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. 2025 Nov 20;49(12):3448–3458. doi: 10.1002/wjs.70162

Outcomes After Bariatric Surgery in Older Adults With Obesity and End‐Stage Kidney Disease

Tanveen Ishaque 1, Allan B Massie 1,2, Darren Stewart 1, Yiting Li 1, Yusi Chen 1, Gayathri Menon 1, Nidhi Ghildayal 1, John R Montgomery 3, Timur Seckin 1, Karan R Chhabra 1,2,4, Megan E Jenkins 1, Christine J Ren‐Fielding 1, Mara A McAdams‐DeMarco 1,2, Dorry L Segev 1,2, Babak J Orandi 1,5,✉
PMCID: PMC12643172  NIHMSID: NIHMS2121137  PMID: 41266080

ABSTRACT

Objective

Given frailty and comorbidities that occur with both aging and end‐stage kidney disease (ESKD), it is unclear if older patients with ESKD derive the improved survival and kidney transplant (KT) access associated with Roux‐en‐Y gastric bypass (RYGB) or sleeve gastrectomy (SG).

Methods

Using 2006–2021 USRDS data, we identified 876 patients with RYGB and 1508 patients with SG and compared 5‐year mortality by age‐group (18–29/30–39/40–49/50–59/60–69/≥ 70 years) to nonsurgical matched controls using 1:3 Mahalanobis distance matching, Kaplan–Meier, and Cox regression. We also compared age‐stratified KT incidence between waitlisted patients and controls.

Results

Among patients with RYGB versus controls, 5‐year mortality was 11.4% versus 17.3% (aHR = 0.230.581.44), 31.5% versus 30.1% (aHR = 0.731.021.41), and 37.9% versus 47.3% (aHR = 0.690.771.00) for 18–29/30–39/40–49 years; however, 5‐year mortality was 77.1% versus 68.3% (aHR =  1.24 1.56 1.95 ) for 60–69 years and 86.8% versus 78.7% (aHR =  1.80 2.39 3.16 ) for ≥ 70 years. Among patients with SG versus controls, 5‐year mortality was 17.8% versus 30.2% (aHR =  0.26 0.47 0.83 ), 18.1% versus 36.3% (aHR =  0.28 0.39 0.53 ), 28.7% versus 48.9% (aHR =  0.35 0.43 0.53 ), 31.1% versus 61.6% (aHR =  0.27 0.35 0.44 ), 37.3% versus 65.7% (aHR =  0.35 0.48 0.66 ), and 51.5% versus 93.6% (aHR =  0.14 0.37 0.94 ) for 18–29/30–39/40–49/50–59/60–69/≥ 70 years. Among listed ≥ 65 years, KT incidence was 21.3% versus 25.4% (aHR = 0.191.015.26) for patients with RYGB versus controls and 66.7% versus 39.9% (aHR = 0.622.318.64) for patients with SG versus controls.

Conclusions

RYGB in older patients with ESKD is associated with increased mortality and lower KT likelihood, whereas SG is associated with decreased mortality and higher KT likelihood compared to nonsurgical matched controls. Choice of bariatric surgery type may play a role in improving survival for older patients with ESKD.

In a national study of patients with end‐stage kidney disease undergoing bariatric surgery, Roux‐en‐Y gastric bypass in older adults was associated with increased mortality, whereas sleeve gastrectomy was associated with decreased mortality compared to nonsurgical matched controls.

graphic file with name WJS-49-3448-g002.webp

Abbreviations

BMI

body mass index

CMS‐2728

Centers for Medicare and Medicaid Services (CMS) Medical Evidence form

ESKD

end‐stage kidney disease

IQR

interquartile range

KT

kidney transplant

RYGB

Roux‐en‐Y gastric bypass

SG

sleeve gastrectomy

USRDS

United States Renal Data System

1. Introduction

In the United State, the prevalence of adult obesity has grown from 30.5% in 1999–2000 [1] to 40.3% in 2021–2023 [2]. Obesity is a risk factor for kidney disease and a driver to end‐stage kidney disease (ESKD) [3, 4]. Indeed, the prevalence of obesity (body mass index [BMI] ≥ 30 kg/m2) among incident dialysis patients has mirrored the general population, rising from 31.9% in 2007 to 38.2% in 2016 [5]. In 2023, the prevalence of class I obesity (BMI 30–34.9 kg/m2) and class II obesity or higher (BMI ≥ 35 kg/m2) on the kidney transplant (KT) waitlist were 27.5% and 19.3%, respectively [6]. Although KT improves survival for patients with ESKD with obesity, they are 15%–71% less likely to be waitlisted [7, 8, 9]. If listed, patients with ESKD with obesity are 88% less likely to be activated from inactive status and 24% less likely to be transplanted [8, 10, 11, 12].

Growing evidence suggests that bariatric surgery enhances KT likelihood and improves survival for patients with ESKD with obesity, independent of KT [13, 14, 15, 16, 17]. Recent guidelines recommend consideration of bariatric surgery in this population [18]. However, Roux‐en‐Y gastric bypass (RYGB) or sleeve gastrectomy (SG) in ESKD is associated with increased postoperative complications and mortality compared to people without ESKD [19, 20, 21, 22, 23, 24]. Patients with ESKD undergoing bariatric surgery have a 3.1‐, 2.9‐, and 11.6‐fold higher odds of 30‐day reoperation, readmission, and death compared to patients without kidney disease undergoing bariatric surgery [19]. However, the incidence of postoperative complications is higher for RYGB than SG (17% vs. 7%), though the difference was not statistically significant [21].

Older adults constitute another high‐risk population when undergoing bariatric surgery [25, 26]. Compared to patients 40–49 years who underwent RYGB, those 60–64, 65–69, and ≥ 70 years had 1.3‐, 1.4‐, and 1.9‐times increased risk of major complications and 2.3‐, 2.2‐, and 4‐times increased 30‐day mortality [26]. However, compared to patients 40–49 years who underwent SG, those 60–64, 65–69, and ≥ 70 years had 1.4‐, 1.6‐, and 2.7‐times increased risk of major complications but comparable 30‐day mortality for all age groups [26]. There is scant data to guide decision‐making about RYBG or SG for older adults with obesity and ESKD, representing a major knowledge gap given the secular trends of aging and obesity in ESKD [27]. Therefore, we sought to quantify mortality risks and likelihood of KT for older patients with ESKD undergoing RYGB or SG and to determine if they differed from those of younger patients with ESKD.

2. Methods

2.1. Data Source

This study used data from the United States Renal Data System (USRDS) [28]. The USRDS is a national registry which contains data on all patients with ESKD in the United States who require renal replacement therapy as well as Medicare billing claims [28, 29, 30]. We obtained information about patient demographics, comorbidities, and body mass index (BMI) at ESKD onset from the Centers for Medicare and Medicaid Services (CMS) Medical Evidence form (CMS‐2728) [28, 29, 30]. This study was classified as “exempt‐not human subjects research” by the NYU Grossman School of Medicine Institutional Review Board.

2.2. RYGB and SG Patients

We identified patients with ESKD undergoing RYGB or SG from 2006 to 2021 through Medicare inpatient billing claims (Supporting Information S1: Table S1) [29]. We excluded patients who had inpatient claims for (1) prior bariatric surgery; (2) gastric or intestinal malignancy occurring on or prior to the bariatric surgery; (3) bariatric surgery submitted prior to the dialysis initiation or after the date of KT or death; (4) those < 18 years; (5) those with BMI < 35 kg/m2; and (6) those missing BMI, comorbid conditions, or who were from outside the 50 US states except Washington DC and Puerto Rico on the day of dialysis initiation. Gastric banding was excluded due to a small sample size.

2.3. Non‐Surgical Matched Controls

We identified 201,464 adult patients with ESKD whose BMI on the first ESKD service was ≥ 35 kg/m2 between 2006–2021 as potential nonsurgical matched controls. We excluded patients who had: (1) missing BMI, comorbid conditions, or were from outside the 50 US states except Washington DC and Puerto Rico on the day of dialysis initiation and (2) ever had bariatric surgery. We matched patients with RYGB and SG with nonsurgical matched controls based on age at dialysis initiation ± 10 years and BMI ± 5 kg/m2. Control patients were excluded if they (1) had died or had KT before the bariatric surgery inpatient claim date of their matched cases and (2) were not diagnosed as patients with ESKD on the bariatric surgery inpatient claim date. For each patient with RYGB and SG, we calculated the Mahalanobis distance between that patient and control based on age, history of hypertension, congestive heart failure, chronic obstructive pulmonary disease, peripheral vascular disease, transient ischemic attack, diabetes, coronary artery disease, smoking status, month, and year of dialysis initiation. For each patient with RYGB and SG, we selected three unique nonsurgical matched controls.

2.4. Secular Trends in RYGB and SG Among ESKD Patients

To illustrate secular trends of bariatric surgery in patients with ESKD, we plotted the number of RYGB and SG by year from 2006 to 2020 for patients for age Group 18–29/30–40/40–49/50–59/60–69/≥ 70 years in separate plots. Because we had bariatric surgery claims through June 2021, we did not include the year 2021 in these diagrams.

2.5. All‐Cause Mortality

Patients were followed from study entry date until the first of death, 5‐years, or administrative censoring on December 31, 2021. Outcomes were not censored for KT. Study entry date was defined as surgery date for patients with RYGB or SG and the same date for their nonsurgical matched controls. We compared all‐cause mortality between surgery patients and their nonsurgical matched controls using Cox regression. Modeling all‐cause mortality allows the understanding of how RYGB or SG affects mortality, including potential differences in mortality after KT. To account for potential residual confounding, all models were adjusted for age groups (18–29/30–40/40–49/50–59/60–69/≥ 70 years), sex, race (White/Black/Other), region (Northeast/Midwest/South/West), BMI (35–44/≥ 45 kg/m2), and months on dialysis. We estimated the cumulative incidence of all‐cause mortality using the Kaplan–Meier method. To investigate whether the mortality risk between RYGB/SG and nonsurgical matched controls varied over time, we estimated hazard ratios for cumulative periods 0–1, 0–2, 0–3, 0–4, and 0–5 years, using the entire cohort of patients at time zero, as recommended by Hernán [31].

To assess whether the mortality risk for older patients significantly varied compared to patients 18–29 years, we included an interaction term between age*RYGB and age*SG in the respective models.

Since the number of patients with SG is comparatively small for the oldest age group, we also conducted the above‐described analysis comparing patients 50–64 and ≥ 65 with 18–49 to assess for consistency of findings.

2.6. Incidence of KT Among Waitlisted Patients

To mitigate selection biases associated with general fitness for surgery and access to healthcare, we limited analysis of the association between RYGB or SG and likelihood of KT to patients already waitlisted at the time of surgery. Waitlisted patients with RYGB and SG were matched with three unique, waitlisted nonsurgical controls as described previously. Since the number of waitlisted patients was low, we divided patients into three groups: 18–49/50–64/≥ 65 years. Censoring for mortality, we used the Kaplan–Meier method to estimate the cumulative incidence of KT and Cox regression to estimate the adjusted hazard ratio (aHR) of KT. To assess whether the likelihood of KT for older surgery patients significantly varied compared to 18–49 years, we included an interaction term between age*RYGB and age*SG in the models. We also used Fine and Gray models to estimate the adjusted subdistribution hazard ratios (aSHR) of KT accounting for the competing risk of mortality for both patients with RYGB and SG.

2.7. Relative Changes in BMI From Dialysis Initiation to KT

We analyzed BMI changes among the subset of patients with RYGB and patients with SG and their nonsurgical matched controls who underwent KT. Specifically, we compared BMI at dialysis initiation (BMIdialysis) and at KT (BMItransplant) between patients of both surgery types and nonsurgical matched controls using the signed rank test for all age groups and plotted the relative change in BMI for individual patients using a waterfall plot. Relative change of BMI was defined as the proportion of BMI change compared to BMI at dialysis initiation and calculated as: [{(BMItransplant − BMIdialysis)/BMIdialysis}*100].

2.8. Statistical Analysis

Confidence intervals are reported per the method of Louis and Zeger [32]. Analyses were performed using Stata 18.0/BE (College Station, Texas) for Linux.

3. Results

3.1. Study Population

Of 876 patients with RYGB and 2628 nonsurgical matched controls, 16.3% and 16.9% were 60–69 years old and 9% and 8.9% were ≥ 70 years old. Of 1508 patients with SG and 4524 nonsurgical matched controls, 9.6% and 9.7% were 60–69 years old and 0.7% and 0.9% were ≥ 70 years old (Table 1).

TABLE 1.

Patient characteristics of patients with end‐stage kidney disease at the time of dialysis initiation by age.

Total Roux‐en‐Y gastric bypass patients Nonsurgical matched controls Total Sleeve gastrectomy patients Nonsurgical matched control
N 3504 876 2628 6032 1508 4524
Age, median (IQR) 49 (40–60) 49 (39–60) 50 (40–60) 45 (38–53) 45 (38–53) 45 (38–53)
Age categories
18–29 years 183 (5.2%) 58 (6.6%) 125 (4.8%) 412 (6.8%) 113 (7.5%) 299 (6.6%)
30–39 years 655 (18.7%) 169 (19.3%) 486 (18.5%) 1411 (23.4%) 349 (23.1%) 1062 (23.5%)
40–49 years 925 (26.4%) 227 (25.9%) 698 (26.6%) 2167 (35.9%) 543 (36.0%) 1624 (35.9%)
50–59 years 840 (23.9%) 200 (22.8%) 640 (24.4%) 1407 (23.3%) 347 (23.0%) 1060 (23.4%)
60–69 years 587 (16.8%) 143 (16.3%) 444 (16.9%) 584 (9.7%) 145 (9.6%) 439 (9.7%)
≥ 70 years 314 (9%) 79 (9.0%) 235 (8.9%) 51 (0.8%) 11 (0.7%) 40 (0.9%)
Body mass index (BMI), median (IQR) (kg/m2) 41.8 (38.2–47.1) 44.2 (39.6–50.4) 41.1 (37.9–45.9) 41.5 (38.2–46.8) 44.9 (40.4–50.8) 40.7 (37.7–45.3)
Time since dialysis initiation, median (IQR) (months) 23.6 (14.8–40.2) 25.4 (14.9–44.2) 23.3 (14.7–38.5) 29.2 (16.3–47.1) 31.9 (17.6–53.9) 28.3 (15.5–45.3)
Female 2065 (58.9%) 520 (59.4%) 1545 (58.8%) 3204 (53.1%) 870 (57.7%) 2334 (51.6%)
Race
White 2051 (58.5%) 532 (60.7%) 1519 (57.8%) 2994 (49.6%) 784 (52.0%) 2210 (48.9%)
Black 1408 (40.2%) 325 (37.1%) 1083 (41.2%) 2952 (48.9%) 685 (45.4%) 2267 (50.1%)
Others 45 (1.3%) 19 (2.2%) 26 (1%) 86 (1.4%) 39 (2.6%) 47 (1%)
Hypertension 3272 (93.4%) 818 (93.4%) 2454 (93.4%) 5592 (92.7%) 1398 (92.7%) 4194 (92.7%)
Congestive heart failure 868 (24.8%) 217 (24.8%) 651 (24.8%) 1345 (22.3%) 336 (22.3%) 1009 (22.3%)
Chronic obstructive pulmonary disease 308 (8.8%) 77 (8.8%) 231 (8.8%) 296 (4.9%) 74 (4.9%) 222 (4.9%)
Peripheral vascular disease 252 (7.2%) 63 (7.2%) 189 (7.2%) 332 (5.5%) 83 (5.5%) 249 (5.5%)
Transient ischemic attack 160 (4.6%) 40 (4.6%) 120 (4.6%) 208 (3.4%) 52 (3.4%) 156 (3.4%)
Diabetes 2330 (66.5%) 582 (66.4%) 1748 (66.5%) 3712 (61.5%) 928 (61.5%) 2784 (61.5%)
Coronary artery disease 368 (10.5%) 92 (10.5%) 276 (10.5%) 420 (7.0%) 105 (7.0%) 315 (7.0%)
Census region
Northeast 329 (9.4%) 109 (12.4%) 220 (8.4%) 480 (8.0%) 182 (12.1%) 298 (6.6%)
Midwest 814 (23.2%) 210 (24.0%) 604 (23.0%) 1171 (19.4%) 315 (20.9%) 856 (18.9%)
South 2006 (57.3%) 429 (49.0%) 1577 (60.0%) 3716 (61.6%) 802 (53.2%) 2914 (64.4%)
West 355 (10.1%) 128 (14.6%) 227 (8.6%) 665 (11.0%) 209 (13.9%) 456 (10.1%)
Waitlisted before study entry 466 (13.3%) 111 (12.7%) 355 (13.5%) 1096 (18.2%) 270 (17.9%) 826 (18.3%)
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Note: Bold denotes statistical significance. Based on geographic proximity, Puerto Rico was included in the South census region. Bariatric surgery patients were matched to nonsurgical matched controls on age, history of hypertension, congestive heart failure, chronic obstructive pulmonary disease, peripheral vascular disease, transient ischemic attack, diabetes, coronary artery disease, smoking status, month, and year of dialysis initiation.

Abbreviations: IQR, interquartile range; y, years.

3.2. Secular Trends in RYGB and SG Among ESKD Patients Stratified by Age Group

Visual representation of secular trends by age groups is presented in Supporting Information S1: Figure S1.

3.3. All‐Cause Mortality

By 5 years, 11.4%, 31.5%, and 37.9% of patients with RYGB 18–29, 30–40, and 40–49 years died compared to 17.3%, 30.1%, and 47.3% of nonsurgical matched controls. Patients with RYGB and nonsurgical matched controls from these age groups had comparable risk of mortality at 1, 2, 3, 4, and 5 years. For patients 50–59 years, 23.5%, 34.0%, 43.1%, 47.9%, and 51.7% of patients with RYGB died compared to 15.4%, 27.3%, 40.4%, 52.9%, and 62.3% of nonsurgical matched controls at 1, 2, 3, 4, and 5 years. Patients with RYGB had 1.7‐fold (aHR = 1.181.672.37 and interaction p = 0.4) and 1.4‐fold (aHR = 1.031.371.82 and interaction p = 0.1) greater mortality risk at 1 and 2 years compared to nonsurgical matched controls and similar mortality risk thereafter. For patients 60–69 years, patients with RYGB mortality was higher at all time points compared to nonsurgical matched controls (45.4%, 54.1%, 64.4%, 73.8%, and 77.1% at 1‐, 2‐, 3‐, 4‐, and 5‐years vs. 22.2%, 39.6%, 52.4, 61.4%, and 68.3%). Patients with RYGB 60–69 years had 2.9‐fold (aHR = 2.082.863.92 and interaction p = 0.1), 1.7‐fold (aHR = 1.311.672.14 and interaction p = 0.1), and 1.5‐fold (aHR = 1.241.561.95 and interaction p = 0.04) higher risk of 1‐year, 3‐year, and 5‐year all‐cause mortality compared to nonsurgical matched controls. For patients ≥ 70 years, mortality for patients with RYGB was higher at all time points compared to nonsurgical matched controls (67.1%, 79.7%, 81.1%, 83.8%, and 86.7% at 1‐, 2‐, 3‐, 4‐, and 5‐years vs. 26.4%, 42.8%, 56.0%, 68.5%, and 78.7%). Patients with RYGB ≥ 70 years had 4.7‐fold (aHR = 3.254.706.81 and interaction p = 0.04), 3.1‐fold (aHR = 2.283.084.16 and interaction p = 0.004), and 2.4‐fold (aHR = 1.802.393.16 and interaction p = 0.004) higher 1‐year, 3‐year, and 5‐year all‐cause mortality compared to nonsurgical matched controls (Figure 1a, Table 2a). The analysis in which we divided patients with RYGB into three subgroups (18–49/50–64/≥ 65 years) yielded consistent findings (Supporting Information S1: Table S2). Both analyses demonstrated that increasing age was associated with increasing mortality for patients with RYGB.

FIGURE 1.

FIGURE 1

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5‐Year all‐cause mortality in (a) patients with Roux‐en‐Y gastric bypass and nonsurgical matched controls, by age and (b) patients with sleeve gastrectomy and nonsurgical matched controls by age. Both surgery patients and controls entered the study on the same day that patients had bariatric surgery.

TABLE 2.

Hazard ratio of all‐cause mortality for (a) patients with Roux‐en‐Y gastric bypass compared to nonsurgical matched controls, by age and (b) patients with sleeve gastrectomy compared to nonsurgical matched controls, by age.

18–29 years 30–39 years 40–49 years 50–59 years 60–69 years ≥ 70 years
(a) Roux‐en‐Y gastric bypass versus nonsurgical matched controls (aHR)
0–1 year 0.150.824.26 0.530.991.86 0.741.131.73 1.18 1.67 2.37 2.08 2.86 3.92 3.25 4.70 6.81 a
0–2 years 0.130.461.61 0.610.971.54 0.530.771.09 1.03 1.37 1.82 1.40 1.85 2.42 a 2.70 3.71 5.09 a
0–3 years 0.240.661.83 0.650.971.45 0.640.861.16 0.921.181.52 1.31 1.67 2.14 2.28 3.08 4.16 a
0–4 years 0.190.541.45 0.731.031.46 0.610.791.04 0.780.991.25 1.30 1.64 2.07 a 2.01 2.68 3.57 a
0–5 years 0.230.581.44 0.731.021.41 0.690.771.00 0.700.881.11 1.24 1.56 1.95 a 1.80 2.39 3.16 a
(b) Sleeve gastrectomy versus nonsurgical matched controls (aHR)
0–1 year 0.09 0.33 1.11 0.20 0.39 0.73 0.19 0.29 0.46 0.23 0.35 0.54 0.330.581.01 0.220.772.69
0–2 years 0.06 0.21 0.68 0.17 0.28 0.47 0.25 0.34 0.46 0.22 0.30 0.42 0.32 0.50 0.79 0.140.471.59
0–3 years 0.15 0.32 0.71 0.19 0.29 0.45 0.32 0.40 0.51 0.24 0.32 0.43 0.39 0.57 0.80 0.120.391.31
0–4 years 0.27 0.49 0.90 0.25 0.36 0.51 0.32 0.39 0.49 0.26 0.34 0.44 0.37 0.52 0.72 0.09 0.30 0.99
0–5 years 0.26 0.47 0.83 0.28 0.39 0.53 0.35 0.43 0.53 0.27 0.35 0.44 0.35 0.48 0.66 0.14 0.37 0.94
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Note: Roux‐en‐Y gastric bypass in older adults was associated with increased mortality, whereas sleeve gastrectomy was associated with decreased mortality compared to nonsurgical matched controls. Bold denotes statistical significance. Bariatric surgery patients were matched to nonsurgical matched controls on age, history of hypertension, congestive heart failure, chronic obstructive pulmonary disease, peripheral vascular disease, transient ischemic attack, diabetes, coronary artery disease, smoking status, month, and year of dialysis initiation. All models were adjusted for age groups (18–29/30–40/40–49/50–59/60–69/≥ 70 years), sex (Male/Female), race (White/Black/Other), census regions (Northeast/Midwest/South/West), BMI (35–44/≥ 44 kg/m2), and months on dialysis.

Abbreviation: aHR, adjusted hazard ratio.

a

denotes interaction p < 0.05.

For patients 18–59 years, patients with SG had lower risk of all‐cause mortality compared to nonsurgical matched controls at 1, 2, 3, 4, and 5 years. By 5‐years, comparing patients with SG to nonsurgical matched controls, 17.8% versus 30.2% of patients 18–29 years, 18.1% versus 36.3% of patients 30–39 years, 28.7% versus 48.9% of patients 40–49 years, 31.1% versus 61.6% of patients 50–59 years, 37.3% versus 65.8% of patients 60–69 years, and 51.5% versus 93.6% of patients ≥ 70 years died (Figure 1b). Patients with SG 18–29, 30–39, 40–49, 50–59, and 60–69 years had 53% (aHR = 0.260.470.83), 61% (aHR = 0.280.390.53 and interaction p = 0.6), 57% (aHR = 0.350.430.53 and interaction p = 0.8), 65% (aHR = 0.270.350.44 and interaction p = 0.4), and 52% (aHR = 0.350.480.66 and interaction p = 0.9) lower 5‐year all‐cause mortality compared to nonsurgical matched controls. Patients ≥ 70 years and their nonsurgical matched controls had similar mortality risk for the first 3 years, but 63% (aHR = 0.140.370.94 and interaction p = 0.7) lower 5‐year all‐cause mortality (Table 2b). The analysis in which we divided patients with SG into three subgroups (18–49/50–64/≥ 65 years) yielded consistent findings (Supporting Information S1: Table S3). SG was associated with decreased mortality across all age groups.

3.4. Incidence of KT Among Waitlisted Patients

For waitlisted patients 18–49, 50–64, and ≥ 65 years, 59.1%, 80.5%, 21.3% of waitlisted patients with RYGB were transplanted within 5 years compared to 48.5%, 42%, and 25.4% of waitlisted nonsurgical matched controls, respectively (Figure 2a). Waitlisted patients with RYGB 18–49 and 50–64 years were 1.8‐times (aHR = 1.131.762.74) and 3.6‐times (aHR = 2.063.656.48 and interaction p = 0.04) more likely to be transplanted compared to waitlisted nonsurgical matched controls. By comparison, waitlisted patients with RYGB and nonsurgical matched controls ≥ 65 years experienced a comparable likelihood of KT (aHR = 0.191.015.26 and interaction p = 0.5). For waitlisted patients 18–49, 50–64, and ≥ 65 years, 65.7%, 73.2%, and 66.7% of patients with SG were transplanted compared to 45.2%, 35.5%, and 39.9% of waitlisted nonsurgical matched controls (Figure 2b). Waitlisted patients with SG 18–49 and 50–64 years were 1.8‐times (aHR = 1.371.782.30) and 3.4‐times (aHR = 2.313.435.09 and interaction p = 0.01) more likely to be transplanted compared to waitlisted nonsurgical matched controls. By comparison, waitlisted patients with SG and nonsurgical matched controls ≥ 65 years had comparable likelihood of being transplanted (aHR = 0.622.318.64 and interaction p = 0.7). For all age groups and both surgery types, the findings were similar within a competing risks framework, and the association of listed patients with RYGB/SG with KT was not consistent across all age groups as shown by the significant interaction term (interaction p < 0.05) (Table 3a).

FIGURE 2.

FIGURE 2

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Incidence of kidney transplant censored for mortality for (a) waitlisted patients with Roux‐en‐Y gastric bypass and waitlisted nonsurgical matched controls, by age and (b) waitlisted patients with sleeve gastrectomy and waitlisted nonsurgical matched controls by age. Both surgery patients and controls entered the study on the same day that patients had bariatric surgery.

TABLE 3.

(a) Relative likelihood of kidney transplantation (KT) within 5 years among waitlisted patients with end‐stage kidney disease undergoing bariatric surgery versus nonsurgical matched controls, by age, and (b) comparison of body mass index (BMI; kg/m2) among patients with transplanted end‐stage kidney disease undergoing bariatric surgery and nonsurgical matched controls, by age.

18–49 years 50–64 years ≥ 65 years
(a) Relative likelihood of kidney transplantation (KT) within 5 years among waitlisted patients with ESKD
RYGB versus nonsurgical matched controls
Waitlisted patients with RYGB patients, N 60 35 16
Waitlisted nonsurgical matched controls, N 176 122 35
KT within 5 years, censoring for mortality (aHR) 1.13 1.76 2.74 2.06 3.65 6.48 a 0.191.015.26
KT within 5 years, mortality as competing risk (aSHR) 1.09 1.74 2.78 1.41 2.49 4.43 0.150.824.45
SG versus nonsurgical matched controls
Waitlisted patients with SG, N 186 76 8
Waitlisted nonsurgical matched controls, N 536 252 22
KT within 5 years, censoring for mortality (aHR) 1.37 1.78 2.30 2.31 3.43 5.09 a 0.622.318.64
KT within 5 years, mortality as competing risk (aSHR) 1.49 1.92 2.47 2.78 4.18 6.27 a 0.823.1311.88
(b) Comparison of BMI (kg/m2) from dialysis initiation to KT among transplanted patients with ESKD
Transplanted patients with RYGB, N 29 18 2
Median BMI at dialysis initiation (IQR) 44.2 (39.1–49.6) 39.4 (37.7–43) 37.5 (36.1–38.9)
Median BMI at transplant (IQR) 31.6 (29.7–35.9) 30.9 (26.3–33.9) 32.1 (31.5–32.6)
Sign test, p‐value < 0.001 0.002 0.5
Transplanted nonsurgical matched controls for RYGB, N 80 39 5
Median BMI at dialysis initiation (IQR) 39.2 (36.6–42.6) 37.9 (36.3–39.9) 38.9 (38.5–39.7)
Median BMI at transplant (IQR) 34.6 (31.2–37.6) 34.9 (32–37.1) 34.7 (32.7–38.0)
Sign test, p‐value < 0.001 0.001 0.4
Transplanted patients with SG, N 101 47 4
Median BMI at dialysis initiation (IQR) 41.6 (38.3–45.4) 39.9 (37.2–46.6) 41.8 (38.4–43.6)
Median BMI at transplant (IQR) 33.4 (29.5–36.7) 32.9 (29.9–35.2) 29.5 (27.6–35.1)
Sign test, p value < 0.001 < 0.001 0.1
Transplanted nonsurgical matched controls for SG, N 189 57 5
Median BMI at dialysis initiation (IQR) 38.2 (36.3–40.7) 38.3 (36.6–41.1) 39.8 (36.5–41.2)
Median BMI at transplant (IQR) 34.8 (32.0–37.1) 35.8 (32.4–37.6) 34 (32.3–34.2)
Sign test, p‐value < 0.001 < 0.001 0.1
Open in a new tab

Note: Bold denotes statistical significance; sign test was used to compare BMI at dialysis initiation to BMI at transplant; bariatric surgery patients were matched to nonsurgical matched controls on age, history of hypertension, congestive heart failure, chronic obstructive pulmonary disease, peripheral vascular disease, transient ischemic attack, diabetes, coronary artery disease, smoking status, month, and year of dialysis initiation; All models were adjusted for age groups (18–49/50–64 ≥ 65 years), sex (Male/Female), race (White/Black/Other), census regions (Northeast/Midwest/South/West), BMI (35–44/≥ 44 kg/m2), and months on dialysis.

Abbreviations: aHR, adjusted hazard ratio; aSHR, adjusted subhazard ratio; BMI, body mass index; IQR, interquartile range.

a

denotes interaction p < 0.05.

3.5. Changes in BMI From Dialysis Initiation to KT

For patients 18–49 and 50–64 years, median BMI (IQR) significantly decreased from dialysis initiation to KT for both patients with RYGB/SG (p < 0.05) and their nonsurgical matched controls (p < 0.05) (Table 3b). For patients 18–49, 50–64, and ≥ 65 years, 50% of both RYGB and nonsurgical matched controls showed ≥ 30.5% versus ≥ 13.4%, ≥ 25.9% versus ≥ 8.9%, and ≥ 14.5% versus ≥ 14.3% reduction in BMI (Supporting Information S1: Figure S2). For patients 18–49, 50–64, and ≥ 65 years, 50% of both SG and nonsurgical matched controls showed ≥ 22.5% versus ≥ 10.4%, ≥ 22.5% versus ≥ 7.8%, and ≥ 25.4% versus ≥ 18.9% reduction in BMI (Supporting Information S1: Figure S3).

4. Discussion

In this national study, RYGB in younger patients with ESKD was associated with comparable survival to nonsurgical matched controls; however, for older patients (60–69/≥ 70 years), RYGB was associated with increased mortality out to 5 years. In contrast, the association between SG and mortality did not vary by age and SG was associated with a significant reduction in mortality compared to nonsurgical matched controls across all age groups.

Although a previous study of patients with ESKD by Sheetz, et al., reported 21% lower risk of 5‐year all‐cause mortality in a cohort of patients with ESKD of all ages undergoing bariatric surgery, we found that RYGB was associated with substantially higher 5‐year all‐cause mortality risk for patients with ESKD ≥ 60 years [15] As in the Sheetz study, we found that SG patients across the age spectrum had 52%–65% lower 5‐year mortality risk compared to nonsurgical matched controls [15]. However, patients 18–59 years undergoing SG had lower 1‐year mortality compared to nonsurgical matched controls, whereas mortality was comparable for patients with SG age ≥ 60 years compared to nonsurgical matched controls [15]. Given that the majority of prevalent ESKD cases are in adults > 65 years, making this distinction is invaluable for patient counseling and surgical decision making [33].

A prior study showed patients with RYGB ≥ 70 years had 5‐fold higher 30‐day mortality compared to patients 40–49 years and our study on elderly patients with ESKD demonstrated risk of mortality for patients with RYGB ≥ 70 and 18–29 years was significantly different (interaction, p < 0.05) [26]. These findings might be explained by the accumulation of frailty and comorbidities that occur with aging, especially in patients with ESKD [34, 35]. In older adults with ESKD, the prevalence of frailty (50%) and sarcopenia (33.7%) are high, especially compared to the general population (frailty prevalence of 9% in community dwelling adults ages 65–69; sarcopenia prevalence of 6%) [34, 36, 37]. Frailty is associated with a 2.6‐fold higher risk of mortality for hemodialysis patients overall and a 3.7‐fold higher risk of mortality for hemodialysis patients with obesity [38, 39]. Sarcopenia is also associated with 3.2‐ and 2.2‐fold higher risk of mortality risk for hemodialysis and peritoneal dialysis patients with obesity, respectively [40, 41]. Patients with ESKD with sarcopenia tend to be older—nearly 9 years, on average—than those without sarcopenia, and sarcopenia is associated with a 1.8‐fold higher mortality risk [42]. The data in this study suggest that although RYGB is not associated with worse long‐term survival in younger patients with ESKD (though nor is it associated with a survival benefit), RYGB in older patients with ESKD is associated significantly worse short‐ and long‐term survival. For patients with ESKD, SG appears to be the preferred surgical approach for obesity management.

Consistent with prior research of bariatric surgery in the ESKD and general populations, we found a decline over time in RYGB and an increase in SG [23, 43]. The relative surgical complexity of RYGB compared to SG may be driving the preference for SG, particularly in the complex ESKD population with its high comorbidity burden [44]. There was substantial decline in BMI between dialysis initiation and KT for bariatric surgery patients and nonsurgical matched controls, which may be due to enhanced fluid status, intentional weight loss through dietary intervention, and/or a result of muscle wasting that occurs in dialysis [45, 46, 47]. However, surgical patients had much greater weight loss. By effectively reducing BMI, RYGB, or SG might facilitate potential transplant candidates' ability to meet BMI‐based criteria for KT [48] increasing KT likelihood [14, 49]. Another prior study which did not restrict on waitlisted population and did not stratify by age or surgical approach reported similar findings [15].

Limitations of the study include the fact that our study included only Medicare patients and may not generalize to other populations. Our findings might be affected by residual confounding from variables not captured in the registry data. Study strengths include the fact that the use of national registry data allowed us to include a larger sample size required to do age‐stratified analysis. Age was categorized into six groups for granular analysis and three groups for broader comparison. We followed a meticulous procedure to identify nonsurgical matched controls, with further adjustments for covariates in the regression model to address residual confounding.

For older patients with ESKD and obesity, RYGB was associated with substantially elevated mortality and SG was associated with decreased mortality. These data are helpful in counseling older patients with ESKD with obesity who are considering bariatric surgery and suggest that SG may be a better option for older patients. Interventions to improve bariatric surgery outcomes—prehabilitation, for example—require further study but may play a role in improving survival in older adults with ESKD and obesity.

Author Contributions

Tanveen Ishaque: data curation, formal analysis, investigation, methodology, writing – original draft. Allan B. Massie: data curation, formal analysis, investigation, methodology, supervision, validation. Darren Stewart: data curation, formal analysis, investigation, methodology, supervision, validation, writing – original draft. Yiting Li: data curation, formal analysis, methodology, validation. Yusi Chen: data curation, formal analysis, methodology, validation. Gayathri Menon: data curation, formal analysis, methodology, validation. Nidhi Ghildayal: methodology, writing – original draft. John R. Montgomery: writing – review and editing. Timur Seckin: writing – review and editing. Karan R. Chhabra: writing – review and editing. Megan E. Jenkins: writing – review and editing. Christine J. Ren‐Fielding: writing – review and editing. Mara A. McAdams‐DeMarco: funding acquisition, methodology, supervision, writing – original draft. Dorry L. Segev: funding acquisition, supervision, writing – review and editing. Babak J. Orandi: conceptualization, investigation, methodology, supervision, validation, writing – original draft.

Funding

This work was supported by Grant K02AG076883 (PI: McAdams‐DeMarco) from the National Institute on Aging (NIA). In addition, it is also supported by Grant K24AI144954 (PI: Segev) from the National Institute of Allergy and Infectious Diseases (NIAID).

Conflicts of Interest

Dr. Orandi reports the following disclosure: Boehringer Ingelheim (advisory board). Dr. McAdams‐DeMarco has received a speaker honorarium from Chiesi. Dr. Segev is a consultant to AstraZeneca, Novavax, Novartis, CareDx, Transmedics, CSL Behring, Jazz Pharmaceuticals, Veloxis, Mallinckrodt, and ThermoFisher Scientific and reports honoraria from Sanofi, AstraZeneca, Optum, CareDx and Novartis and grant support from the National Institutes of Health, all unrelated to the present work.

Supporting information

Supporting Information S1

WJS-49-3448-s001.docx (517.8KB, docx)

Acknowledgments

This work was supported by Grant K02AG076883 (PI: McAdams‐DeMarco) from the National Institute on Aging (NIA). In addition, it was also supported by Grant K24AI144954 (PI: Segev) from the National Institute of Allergy and Infectious Diseases (NIAID). The analyses described here are the responsibility of the authors alone and do not necessarily reflect the views or policies of the Department of Health and Human Services nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government. The data reported here have been supplied by the United States Renal Data System (USRDS). The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the U.S. government.

Data Availability Statement

The data that support the findings of this study are available in United States Renal Data System at https://www.niddk.nih.gov/about‐niddk/strategic‐plans‐reports/usrds. These data were derived from the following resources available in the public domain: United States Renal Data System, https://www.niddk.nih.gov/about‐niddk/strategic‐plans‐reports/usrds.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supporting Information S1

WJS-49-3448-s001.docx (517.8KB, docx)

Data Availability Statement

The data that support the findings of this study are available in United States Renal Data System at https://www.niddk.nih.gov/about‐niddk/strategic‐plans‐reports/usrds. These data were derived from the following resources available in the public domain: United States Renal Data System, https://www.niddk.nih.gov/about‐niddk/strategic‐plans‐reports/usrds.

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