Obesity, kidney and metabolic bariatric surgery: a surgeon’s narrative review

Abstract

Excess body weight impacts kidney function in individuals with severe obesity, primarily through metabolic alterations in adipocytes, especially in visceral adipose tissue. The relationship between persistent sterile inflammation associated with obesity and the progression of obesity-related kidney disease to chronic kidney disease (CKD) is an area of growing interest. The beneficial effects of weight loss on the prevention of kidney disease and the improvement of kidney function in individuals with obesity have been well documented. Currently, the most effective weight loss strategy is metabolic bariatric surgery (MBS), which has been proven to not only prevent the progression of CKD but also reverse it. However, awareness and understanding of the impact of obesity on the kidney should also extend to the severely obese population with clinically normal renal function. The purpose of this review is to outline the current knowledge on the pathophysiology of obesity-induced kidney damage, the effects of MBS on renal function in severely obese individuals with or without CKD, and provide the current evidence on perioperative management strategies for CKD patients, including diet and nutrition.

Keywords

Kidney function / severe obesity / metabolic bariatric surgery / chronic kidney disease / albuminuria / proteinuria / obesity-related kidney disease / obesity-related glomerulopathy

References

[1] World Obesity Federation. World Obesity Atlas 2023. Available from: https://www.worldobesity.org/resources/resource-library/world-obesity-atlas-2023. [Last accessed on 14 Oct 2024].

[2] World Health Organization. Obesity and overweigh. Available from: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight. [Last accessed on 14 Oct 2024]

[3] Afshin A, Forouzanfar MH, Reitsma MB, et al; GBD 2015 Obesity Collaborators. Health effects of overweight and obesity in 195 countries over 25 years. N Engl J Med 2017;377:13-27. PMCID:PMC5477817

[4] Stefan N.Metabolic health and cardiometabolic risk clusters: implications for prediction, prevention, and treatment.Lancet Diabetes Endocrinol2023;11:426-40

[5] Musso G,Cohney S,Saba F.Emerging liver-kidney interactions in nonalcoholic fatty liver disease.Trends Mol Med2015;21:645-62

[6] Marcuccilli M.NAFLD and chronic kidney disease.Int J Mol Sci2016;17:562 PMCID:PMC4849018

[7] Lonardo A,Targher G.Nonalcoholic fatty liver disease and chronic kidney disease: epidemiology, pathogenesis, and clinical and research implications.Int J Mol Sci2022;23:13320 PMCID:PMC9654863

[8] Gómez-Hernández A,Díaz-Castroverde S.Differential role of adipose tissues in obesity and related metabolic and vascular complications.Int J Endocrinol2016;2016:1216783 PMCID:PMC5059561

[9] Ardiles LG.Obesity and renal disease: benefits of bariatric surgery.Front Med2023;10:1134644 PMCID:PMC10011092

[10] Moriconi D,Masi S.Glomerular hyperfiltration in morbid obesity: role of the inflammasome signalling.Nephrology (Carlton)2022;27:673-80

[11] Moriconi D,Dadson P,Tentolouris N.The beneficial effects of bariatric-surgery-induced weight loss on renal function.Metabolites2022;12:967 PMCID:PMC9608617

[12] Serra A,Lopez D.Renal injury in the extremely obese patients with normal renal function.Kidney Int2008;73:947-55

[13] Park JY, Kim YJ. Improvement of end-stage renal disease in an obese diabetic patient after gastric bypass: bariatric times. Bariatric Times 2013;10:22-4. Available from: https://bariatrictimes.com/improvement. [Last accessed on 24 Oct 2024].

[14] Park S,Choi CY,Gil HW.Bariatric surgery can reduce albuminuria in patients with severe obesity and normal kidney function by reducing systemic inflammation.Obes Surg2018;28:831-7

[15] Schwartz P,Quaintenne M,Aroca-Martinez G.Obesity and glomerular filtration rate.Int Urol Nephrol2023;56:1663-68

[16] Kim EY.Does bariatric surgery really prevent deterioration of renal function?.Surg Obes Relat Dis2016;12:856-61

[17] D'Agati VD,de Vries AP.Obesity-related glomerulopathy: clinical and pathologic characteristics and pathogenesis.Nat Rev Nephrol2016;12:453-71

[18] Sandino J,Morales E.Which patients with obesity are at risk for renal disease?.Nephron2021;145:595-603

[19] Schütten MT,de Leeuw PW.The link between adipose tissue renin-angiotensin-aldosterone system signaling and obesity-associated hypertension.Physiology (Bethesda)2017;32:197-209

[20] García-Carro C,Bermejo S,Sellarés J.A nephrologist perspective on obesity: from kidney injury to clinical management.Front Med (Lausanne)2021;8:655871 PMCID:PMC8076523

[21] Artunc F,Weigert C,Stefan N.The impact of insulin resistance on the kidney and vasculature.Nat Rev Nephrol2016;12:721-37

[22] Stasi A,Caggiano G.Obesity-related chronic kidney disease: principal mechanisms and new approaches in nutritional management.Front Nutr2022;9:925619 PMCID:PMC9263700

[23] Praga M.The fatty kidney: obesity and renal disease.Nephron2017;136:273-6

[24] Verde L,Cernea S.The fat kidney.Curr Obes Rep2023;12:86-98 PMCID:PMC10250266

[25] Yang S,Deng T.Obesity-related glomerulopathy: a latent change in obesity requiring more attention.Kidney Blood Press Res2020;45:510-22

[26] Kotsis V,Trakatelli C.Impact of obesity in kidney diseases.Nutrients2021;13:4482 PMCID:PMC8703549

[27] Alicic RZ,Tuttle KR.Diabetic kidney disease: challenges, progress, and possibilities.Clin J Am Soc Nephrol2017;12:2032-45 PMCID:PMC5718284

[28] Górriz JL,Ortiz A.Sodium-glucose cotransporter 2 inhibition: towards an indication to treat diabetic kidney disease.Nephrol Dial Transplant2020;35:i13-23 PMCID:PMC6993197

[29] Neuen BL,Heerspink HJL.SGLT2 inhibitors for the prevention of kidney failure in patients with type 2 diabetes: a systematic review and meta-analysis.Lancet Diabetes Endocrinol2019;7:845-54

[30] Chagnac A,Rozen-Zvi B.Consequences of glomerular hyperfiltration: the role of physical forces in the pathogenesis of chronic kidney disease in diabetes and obesity.Nephron2019;143:38-42

[31] Denic A.Obesity-related glomerulopathy and single-nephron GFR.Kidney Int Rep2020;5:1126-8 PMCID:PMC7403627

[32] Ruggenenti P.Time to abandon microalbuminuria?.Kidney Int2006;70:1214-22

[33] Zoja C,Remuzzi G.Progression of renal injury toward interstitial inflammation and glomerular sclerosis is dependent on abnormal protein filtration.Nephrol Dial Transplant2015;30:706-12

[34] Yim HE.Obesity and chronic kidney disease: prevalence, mechanism, and management.Clin Exp Pediatr2021;64:511-8 PMCID:PMC8498012

[35] Xu T,Yao L.Obesity-related glomerulopathy: pathogenesis, pathologic, clinical characteristics and treatment.Front Med2017;11:340-8

[36] Lakkis JI.Obesity and kidney disease.Prog Cardiovasc Dis2018;61:157-67

[37] Martínez-Montoro JI,Cornejo-Pareja I,Fernández-García JC.Obesity-related glomerulopathy: current approaches and future perspectives.Obes Rev2022;23:e13450 PMCID:PMC9286698

[38] Herman-Edelstein M,Chagnac A.Obesity-related glomerulopathy: clinical management.Semin Nephrol2021;41:358-70

[39] Friedman AN,Fadel WF.Predicting the glomerular filtration rate in bariatric surgery patients.Am J Nephrol2014;39:8-15 PMCID:PMC3945154

[40] Scholten BJ, Persson F, Svane MS, Hansen TW, Madsbad S, Rossing P. Effect of large weight reductions on measured and estimated kidney function.BMC Nephrol2017;18:52 PMCID:PMC5294831

[41] de Vries AP, Ruggenenti P, Ruan XZ, et al; ERA-EDTA Working Group Diabesity. Fatty kidney: emerging role of ectopic lipid in obesity-related renal disease. Lancet Diabetes Endocrinol 2014;2:417-26.

[42] Friedman AN,Beddhu S.Obstacles and opportunities in managing coexisting obesity and CKD: report of a scientific workshop cosponsored by the National Kidney Foundation and The Obesity Society.Am J Kidney Dis2022;80:783-93

[43] Aboueisha MA,Allotey JK.A 5-year propensity-matched analysis of perioperative outcomes in patients with chronic kidney disease undergoing bariatric surgery.Surg Endosc2023;37:2335-46

[44] Nguyen NT.The physiologic effects of pneumoperitoneum in the morbidly obese.Ann Surg2005;241:219-26 PMCID:PMC1356906

[45] Filho MA, Alves RL, Nascimento PD Junior, Tarquinio GDS, Mega PF, Pinheiro Módolo NS. Effects of pneumoperitoneum on kidney injury biomarkers: a randomized clinical trial.PLoS One2021;16:e0247088 PMCID:PMC7895340

[46] Brethauer SA,Schirmer BD. Minimally invasive bariatric surgery. Springer New York; 2015. Available from: https://link.springer.com/content/pdf/10.1007/978-1-4939-1637-5.pdf. [Last accessed on 14 Oct 2024].

[47] The ASMBS Textbook of Bariatric Surgery. Cham: Springer International Publishing; 2020. Available from: https://link.springer.com/book/10.1007/978-3-030-27021-6. [Last accessed on 14 Oct 2024].

[48] Valera RJ,Montorfano L.Predictors and outcomes of acute kidney injury after bariatric surgery: analysis of the metabolic and bariatric surgery accreditation and quality improvement program data registry.Surg Obes Relat Dis2023;19:1302-7

[49] Thakar CV,Blanck S.Acute kidney injury after gastric bypass surgery.Clin J Am Soc Nephrol2007;2:426-30

[50] Chang AR,Navaneethan SD.Bariatric surgery and kidney-related outcomes.Kidney Int Rep2017;2:261-70 PMCID:PMC5399773

[51] Laurenius A,Ottosson J,Stenberg E.Incidence of kidney stones after metabolic and bariatric surgery-data from the scandinavian obesity surgery registry.Obes Surg2023;33:1564-70 PMCID:PMC10156825

[52] Froeder L,Malheiros CA,Heilberg IP.Response to dietary oxalate after bariatric surgery.Clin J Am Soc Nephrol2012;7:2033-40 PMCID:PMC3513742

[53] Bhatti UH,Roberts KE.Nephrolithiasis after bariatric surgery: a review of pathophysiologic mechanisms and procedural risk.Int J Surg2016;36:618-23

[54] Guan Y,Li J,Luo P.Obesity-related glomerulopathy: recent advances in inflammatory mechanisms and related treatments.J Leukoc Biol2024;115:819-39

[55] He J,Wang J.Potential therapeutic targets of obesity-related glomerulopathy.Metab Syndr Relat Disord2021;19:367-71

[56] Wahab R, Cohen RV, le Roux CW. Recent advances in the treatment of patients with obesity and chronic kidney disease.Ann Med2023;55:2203517 PMCID:PMC10124979

[57] Rogula TG,Fouse T. Prevention and management of complications in bariatric surgery. Oxford University Press; 2018. Available from: https://books.google.com/books?hl=zh-CN&lr=&id=X39XDwAAQBAJ&oi=fnd&pg=PP1&dq=Prevention+and+Management+of+Complications+in+Bariatric+Surgery&ots=zLBMZvkb_-&sig=W990pbqaDCYCkZbUyxfhbnD_oyQ#v=onepage&q=Prevention%20and%20Management%20of%20Complications%20in%20Bariatric%20Surgery&f=false. [Last accessed on 14 Oct 2024].

[58] Lee H,Yang W.Bariatric surgery reduces elevated urinary mitochondrial DNA copy number in patients with obesity.J Clin Endocrinol Metab2019;104:2257-66

[59] Cañizares S,Velarde F,Terán F.Is bariatric surgery improving mitochondrial function in the renal cells of patients with obesity-induced kidney disease?.Pharmacol Res2022;185:106488

[60] Huang H,Dai X.Improvement of renal function after bariatric surgery: a systematic review and meta-analysis.Obes Surg2021;31:4470-84

[61] Currie A,Ahmed AR.Bariatric surgery and renal function.Obes Surg2011;21:528-39

[62] Saliba J,Tamboli RA.Roux-en-Y gastric bypass reverses renal glomerular but not tubular abnormalities in excessively obese diabetics.Surgery2010;147:282-7 PMCID:PMC2813906

[63] Chagnac A,Herman M,Gafter U.The effects of weight loss on renal function in patients with severe obesity.J Am Soc Nephrol2003;14:1480-6

[64] Izzedine H,Reach I.Gastric bypass and resolution of proteinuria in an obese diabetic patient.Diabet Med2005;22:1761-2

[65] Schauer PR,Kirwan JP.Bariatric surgery versus intensive medical therapy for diabetes - 5-year outcomes.N Engl J Med2017;376:641-51 PMCID:PMC5451258

[66] Friedman AN,Wang J.Effect of bariatric surgery on CKD risk.J Am Soc Nephrol2018;29:1289-300 PMCID:PMC5875949

[67] Li Z,Xiong J,Jiang B.Renal function following bariatric surgery: a literature review of potential mechanisms.Obes Surg2022;32:1734-40

[68] Zubiaga L.Correlation of preoperative neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio with metabolic parameters in patients undergoing sleeve gastrectomy.Surg Obes Relat Dis2020;16:999-1004

[69] Kassam AF,Morris MC.The impact of sleeve gastrectomy on renal function in patients with chronic kidney disease varies with severity of renal insufficiency.Surg Obes Relat Dis2020;16:607-13

[70] Johnsen EM,Chen J,Le Jemtel T.Roux-en-Y gastric bypass and sleeve gastrectomy for obesity-associated hypertension.J Investig Med2021;69:730-5

[71] Hou CC,Lee WJ,Lee YC.Improved renal function 12 months after bariatric surgery.Surg Obes Relat Dis2013;9:202-6

[72] Imam TH,Jing B.Estimated GFR before and after bariatric surgery in CKD.Am J Kidney Dis2017;69:380-8 PMCID:PMC6264887

[73] Billeter AT,Brock J.Obesity surgery in patients with end-stage organ failure: is it worth it?.Surg Obes Relat Dis2022;18:495-503

[74] Sheetz KH,Shahinian VB,Montgomery JR.Trends in bariatric surgery procedures among patients with ESKD in the United States.Clin J Am Soc Nephrol2019;14:1193-9 PMCID:PMC6682821

[75] Pané A,Molina-Andujar A.Bariatric surgery outcomes in patients with chronic kidney disease.J Clin Med2023;12:6095 PMCID:PMC10532233

[76] Pané A,Olbeyra R.Bariatric surgery outcomes in patients with kidney transplantation.J Clin Med2022;11:6030 PMCID:PMC9604744

[77] Fernando S,Dengu F,Malik S.Bariatric surgery improves access to renal transplantation and is safe in renal failure as well as after transplantation: a systematic review and meta-analysis.Transplant Rev (Orlando)2023;37:100777

[78] Potrykus M,Małgorzewicz S,Dębska-Ślizień A.Diet management of patients with chronic kidney disease in bariatric surgery.Nutrients2022;15:165 PMCID:PMC9824280

[79] Bruci A,Tozzi R.Very low-calorie ketogenic diet: a safe and effective tool for weight loss in patients with obesity and mild kidney failure.Nutrients2020;12:333 PMCID:PMC7071259

[80] Watanabe M,Ernesti I.Scientific evidence underlying contraindications to the ketogenic diet: an update.Obes Rev2020;21:e13053 PMCID:PMC7539910

[81] Moriconi E,Fabbri A,Caprio M.Very-low-calorie ketogenic diet as a safe and valuable tool for long-term glycemic management in patients with obesity and type 2 diabetes.Nutrients2021;13:758 PMCID:PMC7996853

[82] Majorowicz RR,Bamlet HM.Nutritional considerations for patients with renal failure undergoing sleeve gastrectomy.J Ren Nutr2024;34:76-86

[83] Mechanick JI,Brethauer S.Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by american association of clinical endocrinologists/American college of endocrinology, the obesity society, American society for metabolic and bariatric surgery, obesity medicine association, and american society of anesthesiologists.Obesity (Silver Spring).2020;28:O1-58

[84] Tabesh MR,Ejtehadi F.Nutrition, physical activity, and prescription of supplements in pre- and post-bariatric surgery patients: a practical guideline.Obes Surg2019;29:3385-400

[85] Fouque D,ter Wee P.EBPG guideline on nutrition.Nephrol Dial Transplant2007;22 Suppl 2:ii45-87

[86] Favre G,Lemoine S,Iannelli A.Longitudinal assessment of renal function in native kidney after bariatric surgery.Surg Obes Relat Dis2018;14:1411-8

[87] Ben-Porat T,Rottenstreich A.Nutritional management for chronic kidney disease patients who undergo bariatric surgery: a narrative review.Adv Nutr2019;10:122-32 PMCID:PMC6370259

[88] Vaugier C,Chemouny JM.Serum iron protects from renal postischemic injury.J Am Soc Nephrol2017;28:3605-15 PMCID:PMC5698058