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Obesity-related cardiorenal disease: the benefits of bariatric surgery

Nature Reviews Nephrology volume 9, pages 539–551 (2013)Cite this article

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Abstract

The inexorable increase in the prevalence of obesity is a global health concern, which will result in a concomitant escalation in health-care costs. Obesity-related metabolic syndrome affects approximately 25% of adults and is associated with cardiovascular and renal disease. The heart and kidneys are physiologically interdependent, and the pathological effects of obesity can lead to cardiorenal syndrome and, ultimately, kidney and heart failure. Weight loss can prevent or ameliorate obesity-related cardiorenal syndrome, but long-term maintenance of a healthy weight has been difficult to achieve through lifestyle changes or pharmacotherapy. Bariatric surgery offers both sustained weight loss and favourable metabolic changes, including dramatic improvements in glycaemic control and symptoms of type 2 diabetes mellitus. Procedures such as Roux-en-Y gastric bypass offer immediate multisystemic benefits, including bile flow alteration, reduced gastric size, anatomical gut rearrangement and altered flow of nutrients, vagal manipulation and enteric hormone modulation. In patients with cardiorenal syndrome, bariatric surgery also offers renoprotection and cardioprotection, and attenuates both kidney and heart failure by improving organ perfusion and reversing metabolic dysfunction. However, further research is required to understand how bariatric surgery acts on the cardiorenal axis, and its pioneering role in novel treatments and interventions for cardiorenal disease.

Key Points

  • The global epidemic of obesity and metabolic syndrome is associated with both renal and cardiovascular disease

  • The physiological interdependence of the kidneys and heart leads to pathology in both organs as a consequence of obesity and metabolic dysregulation—termed cardiorenal syndrome

  • Bariatric surgery offers long-term weight reduction and profound improvements in metabolic dysfunction, including the resolution of type 2 diabetes mellitus and decreased cardiovascular risk

  • The renoprotective and cardioprotective effects of bariatric surgery ameliorate renal and cardiac failure through weight-dependent and weight-independent mechanisms leading to improved organ perfusion and improved metabolic function

  • Increased knowledge of the mechanisms through which bariatric surgery acts on the cardiorenal axis could lead to future advances in the management of obesity-related cardiorenal disease

  • Functional metabolic and endocrinological phenotyping might increase the efficiency of identifying patients with obesity who are at high risk of cardiorenal complications and might benefit from early bariatric management

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Figure 1: Mechanisms of obesity-related cardiorenal syndrome and the beneficial effects of metabolic surgery.
Figure 2: Proposed algorithm for the management of patients with obesity-related cardiorenal syndrome.
Figure 3: The mechanisms by which bariatric surgery induces resolution of cardiac and renal disease.

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Acknowledgements

The authors' research work is supported by individual Wellcome Trust fellowships to H. Ashrafian and L. Harling.

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Authors and Affiliations

  1. Department of Internal Medicine, Endocrine and Diabetes Unit, University of Würzburg, Oberduerrbacherstr 6, Würzburg, 97080, Germany

    Wiebke Fenske

  2. Department of Medicine, Division of Nephrology, University Hospital Würzburg, Oberduerrbacherstr 6, Würzburg, 97080, Germany

    Christiane Drechsler

  3. Department of Surgery and Cancer, Imperial College London, 10th Floor, Queen Elizabeth the Queen Mother Building, St Mary's Hospital, Praed Street, London, W2 1NY, UK

    Thanos Athanasiou, Leanne Harling, Ara Darzi & Hutan Ashrafian

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  1. Wiebke Fenske
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W. Fenske, L. Harling, C. Drechsler and H. Ashrafian researched data for and wrote the article. T. Athanasiou, L. Harling, A. Darzi and H. Ashrafian reviewed and edited the manuscript before submission. A. Darzi and H. Ashrafian made substantial contributions to discussions of the content.

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Correspondence to Hutan Ashrafian.

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Fenske, W., Athanasiou, T., Harling, L. et al. Obesity-related cardiorenal disease: the benefits of bariatric surgery. Nat Rev Nephrol 9, 539–551 (2013). https://doi.org/10.1038/nrneph.2013.145

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