Expired CME Article
Metabolic, Renal, and Nutritional Consequences of Bariatric Surgery: Implications for the Clinician
Abstract
Management of obesity-associated comorbidities costs about $60 billion/year, about 5% of total US healthcare expenditure. Bariatric surgery is the only proven effective weight loss therapy for severely obese patients with a BMI ≥35 kg/m2. Bariatric surgery produces long-term weight loss, improves quality of life, and reduces the number of sick days and medication costs. Surgery has a profound effect on the metabolic milieu and nutritional status from the first few days after surgery, even before significant weight loss has been achieved. Metabolic effects of bariatric surgery reduce obesity-related comorbidities like type 2 diabetes, hypertension, metabolic syndrome, and cardiovascular disease risk. Improvement in renal function is seen, but adverse effects like oxalate nephropathy can lead to chronic kidney disease or end-stage renal disease (CKD/ESRD). Surgery can also lead to micronutrient deficiencies, making dietary supplementation necessary. Reduction in insulin resistance and hypertension after surgery makes medication adjustment imperative. Improvement in comorbidities and nutritional deficiencies after bariatric surgery has important clinical implications.
Key Points
* Reduction in obesity-related mortality and comorbidities after bariatric surgery is largely due to metabolic effects like decreased insulin resistance, better blood pressure control, and improvements seen in the lipid profile.
* Improved renal function is usually seen after surgery; however, oxalate nephropathy is a potential complication that can lead to irreversible renal failure.
* Increased insulin sensitivity, decreased baseline blood pressure and low-density lipoprotein levels, and improvement in kidney function make medication adjustments imperative after bariatric procedures. Nutritional requirements change and need to be monitored, and supplementation may be required.
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References
1. Lara MD, Kothari SN, Sugerman HJ. Surgical management of obesity: a review of the evidence relating health benefits to risks. Treat Endocrinol 2005;4:55–64.
2. Martin LF, Tan TL, Horn JR, et al. Comparison of the costs associated with medical and surgical treatment of obesity. Surgery 1995;118:599–606.
3 .North American Association for the Study of Obesity and the National Heart, Lung, and Blood Institute. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NIH publication 00-4084. Bethesda, National Institutes of Health, 2000.
4. NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med 1991;115:956–961.
5. NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg 2004;240:416–423.
6. Ballantyne GH. Measuring outcomes following bariatric surgery: weight loss parameters, improvement in co-morbid conditions, change in quality of life and patient satisfaction. Obes Surg 2003;13:954–964.
7. Monk JS Jr, Dia Nagib N, Stehr W. Pharmaceutical savings after gastric bypass surgery. Obes Surg 2004;14:13–15.
8. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222:339–350.
9. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med 2007;357:753–761.
10. United States National Commission on Diabetes. Report of the United States National Commission on Diabetes to the Congress of the United States. Publication number 76-1021. Bethesda, US Department of Health, Education, and Welfare, 1975.
11. Buchwald H. Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724–1737.
12. Sjöström L, Lindroos AK, Peltonen M, et al; Swedish Obese Subjects Study Scientific Group. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med2004;351:2683–2693.
13. Faraj M, Havel PJ, Phélis S, et al. Plasma acylation-stimulating protein, adiponectin, leptin, and ghrelin before and after weight loss induced by gastric bypass surgery in morbidly obese subjects. J Clin Endocrinol Metab 2003;88:1594–1602.
14. Creutzfeldt W, Nauck M. Gut hormones and diabetes mellitus. Diabetes Metab Rev 1992;8:149–177.
15. Yannakoulia M, Yiannakouris N, Blüher S, et al. Body fat mass and macronutrient intake in relation to circulating soluble leptin receptor, free leptin index, adiponectin, and resistin concentrations in healthy humans. J Clin Endocrinol Metab 2003;88:1730–1736.
16. Laferrère B, Heshka S, Wang K, et al. Incretin levels and effect are markedly enhanced 1 month after Roux-en-Y gastric bypass surgery in obese patients with type 2 diabetes. Diabetes Care 2007;30:1709–1716.
17. Gumbs AA, Modlin IM, Ballantyne GH. Changes in insulin resistance following bariatric surgery: role of caloric restriction and weight loss. Obes Surg 2005;15:462–473.
18. Dixon JB, O'Brien PE, Playfair J, et al. Adjustable gastric banding and conventional therapy for type 2 diabetes. JAMA 2008;299:316–323.
19. Busseto L, Pisent C, Rinaldi D, et al. Variation in lipid levels in morbidly obese patients operated with Lap-Band adjustable gastric banding system: effects of different levels of weight loss. Obes Surg 2000;10:569–577.
20. Cowan GS Jr, Buffington CK. Significant changes in blood pressure, glucose, and lipids with gastric bypass surgery. World J Surg 1998;22:987–992.
21. Sjöström CD, Lissner L, Wedel H, et al. Reduction in incidence of diabetes, hypertension, and lipid disturbances after intentional weight loss induced by bariatric surgery: the SOS Intervention Study. Obes Res 1999;7:477–484.
22. Gleysteen JJ. Results of surgery: long-term effects on hyperlipidemia. Am J Clin Nutr 1992;55:591S–593S.
23. Buffington CK, Cowan GS Jr, Smith H. Significant changes in the lipid-lipoprotein status of premenopausal morbidly obese females following gastric bypass surgery. Obes Surg 1994;4:328–335.
24. Buchwald H, Varco RL, Matts JP, et al. Effect of partial ileal bypass surgery on mortality and morbidity from coronary heart disease in patients with hypercholesterolemia: report of the Program on the Surgical Control of the Hyperlipidemias (POSCH). N Engl J Med 1990;323:946–955.
25. Buchwald H, Varco RL, Boen JR, et al. Effective lipid modification by partial ileal bypass reduced long-term coronary heart disease mortality and morbidity: five-year posttrial follow-up report from the POSCH. Program on the Surgical Control of the Hyperlipidemias. Arch Intern Med1998;158:1253–1261.
26. H Buchwald, Campos CT, Boen JR, et al. Disease-free intervals after partial ileal bypass in patients with coronary heart disease and hypercholesterolemia: report from the Program on the Surgical Control of the Hyperlipidemias (POSCH). J Am Coll Cardiol 1995;26:351–357.
27. Howard BV. Insulin actions in vivo: insulin and lipoprotein metabolism, in Alberti KGMM, DeFronzo RA, Keen H (eds): International Textbook of Diabetes Mellitus. West Sussex, United Kingdom, John Wiley & Sons, 1995, pp 531–539.
28. Jones DW, Kim JS, Andrew ME, et al. Body mass index and blood pressure in Korean men and women: the Korean National Blood Pressure Survey. J Hypertens 1994;12:1433–1437.
29. Garrison RJ, Kannel WB, Stokes J III, et al. Incidence and precursors of hypertension in young adults: the Framingham Offspring Study. Prev Med 1987;16:234–251.
30. Hypertension Prevention Trial Research Group: three-year effects of dietary changes on blood pressure. The Hypertension Prevention Trial. Arch Intern Med 1990;150:153–162.
31. Tuck ML, Sowers J, Dornfeld L, et al. The effect of weight reduction on blood pressure, plasma renin activity, and plasma aldosterone levels in obese patients. N Engl J Med 1981;304:930–933.
32. Davis BR, Blaufox MD, Oberman A, et al. Reduction in long-term antihypertensive medication requirements: effect of weight reduction by dietary intervention in overweight persons with mild hypertension. Arch Intern Med 1993;153:1773–1782.
33. Kirschner MA, Schneider G, Ertel NH, et al. An eight-year experience with a very-low-calorie formula diet for control of major obesity. Int J Obes 1988;12:69–80.
34. Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg 2001;234:279–289.
35. Carson JL, Ruddy ME, Duff AE, et al. The effect of gastric bypass surgery on hypertension in morbidly obese patients. Arch Intern Med 1994;154:193–200.
36. Sugerman HJ, Wolfe LG, Sica DA, et al. Diabetes and hypertension in severe obesity and effects of gastric bypass-induced weight loss. Ann Surg 2003;237:751–756.
37 .Lakka HM, Laaksonen DE, Lakka TA, et al. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. JAMA 2002;288:2709–2716.
38. The Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment program III). JAMA 2001;285:2486–2497.
39. Kelley DE. Influence of weight loss and physical activity interventions upon muscle lipid content in relation to insulin resistance. Curr Diab Rep 2004;4:165–168.
40. Pender C, Goldfine ID, Tanner CJ, et al. Muscle insulin receptor concentrations in obese patients post bariatric surgery: relationship to hyperinsulinemia. Int J Obes Relat Metab Disord 2004;28:363–369.
41. van Dielen FM, Buurman WA, Hadfoune M, et al. Macrophage inhibitory factor, plasminogen activator inhibitor-1, other acute phase proteins, and inflammatory mediators normalize as a result of weight loss in morbidly obese subjects treated with gastric restrictive surgery. J Clin Endocrinol Metab 2004;89:4062–4068.
42. Cottam DR, Mattar SG, Barinas-Mitchell E, et al. The chronic inflammatory hypothesis for the morbidity associated with morbid obesity: implications and effects of weight loss. Obes Surg 2004;14:589–600.
43. Kannel WB, Gordon T. Obesity and cardiovascular disease, in Burland W, Samuel PD, Yudkin J (eds): Obesity. London, Churchill Davidson, 1974.
44. Kotsis V, Stabouli S, Bouldin M, et al. Impact of obesity on 24-hour ambulatory blood pressure and hypertension. Hypertension 2005;45:602–607.
45. Alpert MA, Terry BE, Kelly DL. Effect of weight loss on cardiac chamber size, wall thickness and left ventricular function in morbid obesity. Am J Cardiol 1985;55:783–786.
46. Sugerman HJ, Baron PL, Fairman RP, et al. Hemodynamic dysfunction in obesity hypoventilation syndrome and the effects of treatment with surgically induced weight loss. Ann Surg 1988;207:604–613.
47. Harrison SA, Kadakia S, Lang KA, et al. Nonalcoholic steatohepatitis: what we know in the new millennium. Am J Gastroenterol 2002;97:2714–2724.
48. Silverman EM, Sapala JA, Appelman HD. Regression of hepatic steatosis in morbidly obese patients after gastric bypass. Am J Clin Pathol 1995;104:23–31.
49. Ranløv I, Hardt F. Regression of liver steatosis following gastroplasty or gastric bypass for morbid obesity. Digestion 1990;47:208–214.
50. De Prisco C, Levine SN. Metabolic bone disease after gastric bypass surgery for obesity. Am J Med Sci 2005;329:57–61.
51. Johnson JM, Maher JW, DeMaria EJ, et al. The long-term effects of gastric bypass on vitamin D metabolism. Ann Surg 2006;243:701–704.
52. Coates PS, Fernstrom JD, Fernstrom MH, et al. Gastric bypass surgery for morbid obesity leads to an increase in bone turnover and a decrease in bone mass. J Clin Endocrinol Metab 2004;89:1061–1065.
53. Sánchez-Hernández J, Ybarra J, Gich I, et al. Effects of bariatric surgery on vitamin D status and secondary hyperparathyroidism: a prospective study. Obes Surg 2005;15:1389–1395.
54.Hamoui N, Anthone G, Crookes PF. Calcium metabolism in the morbidly obese. Obes Surg 2004;14:9–12.
55. DiGiorgi M, Daud A, Inabnet WB, et al. Markers of bone and calcium metabolism following gastric bypass and laparoscopic adjustable gastric banding. Obes Surg 2008;18:1144–1148.
56. Shiffman ML, Sugerman HJ, Kellum JM, et al. Changes in gallbladder bile composition following gallstone formation and weight reduction. Gastroenterology 1992;103:214–221.
57. Shiffman ML, Sugerman HJ, Kellum JM, et al. Gallstone formation after rapid weight loss: a prospective study in patients undergoing gastric bypass surgery for treatment of morbid obesity. Am J Gastroenterol 1991;86:1000–1005.
58. Sugerman HJ, Brewer WH, Shiffman ML, et al. A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss. Am J Surg 1995;169:91–96.
59. Lastra G, Manrique C, Sowers JR. Obesity, cardiometabolic syndrome, and chronic kidney disease: the weight of the evidence. Adv Chronic Kidney Dis 2006;13:365–373.
60. Agnani S, Vachharajani VT, Gupta R, et al. Does treating obesity stabilize chronic kidney disease? BMC Nephrol 2005;6:7.
61. Navarro-Díaz M, Serra A, Romero R, et al. Effect of drastic weight loss after bariatric surgery on renal parameters in extremely obese patients: long-term follow-up. J Am Soc Nephrol 2006;17(12 suppl 3):S213–S217.
62. Asplin JR, Coe FL. Hyperoxaluria in kidney stone formers treated with modern bariatric surgery. J Urol 2007;177:565–569.
63. Patel BN, Passman CM, Fernandez A, et al. Prevalence of hyperoxaluria after bariatric surgery. J Urol 2009;181:161–166.
64. Nasr SH, D'Agati VD, Said SM, et al. Oxalate nephropathy complicating Roux-en-Y Gastric Bypass: an underrecognized cause of irreversible renal failure. Clin J Am Soc Nephrol 2008;3:1676–1683.
65. Adams ND, Gray RW, Lemann J Jr, et al. Effects of calcitriol administration on calcium metabolism in healthy men. Kidney Int 1982;21:90–97.
66. Williams HE. Oxalic acid and the hyperoxaluric syndromes. Kidney Int 1978;13:410–417.
67. Kathpalia SC, Favus MJ, Coe FL. Evidence for size and charge permselectivity of rat ascending colon. Effects of ricinoleate and bile salts on oxalic acid and neutral sugar transport. J Clin Invest1984;74:805–811.
68. Schaffalitzky de Muckadell OB, Ladefoged J, Thorup J. Renal tubular acidosis secondary to jejunoileal bypass for morbid obesity. Scand J Gastroenterol 1985;20:823–828.
69. Korzets Z, Smorjik Y, Zahavi T, et al. Renal AA amyloidosis—a long-term sequela of jejuno-ileal bypass. Nephrol Dial Transplant 1998;13:1843–1845.
70. Nguyen NT, Perez RV, Fleming N, et al. Effect of prolonged pneumoperitoneum on intraoperative urine output during laparoscopic gastric bypass. J Am Coll Surg 2002;195:476–483.
71. de Oliveira LD, Diniz MT, de Fátima H S Diniz M, et al. Rhabdomyolysis after bariatric surgery by Roux-en-Y gastric bypass: a prospective study. Obes Surg 2009;19:1102–1107.
72. de Freitas Carvalho DA, Valezi AC, de Brito EM, et al. Rhabdomyolysis after bariatric surgery. Obes Surg 2006;16:740–744.
73. Tucker ON, Szomstein S, Rosenthal RJ. Nutritional consequences of weight-loss surgery. Med Clin North Am 2007;91:499–514, xii.
74.T haisetthawatkul P, Collazo-Clavell ML, Sarr MG, et al. A controlled study of peripheral neuropathy after bariatric surgery. Neurology 2004;63:1462–1470.
75. Love AL, Billett HH. Obesity, bariatric surgery, and iron deficiency: true, true, true and related. Am J Hematol 2008;83:403–409.
76. Chaves LC, Faintuch J, Kahwage S, et al. A cluster of polyneuropathy and Wernicke-Korsakoff syndrome in a bariatric unit. Obes Surg 2002;12:328–334.
77. Mechanick JI, Kushner RF, Sugerman HJ, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Endocr Pract 2008;14 suppl 1:1–83.
78. Service GJ, Thompson GB, Service FJ, et al. Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric bypass surgery. N Engl J Med 2005;353:249–254.
79. Patti ME, McMahon G, Mun EC, et al. Severe hypoglycaemia post-gastric bypass requiring partial pancreatectomy: evidence for inappropriate insulin secretion and pancreatic islet hyperplasia.Diabetologia 2005;48:2236–2240.
80. Clancy TE, Moore FD Jr, Zinner MJ. Post-gastric bypass hyperinsulinism with nesidioblastosis: subtotal or total pancreatectomy may be needed to prevent recurrent hypoglycemia. J Gastrointest Surg 2006;10:1116–1119.
