Ask the Experts - Obesity Surgery in Renal Transplantation?
Ask the Experts - Obesity Surgery in Renal Transplantation?
Does anyone have experience in gastric bypass as a pretransplant therapy for morbidly obese end-stage renal disease patients?
John Tomasula, MD
Obesity has been recognized as a risk factor in renal transplantation for many years. While obesity does not seem to influence immunologic failure of the graft, excess body mass index (BMI) is associated with an increase in posttransplant complications, especially wound infection, diabetes mellitus, readmission rates, and pulmonary complications. Patients who are obese pretransplantation tend to gain additional weight after transplantation and this weight gain tends to exacerbate the hyperlipidemic and hypertensive effects of cyclosporine. Dietary intervention can be successful after transplantation in limiting weight gain, but is unlikely to successfully reverse morbid obesity, which is the case in nontransplant patients as well.
Most centers use a flexible approach to evaluation of the obese candidate. Careful attention is given to the presence of coronary vascular disease. Pretransplant weight reduction regimens are indicated, albeit with unpredictable results. Surgical intervention prior to transplantation in order to correct morbid obesity has been described. In the past 5 years, morbid obesity surgery (bariatric surgery) utilizing gastric stapling and Roux-en-y bypass has gained considerable favor. The growing experience suggests that this procedure is generally successful with low rates of morbidity, unlike previous procedures for obesity such as jejunoileal bypass and vertical banded gastroplasty.
Consequently, application of the gastric stapling procedure in the pretransplant candidate is inevitable and likely to be a useful means of improving the risk profile of obese transplant recipients. A few isolated cases have already been reported in posttransplant patients. Selection of patients for pretransplant bariatric surgery should be no different from that of the nontransplant population; patients who meet BMI criteria for surgical intervention have known diminished long-term survival without correction of their obesity. Therefore, the decision to proceed with obesity surgery should be viewed as an intervention to improve long-term patient survival, with renal transplantation as an additional intervention towards the same goal. When a choice is available, obesity surgery is better performed first, with renal transplantation second, to avoid heightened risks associated with immunosuppression. However, if posttransplant morbidly obese patients are identified with stable graft function, they should not be excluded from obesity surgery.
Does anyone have experience in gastric bypass as a pretransplant therapy for morbidly obese end-stage renal disease patients?
John Tomasula, MD
Obesity has been recognized as a risk factor in renal transplantation for many years. While obesity does not seem to influence immunologic failure of the graft, excess body mass index (BMI) is associated with an increase in posttransplant complications, especially wound infection, diabetes mellitus, readmission rates, and pulmonary complications. Patients who are obese pretransplantation tend to gain additional weight after transplantation and this weight gain tends to exacerbate the hyperlipidemic and hypertensive effects of cyclosporine. Dietary intervention can be successful after transplantation in limiting weight gain, but is unlikely to successfully reverse morbid obesity, which is the case in nontransplant patients as well.
Most centers use a flexible approach to evaluation of the obese candidate. Careful attention is given to the presence of coronary vascular disease. Pretransplant weight reduction regimens are indicated, albeit with unpredictable results. Surgical intervention prior to transplantation in order to correct morbid obesity has been described. In the past 5 years, morbid obesity surgery (bariatric surgery) utilizing gastric stapling and Roux-en-y bypass has gained considerable favor. The growing experience suggests that this procedure is generally successful with low rates of morbidity, unlike previous procedures for obesity such as jejunoileal bypass and vertical banded gastroplasty.
Consequently, application of the gastric stapling procedure in the pretransplant candidate is inevitable and likely to be a useful means of improving the risk profile of obese transplant recipients. A few isolated cases have already been reported in posttransplant patients. Selection of patients for pretransplant bariatric surgery should be no different from that of the nontransplant population; patients who meet BMI criteria for surgical intervention have known diminished long-term survival without correction of their obesity. Therefore, the decision to proceed with obesity surgery should be viewed as an intervention to improve long-term patient survival, with renal transplantation as an additional intervention towards the same goal. When a choice is available, obesity surgery is better performed first, with renal transplantation second, to avoid heightened risks associated with immunosuppression. However, if posttransplant morbidly obese patients are identified with stable graft function, they should not be excluded from obesity surgery.
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