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American Journal of Transplantation 2015; 15: 1126–1127 Wiley Periodicals Inc.

Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.13206

Letter to the Editor

Laparoscopic Sleeve Gastrectomy as a Weight Reduction Strategy in Obese Patients After Kidney Transplantation To the Editor: We read with interest the paper by Golomb et al that has been recently published in your journal (1). In the paper, the authors describe their expertise in the strategy for weight reduction in obese patients (OP) after kidney transplantation (KT). Although we acknowledge their remarkable results, we would like to point out the key issues of OP with end stage renal disease (ESRD) candidates to KT, and add some comments regarding the possible therapies to correct obesity. Specifically, an important topic is represented by the choice of the best surgical approach and by its timing (e.g. before or after KT). In our experience, the best time for bariatric surgery is represented by the pretransplant period. Despite significant improvement in both kidney graft and patient survival have been registered in the last decade, several risk factors, including an elevated body mass index (BMI), are still associated with poor outcomes. Recent guidelines (2) recommend that OP candidates for KT should be rigorously screened for age, cardiovascular status, diabetes mellitus, and quality of dialysis, and each risk factor should be considered individually. Other guidelines (3) report that patients with a BMI greater than 40 kg/m2 are less likely to benefit from KT. Furthermore, supervised weight loss therapy is recommended, targeting toward a BMI below 30 kg/m2. A meta-analysis (4) considering the posttransplant period complications reported that OP have an increased risk of delay graft function (DGF), are often refractory to steroids, or have higher possibility of developing diabetes. On the contrary, controlled weight loss has a positive effect on renal function, reducing serum creatinine, albuminuria and proteinuria, and increasing creatinine clearance. Moreover, despite the ‘‘BMI paradox‘‘ in dialysis patients, obesity is a strong risk factor for the deterioration of kidney function after initiation of dialysis. Regarding the surgical approach, Golomb et al (1) have shown that posttransplant bariatric surgery does not reduce the intraoperative and perioperative risks for the patients and does not offer advantages in term of graft survival. Overall, all posttransplant surgical procedures have higher risks of general and surgical site infections. Furthermore, bariatric surgery after KT requires adjustments in the dosage of immunosuppressants, thus leading to the 1126

possibility of an acute organ rejection. Thus the point is: Is pretransplant bariatric surgery a better approach for OP? A report by Lin et al showed how pretransplant sleeve gastrectomy can be safe (5). In our personal experience, we have treated three patients with BMI>37 kg/m2 using pretransplant sleeve gastrectomy and obtaining a reduction of BMI up to 30 kg/m2. All patients received organs from deceased donors. Of these, two patients were successfully transplanted, and one is still on dialysis. Our decision to proceed with the surgical approach before KT was justified in order to reduce all the possible risks that we have previously considered. Furthermore, we preferred to stabilize the OP from the metabolic point of view in order to avoid any possible modification of the immunosuppressive therapy after transplantation. No specific problems regarding the chronic dialysis treatment were encountered in the period between the bariatric surgery, the weight loss, and the kidney transplant. In conclusion, our data suggest that OP candidates for KT could undergo bariatric surgery before transplantation. In nontransplantable OP undergoing bariatric surgery might allow to be newly reconsidered for KT. In this context, we believe that sleeve gastrectomy represents a good choice for treating OP. G. L. Adani*, E. Righi, U. Baccarani, D. Montanaro, P. Tulissi, G. Terrosu and A. Risaliti Kidney Transplant Program, Department of Medical & Biological Sciences, University Hospital, Udine, Italy *

Corresponding author: Gian L. Adani, [email protected]

Disclosure The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

References 1. Golomb I, Winkler J, Ben-Yakov A, Benitez CC, Keidar A. Laparoscopic sleeve gastrectomy as a weight reduction strategy

Letter to the Editor in obese patients after kidney transplantation. Am J Transplant 2014; 14: 2384–2390. 2. Gore JL, Pham PT, Danovitch GM, et al. Obesity and outcome following renal transplantation. Am J Transplant 2006; 6: 357–363. 3. Ghahramani N, Reeves WB, Hollenbeak C. Association between increased body mass index, calcineurin inhibitor use, and renal graft survival. Exp Clin Transplant 2008; 6: 199–202.

American Journal of Transplantation 2015; 15: 1126–1127

4. Nicoletto BB, Fonseca NK, Manfro RC, GonSc alves LF, Leit~ ao CB, Souza GC. Effects of obesity on kidney transplantation outcomes: A systematic review and meta-analysis. Transplantation 2014; 98: 167–176. 5. Lin MY, Tavakol MM, Sarin A, et al. Laparoscopic sleeve gastrectomy is safe and efficacious for pretransplant candidates. Surg Obes Relat Dis 2013; 9: 653–658.

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Laparoscopic sleeve gastrectomy as a weight reduction strategy in obese patients after kidney transplantation.

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