THE NOVEL CONCEPT OF DECREMENTAL HOME HEMODIALYSIS FOLLOWING SUCCESSFUL BARIATRIC SURGERY IN END STAGE RENAL DISEASE

THE NOVEL CONCEPT OF DECREMENTAL HOME HEMODIALYSIS FOLLOWING SUCCESSFUL BARIATRIC SURGERY IN END STAGE RENAL DISEASE

Bariatric surgery (BS) is an established treatment for achieving weight loss in morbidly obese patients. Patients with chronic kidney disease but not on dialysis who had BS experienced reduced mortality compared to matched controls, with vertical laparoscopic sleeve gastrectomy (LSG) being the safer option compared to Roux-en-Y gastric bypass. Nevertheless, BS in dialysis patients is uncommon due to concern regarding complications including high post-operative mortality and myocardial infarction. Furthermore, there remains controversy about the role of weight loss interventions in patients with kidney failure on dialysis. Moreover, observational studies suggest a protective association of elevated BMI versus death in hemodialysis patients, although this has not been consistently observed among peritoneal dialysis patients. Our patient on maintenance home hemodialysis (HHD) achieved >40% weight reduction following LSG, and was able to reduce HHD frequency from 5x/week to 4x/week while maintaining overall improved physical and mental well-being, together with acceptable laboratory indices. This novel concept of personalized decremental hemodialysis calls for further study.

This is the first case report of an ESRD patient on HHD undergoing BS with successful weight loss. BS is an excellent option to help a patient lose weight with the potential to reach BMI goals for kidney transplantation. She has since started kidney transplant evaluation. Despite a paucity of literature on intentional approaches to weight loss in ESRD, LSG is increasingly used for patients with kidney failure and severe obesity. More research is needed to assess long-term cardiovascular and kidney transplant outcomes following BS. 

Finally, the novel concept of personalized decremental hemodialysis was validated with our patient as she was able to downshift to 4 vs 5 HHD treatments per week, and yet maintained both physical and mental wellness, good laboratory indices and adequate Kt/v targets. This again calls for further investigation.