Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery · 2026
Metabolic bariatric surgery versus GLP-1 receptor agonists in dialysis patients with diabetes and obesity: a target trial emulation study.
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Gao Chenxi, Menon Gayathri, Chen Yusi, Li Yiting, Bae Sunjae, Lonze Bonnie E, Ren-Fielding Christine J, Chhabra Karan R, Segev Dorry L, McAdams-DeMarco Mara A, Orandi Babak J
Аннотация
BACKGROUND: Metabolic and bariatric surgery (MBS) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) are effective treatments for obesity and type 2 diabetes, but their comparative survival and waitlisting benefits in end-stage kidney disease (ESKD) remain unclear.
OBJECTIVES: To compare survival and kidney transplant (KT) waitlisting after MBS and GLP-1RA use among patients with ESKD, using dipeptidyl peptidase-4 inhibitors (DPP-4is) as an active comparator.
SETTING: US Renal Data System, 2010-2022.
METHODS: We included adults with ESKD, type 2 diabetes, and ≥class II obesity treated with MBS, GLP-1RA, or DPP-4i. Three target trials were emulated: MBS versus GLP-1RA (N = 1818), MBS versus DPP-4i (N = 2111), and GLP-1RA versus DPP-4i (N = 4338). Cox models estimated adjusted hazard ratios (aHRs) for all-cause mortality and KT waitlisting over 1-5 years.
RESULTS: MBS recipients were younger at dialysis initiation than matched GLP-1RA and DPP-4i users. MBS was associated with higher short-term mortality than matched GLP-1RA (1-year aHR = 2.68, 95% confidence interval [CI]:1.98-3.63; 3-year aHR = 1.34, 95% CI: 1.09-1.64) and DPP-4i users (1-year aHR = 1.74, 95% CI: 1.35-2.25), but comparable longer-term mortality. GLP-1RA users had consistently lower mortality than matched DPP-4i users. MBS was associated with higher KT waitlisting than GLP-1RA and DPP-4i use, with no differences between GLP-1RA and DPP-4i users.
CONCLUSIONS: Among patients with ESKD, type 2 diabetes, and obesity, MBS was associated with higher short-term but comparable long-term mortality, whereas GLP-1RA use was associated with lower mortality than DPP-4i use. MBS was also associated with higher KT waitlisting than GLP-1RA and DPP-4i use, suggesting distinct risk-benefit profiles of metabolic treatment in this high-risk population.
OBJECTIVES: To compare survival and kidney transplant (KT) waitlisting after MBS and GLP-1RA use among patients with ESKD, using dipeptidyl peptidase-4 inhibitors (DPP-4is) as an active comparator.
SETTING: US Renal Data System, 2010-2022.
METHODS: We included adults with ESKD, type 2 diabetes, and ≥class II obesity treated with MBS, GLP-1RA, or DPP-4i. Three target trials were emulated: MBS versus GLP-1RA (N = 1818), MBS versus DPP-4i (N = 2111), and GLP-1RA versus DPP-4i (N = 4338). Cox models estimated adjusted hazard ratios (aHRs) for all-cause mortality and KT waitlisting over 1-5 years.
RESULTS: MBS recipients were younger at dialysis initiation than matched GLP-1RA and DPP-4i users. MBS was associated with higher short-term mortality than matched GLP-1RA (1-year aHR = 2.68, 95% confidence interval [CI]:1.98-3.63; 3-year aHR = 1.34, 95% CI: 1.09-1.64) and DPP-4i users (1-year aHR = 1.74, 95% CI: 1.35-2.25), but comparable longer-term mortality. GLP-1RA users had consistently lower mortality than matched DPP-4i users. MBS was associated with higher KT waitlisting than GLP-1RA and DPP-4i use, with no differences between GLP-1RA and DPP-4i users.
CONCLUSIONS: Among patients with ESKD, type 2 diabetes, and obesity, MBS was associated with higher short-term but comparable long-term mortality, whereas GLP-1RA use was associated with lower mortality than DPP-4i use. MBS was also associated with higher KT waitlisting than GLP-1RA and DPP-4i use, suggesting distinct risk-benefit profiles of metabolic treatment in this high-risk population.