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The impact and treatment of obesity in kidney transplant candidates and recipients.

Chan G, Garneau P, Hajjar R - Can J Kidney Health Dis (2015)

Bottom Line: Laparoscopy has radically shortened the recovery time and decreased the complications associated with bariatric surgery.Rigorous prospective studies will be essential to properly evaluate the expected weight loss and the effect on pharmacokinetics of immunosuppressive medications.Abstract available from the publisher.

View Article: PubMed Central - PubMed

Affiliation: Département de Chirurgie, Université de Montréal and Service de Transplantation Rénale, Hôpital Maisonneuve-Rosemont, Montreal, Canada.

ABSTRACT
The prevalence of obesity in patients with chronic kidney failure and renal transplant candidates has paralleled the epidemic in the general population. The associated risks of surgical complications and long-term cardiovascular death are significant: most transplant centers consider obesity a relative contra-indication for transplant. Few studies have focused on conservative weight loss strategies in transplant patients. Studies using administrative databases have found that only a minority of wait-listed patients lose weight and with no apparent benefit to transplant outcomes. The only clinical trial in this area found that an intensive weight-loss program had significantly better success (to listing) than self-directed weight loss. However, only a minority that succeeded with the help of a program (36 %), while the "diet and exercise" group had negligible results. Laparoscopy has radically shortened the recovery time and decreased the complications associated with bariatric surgery. Reports in transplant patients, who were previously deemed too medically complex, have demonstrated a dramatic and rapid weight loss. The only randomized clinical trial in patients with CKD, which compared sleeve gastrectomy to best medical care clearly favoured the surgical arm for weight loss, but was too small to assess other outcomes. The emerging experience is small but quite promising. Surgical complications and the effect on immunosuppression remain the chief concerns regarding the use of bariatric surgery in transplant patients. Rigorous prospective studies will be essential to properly evaluate the expected weight loss and the effect on pharmacokinetics of immunosuppressive medications. A routine role for bariatric surgery in transplantation would require evidence of improvements in patient-important outcomes and evidence of safety.

No MeSH data available.


Related in: MedlinePlus

Sleeve Gastrectomy. The sleeve (S) is outlined by the dashed lines. The resected gastrectomy specimen (G) is seen on the right.
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Fig2: Sleeve Gastrectomy. The sleeve (S) is outlined by the dashed lines. The resected gastrectomy specimen (G) is seen on the right.

Mentions: Presently, the most common laparoscopic bariatric techniques are the Roux-en-Y gastric bypass (LGB) (Fig. 1), the duodenal switch (or bilio-pancreatic diversion) (LDS) and the sleeve (or vertical) gastrectomy (LSG) (Fig. 2). The gastric band procedure has fallen out of favour due to multiple factors including the need for manipulations post-implantation, the risk of technical complications and the emergence of the LSG. The characteristics of the four types of bariatric surgeries are summarized in Table 1. The minimally invasive or laparoscopic technique has transformed bariatric surgery by dramatically decreasing operative times, post-operative complications and length of stay, with similar weight loss outcomes. The LGB and the LDS both use restrictive and malabsorptive mechanisms. The restrictive mechanism reduces the capacity of the stomach to as little as 30 ml. and induces early satiety. The malabsorptive mechanism works by bypassing a significant portion of the small intestine and decreasing the number of calories absorbed into the body. The LSG is a purely restrictive procedure that involves the resection of the majority of the stomach to leave a remnant gastric tube along the lesser curve between the esophagus and the duodenum. The technique was traditionally the first step of the LDS, which was occasionally performed in two separate surgical stages for medically high risk patients. This experience found that in many cases LSG alone was sufficient to induce a significant weight loss. The use of LSG has expanded widely over the last decade [35] likely due to its simplicity and has made the gastric band procedures obsolete. The hormonal mechanism of weight loss has been associated with the bypass or resection of the stomach, and the subsequent loss of the influence of ghrelin, the “hunger” hormone. After bariatric surgery, patients will report a loss of appetite that was previously excessive or insatiable.Fig. 1


The impact and treatment of obesity in kidney transplant candidates and recipients.

Chan G, Garneau P, Hajjar R - Can J Kidney Health Dis (2015)

Sleeve Gastrectomy. The sleeve (S) is outlined by the dashed lines. The resected gastrectomy specimen (G) is seen on the right.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4522095&req=5

Fig2: Sleeve Gastrectomy. The sleeve (S) is outlined by the dashed lines. The resected gastrectomy specimen (G) is seen on the right.
Mentions: Presently, the most common laparoscopic bariatric techniques are the Roux-en-Y gastric bypass (LGB) (Fig. 1), the duodenal switch (or bilio-pancreatic diversion) (LDS) and the sleeve (or vertical) gastrectomy (LSG) (Fig. 2). The gastric band procedure has fallen out of favour due to multiple factors including the need for manipulations post-implantation, the risk of technical complications and the emergence of the LSG. The characteristics of the four types of bariatric surgeries are summarized in Table 1. The minimally invasive or laparoscopic technique has transformed bariatric surgery by dramatically decreasing operative times, post-operative complications and length of stay, with similar weight loss outcomes. The LGB and the LDS both use restrictive and malabsorptive mechanisms. The restrictive mechanism reduces the capacity of the stomach to as little as 30 ml. and induces early satiety. The malabsorptive mechanism works by bypassing a significant portion of the small intestine and decreasing the number of calories absorbed into the body. The LSG is a purely restrictive procedure that involves the resection of the majority of the stomach to leave a remnant gastric tube along the lesser curve between the esophagus and the duodenum. The technique was traditionally the first step of the LDS, which was occasionally performed in two separate surgical stages for medically high risk patients. This experience found that in many cases LSG alone was sufficient to induce a significant weight loss. The use of LSG has expanded widely over the last decade [35] likely due to its simplicity and has made the gastric band procedures obsolete. The hormonal mechanism of weight loss has been associated with the bypass or resection of the stomach, and the subsequent loss of the influence of ghrelin, the “hunger” hormone. After bariatric surgery, patients will report a loss of appetite that was previously excessive or insatiable.Fig. 1

Bottom Line: Laparoscopy has radically shortened the recovery time and decreased the complications associated with bariatric surgery.Rigorous prospective studies will be essential to properly evaluate the expected weight loss and the effect on pharmacokinetics of immunosuppressive medications.Abstract available from the publisher.

View Article: PubMed Central - PubMed

Affiliation: Département de Chirurgie, Université de Montréal and Service de Transplantation Rénale, Hôpital Maisonneuve-Rosemont, Montreal, Canada.

ABSTRACT
The prevalence of obesity in patients with chronic kidney failure and renal transplant candidates has paralleled the epidemic in the general population. The associated risks of surgical complications and long-term cardiovascular death are significant: most transplant centers consider obesity a relative contra-indication for transplant. Few studies have focused on conservative weight loss strategies in transplant patients. Studies using administrative databases have found that only a minority of wait-listed patients lose weight and with no apparent benefit to transplant outcomes. The only clinical trial in this area found that an intensive weight-loss program had significantly better success (to listing) than self-directed weight loss. However, only a minority that succeeded with the help of a program (36 %), while the "diet and exercise" group had negligible results. Laparoscopy has radically shortened the recovery time and decreased the complications associated with bariatric surgery. Reports in transplant patients, who were previously deemed too medically complex, have demonstrated a dramatic and rapid weight loss. The only randomized clinical trial in patients with CKD, which compared sleeve gastrectomy to best medical care clearly favoured the surgical arm for weight loss, but was too small to assess other outcomes. The emerging experience is small but quite promising. Surgical complications and the effect on immunosuppression remain the chief concerns regarding the use of bariatric surgery in transplant patients. Rigorous prospective studies will be essential to properly evaluate the expected weight loss and the effect on pharmacokinetics of immunosuppressive medications. A routine role for bariatric surgery in transplantation would require evidence of improvements in patient-important outcomes and evidence of safety.

No MeSH data available.


Related in: MedlinePlus