Background: Severe obesity, BMI ≥40 kg/m2, confers a greater risk for graft loss and mortality among renal transplant patients. Transplantation provides a better survival and quality of life in overweight dialysis patients. Higher BMI is associated with progressively increased risk of CKD stages 45, hazard ratio of 3.10 (CI 2.953.25) for BMI ≥35 kg/m2. A recent meta-analysis found pre-transplant BMI <30 kg/m2 is associated with positive outcome measures, including mortality and graft rejection. Indeed, certain transplant centres (London), have categorically suggested a cut-off BMI < 30 kg/m2 before consideration for transplant, but overall there is insufficient evidence to demonstrate that intentional weight loss pre-transplantation improves post-transplant outcomes. Roux-en-Y gastric bypass (RYGB) supports excellent weight loss (in the range of 5060% excess weight lost at 1 year). It is clear that this is an area which requires further study. We report a rare case of simultaneous kidney and islet cell transplant in a patient post-RYGB.
Case Report: 58-year old female with a 22-year history of type 1 diabetes and severe obesity (BMI 45.4 kg/m2; weight 126.6 kg, 51.8% fat mass) had a RYGB 9 years previously; weight lost 32.1 kg (25.4% of baseline weight), and although glycaemic control improved (HbA1c 97 mmol/mol reduced to 69 mmol/mol), she had erratic glycemic control and significant concerns over hypoglycemia unawareness (scored 7 on Clark questionnaire & 5 on Gold questionnaire). She subsequently developed end-stage renal failure (ESRF), classed as CKD G5A3 and received peritoneal dialysis. Insulin pump therapy was discussed, but a donor became available and she safely underwent simultaneous islet and cadaveric donor kidney transplant, with a BMI of 33.4 kg/m2. She reaped benefits in terms of glycaemic control (HBA1c 38 mmol/mol), markedly reduced insulin requirement (70 units to 20 units/day of insulin; random C-peptide 513 pmol/l), reduction of frequency of hypoglycaemia and maintenance of weight loss. Such an approach offers feasible treatment option for post-bariatric surgery patients with ESRD and unstable diabetes.