Obesity is a major public health problem leading to co-morbidities such as diabetes, hypertension and kidney failure. Bariatric surgery results in pronounced and maintained weight loss and prevention of obesity-related diseases and their complications. Most studies of bariatric surgery on kidney disease show improvements after surgery. However, long-term studies analyzing hard end-points are lacking. Here we report on the long-term effects of bariatric surgery compared to usual obesity care on incidence of end-stage renal disease (ESRD) alone and in combination with chronic kidney disease stage 4 (CKD4/ESRD).
4047 patients were included in the Swedish Obese Subjects (SOS) study. Inclusion criteria were age 37–60 years and BMI ≥ 34 in men and BMI ≥ 38 in women. Patients in the bariatric surgery group (N = 2010) underwent banding (18%), vertical banded gastroplasty (69%), or gastric bypass (13%); controls (N = 2037) received usual obesity care. In this analysis, patients were followed up for a median time of 18 years. The incidence of ESRD and CKD4 was obtained by crosschecking the SOS database with the Swedish National Patient Register.
During follow-up, ESRD occurred in 13 patients in the surgery group and in 26 patients in the control group (adjusted hazard ratio (HR) = 0.27; 95% CI 0.12–0.60; p = 0.001). The number of CKD4/ESRD events was 23 in the surgery group and 39 in the control group (adjusted HR = 0.33; 95% CI 0.18–0.62; p < 0.001). In both analyses, bariatric surgery had a more favorable effect in patients with baseline serum insulin levels above median compared to those with lower insulin levels (interaction p = 0.010). Treatment benefit of bariatric surgery was also greater in patients with macroalbuminuria at baseline compared to those without macroalbuminuria (interaction p < 0.001).
Our study showed for the first time that bariatric surgery is associated with a long-term protection against ESRD and CKD4/ESRD.
Subscribe to Journal
Get full journal access for 1 year
only $41.58 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
World Health Organization. Obesity and overweight: Fact sheet http://www.who.int/mediacentre/factsheets/fs311/en/ (2016).
Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303:235–41.
Bray GA. Medical consequences of obesity. J Clin Endocrinol & Metab. 2004;89:2583–9.
Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA. 2003;289:76–9.
Rhéaume C, Arsenault BJ, Bélanger S, Pérusse L, Tremblay A, Bouchard C, et al. Low cardiorespiratory fitness levels and elevated blood pressure: what is the contribution of visceral adiposity? Hypertension. 2009;54:91–7.
Kazancioğlu R. Risk factors for chronic kidney disease: an update. Kidney Int Suppl. 2013;3:368–71.
Hunley TE, Ma LJ, Kon V. Scope and mechanisms of obesity-related renal disease. Curr Opin Nephrol Hypertens. 2010;19:227–34.
Ejerblad E, Fored CM, Lindblad P, Fryzek J, McLaughlin JK, Nyrén O. Obesity and risk for chronic renal failure. J Am Soc Nephrol. 2006;17:1695–702.
Sjöström L, Narbro K, Sjöström CD, Karason K, Larsson B, Wedel H, et al. Effects of bariatric surgery on mortality in Swedish Obese Subjects. New Engl J Med. 2007;357:741–52.
Carlsson LMS, Peltonen M, Ahlin S, Anveden Å, Bouchard C, Carlsson B, et al. Bariatric surgery and prevention of type 2 diabetes in Swedish Obese Subjects. New Engl J Med. 2012;367:695–704.
Heneghan HM, Cetin D, Navaneethan SD, Orzech N, Brethauer SA, Schauer PR. Effects of bariatric surgery on diabetic nephropathy after 5 years of follow-up. Surg Obes Relat Dis. 2013;9:7–14.
Miras AD, Chuah LL, Lascaratos G, Faruq S, Mohite AA, Shah PR, et al. Bariatric surgery does not exacerbate and may be beneficial for the microvascular complications of type 2 diabetes. Diabetes Care. 2012;35:e81.
Miras AD, Chuah LL, Khalil N, Nicotra A, Vusirikala A, Baqai N, et al. Type 2 diabetes mellitus and microvascular complications 1 year after Roux-en-Y gastric bypass: a case–control study. Diabetologia. 2015;58:1443–7.
Li K, Zou J, Ye Z, Di J, Han X, Zhang H, et al. Effects of bariatric surgery on renal function in obese patients: a systematic review and meta analysis. PLoS ONE. 2016;11:e0163907.
Sjöström L, Larsson B, Backman L, Bengtsson C, Bouchard C, Dahlgren S, et al. Swedish obese subjects (SOS). Recruitment for an intervention study and a selected description of the obese state. Int J Obes Relat Metab Disord. 1992;16:465–79.
Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Ann Intern Med. 1999;130:461–70.
Levey AS, Coresh J, Greene T, Marsh J, Stevens LA, Kusek JW, et al. Expressing the modification of diet in renal disease study equation for estimating glomerular filtration rate with standardized serum creatinine values. Clin Chem. 2007;53:766–72.
Sugerman HJ. Effects of increased intra-abdominal pressure in severe obesity. Surg Clin North Am. 2001;81:1063–75.
Sjöström L, Peltonen M, Jacobson P. Bariatric surgery and long-term cardiovascular events. JAMA. 2012;307:56–65.
Torgerson JS, Lindroos AK, Naslund I, Peltonen M. Gallstones, gallbladder disease, and pancreatitis: cross-sectional and 2-year data from the Swedish obese subjects (SOS) and SOS reference studies. Am J Gastroenterol. 2003;98:1032–41.
Carlsson LMS, Romeo S, Jacobson P, Burza MA, Maglio C, Sjoholm K, et al. The incidence of albuminuria after bariatric surgery and usual care in swedish obese subjects (SOS): a prospective controlled intervention trial. Int J Obes. 2015;39:169–75.
Sjöström L. Review of the key results from the Swedish Obese Subjects (SOS) trial – a prospective controlled intervention study of bariatric surgery. J Intern Med. 2013;273:219–34.
Anveden Å, Taube M, Peltonen M, Jacobson P, Andersson-Assarsson JC, Sjöholm K, et al. Long-term incidence of female-specific cancer after bariatric surgery or usual care in the Swedish Obese Subjects Study. Gynecol Oncol. 2017;145:224–9.
Carlsson LMS, Sjöholm K, Karlsson C, Jacobson P, Andersson-Assarsson JC, Svensson P-A, et al. Long-term incidence of microvascular disease after bariatric surgery or usual care in patients with obesity, stratified by baseline glycaemic status: a post-hoc analysis of participants from the Swedish Obese Subjects study. Lancet Diabetes Endocrinology. 2017;5:271–9.
Keating C, Neovius M, Sjöholm K, Peltonen M, Narbro K, Eriksson JK, et al. Health-care costs over 15 years after bariatric surgery for patients with different baseline glucose status: results from the Swedish Obese Subjects study. Lancet Diabetes Endocrinol. 2015;3:855–65.
Ludvigsson JF, Andersson E, Ekbom A, Feychting M, Kim J-L, Reuterwall C, et al. External review and validation of the Swedish national inpatient register. BMC Public Health. 2011;11:450–65.
This project was supported by grants from the US National Institute of Diabetes and Digestive and Kidney Diseases (R01DK105948), the Swedish Research Council (K2013-99 × -22279-01, K2013-54 × -11285-19), Sahlgrenska University Hospital Regional Agreement on Medical Education and Research, and the Swedish Diabetes Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the US National Institutes of Health. We thank the staff members at the SOS Secretariat and at 480 primary health care centers and 25 surgical departments in Sweden that participated in the study.
JCA-A and MT provided data collection and linkage with the Swedish authorities. MP and JCA-A had access to all the data in the study and were responsible for acquisition and integrity of the data. MP and AS were responsible for the accuracy of the statistical data analysis. AS, MP, CDS, JCA-A, MT, KS, CWlR, LMSC, and P-AS were responsible for interpretation of the data. AS and P-AS drafted the manuscript. All authors participated in critical revision of the manuscript and provided intellectual input. LMSC, PAS, JCA-A, KS, and MT were involved in fundraising. All authors approved the final version and agree to be accountable for all aspects of the work.
Conflict of interest
CDS is employed by AstraZeneca. CWlR reports personal fees from Johnson and Johnson, Sanofi Aventis, AstraZeneca, Janssen, Bristol-Myers Squibb, Boehringer-Ingelheim. LMSC has obtained lecture fees from AstraZeneca, Johnson&Johnson and MSD. The remaining authors declare that they have no conflict of interest.
Electronic supplementary material
About this article
Cite this article
Shulman, A., Peltonen, M., Sjöström, C.D. et al. Incidence of end-stage renal disease following bariatric surgery in the Swedish Obese Subjects Study. Int J Obes 42, 964–973 (2018). https://doi.org/10.1038/s41366-018-0045-x
Identification of Proteins Associated with the Early Restoration of Insulin Sensitivity After Biliopancreatic Diversion
The Journal of Clinical Endocrinology & Metabolism (2020)
Journal of Clinical Medicine (2020)
Der Chirurg (2020)
Annals of the New York Academy of Sciences (2020)
Response to the letter to the editor: Different effect on improvement of renal injury in urinary albumin-creatinine ratio at different follow-up time and metabolic surgery
Surgery for Obesity and Related Diseases (2020)