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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.
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
Estimated glomerular filtration rate (eGFR) and hyperfiltration
Urine Albumin-to-Creatinine Ratio (UACR) and elevated urinary albumin excretion (UAE)
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.