Sleeve Gastrectomy Outperforms Tirzepatide for Survival in Stage 5 CKD Patients with BMI Over 40 kg/m²

Managing morbid obesity in patients with stage 5 chronic kidney disease (CKD) presents a significant clinical challenge, as weight loss is critical for improving long-term outcomes. Historically, bariatric surgery like sleeve gastrectomy (SG) has been a primary intervention. However, the increasing use of dual GLP-1R/GIPR agonists, such as tirzepatide, has led to declining bariatric surgery referrals. This shift raises questions about which strategy optimizes long-term survival for this vulnerable patient population, especially given the distinct mechanisms and efficacy profiles of surgical versus pharmacological interventions.

Researchers employed a Markov state transition model to simulate the life course of 30,000 hypothetical patients with morbid obesity and stage 5 CKD. Base case patients were 45 years old with a pre-intervention BMI of 45 kg/m². Three weight loss interventions were compared: diet and exercise (DE), sleeve gastrectomy (SG), and tirzepatide treatment. SG patients were assigned a mortality risk during the initial three months. Sensitivity analyses were performed on pre-intervention BMI to assess the robustness of the findings across different obesity severities, with long-term survival as the primary endpoint.

The decision-analytic model projected similar survival outcomes for patients undergoing sleeve gastrectomy (SG) or receiving tirzepatide treatment when pre-intervention BMIs were below 38 kg/m². However, a clear divergence emerged as baseline BMI increased, with SG demonstrating progressively greater projected survival compared to tirzepatide.

At a BMI of 40 kg/m², SG was associated with an additional 0.6 life-years relative to tirzepatide, which further increased to 3.2 life-years at a BMI of 50 kg/m². For all BMIs above 37 kg/m², both SG and tirzepatide interventions significantly improved survival compared to diet and exercise (DE). The study concluded that greater and more sustained weight loss was the primary driver of improved long-term survival among patients with stage 5 CKD and morbid obesity.