Diabetes Complications Research Centre, School of Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland.
Instituto de Estudios de Ciencias de la Salud de Castilla y León-Instituto de Investigación Biomédica de Salamanca (IECSCYL-IBSAL), Hospital Virgen Vega, Salamanca, Spain.
Front Endocrinol (Lausanne). 2020 Aug 17;11:289. doi: 10.3389/fendo.2020.00289. eCollection 2020.
Obesity is a major factor in contemporary clinical practice in nephrology. Obesity accelerates the progression of both diabetic and non-diabetic chronic kidney disease and, in renal transplantation, both recipient and donor obesity increase the risk of allograft complications. Obesity is thus a major driver of renal disease progression and a barrier to deceased and living donor kidney transplantation. Large observational studies have highlighted that metabolic surgery reduces the incidence of albuminuria, slows chronic kidney disease progression, and reduces the incidence of end-stage kidney disease over extended follow-up in people with and without type 2 diabetes. The surgical treatment of obesity and its metabolic sequelae has therefore the potential to improve management of diabetic and non-diabetic chronic kidney disease and aid in the slowing of renal decline toward end-stage kidney disease. In the context of patients with end-stage kidney disease, although complications of metabolic surgery are higher, absolute event rates are low and it remains a safe intervention in this population. Pre-transplant metabolic surgery increases access to kidney transplantation in people with obesity and end-stage kidney disease. Metabolic surgery also improves management of metabolic complications post-kidney transplantation, including new-onset diabetes. Procedure selection may be critical to mitigate the risks of oxalate nephropathy and disruption to immunosuppressant pharmacokinetics. Metabolic surgery may also have a role in the treatment of donor obesity, which could increase the living kidney donor pool with potential downstream impact on kidney paired exchange programmes. The present paper provides a comprehensive coverage of the literature concerning renal outcomes in clinical studies of metabolic surgery and integrates findings from relevant mechanistic pre-clinical studies. In so doing the key unanswered questions for the field are brought to the fore for discussion.
肥胖是当代肾脏病学临床实践中的一个主要因素。肥胖加速了糖尿病和非糖尿病慢性肾脏病的进展，在肾移植中，受者和供者肥胖都会增加移植物并发症的风险。因此，肥胖是肾脏疾病进展的主要驱动因素，也是阻止已故和活体供肾移植的障碍。大型观察性研究强调，代谢手术可降低蛋白尿的发生率，减缓慢性肾脏病的进展，并在延长随访中降低 2 型糖尿病和非 2 型糖尿病患者发生终末期肾病的风险。肥胖及其代谢后果的手术治疗因此有可能改善糖尿病和非糖尿病慢性肾脏病的管理，并有助于减缓向终末期肾脏病的肾脏衰退。在终末期肾病患者中，尽管代谢手术的并发症更高，但绝对事件发生率较低，在该人群中仍然是一种安全的干预措施。移植前代谢手术增加了肥胖和终末期肾病患者接受肾移植的机会。代谢手术还改善了肾移植后的代谢并发症管理，包括新发糖尿病。手术方式的选择可能对减轻草酸盐肾病的风险和免疫抑制剂药代动力学的干扰至关重要。代谢手术也可能在治疗供体肥胖方面发挥作用，这可能会增加活体供肾捐献者的数量，从而对肾对换计划产生潜在的下游影响。本文全面介绍了代谢手术临床研究中与肾脏结局相关的文献，并整合了相关机制性临床前研究的结果。这样做可以将该领域的关键未解决问题提出来进行讨论。
