Bariatric surgery, a new cause of acute renal failure
Cirugía bariátrica, una nueva causa de fracaso renal agudo
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Tabernero-Romo" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Pilar" "apellidos" => "Fraile-Gómez" "email" => array:1 [ 0 => "pilarfg@usal.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "Susana" "apellidos" => "Domínguez-Quibén" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 2 => array:3 [ "nombre" => "Josepha" "apellidos" => "Sebastía-Morant" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "nombre" => "Cristina" "apellidos" => "Lucas-Álvarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 4 => array:3 [ "nombre" => "José M." "apellidos" => "Tabernero-Romo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario de Salamanca " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Unidad Docente Medicina Familiar y Comunitaria, Hospital Universitario de Salamanca " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cirugía bariátrica, una nueva causa de fracaso renal agudo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11931_16025_49179_en_f111931.jpg" "Alto" => 1010 "Ancho" => 1380 "Tamanyo" => 251615 ] ] "descripcion" => array:1 [ "en" => "Creatinine progression (mg/dl) after bariatric surgery" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor:</span></p><p class="elsevierStylePara">Obesity, defined by a body mass index (BMI)> 30 kg/m<span class="elsevierStyleSup">2</span>, is a global public health problem, on an epidemic scale. The prevalence of obesity in the Spanish adult population (25 years-60 years) is 14.5%, while the figure for overweight is 38.5% and it increases each year. Obesity is associated with other cardiovascular risk factors such as high blood pressure (HBP), insulin resistance, type 2 diabetes mellitus (DM), dyslipidaemia and coronary disease, and can lead to progressive renal failure (RF). RF associated with obesity is a glomerulopathy with variable proteinuria and histopathological findings of focal segmental glomerulonephritis.<span class="elsevierStyleSup">1</span> Currently, the treatment for obesity includes bariatric surgery when the ponderal target is not achieved with medical treatment, and even in RF associated with obesity. But it is not an innocuous surgical procedure and can cause RF <span class="elsevierStyleItalic">per se</span>.<span class="elsevierStyleSup">2</span> We report two cases of acute renal failure (ARF) following bariatric surgery, recorded at our service.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORTS</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 1</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">A 60-year-old male with a history of morbid obesity (BMI 47kg/m<span class="elsevierStyleSup">2</span>), high blood pressure, type 2 DM, obstructive sleep apnoea syndrome (OSAS), hypercholesterolaemia and acute myocardial infarction ischaemic heart disease was treated with 2 stents after percutaneous-stent transluminal coronary angioplasty. He was transferred to the Surgery department for bariatric surgery, using the laparoscopic sleeve gastrectomy technique. At discharge, he was treated with 10mg/24 hour ramipril, 10/25mg/24 hour bisoprolol/hydrochlorothiazide, 10mg/24 hour atorvastatin, 20mg/24 hour barnidipine and 1/8 hour metformin. After surgery, the patient reported low intake of food and water, occasional episodes of dizziness and loss of 20kg in a month. Given his progressive deteriorating clinical profile and the association with diarrhoea, he was admitted to the Emergency department, where general poor condition, bradypsychia, dry skin, mucous membranes and blood pressure (BP) of 92/65mmHg were observed. Tests were performed: glucose 214mg/dl, urea 403mg/dl, creatinine (Cr) 9.2mg/dl, Na 151mmol/l, Cl 113mmol/l, K 4mmol/l; Complete blood count: haemoglobin (Hb) 15.4g/dl, VH 44.5%, leukocytes 18,800/ul; platelets 287,000/ul; renal function in urine: urea 239mg/dl, Cr 339mg/dl, Na 52mmol/l, K 9.1mmol/l, fractional excretion of sodium (FENa) 0.9%; venous blood gases: pH 7.33, bicarbonate 11.1mmol/l, pCO<span class="elsevierStyleInf">2</span> 21mmHg. He was transferred to the Nephrology department with the diagnosis of with prerenal ARF, hypernatraemia and urinary tract infection. Antibiotic treatment and controlled electrolyte replacement was initiated with good response, with creatinine levels of 0.86mg/dl at discharge (Figure 1).</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 2</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">A 44-year-old woman with the following history: ex-smoker, HBP, type 2 DM, morbid obesity (BMI 59.19kg/m<span class="elsevierStyleSup">2</span>), cholecystectomy, appendectomy, umbilical hernia and caesarean section. She was referred to General Surgery for bariatric surgery using the Larrad technique. She came to the Emergency department two months after surgery, complaining of repeated postprandial vomiting since discharge and syncope. In the physical examination, poor general condition, signs of salt and water depletion, BP 66/48 and CVP 4 cc H<span class="elsevierStyleInf">2</span>O were observed. A test was performed: urea 284mg/dl, Cr 6.98mg/dl, Na 119mmol/l, K 2.4mmol/l, Cl 65mmol/l, Pcr 4.8mg/dl, lactate 4.7mmol/l, osmolarity 333mOsm/kg; complete blood count: Hb 14.2g/dl, VH 42%; leukocytes 19,000/ul; platelets 251,000/ul; venous blood gases: pH 7.49, bicarbonate 25.9mmol/l, pCO<span class="elsevierStyleInf">2</span> 34mmHg; renal function in urine: FENa 0.11%, urea 276mg/dl, Cr 274.8mg/dl, Na 5mmol/l, K 15.4mmol/l. She was admitted to the Nephrology department with diagnosis of prerenal ARF secondary to volume depletion, hyponatraemia and hypokalaemia. She started on salt and water replacement and progressive electrolytic correction with improvement of renal function, until normalisation (Figure 1). During hospitalisation, the patient developed respiratory failure and septic shock secondary to respiratory infection. She was transferred to the intensive care unit and died after two months.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The treatment of morbid obesity includes: a) diet and modification of lifestyle, b) pharmacotherapy and c) bariatric surgery.<span class="elsevierStyleSup">2</span> Bariatric surgery is indicated in patients with BMI ≥40kg/m<span class="elsevierStyleSup">2</span> in whom treatment with diet and exercise, associated or not with drug treatment, is not effective and in patients with BMI>35kg/m<span class="elsevierStyleSup">2</span> and obesity-related comorbidities such as HBP, glucose intolerance, DM, dyslipidaemia, or OSAS.</p><p class="elsevierStylePara">Bariatric surgery has high morbidity and its mean mortality rate at 30 days is 1%. Surgical techniques are divided into restrictive, malabsorptive and mixed. The complications are different according to the surgical technique employed. Early complications of bariatric surgery are bleeding, perforation, deep vein thrombosis, pulmonary thromboembolism and pulmonary and cardiovascular complications, while late complications include cholelithiasis, malnutrition and neurological and psychiatric complications. Although bariatric surgery is an effective treatment for obesity and is even one form of treatment for associated RF, it may result in ARF<span class="elsevierStyleSup">3</span> and very severe, life-threatening water-electrolyte imbalances, especially when the surgical technique used is the Roux-en-Y gastric bypass or a jejunoileal bypass. RF aetiology may be dehydration secondary to diarrhoea and/or vomiting<span class="elsevierStyleSup">4</span> or ARF due to intratubular calcium oxalate crystal deposition. ARF usually appears a month after bariatric surgery and is characterised by high creatinine levels in relation to the patient’s weight. The absence of nephrocalcinosis and urolithiasis and the fact that the ARF may have been prerenal and not parenchymal allowed us to rule out the diagnosis of ARF due to intratubular calcium oxalate crystal deposition. The treatment includes progressive hydration and correction of electrolyte abnormalities, haemodialysis in cases of established ARF and even conversion of the surgical technique employed in cases of oxalate-induced nephropathy.<span class="elsevierStyleSup">3,4</span></p><p class="elsevierStylePara">In conclusion, bariatric surgery is part of the therapeutic arsenal for obesity, but it is not without risks. Patients should be followed closely after surgery, with early referral to Nephrology if there is renal function deterioration, since it is a reversible form of RF if treated early, or the appearance of electrolyte disturbances that may put the patient’s life at risk.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article.</p><p class="elsevierStylePara"><a href="grande/11931_16025_49179_en_f111931.jpg" class="elsevierStyleCrossRefs"><img src="11931_16025_49179_en_f111931.jpg" alt="Creatinine progression (mg/dl) after bariatric surgery"></img></a></p><p class="elsevierStylePara">Figure 1. Creatinine progression (mg/dl) after bariatric surgery</p>" "pdfFichero" => "P1-E557-S4311-A11931-EN.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11931_16025_49179_en_f111931.jpg" "Alto" => 1010 "Ancho" => 1380 "Tamanyo" => 251615 ] ] "descripcion" => array:1 [ "en" => "Creatinine progression (mg/dl) after bariatric surgery" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Ramírez J, Carpio D, Mezzano S, Mukdsi J, Ardiles L. Cirugía bariátrica en pacientes con glomeruloesclerosis focal y segmentaria secundaria a obesidad. 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| 2024 October | 109 | 27 | 136 |
| 2024 September | 129 | 21 | 150 |
| 2024 August | 183 | 53 | 236 |
| 2024 July | 159 | 39 | 198 |
| 2024 June | 168 | 42 | 210 |
| 2024 May | 160 | 31 | 191 |
| 2024 April | 130 | 30 | 160 |
| 2024 March | 122 | 27 | 149 |
| 2024 February | 128 | 39 | 167 |
| 2024 January | 152 | 16 | 168 |
| 2023 December | 119 | 38 | 157 |
| 2023 November | 131 | 44 | 175 |
| 2023 October | 144 | 44 | 188 |
| 2023 September | 177 | 31 | 208 |
| 2023 August | 196 | 22 | 218 |
| 2023 July | 167 | 36 | 203 |
| 2023 June | 184 | 13 | 197 |
| 2023 May | 191 | 38 | 229 |
| 2023 April | 134 | 16 | 150 |
| 2023 March | 123 | 24 | 147 |
| 2023 February | 131 | 28 | 159 |
| 2023 January | 114 | 26 | 140 |
| 2022 December | 111 | 18 | 129 |
| 2022 November | 126 | 30 | 156 |
| 2022 October | 128 | 47 | 175 |
| 2022 September | 150 | 23 | 173 |
| 2022 August | 130 | 39 | 169 |
| 2022 July | 116 | 39 | 155 |
| 2022 June | 98 | 32 | 130 |
| 2022 May | 135 | 37 | 172 |
| 2022 April | 167 | 52 | 219 |
| 2022 March | 165 | 42 | 207 |
| 2022 February | 168 | 42 | 210 |
| 2022 January | 211 | 29 | 240 |
| 2021 December | 159 | 48 | 207 |
| 2021 November | 161 | 45 | 206 |
| 2021 October | 198 | 39 | 237 |
| 2021 September | 154 | 35 | 189 |
| 2021 August | 201 | 33 | 234 |
| 2021 July | 176 | 42 | 218 |
| 2021 June | 124 | 20 | 144 |
| 2021 May | 158 | 25 | 183 |
| 2021 April | 399 | 69 | 468 |
| 2021 March | 284 | 26 | 310 |
| 2021 February | 226 | 28 | 254 |
| 2021 January | 221 | 18 | 239 |
| 2020 December | 183 | 10 | 193 |
| 2020 November | 178 | 24 | 202 |
| 2020 October | 114 | 11 | 125 |
| 2020 September | 153 | 9 | 162 |
| 2020 August | 154 | 12 | 166 |
| 2020 July | 148 | 8 | 156 |
| 2020 June | 156 | 28 | 184 |
| 2020 May | 164 | 15 | 179 |
| 2020 April | 131 | 11 | 142 |
| 2020 March | 155 | 14 | 169 |
| 2020 February | 192 | 27 | 219 |
| 2020 January | 180 | 26 | 206 |
| 2019 December | 198 | 23 | 221 |
| 2019 November | 160 | 20 | 180 |
| 2019 October | 177 | 9 | 186 |
| 2019 September | 230 | 27 | 257 |
| 2019 August | 176 | 20 | 196 |
| 2019 July | 197 | 25 | 222 |
| 2019 June | 156 | 24 | 180 |
| 2019 May | 173 | 23 | 196 |
| 2019 April | 243 | 48 | 291 |
| 2019 March | 197 | 24 | 221 |
| 2019 February | 152 | 20 | 172 |
| 2019 January | 172 | 22 | 194 |
| 2018 December | 168 | 44 | 212 |
| 2018 November | 244 | 10 | 254 |
| 2018 October | 278 | 13 | 291 |
| 2018 September | 293 | 14 | 307 |
| 2018 August | 259 | 17 | 276 |
| 2018 July | 199 | 15 | 214 |
| 2018 June | 159 | 6 | 165 |
| 2018 May | 176 | 15 | 191 |
| 2018 April | 132 | 8 | 140 |
| 2018 March | 116 | 9 | 125 |
| 2018 February | 112 | 10 | 122 |
| 2018 January | 81 | 9 | 90 |
| 2017 December | 81 | 6 | 87 |
| 2017 November | 95 | 10 | 105 |
| 2017 October | 105 | 7 | 112 |
| 2017 September | 87 | 13 | 100 |
| 2017 August | 97 | 11 | 108 |
| 2017 July | 78 | 15 | 93 |
| 2017 June | 83 | 8 | 91 |
| 2017 May | 72 | 6 | 78 |
| 2017 April | 78 | 7 | 85 |
| 2017 March | 69 | 3 | 72 |
| 2017 February | 60 | 6 | 66 |
| 2017 January | 43 | 6 | 49 |
| 2016 December | 81 | 4 | 85 |
| 2016 November | 93 | 6 | 99 |
| 2016 October | 117 | 10 | 127 |
| 2016 September | 131 | 2 | 133 |
| 2016 August | 228 | 6 | 234 |
| 2016 July | 195 | 8 | 203 |
| 2016 June | 131 | 0 | 131 |
| 2016 May | 151 | 0 | 151 |
| 2016 April | 102 | 0 | 102 |
| 2016 March | 94 | 0 | 94 |
| 2016 February | 90 | 0 | 90 |
| 2016 January | 89 | 0 | 89 |
| 2015 December | 142 | 0 | 142 |
| 2015 November | 105 | 0 | 105 |
| 2015 October | 76 | 0 | 76 |
| 2015 September | 80 | 0 | 80 |
| 2015 August | 81 | 0 | 81 |
| 2015 July | 74 | 0 | 74 |
| 2015 June | 41 | 0 | 41 |
| 2015 May | 62 | 0 | 62 |
| 2015 April | 7 | 0 | 7 |
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