Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass for Obese Kidney Transplant Candidates: A Systematic Review, Meta-Analysis, and Development of a Transplant-Specific Decision Framework.

Obesity remains a major barrier to kidney transplantation and is associated with inferior transplant outcomes. We conducted a PRISMA 2020-compliant systematic review and meta-analysis comparing sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) in kidney transplant candidates and recipients. PubMed/MEDLINE, Embase, Scopus, and Cochrane CENTRAL were searched through January 2026. Eleven observational studies involving 2,553 patients (1,461 SG; 1,092 RYGB) were included. SG was associated with lower mortality (RR 0.46, 95% CI 0.32-0.66) and graft loss (RR 0.39, 95% CI 0.21-0.73) than RYGB, while access to transplantation was similar between procedures. SG also demonstrated fewer nutritional complications and greater pharmacokinetic stability. Current evidence suggests that SG may be the preferred bariatric procedure among kidney transplant recipients, although prospective comparative studies are needed.