therapy: a population-based cohort study. BMJ Open, 2014. 4(2): p. e004251.

  17. 17.

    Zerrweck, C., et al., Laparoscopic Gastric Bypass vs. Sleeve Gastrectomy in the Super Obese Patient: Early Outcomes of an Observational Study. Obesity Surgery, 2014. 24(5): p. 712–717.

    PubMed  Google Scholar 

  18. 18.

    Pekkarinen, T., et al., Long-Term Effect of Gastric Bypass and Sleeve Gastrectomy on Severe Obesity: Do Preoperative Weight Loss and Binge Eating Behavior Predict the Outcome of Bariatric Surgery? Obesity Surgery, 2016. 26(9): p. 2161–2167.

    PubMed  Google Scholar 

  19. 19.

    MacLaughlin, H.L., et al., Laparoscopic Sleeve Gastrectomy is a Novel and Effective Treatment for Obesity in Patients with Chronic Kidney Disease. Obesity Surgery, 2012. 22(1): p. 119–123.

    PubMed  Google Scholar 

  20. 20.

    Kienzl-Wagner, K., et al., Laparoscopic sleeve gastrectomy: gateway to kidney transplantation. Surgery for Obesity and Related Diseases, 2017. 13(6): p. 909–915.

    PubMed  Google Scholar 

  21. 21.

    Lu, Z., et al., Stochastic Modeling of Imperfect Salmonella Vaccines in an Adult Dairy Herd. Bulletin of Mathematical Biology, 2014. 76(3): p. 541–565.

    PubMed  Google Scholar 

  22. 22.

    Lokkerbol, J., et al., Improving the cost-effectiveness of a healthcare system for depressive disorders by implementing telemedicine: a health economic modeling study. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2014. 22(3): p. 253–262.

    Google Scholar 

  23. 23.

    Eells, S.J., et al., Recurrent Urinary Tract Infections Among Women: Comparative Effectiveness of 5 Prevention and Management Strategies Using a Markov Chain Monte Carlo Model. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America, 2014. 58(2): p. 147–160.

    CAS  Google Scholar 

  24. 24.

    Sonntag, D., et al., Estimating the lifetime cost of childhood obesity in Germany: Results of a Markov Model. Pediatric Obesity, 2015. 10(6): p. 416–422.

    PubMed  CAS  Google Scholar 

  25. 25.

    Choudhury, R.A., et al., Roux-en-Y gastric bypass compared with aggressive diet and exercise therapy for morbidly obese patients awaiting renal transplant: a decision analysis. Surgery for Obesity and Related Diseases, 2014. 10(1): p. 79–87.

    PubMed  Google Scholar 

  26. 26.

    Choudhury, R.A., et al., Re-examining the BMI Threshold for Bariatric Surgery in the USA. Journal of Gastrointestinal Surgery, 2014. 18(12): p. 2074–2079.

    PubMed  Google Scholar 

  27. 27.

    Bromberger, B., et al., Weight Loss Interventions for Morbidly Obese Patients with Compensated Cirrhosis: A Markov Decision Analysis Model. Journal of Gastrointestinal Surgery, 2014. 18(2): p. 321–327.

    PubMed  Google Scholar 

  28. 28.

    Khorgami, Z., et al., Trends in utilization of bariatric surgery, 2010-2014: sleeve gastrectomy dominates. Surgery for Obesity and Related Diseases, 2017. 13(5): p. 774–778.

    PubMed  Google Scholar 

  29. 29.

    Clapp, B., et al., Alarming Trends Regarding Laparoscopic Sleeve Gastrectomy. Surgery for Obesity and Related Diseases, 2017. 13(10): p. S2.

    Google Scholar 

  30. 30.

    Modanlou, K.A., 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): p. 1167–1173.

    PubMed  PubMed Central  Google Scholar 

  31. 31.

    Jamal, M.H., et al., Safety and effectiveness of bariatric surgery in dialysis patients and kidney transplantation candidates. Surgery for Obesity and Related Diseases, 2015. 11(2): p. 419–423.

    PubMed  Google Scholar 

  32. 32.

    Buchwald, H., et al., Bariatric surgery: A systematic review and meta-analysis. JAMA, 2004. 292(14): p. 1724–1737.

    PubMed  CAS  Google Scholar 

  33. 33.

    Hajer, A.A., et al., Trends in Early Morbidity and Mortality after Sleeve Gastrectomy in Patients over 60 Years. Obesity Surgery, 2018. 28(7): p. 1831–1837.

    PubMed  Google Scholar 

  34. 34.

    Abbott, K.C., et al., Body mass index, dialysis modality, and survival: Analysis of the United States Renal Data System Dialysis Morbidity and Mortality Wave II Study. Kidney International, 2004. 65(2): p. 597–605.

    PubMed  Google Scholar 

  35. 35.

    Yamamoto, S., et al., The impact of obesity in renal transplantation: an analysis of paired cadaver kidneys. Clinical Transplantation, 2002. 16(4): p. 252–256.

    PubMed  Google Scholar 

  36. 36.

    Prospective Studies, C., Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet, 2009. 373(9669): p. 1083–1096.

    Google Scholar 

  37. 37.

    Hoogeveen, E.K., et al., Effect of Obesity on the Outcome of Kidney Transplantation: A 20-Year Follow-Up. Transplantation, 2011. 91(8).

  38. 38.

    Freeman, C.M., et al., Addressing Morbid Obesity as a Barrier to Renal Transplantation With Laparoscopic Sleeve Gastrectomy. American Journal of Transplantation, 2015. 15(5): p. 1360–1368.

    PubMed  CAS  Google Scholar 

  39. 39.

    Curioni, C.C. and P.M. Lourenço, Long-term weight loss after diet and exercise: a systematic review. International Journal Of Obesity, 2005. 29: p. 1168.

    PubMed  CAS  Google Scholar 

  40. 40.

    Naugler, W.E. and A. Sonnenberg, Survival and cost-effectiveness analysis of competing strategies in the management of small hepatocellular carcinoma. Liver Transplantation, 2010. 16(10): p. 1186–1194.

    PubMed  Google Scholar 

  41. 41.

    Sjöström, L., et al., Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. New England Journal of Medicine, 2007. 357(8): p. 741–752.

    PubMed  Google Scholar 

  42. 42.

    Badve, S.V., et al., The Association between Body Mass Index and Mortality in Incident Dialysis Patients. PLoS ONE, 2014. 9(12): p. e114897.

  43. 43.

    Vashistha, T., et al., Effect of Age and Dialysis Vintage on Obesity Paradox in Long-term Hemodialysis Patients. American journal of kidney diseases : the official journal of the National Kidney Foundation, 2014. 63(4): p. 612–622.

    Google Scholar 

  44. 44.

    Park, J., et al., Obesity Paradox in End-Stage Kidney Disease Patients. Progress in cardiovascular diseases, 2014. 56(4): p. 415–425.

    PubMed  Google Scholar 

  45. 45.

    Schauer, P.R., et al., Bariatric Surgery versus Intensive Medical Therapy for Diabetes — 3-Year Outcomes. The New England journal of medicine, 2014. 370(21): p. 2002–2013.

    PubMed  PubMed Central  Google Scholar 

  46. 46.

    Peterli, R., et al., Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss in Patients With Morbid Obesity: The SM-BOSS Randomized Clinical Trial. JAMA, 2018. 319(3): p. 255–265.

    PubMed  PubMed Central  Google Scholar 

  47. 47.

    Salminen, P., et al., Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss at 5 Years Among Patients With Morbid Obesity: The SLEEVEPASS Randomized Clinical Trial. JAMA, 2018. 319(3): p. 241–254.

    PubMed  PubMed Central  Google Scholar 

  48. 48.

    Neff, K.J., T. Olbers, and C.W. le Roux, Bariatric surgery: the challenges with candidate selection, individualizing treatment and clinical outcomes. BMC Medicine, 2013. 11: p. 8–8.

    PubMed  PubMed Central  CAS  Google Scholar 

  49. 49.

    Carandina, S., et al., Laparoscopic Sleeve Gastrectomy in Kidney Transplant Candidates: a Case Series. Obesity Surgery, 2017. 27(10): p. 2613–2618.

    PubMed  Google Scholar 

  50. 50.

    Wissing, K.M. and L. Pipeleers, Obesity, metabolic syndrome and diabetes mellitus after renal transplantation: Prevention and treatment. Transplantation Reviews, 2014. 28(2): p. 37–46.

    PubMed  Google Scholar 

  51. 51.

    Kiortsis, D.N. and M.A. Christou, Management of Obesity-Induced Kidney Disease: A Critical Review of the Literature. Obesity Facts, 2012. 5(6): p. 821–832.

    PubMed  Google Scholar 

  52. 52.

    Loubeau, P.R., J.-M. Loubeau, and R. Jantzen, The Economics of Kidney Transplantation versus Hemodialysis. Progress in Transplantation, 2001. 11(4): p. 291–297.

    PubMed  CAS  Google Scholar 

  53. 53.

    Howard, K., et al., The cost-effectiveness of increasing kidney transplantation and home-based dialysis. Nephrology, 2009. 14(1): p. 123–132.

    PubMed  Google Scholar 

  54. 54.

    Wing, R.R., et al., Do weight loss and adherence cluster within behavioral treatment groups? Obesity (Silver Spring, Md.), 2014. 22(3): p. 638–644.

    Google Scholar 

  55. 55.

    Arias, R.H., et al., Kidney Transplantation and Gastric Bypass: A Better Control of Comorbidities. Obesity Surgery, 2010. 20(7): p. 851–854.

    PubMed  Google Scholar 

  56. 56.

    Alexander, J.W., et al., Gastric Bypass in Morbidly Obese Patients with Chronic Renal Failure and Kidney Transplant. Transplantation, 2004. 78(3): p. 469–474.

    PubMed  Google Scholar 

  57. 57.

    Rogers, C.C., et al., Pharmacokinetics of mycophenolic acid, tacrolimus and sirolimus after gastric bypass surgery in end-stage renal disease and transplant patients: a pilot study. Clinical Transplantation, 2008. 22(3): p. 281–291.

    PubMed  PubMed Central  Google Scholar 

  58. 58.

    Padwal, R., D. Brocks, and A.M. Sharma, A systematic review of drug absorption following bariatric surgery and its theoretical implications. Obesity Reviews, 2010. 11(1): p. 41–50.

    PubMed  CAS  Google Scholar 

  59. 59.

    Alexander, J.W., et al., Improvement and stabilization of chronic kidney disease after gastric bypass. Surgery for Obesity and Related Diseases, 2009. 5(2): p. 237–241.

    PubMed  Google Scholar 

  60. 60.

    Saliba, J., et al., Roux-en-Y gastric bypass reverses renal glomerular but not tubular abnormalities in excessively obese diabetics. Surgery, 2010. 147(2): p. 282–287.

    PubMed  Google Scholar 

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Authors

Contributions

Co-authors involved with each segment of manuscript listed below each requirement. All co-authors listed contributed/agree to below requirements:

- Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: Rashikh A Choudhury MD, Gerard Hoeltzel BS, Kas Prins BSc, Eric Chow MSc, Hunter B Moore MD PhD, Peter J Lawson BS, Dor Yoeli MD, Akshay Chauhan MD, Peter L Abt MD, Kristoffel R Dumon MD, Kendra D Conzen MD, Trevor L Nydam MD.

- Drafting the work or revising it critically for important intellectual content: Rashikh A Choudhury MD, Gerard Hoeltzel BS, Kas Prins BSc, Eric Chow MSc, Hunter B Moore MD PhD, Peter J Lawson BS, Dor Yoeli MD, Akshay Chauhan MD, Peter L Abt MD, Kristoffel R Dumon MD, Kendra D Conzen MD, Trevor L Nydam MD.

- Final approval of the version to be published: Rashikh A Choudhury MD, Gerard Hoeltzel BS, Kas Prins BSc, Eric Chow MSc, Hunter B Moore MD PhD, Peter J Lawson BS, Dor Yoeli MD, Akshay Chauhan MD, Peter L Abt MD, Kristoffel R Dumon MD, Kendra D Conzen MD, Trevor L Nydam MD.

- Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: Rashikh A Choudhury MD, Gerard Hoeltzel BS, Kas Prins BSc, Eric Chow MSc, Hunter B Moore MD PhD, Peter J Lawson BS, Dor Yoeli MD, Akshay Chauhan MD, Peter L Abt MD, Kristoffel R Dumon MD, Kendra D Conzen MD, Trevor L Nydam MD.

-Review of reviewers’ comments, suggestions for improvement, review of the revised manuscript: Rashikh A Choudhury MD, Gerard Hoeltzel BS, Kas Prins BSc, Eric Chow MSc, Hunter B Moore MD PhD, Peter J Lawson BS, Dor Yoeli MD, Akshay Chauhan MD, Peter L Abt MD, Kristoffel R Dumon MD, Kendra D Conzen MD, Trevor L Nydam MD.

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Correspondence to Rashikh A. Choudhury.

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Choudhury, R.A., Hoeltzel, G., Prins, K. et al. Sleeve Gastrectomy Compared with Gastric Bypass for Morbidly Obese Patients with End Stage Renal Disease: a Decision Analysis. J Gastrointest Surg 24, 756–763 (2020). https://doi.org/10.1007/s11605-019-04225-w

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Keywords

  • Bariatric surgery
  • Kidney transplantation
  • Markov
  • Decision analysis