Endoscopic Sleeve Gastroplasty as Facilitatorfor Renal Transplantation in Patients withObesity: Rationale and Protocol
DOI:
https://doi.org/10.71749/pkj.105Keywords:
Gastroplasty, Kidney Failure, Chronic, Kidney Transplantation, Obesity/surgeryAbstract
Introduction: Obesity is a major barrier to kidney transplantation, associated with increased perioperative complications and reduced graft survival. Traditional bariatric surgeries have shown effectiveness in weight reduction but present challenges in pharmacokinetics and nutritional status. Endoscopic sleeve gastroplasty has emerged as a less invasive alternative, potentially suitable as a bridge to renal transplantation in obese patients. This study aims to evaluate the efficacy and safety of ESG in patients with end‑stage kidney disease and obesity as a preparatory step to kidney transplantation. Primary endpoints include weight loss, BMI change, and transplant‑related complications. Secondary endpoints address ESG failure, need for adjunct therapy, and procedural safety.
Methods: A prospective, single‑center cohort trial will include 13 adult end‑stage kidney disease patients with BMI 30–42 kg/m² undergoing ESG. Outcomes will be compared with a case matched retrospective control cohort of previously transplanted obese patients who received no structured weight loss intervention. Patients will undergo ESG and follow a 6‑month monitored weight loss program. Those who do not reach a BMI <35 kg/m² may receive GLP‑1 agonists, repeat ESG or undergo surgical sleeve conversion.
Results: Preliminary institutional data show ESG achieves moderate weight loss with lower severe adverse event rates (1.8% vs 3.5%) and shorter hospital stay compared to laparoscopic sleeve gastrectomy. Study enrollment begins in May 2025.
Conclusion: ESG may represent a safe and effective strategy to optimize transplant eligibility in obese ESKD patients, with potential for integration into pre‑transplant assessment pathways.
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Stier CK, Téoule P, Dayyeh BKA. Endoscopic sleeve gastroplasty (ESG): indications and results-a systematic review. Updates Surg. 2025 Jan 28. doi: 10.1007/s13304-025-02097-1.
Salminen P, Kow L, Aminian A, Kaplan LM, Nimeri A, Prager G, et al. IFSO Experts Panel. IFSO Consensus on Definitions and Clinical Practice Guidelines for Obesity Management-an International Delphi Study. Obes Surg. 2024 Jan;34(1):30-42. doi: 10.1007/s11695-023-06913-8.
Marzorati S, Iovino D, Inversini D, Iori V, Parise C, Masci F, et al. Open Renal Transplantation in Obese Patients: A Correlation Study between BMI and Early and Late Complications with Implementation of a Prognostic Risk Score. Life (Basel). 2024 Jul 22;14(7):915. doi: 10.3390/life14070915.
Kermansaravi M, Chiappetta S, Parmar C, Shikora SA, Prager G, LaMasters T, et al. Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus. Sci Rep. 2024;14:3445.doi:10.1038/s41598-024-54141-6.
Gadwal S, Madipalli RT, Sharma S, Raju SB. Obesity in renal transplantation. Indian J Transplant. 2024 Jan-Mar;18(1):3-8. doi: 10.4103/ijot.ijot_134_23.
Dayyeh BKA, Stier C, Alqahtani A, Sharaiha R, Bandhari M, Perretta S, et al. IFSO Bariatric Endoscopy Committee Evidence-Based Review and Position Statement on Endoscopic Sleeve Gastroplasty for Obesity Management. Obes Surg. 2024 Dec;34(12):4318-4348. doi: 10.1007/s11695-024-07510-z.
Scheuermann U, Babel J, Pietsch UC, Weimann A, Lyros O, Semmling K, et al. Recipient obesity as a risk factor in kidney transplantation. BMC Nephrol. 2022;23:37. doi: 10.1186/s12882-022-02668-z.
Foucher Y, Lorent M, Albano L, Roux S, Pernin V, Le Quintrec M, et al. DIVAT consortium. Renal transplantation outcomes in obese patients: a French cohort-based study. BMC Nephrol. 2021 Mar 5;22(1):79. doi: 10.1186/s12882-021-02278-1.
Hill CJ, Courtney AE, Cardwell CR, Maxwell AP, Lucarelli G, Veroux M, et al. Recipient obesity and outcomes after kidney transplantation: a systematic review and meta-analysis. Nephrol Dial Transplant. 2015 Aug;30(8):1403-11. doi: 10.1093/ndt/gfv214.
Oniscu GC, Abramowicz D, Bolignano D, Gandolfini I, Hellemans R, Maggiore U, et al. Management of obesity in kidney transplant candidates and recipients: A clinical practice guideline by the DESCARTES Working Group of ERA. Nephrol Dial Transplant. 2021 Dec 24;37(Suppl 1):i1-i15. doi: 10.1093/ndt/gfab310.
Barroso Hernández S, Álvarez López Á, Rodríguez Sabillón JA, López Arnaldo C, Hernández Gallego R, García de Vinuesa Calvo E, et al. Effect of weight change after renal transplantation on outcomes of graft survival. Nefrologia (Engl Ed). 2022 Sep-Oct;42(5):568-577. doi: 10.1016/j.nefroe.2021.08.009.
Dobrzycka M, Spychalski P, Łącka M, Proczko-Stepaniak M, Kaska Ł, Dębska-Ślizień A, et al. Obesity in work-up of kidney transplant candidates – review of clinical practice guidelines. Eur J Transl Clin Med. 2020;3(2):72-79. doi: 10.31373/ejtcm/128771.
Di Cocco P, Okoye O, Almario J, Benedetti E, Tzvetanov IG, Spaggiari M. Obesity in kidney transplantation. Transpl Int. 2020 Jun;33(6):581-589. doi: 10.1111/tri.13547.
Chadban SJ, Ahn C, Axelrod DA, Foster BJ, Kasiske BL, Kher V, et al. Summary of the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation. 2020 Apr;104(4):708-714. doi: 10.1097/TP.0000000000003137.
Carvalho JA, Nunes P, Antunes HP, Tavares-da-Silva E, Parada B, Roseiro A, et al. Is Pretransplantation Overweight and Obesity still a Nightmare for Kidney Transplantation Outcomes? Acta Urol Port. 2019. doi: 10.24915/aup.35.3-4.87
Bellini MI, Ayathamattam J, Herbert PE, Koutroutsos K, Galliford J, Deurloo E, et al. The Conundrum of High Body Mass Index in Kidney Transplant Patients. OBM Transplantation. 2021;5(1):17. doi: 10.21926/obm.transplant.2101171.
Tran MH, Foster CE, Kalantar-Zadeh K, Ichii H. Kidney transplantation in obese patients. World J Transplant. 2016 Mar 24;6(1):135-43. doi: 10.5500/wjt.v6.i1.135.
Marinaki S, Kriki P, Kolovou K, Boletis JN. Obesity in kidney transplant donors and recipients: does the benefit outweigh the risk? Integr Obesity Diabetes. 2016;2. doi: 10.15761/IOD.1000147.
Freeman CM, Woodle ES, Shi J, Alexander JW, Leggett PL, Shah SA, et al. Addressing morbid obesity as a barrier to renal transplantation with laparoscopic sleeve gastrectomy. Am J Transplant. 2015 May;15(5):1360-8. doi: 10.1111/ajt.13116.
Abramowicz D, Cochat P, Claas FH, Heemann U, Pascual J, Dudley C, et al. European Renal Best Practice Guideline on kidney donor and recipient evaluation and perioperative care. Nephrol Dial Transplant. 2015 Nov;30(11):1790-7. doi: 10.1093/ndt/gfu216.
Campbell S, Pilmore H, Gracey D, Mulley W, Russell C, McTaggart S. KHA-CARI guideline: recipient assessment for transplantation. Nephrology (Carlton). 2013 Jun;18(6):455-462. doi: 10.1111/nep.12068.
Dudley C, Harden P. Renal Association Clinical Practice Guideline on the assessment of the potential kidney transplant recipient. Nephron Clin Pract. 2011;118 Suppl 1:c209-24. doi: 10.1159/000328070.
Gore JL, Pham PT, Danovitch GM, Wilkinson AH, Rosenthal JT, Lipshutz GS, et al. Obesity and outcome following renal transplantation. Am J Transplant. 2006 Feb;6(2):357-63. doi: 10.1111/j.1600-6143.2005.01198.x.
Jirapinyo P, Hadefi A, Thompson CC, Patai ÁV, Pannala R, Goelder SK, et al. American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity. Endoscopy. 2024 Jun;56(6):437-456. doi: 10.1055/a-2292-2494.
ASGE Bariatric Endoscopy Task Force and ASGE Technology Committee; Abu Dayyeh BK, Kumar N, Edmundowicz SA, Jonnalagadda S, Larsen M, et al. ASGE Bariatric Endoscopy Task Force systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting endoscopic bariatric therapies. Gastrointest Endosc. 2015 Sep;82(3):425-38.e5. doi: 10.1016/j.gie.2015.03.1964.
Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007 May;39(2):175-91. doi: 10.3758/bf03193146.
Cohen JB, Lim MA, Tewksbury CM, Torres-Landa S, Trofe-Clark J, Abt PL, Williams NN, Dumon KR, Goral S. Bariatric surgery before and after kidney transplantation: long-term weight loss and allograft outcomes. Surg Obes Relat Dis. 2019 Jun;15(6):935-941. doi: 10.1016/j.soard.2019.04.002
Buemi A, Romero L, Zech F, Darius T, De Meyer M, Devresse A, et al. Impact of Recipient Obesity on Kidney Transplantation Outcome: A Retrospective Cohort Study with a Matched Comparison. Transplant Proc. 2022 Sep;54(7):1786-1794. doi: 10.1016/j.transproceed.2022.03.058.
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Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
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Copyright (c) 2025 Vítor Patrício Correia, Teresa Pereira, Carlos Miranda, Raquel Lalanda, Helena Filipa Nogueira, Pedro Marques, Olavo Costa Gomes, Ana Craciun, Ana Rita Gonçalves, Maria João Melo, Alice Santana, Luís Correia, Rui Tato Marinho, José António Lopes, Luís Miranda
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