Impact of intentional weight loss on diabetic kidney disease

Abstract

Type 2 diabetes mellitus (T2DM) and obesity constitute interwoven pandemics challenging healthcare systems in developed countries, where diabetic kidney disease (DKD) is the most common cause of end‐stage renal disease. Obesity accelerates renal functional decline in people with T2DM. Intentional weight loss (IWL) strategies in this population hold promise as a means of arresting DKD progression. In the present paper, we summarize the impact of IWL strategies (stratified by lifestyle intervention, medications, and metabolic surgery) on renal outcomes in obese people with DKD. We reviewed the Medline, EMBASE and Cochrane databases for relevant randomized control trials and observational studies published between August 1, 2018 and April 15, 2019. We found that IWL improves renal outcomes in the setting of DKD and obesity. Rate of progression of DKD slows with IWL, but varying outcome measures among studies makes direct comparison difficult. Furthermore, established means of estimating renal function are imperfect owing to loss of lean muscle mass with IWL strategies. The choice of optimal IWL strategy needs to be individualized; future work should establish the comparative efficacy of IWL strategies in obese people with DKD to better inform such decisions.

Parallel assessment of albuminuria and plasma sTNFR1 in people with type 2 diabetes and advanced chronic kidney disease provides accurate prognostication of the risks of renal decline and death

“…New therapies which improve outcomes for people with type 2 diabetes and more advanced CKD are required. Intentional weight loss strategies, including metabolic surgery, and mesenchymal stem cells hold promise in this regard 6,7,33 . Integrated diabetes and nephrology care at later CKD stages may also improve patient outcomes, particularly for people with diabetes and additional CKD aetiologies 5 , and should be considered to lower cardiovascular and renal risk in those with higher sTNFR1 values.…”

“…Enhanced integration of diabetes and nephrology care, including earlier referral to nephrology services, can improve renal outcomes for people with diabetes and chronic kidney disease (CKD) 5 . Intentional weight loss strategies, including metabolic surgery, may also reduce the burden of cardiovascular disease and slow renal functional decline in people with type 2 diabetes and CKD [6][7][8] . Given the range of new and efficacious options for the treatment of diabetes and its complications, identifying subgroups at the highest risk of rapid renal functional decline and/or death will help clinicians to appropriately stratify intensification of therapy.…”

Metabolic Surgery to Treat Obesity in Diabetic Kidney Disease, Chronic Kidney Disease, and End-Stage Kidney Disease; What Are the Unanswered Questions?

“…Metabolic surgery achieves sustained weight loss and substantially lowers mortality in people with obesity ( 57 , 58 ). Obesity is increasingly recognised as an important driver of CKD progression and is an important barrier to kidney transplantation, yet obesity is not specifically addressed during routine management of CKD and ESKD despite evidence of benefit ( 59 ). We herein summarise evidence supporting the potentially diverse roles of metabolic surgery in slowing DKD and CKD progression, as well as facilitating access to kidney transplantation and management of post-transplant metabolic complications.…”

Impact of Metabolic Surgery on Renal Injury in Pre-Clinical Models of Diabetic Kidney Disease

“…Large-scale observational studies have demonstrated that metabolic surgery reduces the incidence of albuminuria, slows progressive renal functional decline, and reduces the incidence of ESKD in patients with obesity [10][11][12][13]. Improved control of body weight, blood pressure, dyslipidaemia, and glycaemia contribute to these findings [14]. However, in patients with type 2 diabetes, the antiproteinuric effect of metabolic surgery occurs independently of improvements in body weight, blood pressure, and glycaemia [15].…”