Children's Hospital Colorado

Bariatric Surgery vs. Medical Therapy and its Effect on Diabetic Kidney Disease in Severely Obese Teens with Youth-onset Type 2 Diabetes

Bariatric Surgery Center | November 03, 2019


For families

  • Type 2 diabetes in children and teens is rising and is associated with a greater risk for diabetic kidney disease (DKD), which can lead to kidney failure and heart disease
  • Severely obese teens who underwent weight loss surgery (bariatric surgery) saw a dramatic reduction in DKD and other health benefits compared with medical therapy
  • The initial cost and risks related to bariatric surgery should be carefully considered

For health professionals

  • Five-year follow up compared TEEN-LABS and TODAY study participants for DKD rates in severely obese youth with type 2 diabetes
  • Surgical treatment substantially lowers the odds of DKD (hyperfiltration and elevated urinary albumin excretion)
  • Longer-term studies are needed to determine if less invasive vertical sleeve gastrectomy provides similar long-term outcomes to gastric bypass and to identify new non-surgical approaches for patients who are not good surgical candidates

Research background and methods: The impact of diabetic kidney disease on youth with type 2 diabetes, comparing effects of medical and surgical treatment

Diabetic kidney disease (DKD) is the leading cause of renal failure in the nation and its occurrence in youth with youth-onset type 2 diabetes is rapidly rising. Medical treatments are only partially effective. Compared to adult-onset type 2 diabetes, those with youth-onset have:

  • Greater insulin resistance
  • More rapid β-cell failure
  • Higher prevalence of complications, including DKD

Data from two multi-center studies lead by researchers at Children’s Hospital Colorado – Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) and Treatment Options of Type 2 Diabetes in Adolescents and Youth (TODAY) – provided several opportunities to evaluate medical and metabolic bariatric surgery treatments in severely obese adolescents with type 2 diabetes. Results of an earlier follow-up study by Children’s Colorado identified several health benefits of bariatric surgery for these patients.

In a new study, Petter Bjornstad, MD, an endocrinologist at Children’s Colorado, and colleagues sought to compare DKD rates between medical and surgical treatment over five years of follow-up in the two cohorts.

Study population

Participants were frequency matched for baseline age of 13 to 18 years, race/ethnicity, sex, and baseline

Research results: Bariatric surgery outperformed medical treatment outcomes in all areas of comparison at five-year follow-up

Teen-LABS participants were older and had a higher mean BMI, systolic blood pressure, diastolic blood pressure, and triglycerides at baseline compared to those in TODAY. Other differences were not statistically significant.

BMI, HbA1c and insulin sensitivity

Diabetic Kidney Disease Chart showing Teen-LABS before bariatric surgery: BMI 54.4 kg/m2, HbA1c 6.8%, insulin sensitivity 0.04 ml/uU; Teen-LABS year 5: BMI 42.9 kg/m2, HbA1c 5.9%, insulin sensitivity 0.12 ml/uU; TODAY before medical treatment: BMI 40.5 kg/m2, HbA1c 6.2%, insulin sensitivity 0.04 ml/uU; TODAY year 5: BMI 41.7 kg/m2, HbA1c 8.8%, insulin sensitivity 0.03 ml/uU.

Estimated glomerular filtration rate (eGFR) and hyperfiltration

Teen-LABS participants maintained stable renal function over five years - a 3% decrease in hyperfiltration; TODAY participants developed hyperfiltration over five years - 41% increase in hyperfiltration

Urine Albumin-to-Creatinine Ratio (UACR) and elevated urinary albumin excretion (UAE)

Teen-LABS participants: 22% decrease in albuminuria vs. TODAY participants: 22% increase in albuminuria (>27-fold increased odds of albuminuria vs. Teen-LABS)

Hypertension

Teen-LABS participants: 23% decreased in hypertension; TODAY participants: 40% increased in hypertension

Research discussion: Bariatric surgery is only treatment to improve several type 2 diabetes complications, but risks remain

Change in HbA1c and BMI were the strongest mediators of the differences observed but researchers still don’t fully understand why bariatric surgery leads to such a dramatic reduction of DKD beyond improved glycemic control and weight loss.

There are still limited medical options to treat youth-onset type 2 diabetes. Adults benefit from therapeutic advances, but youth remain limited to metformin and insulin, with GLP-1 receptor agonist added in June 2019. An earlier TODAY study showed metformin and intense lifestyle changes did not improve glycemic control in half of the participants and insulin promoted additional weight gain.

Novel therapies are needed. Bariatric surgery is the only available treatment that leads to considerable weight loss, substantial improvement in glycemic control in the majority of patients, and potential remission of diabetes. Almost all Teen-LABS study participants received a Roux-en-Y gastric bypass. Vertical sleeve gastrectomy is now the preferred technique with less surgical complications, although longer-term outcomes data is needed. Researchers surmised the benefit of bariatric surgery may outweigh the risks and initial costs for carefully chosen patients in a specialized, experienced medical center.

Research conclusion: DKD rates dramatically decreased after bariatric surgery

For the first time, the study authors demonstrated surgical treatment substantially lowers the odds of DKD for severely obese youth with type 2 diabetes compared to medical therapy. Additional long-term studies of bariatric surgery for this population is needed, as well as the identification of potential new non-surgical approaches.

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