Back
Prevalence of obesity is increasing worldwide .This increment is noted in patients with chronic kidney disease (CKD). Severe obesity is associated with multiple medical problems.
A 21 year old male patient known to have a history of childhood nephrotic syndrome. A biopsy proven minimal change disease, diagnosed at age of 7 years. He has a normal renal function. he received multiple regimens of immunosuppressive medications, including tacrolimus, mycophenolate mofetil, steroids, and cyclosporine. He also received rituximab .The nephrotic syndrome response is fluctuating but predominantly remained in partial remission with proteinuria average range at around 2 g per day despite the patient was maintained on cyclosporine ,small dose Prednisolone and ACEi. The patient had morbid obesity with BMI of 42 kg/m2 and body weight 140 kg. He referred to Bariatric Service, and in mid-July 2019, he underwent laparoscopic sleeve gastrectomy. A follow up post bariatric surgery showed a significant drop in proteinuria and patient achieved complete remission (proteinuria below 0.5 g/day). This was associated in parallel of weight reduction to average around 85 kg .More importantly, we stopped his immunosuppressive medication gradually and patient maintained in complete remission without any medications.
Obesity associated with increased risk of CKD, which may progress to ESRD , nephrolithiasis and renal cell cancer. The mechanism includes obesity-mediated hypertension, insulin resistance, glomerular hyper filtration, activation of the renin−angiotensin−aldosterone system, inflammation, and adipocytokine dysregulation. Obesity related glomerularpathy (ORG) is emerging term in which the obesity affect the kidney and manifested by variable degree of proteinuria also nephrotic range proteinuria can be seen without another manifestation . The renal biopsy shows focal global and segmental glomerulosclerosis (FSGS) of perihilar variant and the presence of glomerulomegaly .The electron microscope shows less degree of foot process effacement in comparison to the primary form of nephrotic syndrome .ORG may progress into renal failure in half of cases if left untreated. The treatment option of obesity is mainly conservative by weight reduction which can lead to improve diabetic control, decrease dyslipidemia, hypertension and decrease cardiovascular event all will improve both proteinuria and renal function. measures with targeting weight reduction are difficult and challenging. Studies showed the effective way of achieving weight reduction is a Bariatric surgery. currently the main management of proteinuric kidney disease is anti proteinuria medications with ACE inhibitors or ARBII. For proteinuric kidney disease associated with autoimmune glomerulonephritis adding immunosuppressive medications is needed .taking into consideration their side effect and variability in response .there is reported cases with glomerulopatheis obese patients with nephrotic syndrome they achieve complete resolution after Bariatric surgery.
Bariatric surgery may consider as acceptable approach in obese patients with impaired renal function and heavy proteinuria. Further randomized controlled studies to compare the traditional treatment versus bariatric surgery in obese patients with nephrotic syndrome is needed.