Renal Function in Type 2 Diabetes Following Gastric Bypass.

BACKGROUND: Metabolic surgery for obese patients with type 2 diabetes (T2D) yields short- and long-term remission rates of 60-90%. Its effects on diabetesassociated complications such as neuropathy and nephropathy have not been well studied to date. Hardly any data are available on this subject with respect to moderately obese patients (body mass index [BMI] 25-35 kg/m2) with insulin-dependent T2D. Our previous studies suggest that, in such patients, treatment with a Roux-en-Y gastric bypass (RYGB) improves diabetic neuropathy. In this pilot study, we investigate the course of diabetic nephropathy after RYGB surgery. METHODS: 20 insulin-dependent patients whose T2D was inadequately controlled with medication, and whose BMI was in the range 25-35 kg/m2, were prospectively included in a pilot study. All patients underwent a standardized RYGB operation. Blood and urine tests for renal function were performed before surgery and 12 and 24 months afterward. RESULTS: The serum creatinine level fell from 0.82 ± 0.23 to 0.69 ± 0.13 mg/dL (p = 0.0025) in the first 12 months after surgery and was unchanged a further 12 months later. The glomerular filtration rate (eGFR) rose in the first 24 months after surgery from 96.4 ± 28.7 to 111.7 ± 23.3 mL/min/1.73 m2 (p = 0.0093). The urinary albumin/creatinine and high-molecular-weight adiponectin/creatinine ratios fell markedly in the first 24 months after surgery (2.89 ± 3.14 versus 1.00 ± 0.24 mg/mmol [p = 0.0491] and 0.18 ± 0.06 versus 0.04 ± 0.01 µg/g [p = 0.0392]). CONCLUSION: RYGB has positive effects on renal function and may therefore be a good treatment option for moderately obese, insulin-dependent patients whose T2D cannot be adequately controlled with medication. These results still need to be confirmed in randomized, controlled trials with longer periods of followup.

Combined Non-alcoholic Fatty Liver Disease and Type 2 Diabetes Mellitus: Sleeve Gastrectomy or Gastric Bypass?-a Controlled Matched Pair Study of 34 Patients.

INTRODUCTION: Although all bariatric procedures improve non-alcoholic fatty liver disease (NAFLD) in metabolically sick obese patients, it remains unclear whether different procedures achieve similar effects. Sleeve gastrectomy (SG) and Roux-Y-gastric bypass (RYGB) were compared for their effects on liver function tests (LFT) and glycemic control in a highly selected group of metabolically sick obese patients with both elevated alanine aminotransferase (ALT), a common marker for NAFLD and type 2 diabetes mellitus (T2DM). METHODS: Thirty-four obese patients with a body mass index (BMI) >35 kg/m(2), ALT > 35 U/L, and T2DM were well-matched from a prospective database and retrospectively analyzed. Seventeen patients each underwent RYGB and SG, respectively. The effects on LFT and glycemic control were evaluated over 12 months. RESULTS: Both procedures significantly lowered ALT and aspartate aminotransferase (AST) after 12 months, but SG improved both LFT significantly better than RYGB (ALT 17.8 ± 8.8 vs. 31.1 ± 11.2 U/L, p = 0.003; AST 17.0 ± 8.8 vs. 24.3 ± 7.5 U/L, p = 0.004). In contrast to RYGB, SG normalized elevated ALT levels completely (41 vs. 0 %, p = 0.007). Both SG and RYGB improved insulin resistance, glycemic control, and reduced the need of insulin significantly without any difference between the procedures. CONCLUSION: SG appears to improve LFT better than RYGB in well-matched obese patients with both elevated ALT and T2DM. This suggests that SG may have a better effect on NAFLD than RYGB with similar effects on glycemic control. The present findings should be verified in randomized controlled trials to obtain further evidence for the decision-making on the most appropriate bariatric procedure for metabolically sick patients.

Risk of Malnutrition, Trace Metal, and Vitamin Deficiency Post Roux-en-Y Gastric Bypass--a Prospective Study of 20 Patients with BMI < 35 kg/m².

BACKGROUND: Due to its reliable effects on type 2 diabetes mellitus (T2DM) remission, Roux-en-Y gastric bypass (RYGB) has recently been investigated as a treatment option for nonseverely obese patients with T2DM (body mass index (BMI) <35 kg/m(2)). The purpose of this study was to investigate whether RGYB induces malnutrition of macro- and micronutrients within 24 months in these patients. METHODS: A prospective cohort of 20 patients with longstanding, insulin-dependent T2DM and a BMI of 25-35 kg/m(2) were treated with RYGB. The patients were supplemented with over-the-counter, multivitamin, and micronutrient supplements. Serum concentrations of albumin, vitamins, and trace elements, hemoglobin, and bone density were measured preoperatively and over a 24-month period (DRKS00004605). RESULTS: RYGB did not result in underweight or protein malnutrition. No new onset of deficiencies of water- or fat-soluble vitamins developed over the study period. However, serum selenium, zinc, and ferritin decreased significantly (selenium, 1.17 ± 0.13 to 0.89 ± 0.11 µmol/l, p = 0.018; zinc, 13.9 ± 0.5 to 10.8 ± 0.5 µmol/l, p = 0.012; ferritin, 171.7 ± 26.9 to 31.8 ± 11.2 µg/l, p = 0.018). Hemoglobin remained stable. Vitamin D (13.7 ± 1.8 to 19.1 ± 1.1 ng/ml, p = 0.017) and osteocalcin (15.3 ± 1.7 to 25.4 ± 2.7 ng/ml, p = 0.025) rose significantly, whereas the parathyroid hormone remained stable. Despite increased bone formation, bone density decreased (T score hip, 0.15 ± 0.25 to -0.71 ± 0.34, p = 0.005) resulting in a significant increase in osteopenia rates (18 to 50 %, p = 0.046). CONCLUSIONS: This is the first prospective cohort to investigate malnutrition after RYGB in nonseverely obese patients. These patients are at risk of developing iron, selenium, and zinc deficiencies within 24 months, as well as osteopenia despite an increase in bone formation.

A cell-based approach to the minimization of immunosuppression in renal transplantation.

Five renal transplant recipients were preoperatively treated with transplant acceptance-inducing cells (TAICs) in a Phase-I safety study of TAICs as an adjunct immune-conditioning therapy in living-donor kidney transplantation. Initially, patients received anti-thymocyte globulin induction therapy in combination with tacrolimus and steroid immunosuppression. Over the course of 12 weeks, steroids were withdrawn and tacrolimus therapy was minimized. Three of the five patients were able to tolerate low-dose tacrolimus monotherapy and one patient was withdrawn from all immunosuppression for over 8 months. No acute or delayed adverse events were associated with the infusion of TAICs. Monitoring of the recipient anti-donor reactivity of TAIC-treated patients in mixed lymphocyte cultures demonstrated that, during periods of clinically stable graft function, recipient T-cell proliferation and cytokine secretion in response to stimulation with donor alloantigen was relatively suppressed. Therefore, although the TAIC-II trial did not provide conclusive evidence of a beneficial effect of preoperative TAIC treatment, the results were encouraging because they suggest that TAICs promote a state of alloantigen-specific unresponsiveness, which might allow safe minimization of pharmacological immunosuppression.