Renal and Cardiovascular Outcomes After Weight Loss From Gastric Bypass Surgery in Type 2 Diabetes: Cardiorenal Risk Reductions Exceed Atherosclerotic Benefits
Article Figures & Tables
Figures
- Figure 1
Cumulative incidence rates during the 9 years of follow-up. A: Macroalbuminuria. B: Severe renal disease or halved eGFR. C: Congestive heart failure. D: Nonfatal CVD.
Tables
- Table 1
Baseline clinical characteristics, including medical history, medications, and socioeconomic variables
Group, n (%) or mean (SD) Characteristic GBP (n = 5,321) Control (n = 5,321) Standardized difference Male sex 2,098 (39.43) 1,926 (36.20) 0.0472 Age (years) 49.0 (9.5) 47.1 (11.5) 0.1220 BMI (kg/m2) 42.0 (5.7) 40.9 (7.3) 0.1167 HbA1c (mmol/mol) 59.9 (16.9) 58.5 (16.9) 0.0589 Creatinine (mmol/L) 68.1 (27.6) 68.0 (25.4) 0.0026 eGFR (MDRD) (mL/min/1.73 m2) 97.2 (25.0) 98.3 (27.5) 0.0282 eGFR (CKD-EPI) (mL/min/1.73 m2) 99.4 (17.6) 100.1 (20.1) 0.0250 LDL (mmol/L) 2.8 (0.9) 2.8 (0.9) 0.0463 HDL (mmol/L) 1.1 (0.3) 1.1 (0.3) 0.0629 Triglycerides (mmol/L) 2.3 (1.5) 2.2 (1.5) 0.0347 Total cholesterol (mmol/L) 4.9 (1.1) 4.9 (1.1) 0.0297 Systolic blood pressure (mmHg) 132.8 (14.5) 132.5 (15.6) 0.0135 Diastolic blood pressure (mmHg) 80.3 (9.6) 80.0 (9.8) 0.0209 Coronary heart disease 395 (7.42) 313 (5.88) 0.0437 CVD 475 (8.93) 408 (7.67) 0.0323 Stroke 109 (2.05) 103 (1.94) 0.0057 Congestive heart failure 142 (2.67) 166 (3.12) 0.0190 Microalbuminuria 481 (19.30) 697 (19.50) 0.0035 Macroalbuminuria 199 (7.50) 298 (7.89) 0.0103 Acute kidney failure 31 (0.58) 50 (0.94) 0.0291 CKD 21 (0.39) 37 (0.70) 0.0289 Diabetic nephropathy 37 (0.70) 43 (0.81) 0.0092 Severe renal disease 56 (1.05) 83 (1.56) 0.0316 Liver disease 16 (0.30) 26 (0.49) 0.0212 Cancer 111 (2.09) 158 (2.97) 0.0398 Psychiatric disorders 520 (9.77) 529 (9.94) 0.0040 Alcohol abuse 94 (1.77) 122 (2.29) 0.0264 Medication Blood pressure medication 2,504 (66.23) 3,034 (60.41) 0.0854 Lipid-lowering drugs 2,688 (50.52) 2,414 (45.37) 0.0730 Insulin 1,967 (36.97) 1,886 (35.44) 0.0224 Metformin 3,947 (74.18) 3,769 (70.83) 0.0530 Sulfonylureas 627 (11.78) 541 (10.17) 0.0366 α-Glucosidase inhibitors 41 (0.77) 38 (0.71) 0.0046 Meglitinides 138 (2.59) 132 (2.48) 0.0051 Glitazones 190 (3.57) 150 (2.82) 0.0302 DPP-4 inhibitors 257 (4.83) 239 (4.49) 0.0113 GLP-1 analogs 310 (5.83) 245 (4.60) 0.0389 SGLT2 inhibitors 1 (0.02) 1 (0.02) 0.0000 NSAIDs 1,852 (34.81) 1,476 (27.74) 0.1081 Opiates 1,658 (31.16) 1,026 (19.28) 0.1952 Physical activity Never 551 (20.95) 836 (20.78) 0.0030 <1 time/week 477 (18.14) 627 (15.59) 0.0482 1–2 times/week 637 (24.22) 992 (24.66) 0.0072 3–5 times/week 515 (19.58) 805 (20.01) 0.0076 5–7 times/week 450 (17.11) 763 (18.97) 0.0341 Smoking status 576 (15.89) 942 (19.72) 0.0708 Income/year (SEK), median (Q1, Q3) 199,638 (139,136, 261,558) 168,380 (121,840, 239,368) 0.1564 Marital status Married 2,518 (47.35) 2,227 (41.87) 0.0781 Separated 1,092 (20.53) 881 (16.56) 0.0723 Widowed 106 (1.99) 147 (2.76) 0.0358 Single 1,602 (30.12) 2,064 (38.80) 0.1297 Education Elementary school 1,069 (20.18) 1,431 (27.48) 0.1216 College level 3,192 (60.25) 2,847 (54.67) 0.0800 Upper secondary school 1,037 (19.57) 930 (17.86) 0.0311 Country Sweden 4,261 (80.08) 4,027 (75.68) 0.0750 Europe except Sweden 514 (9.66) 602 (11.31) 0.0382 Rest of world 546 (10.26) 692 (13.01) 0.0606 DPP-4, dipeptidyl peptidase 4; GLP-1, glucagon-like peptide 1; NSAID, nonsteroidal anti-inflammatory drug; Q, quartile; SEK, Swedish krona; SGLT2, sodium–glucose cotransporter 2.
- Table 2
Number of events, incidence rate per 10,000 person-years by type, and adjusted HRs comparing GBP and matched control patients for sex, age, BMI, eGFR, and socioeconomic variables, including country of birth
End point GBP (n = 5,321) Control (n = 5,321) HR (95% CI) P value Half eGFR (MDRD) (mL/min/1.73 m2) 51 (20.43) 120 (49.00) 0.63 (0.45, 0.89) 0.0076 Half eGFR (CKD-EPI) (mL/min/1.73 m2) 40 (16.02) 105 (42.86) 0.58 (0.40, 0.85) 0.0046 Macroalbuminuria 305 (127.22) 575 (252.33) 0.55 (0.47, 0.65) <0.0001 Acute kidney failure 52 (20.85) 74 (30.14) 0.57 (0.36, 0.90) 0.0147 CKD 52 (20.84) 114 (46.62) 0.45 (0.30, 0.67) 0.0001 Diabetic nephropathy 17 (6.79) 53 (21.59) 0.22 (0.10, 0.47) <0.0001 Severe renal disease 98 (39.49) 187 (76.87) 0.50 (0.37, 0.68) <0.0001 Severe renal disease or half eGFR value (MDRD) 135 (54.57) 260 (107.39) 0.56 (0.44, 0.71) <0.0001 Severe renal disease or half eGFR value (CKD-EPI) 124 (50.09) 245 (101.14) 0.54 (0.42, 0.70) <0.0001 Hemodialysis or peritoneal dialysis 6 (2.39) 27 (10.97) 0.25 (0.08, 0.72) 0.0104 Kidney transplantation 6 (2.39) 6 (2.43) 0.62 (0.12, 3.39) 0.5854 Fatal kidney disease 12 (4.79) 32 (12.97) 0.48 (0.22, 1.04) 0.0636 CVD 291 (120.10) 346 (145.29) 0.74 (0.61, 0.89) 0.0015 Nonfatal CVD 286 (117.91) 333 (139.69) 0.82 (0.70, 0.97) 0.0184 Congestive heart failure 86 (34.56) 233 (96.40) 0.33 (0.24, 0.46) <0.0001 Fatal CVD 31 (12.36) 93 (37.69) 0.36 (0.22, 0.58) <0.0001 All-cause mortality 183 (72.90) 351 (142.06) 0.58 (0.47, 0.72) <0.0001 - Table 3
Number of events, incidence rate per 10,000 person-years by type, and adjusted HR compared with control patients, adjusted for sex, age, and BMI
End point eGFR (mL/min/1.73 m2)* GBP Control HR (95% CI) P value Half eGFR (MDRD) ≥90 32 (33.59) 64 (49.63) 0.68 (0.44, 1.05) 0.0788 90–60 11 (19.22) 31 (44.71) 0.47 (0.23, 0.95) 0.0356 60–45 5 (93.88) 6 (70.42) 1.42 (0.40, 5.03) 0.5835 45–30 1 (61.87) 11 (352.92) 0.13 (0.02, 1.03) 0.0538 <30 2 (2.22) 8 (22.86) 0.10 (0.02, 0.49) 0.0046 Half eGFR (CKD-EPI) ≥90 18 (18.84) 36 (27.84) 0.69 (0.39, 1.22) 0.2039 90–60 13 (22.74) 41 (59.32) 0.41 (0.22, 0.78) 0.0063 60–45 5 (93.88) 7 (82.33) 1.26 (0.38, 4.21) 0.7110 45–30 1 (61.87) 12 (386.52) 0.12 (0.02, 0.97) 0.0463 <30 3 (3.33) 9 (25.73) 0.14 (0.04, 0.52) 0.0036 Macroalbuminuria ≥90 102 (110.48) 268 (221.22) 0.48 (0.38, 0.61) <0.0001 90–60 72 (130.93) 157 (244.41) 0.50 (0.38, 0.66) <0.0001 60–45 29 (661.83) 38 (504.37) 1.12 (0.68, 1.82) 0.6621 45–30 14 (1,147.50) 32 (1,471.47) 0.81 (0.42, 1.56) 0.5245 <30 88 (101.35) 80 (244.03) 0.39 (0.29, 0.53) <0.0001 Acute kidney failure ≥90 7 (7.31) 25 (19.32) 0.36 (0.15, 0.83) 0.0168 90–60 15 (26.27) 30 (43.25) 0.61 (0.32, 1.14) 0.1226 60–45 3 (55.00) 6 (69.92) 0.94 (0.22, 3.98) 0.9321 45–30 1 (60.42) 6 (190.21) 0.39 (0.04, 3.42) 0.3972 <30 26 (29.07) 7 (19.96) 1.24 (0.54, 2.88) 0.6143 CKD ≥90 2 (2.09) 6 (4.63) 0.45 (0.09, 2.34) 0.3417 90–60 11 (19.18) 28 (40.37) 0.48 (0.23, 0.97) 0.0424 60–45 6 (110.87) 20 (241.33) 0.38 (0.15, 0.97) 0.0419 45–30 6 (386.90) 28 (1,033.37) 0.29 (0.11, 0.71) 0.0074 <30 27 (30.18) 32 (92.89) 0.28 (0.16, 0.47) <0.0001 Diabetic nephropathy ≥90 2 (2.09) 14 (10.81) 0.22 (0.05, 0.99) 0.0485 90–60 0 8 (11.51) 0.00 (0.00, —) 0.9930 60–45 2 (36.33) 9 (106.71) 0.30 (0.06, 1.43) 0.1313 45–30 1 (60.97) 8 (258.30) 0.19 (0.02, 1.61) 0.1286 <30 12 (13.36) 14 (40.13) 0.34 (0.15, 0.75) 0.0079 Severe renal disease ≥90 10 (10.45) 30 (23.21) 0.42 (0.21, 0.88) 0.0204 90–60 24 (42.15) 55 (79.83) 0.52 (0.32, 0.86) 0.0098 60–45 10 (189.88) 28 (341.15) 0.51 (0.24, 1.07) 0.0754 45–30 7 (453.82) 33 (1,281.85) 0.30 (0.13, 0.70) 0.0055 <30 47 (52.96) 41 (119.43) 0.39 (0.25, 0.60) <0.0001 Severe renal disease or half eGFR value (MDRD) ≥90 39 (40.99) 86 (66.96) 0.59 (0.41, 0.87) 0.0077 90–60 29 (51.04) 72 (104.95) 0.51 (0.33, 0.79) 0.0024 60–45 11 (211.45) 28 (342.66) 0.57 (0.28, 1.15) 0.1171 45–30 8 (532.92) 33 (1,289.79) 0.37 (0.17, 0.83) 0.0153 <30 48 (54.09) 41 (119.43) 0.40 (0.26, 0.61) <0.0001 Severe renal disease or half eGFR value (CKD-EPI) ≥90 26 (27.25) 60 (46.59) 0.57 (0.36, 0.90) 0.0168 90–60 31 (54.62) 81 (118.37) 0.48 (0.31, 0.73) 0.0006 60–45 11 (211.45) 29 (355.70) 0.55 (0.27, 1.12) 0.1007 45–30 8 (532.92) 34 (1,335.28) 0.36 (0.16, 0.80) 0.0120 <30 48 (54.12) 41 (119.45) 0.40 (0.26, 0.61) <0.0001 Hemodialysis or peritoneal dialysis ≥90 0 4 (3.08) 0.00 (0.00, —) 0.9958 90–60 0 3 (4.30) 0.00 (0.00, —) 0.9957 60–45 0 1 (11.60) 0.00 (0.00, —) 0.9986 45–30 1 (60.68) 8 (254.26) 0.15 (0.02, 1.24) 0.0788 <30 5 (5.55) 11 (31.47) 0.19 (0.06, 0.56) 0.0027 CVD ≥90 81 (86.44) 133 (105.13) 0.73 (0.55, 0.96) 0.0260 90–60 75 (135.04) 123 (184.82) 0.66 (0.49, 0.89) 0.0056 60–45 17 (331.56) 23 (287.14) 1.11 (0.58, 2.12) 0.7494 45–30 4 (259.25) 22 (778.56) 0.30 (0.10, 0.90) 0.0323 <30 114 (131.96) 45 (131.42) 0.89 (0.62, 1.27) 0.5087 Congestive heart failure ≥90 21 (22.02) 71 (55.37) 0.35 (0.21, 0.57) <0.0001 90–60 15 (26.21) 83 (122.29) 0.22 (0.12, 0.38) <0.0001 60–45 6 (110.67) 29 (360.76) 0.33 (0.14, 0.82) 0.0165 45–30 4 (250.82) 17 (569.27) 0.49 (0.16, 1.51) 0.2127 <30 40 (44.83) 33 (95.41) 0.37 (0.23, 0.60) <0.0001 Fatal kidney disease ≥90 1 (1.04) 5 (3.85) 0.34 (0.04, 3.13) 0.3396 90–60 4 (6.96) 8 (11.46) 0.76 (0.21, 2.74) 0.6777 60–45 0 2 (23.19) 0.00 (0.00, —) 0.9979 45–30 1 (60.33) 6 (182.06) 0.34 (0.04, 2.96) 0.3317 <30 6 (6.65) 11 (31.26) 0.18 (0.06, 0.50) 0.0010 Fatal CVD ≥90 8 (8.35) 32 (24.65) 0.30 (0.14, 0.66) 0.0026 90–60 13 (22.62) 33 (47.27) 0.45 (0.23, 0.86) 0.0151 60–45 0 12 (139.15) 0.00 (0.00, —) 0.9927 45–30 1 (60.33) 4 (121.37) 0.48 (0.05, 4.62) 0.5287 <30 9 (9.98) 12 (34.10) 0.28 (0.11, 0.70) 0.0066 All-cause mortality ≥90 57 (59.41) 136 (104.64) 0.53 (0.39, 0.72) <0.0001 90–60 54 (93.81) 108 (154.52) 0.65 (0.46, 0.91) 0.0115 60–45 4 (71.93) 32 (370.51) 0.24 (0.08, 0.68) 0.0072 45–30 4 (240.46) 24 (719.62) 0.40 (0.13, 1.19) 0.0996 <30 64 (70.88) 51 (144.73) 0.35 (0.24, 0.51) <0.0001 ↵* Number of patients in the eGFR strata (GBP and control groups, respectively): eGFR ≥90 mL/min/1.73 m2, 2,144 and 2,805; eGFR 90–60 mL/min/1.73 m2, 1,274 and 1,493; eGFR 60–45 mL/min/1.73 m2, 125 and 190; eGFR 45–30 mL/min/1.73 m2, 35 and 79; and eGFR <30 mL/min/1.73 m2, 1,743 and 754.
In this Issue
June 2020, 43(6)
Renal and Cardiovascular Outcomes After Weight Loss From Gastric Bypass Surgery in Type 2 Diabetes: Cardiorenal Risk Reductions Exceed Atherosclerotic Benefits
