Bariatric Surgery Reduces CKD Risk in MASH/MASLD Patients with Obesity and Type 2 Diabetes

Patients who have MASH or MASLD in combination with obesity and diabetes face unique challenges in losing weight. They are also a vulnerable group that’s at particular risk for cardiometabolic and cardiovascular diseases. New research by Cleveland Clinic scientists shows that bariatric surgery and GLP-1 agonists offer distinct advantages in this population.

The study found that the two approaches had similar benefits for major adverse cardiovascular events and hypertension. However, bariatric surgery offered better short-term kidney protection, while GLP-1s were associated with improved mortality and hepatic outcomes. The results highlight the importance of considering each patient’s individual disease course and treatment goals when choosing a strategy, says first author Zehra Naseem, MD, an internal medicine resident at Cleveland Clinic.

“Whenever a patient with this combination of comorbidities comes to the clinic, there should be a very personalized approach to the treatment modalities for that patient,” she says.

Methodology and outcomes

Previous studies have found that both bariatric surgery and GLP-1s improve cardiovascular outcomes, but this is the first to compare the two approaches in patients who have metabolic dysfunction-associated steatotic liver disease (MASLD) or metabolic dysfunction-associated steatohepatitis (MASH) with obesity and Type 2 diabetes.

The research group conducted a global cohort study using the TriNetX database, identifying adults with a combination of obesity, Type 2 diabetes, and MASLD/MASH. They compared outcomes at five and 10 years for 645 patients who received bariatric surgery and 645 patients who received GLP-1 agonists.

Their study suggested that both bariatric surgery and GLP-1s had comparable outcomes for major adverse cardiovascular events and hypertension. However, patients who underwent bariatric surgery had a 30% lower risk of chronic kidney disease (CKD) compared to those on GLP-1s at five years. Patients receiving GLP-1s were associated with lower risk of mortality and progression of liver disease at both five and ten years

Dr. Naseem notes that obesity itself is a risk factor for CKD, so it makes sense that bariatric surgery could reduce risk by treating obesity. Surgery also helps reduce albuminuria and improves glycemic control, additional risk factors for CKD.

“It addresses the risk factors which lead to kidney disease,” Dr. Naseem explains. “So many patients with these risk factors have some sort of kidney disease, so to see that it could have a good outcome on the kidney itself was pretty interesting. However, the observed short-term renal benefits of bariatric surgery over a five-year period align with existing literature, which suggests that the most significant improvements in kidney function typically occur within 6 to 12 months post-surgery. These benefits tend to diminish in subsequent years, likely due to the waning effects of weight loss and metabolic control.”

At the same time, the group found that the GLP-1 group had a 50-67% lower risk of mortality and 37-50% lower risk of progression of liver disease at both intervals. This may be partially explained by the understaging of liver disease, a critical factor, as advanced hepatic fibrosis is known to significantly elevate perioperative risk. These results underscore the need for careful consideration of bariatric surgery, particularly given its operative risks.

"Although GLP-1 medications are very promising, as seen in our study; it's important to understand that the management of obesity and metabolic syndrome requires multi-modal treatment approaches, such as medication, endoscopic procedures or surgery,” explains Roberto Simons-Linares, MD, Director of Bariatric Surgery at Cleveland Clinic and senior author on the study. “Having patients receive treatment at a facility that provides that kind of treatment in a medical home setting, such as Cleveland Clinic, is paramount."

Looking ahead

“GLP-1s are still relatively new to the market, so to see comparable cardiovascular effects along with favorable effects on liver disease on mortality was interesting to us,” Dr. Naseem says.

Next, the group plans to conduct a follow-up retrospective study comparing bariatric surgery and GLP-1s in a similar patient population treated at Cleveland Clinic. The team will look at outcomes in greater detail, such as measuring markers for liver fibrosis and evaluating liver biopsy samples.

They also plan to study outcomes in patients who receive bariatric surgery and GLP-1s in combination.

“There are a good number of people who are treated with both therapies, therefore adding an additional study group who receive a combination of both treatment modalities will reflect real clinical scenarios,” Dr. Naseem says.

The study, “Outcomes in Patients with Type 2 Diabetes with MASH and MASLD: A Comparison between Bariatric Surgery and GLP-1 agonists,” was presented at the Digestive Disease Week annual meeting in San Diego.