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Saturday, February 2, 2008

Bariatric Nephrology

This morning, I am presenting at the Nephrology Educator's Forum in Lake Louise. The audience are nephrologists from across Canada.

The fact that I was invited to speak on obesity is of course related to the fact that nephrology, as practically all fields of medicine, are beginning to see the impact of the obesity epidemic.

Indeed, from a nephrologist's perspective (remember - I am one), not only is obesity a major driver of the most common causes of end-stage renal failure (i.e. type 2 diabetes and hypertension), it also complicates things for patients on dialysis (especially peritoneal dialysis) and renal transplantation.

While there is an apparent survival paradox, whereby obese patients with end-stage renal failure seem to do better than leaner patients (a similar paradox is seen for other chronic diseases including heart failure and chronic obstructive lung disease), there is a high likelihood that this paradox is largely explained by malnutrition or more severe comorbidities than by a true protective effect of the extra weight. Perhaps, maintaining a higher weight or even gaining more weight is simply a sign of adequate nutrition and therefore a surrogate marker for "better health" and thus better outcomes.

On the other hand, in dialysis patients awaiting transplantation or patients who have had transplants, severe obesity and/or further weight gain can be a major problem. Not surprisingly, there is now an increasing number of reports on patients with end-stage renal failure undergoing bariatric surgery either prior to or following kidney transplantation - apparently with great success.

Clearly, the brunt of the obesity epidemic on nephrology is still ahead - nephrologists, like everyone else, will probably have to brush up on the essentials of bariatric care.


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