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Bariatric surgery reduces renal impairment in teens with severe obesity
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SAN FRANCISCO — A cohort of adolescents with morbid obesity and type 2 diabetes had 27-fold lower odds of developing elevated albumin excretion 5 years after undergoing bariatric surgery when compared with similar teens who received standard medical therapy, according to study data presented at the American Diabetes Association Scientific Sessions.
“In an age, ethnicity, sex and BMI-matched analysis of the Teen-LABS and TODAY studies, surgical treatment of severely obese youth with type 2 diabetes conferred substantially lower odds for kidney disease over 5-years of follow-up compared with standard medical therapy,” Petter Bjornstad, MD, assistant professor of pediatrics and medicine in the division of renal diseases and hypertension at Children’s Hospital Colorado, told Endocrine Today. “Improvement in HbA1c and BMI were the strongest mediators of the difference observed in Teen-LABS and TODAY.”
In a secondary analysis, Bjornstad and colleagues assessed rates of diabetic kidney disease over 5 years of follow-up in two cohorts of adolescents with severe obesity and type 2 diabetes who underwent bariatric surgery (Teen-LABS study) or standard medical therapy (TODAY). Teen-LABS participants underwent bariatric surgery (n = 30; mean age, 17 years; 70% girls; 66% white; mean baseline BMI, 54.4 kg/m²). TODAY participants were randomly assigned to metformin therapy alone or in combination with rosiglitazone or intensive lifestyle intervention, with insulin therapy prescribed when needed (n = 63; mean age, 15 years; 44% girls; 71% white; mean baseline BMI, 40.5 kg/m²).
Researchers frequency matched TODAY participants (irrespective of treatment group assignment) to the 30 Teen-LABS participants by age, ethnicity, sex and baseline BMI. Researchers assessed levels of urinary albumin excretion, estimated glomerular filtration rate (eGFR) by creatinine and cystatin C equation, and prevalence of elevated urinary albumin excretion ( 30mg/g) and hyperfiltration (eGFR 135ml/min/1.73m²).
During 5-years of follow-up, hyperfiltration decreased from 20% to 13% in Teen-LABS and increased from 5% to 37% in TODAY, according to researchers. Elevated urinary albumin excretion decreased from 27% to 5% in Teen-LABS and increased from 21% to 43% in TODAY.
After adjusting for baseline age, sex, BMI and HbA1c, Teen-LABS participants had 15-fold lower odds of hyperfiltration (OR = 0.06; 95% CI 0.01-0.38) and 27-fold lower odds of elevated urinary albumin excretion (OR = 0.04; 95% 0.01-0.2) at 5-years of follow-up. Decreases in HbA1c and BMI showed the strongest associations with the attenuation of hyperfiltration and elevated urinary albumin excretion, respectively.
“We were surprised by the magnitude of difference in diabetic kidney disease risk observed for youth undergoing bariatric surgery compared with standard medical therapy,” Bjornstad said in an interview. “Adolescents in the bariatric surgery group had 27-fold lower odds of elevated albumin excretion at 5-year follow-up vs. youth receiving standard medical therapy.”
Bjornstad said the data support bariatric surgery as a treatment alternative for youths with severe obesity and type 2 diabetes, particularly those with high risk for diabetic kidney disease.
“Although bariatric surgery incurs a substantial initial cost, the benefit of bariatric surgery in youth-onset type 2 diabetes may outweigh the potential morbidity and initial costs for the carefully chosen patient in a specialized and experienced medical center,” Bjornstad said. “Future studies are needed to determine the nephroprotective effects of gastric bypass vs. vertical sleeve gastrectomy in youth with type 2 diabetes. Future directions should also include translational studies dedicated to enhancing our understanding of the mechanisms of surgical benefit and identify potential novel nonsurgical approaches to diabetic kidney disease in youth-onset type 2 diabetes.” – by Regina Schaffer
Reference:
Bjornstad P, et al. 123-OR. Presented at: American Diabetes Association 79th Scientific Sessions; June 7-11, San Francisco.
Disclosures: Bjornstad reports he serves on advisory panels for Horizon and XORTX and receives consulting fees from Bayer, Boehringer Ingelheim and Bristol-Myers Squibb. Please see the abstract for all other authors’ relevant financial disclosures.
Perspective
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Katherine R. Tuttle, MD, FASN, FACP, FNKF
Rapidly increasing numbers of youths are developing type 2 diabetes, which is inextricably linked to the obesity epidemic. Youth-onset type 2 diabetes is associated with higher risk and earlier onset of severe complications, such as diabetic kidney disease. Options for management are limited and have been largely understudied. The comparison analysis of the Teen-LABS and TODAY studies is an important observation that the makes the case for bariatric surgery to prevent diabetic kidney disease, along with improving control of metabolic risk factors, in obese patients with youth-onset type 2 diabetes. Future research should be done to identify appropriate candidates for bariatric surgery and to delineate mechanisms that may inform development of less-invasive therapies for preventing complications in these young patients.
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