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Bariatric surgery for the treatment of chronic kidney disease in obesity and type 2 diabetes mellitus

Nature Reviews Nephrology volume 16, pages 709–720 (2020)Cite this article

Subjects

Abstract

Bariatric surgery is an effective therapy for obesity, hypertension and type 2 diabetes mellitus that is refractory to maximal medical therapy. Results of long-term cohort studies and emerging evidence from randomized clinical trials have revealed that, in addition to its beneficial effects on weight reduction, blood pressure and metabolic control, bariatric surgery might reduce the incidence and long-term progression of chronic kidney disease (CKD). Preclinical studies have provided experimental verification that bariatric surgery improves key parameters of kidney injury at the functional, structural and ultrastructural levels, and effects a programme of transcriptomic change in the kidney that is coherent with injury resolution. Multiple mechanisms explain these observations, ranging from predictable aspects of risk-factor reduction to some novel and unforeseen renoprotective benefits of surgery. Current evidence therefore supports the judicious use of bariatric surgery to treat patients with obesity, diabetes and CKD. Optimizing the benefits of surgery requires careful patient selection and consideration of how to identify and mitigate some of the challenges associated with these surgical procedures.

Key points

  • A causal link between elevated BMI and the incidence and progression of chronic kidney disease (CKD) is now well substantiated.

  • Bariatric surgery reduces risk factors implicated in the progression of kidney injury in obesity and type 2 diabetes mellitus.

  • Long-term outcomes of bariatric surgery confirm the role of obesity as a modifiable risk factor for advanced CKD.

  • Preclinical studies demonstrate that bariatric surgery improves biochemical, structural and ultrastructural measures of experimental diabetic kidney disease and interrupts the transcriptional programme characteristic of progressive CKD.

  • Definitive randomized clinical trial studies comparing kidney outcomes and safety following best medical therapy alone or best medical therapy in combination with bariatric surgery at various stages of disease progression are required.

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Fig. 1: Precipitating phenomena, pathogenic stimuli and injury responses in obesity-associated chronic kidney disease.
Fig. 2: Anatomical reconfigurations in vertical sleeve gastrectomy and Roux-en-Y gastric bypass.
Fig. 3: Renoprotective effects of bariatric surgery.

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Acknowledgements

N.G.D. is also a visiting researcher at the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden. C.W.l.R. also holds an adjunct Professor position in Investigative Science at Imperial College London, UK. The authors acknowledge funding support from the following agencies: Swedish Medical Research Council (2015-02733) and European Foundation for the Study of Diabetes/Boehringer Ingelheim European Diabetes Research Programme (BI 2017_3) to C.W.l.R. and N.G.D., and Science Foundation Ireland (12/YI/B2480) to C.W.l.R.

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  1. Diabetes Complications Research Centre, Conway Institute, School of Medicine and Medical Sciences, University College, Dublin, Ireland

    Neil G. Docherty & Carel W. le Roux

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Both authors researched data for the article, wrote the manuscript, made substantial contributions to discussions of the content, and reviewed or edited the manuscript before submission.

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Correspondence to Neil G. Docherty.

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Competing interests

C.W.l.R. is an advisory board member for Novo Nordisk, Herbalife, Johnson & Johnson, Keyron and GI Dynamics, and has received honoraria for speaking from Novo Nordisk, Herbalife, Johnson & Johnson, GI Dynamics, Lilly, MSD and Consilient Health. N.G.D. declares no competing interests.

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Critical adipose threshold

A concept that postulates that adipose storage capacity varies among individuals owing to a threshold or upper limit in the triglyceride storage capacity of individual adipocytes.

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Docherty, N.G., le Roux, C.W. Bariatric surgery for the treatment of chronic kidney disease in obesity and type 2 diabetes mellitus. Nat Rev Nephrol 16, 709–720 (2020). https://doi.org/10.1038/s41581-020-0323-4

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