Long-Term Renal, Cardiovascular, and Survival Outcomes in Patients with Obesity and Chronic Kidney Disease Following Metabolic and Bariatric Surgery: A Propensity Score-Matched TriNetX Real-World Cohort Study

Background Obesity accelerates the progression of chronic kidney disease (CKD) and often limits access to kidney transplantation. Although metabolic and bariatric surgery has been associated with improvements in kidney function and cardiometabolic outcomes, evidence regarding long-term kidney failure, dialysis, transplantation, cardiovascular, and survival outcomes among patients with established CKD remains heterogeneous. Objectives To evaluate the association between MBS and long-term renal, cardiovascular, and transplant outcomes, and all-cause mortality, in patients with obesity and CKD using a large, propensity score-matched real-world cohort. Settings Analysis of TriNetX Global Collaborative Network, a de-identified real-world database from over 140 health care organizations. Methods Adults (≥18 years) with severe obesity and CKD who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between 2010 and 2020. Patients were propensity score-matched 1:1 to those without MBS based on demographics, comorbidities, baseline kidney function, and medication use. Outcomes were assessed over five years. Primary endpoints included incidence of end-stage renal disease (ESRD), dialysis initiation, kidney transplantation, cardiovascular events, and all-cause mortality. A subgroup analysis comparing SG and RYGB was performed using propensity score matching. Results A total of 4,481 MBS patients were matched to 4,481 non-MBS patients, with well-balanced baseline characteristics. Compared to the non-MBS group, MBS was associated with significantly lower risks of ESRD (5.9% vs. 11.9%; OR 0.47, 95% CI 0.40–0.55), dialysis dependence (4.1% vs. 9.0%; OR 0.43, 95% CI 0.36–0.52), and composite cardiovascular events (15.5% vs. 27.7%; OR 0.48, 95% CI 0.42–0.54). Interestingly, kidney transplant rates were more than twice as high in the MBS group (4.6% vs. 2.2%; OR 2.13, 95% CI 1.67–2.72), and all-cause mortality was markedly lower (5.0% vs. 16.3%; OR 0.27, 95% CI 0.23–0.32). In subgroup analyses, outcomes were comparable between SG and RYGB, although SG was associated with higher kidney transplantation rates. Conclusions In this large TriNetX cohort of patients with obesity and CKD, MBS was associated with lower observed rates of ESRD, dialysis dependence, cardiovascular events, and all-cause mortality and with a higher rate of kidney transplantation. Similar renal, cardiovascular, and survival outcomes were observed after SG and RYGB. Because of residual differences in baseline kidney function, unmeasured treatment-selection factors, and limitations in the geographic and institutional characterization of the TriNetX network, these findings should be interpreted as associations within the study cohort rather than causal effects or population-level estimates. Further prospective and population-based studies are needed to confirm these associations.