• Abdallah Attia, Eman Toraih, Claire Ardis, Mahmoud Omar, Ahmed Abdelmaksoud, Danielle Tatum, Mary Killackey, Shauna Levy, and Anil Paramesh.
• Department of Surgery, Tulane University School of Medicine, New Orleans, LA, 70112, USA.
• J. Am. Coll. Surg. 2025 Jan 27.

BackgroundObesity is a significant barrier to kidney transplantation for patients with end-stage renal disease (ESRD). We aimed to evaluate the long-term impact of metabolic and bariatric surgery (MBS) on kidney transplantation access and outcomes in individuals with obesity and ESRD patients.Study DesignA retrospective cohort study using data from 64 US healthcare organizations included 132,989 individuals with obesity (BMI ≥30kg/m²) and ESRD requiring dialysis, of whom 6,263 (4.6%) underwent MBS. Propensity score matching produced 1:1 matched groups of 6,238 patients each, analyzed over 10 years. Primary outcomes included rates of kidney transplant waitlist placement, transplantation, and overall mortality. Secondary outcomes focused on 22,979 transplant recipients, including 1,701 (7.4%) MBS patients, to evaluate post-transplant adverse events.ResultsOver a median follow-up of 33.3 months (MBS) and 28.5 months (controls), MBS patients demonstrated higher rates of waitlist placement (19.12% vs 10.53%, HR=1.800, 95%CI=1.636-1.980, p<0.001) and transplantation (27.06% vs 16.09%, HR=1.712, 95%CI=1.584-1.852, p<0.001) at 10 years, with benefits evident within 1-month postoperation. Mortality was lower in the MBS group (30.55% vs 36.44%, HR=0.768, 95%CI=0.723-0.817, p<0.001). In transplant recipients, MBS patients had lower cardiovascular complications (37.3% vs 40.6%, RR=0.92, p=0.007) and all-cause mortality (16.70% vs 20.88%, HR=0.82, p<0.001), with no significant differences in graft rejection or failure.ConclusionMBS significantly improves access to kidney transplantation and long-term survival for obese ESRD patients. Patients who underwent MBS demonstrated notable improvements in cardiovascular health, potentially leading to a better quality of life and survival.These findings suggest that MBS should be considered as part of the comprehensive care for this high-risk population.Copyright © 2025 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.

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