Comparable Outcomes Following Bariatric Surgery Before or After Kidney Transplantation Support Individualized Sequencing

Obesity and end-stage kidney disease (ESKD) present deeply complex metabolic and immunological challenges. Metabolic and bariatric surgery (MBS) is increasingly recognized for its role in pretransplant weight optimization and metabolic regulation and has been shown to improve access to and allograft outcomes of kidney transplant (KTx). Whether MBS should be performed before or after KTx remains an important clinical decision, particularly when both approaches appear feasible and safe. Determining whether operative sequencing meaningfully influences patient outcomes may help guide individualized surgical planning in patients with obesity and end-stage kidney disease. This single-center cohort study (2012-2023) identified adults who underwent MBS and KTx using institutional databases. Patient characteristics, allograft function, immunosuppression, and perioperative outcomes were evaluated according to operative sequencing (MBS-first vs KTx-first). Twenty patients (n = 11 KTx-first, n = 9 MBS-first) were identified. At the time of transplant, BMI was lower in patients in the MBS-first cohort (31.9 kg/m 2 vs 38.1, P = .044). Weight loss at 1-year post-MBS was similar between groups (KTx-first BMI change −7.6 kg/m 2 vs MBS-first −8.9, P = .790). Metabolic and bariatric surgery 30-day perioperative events occurred in five (25%) patients: three emergency room visits, one readmission, two wound complications, and one peritoneal dialysis catheter infection. At a median of 4.6 years post-KTx, graft survival was 80% (n = 16), which was similar between KTx-first (81.8%) and MBS-first (77.8%). Within the limitations of this retrospective study, no significant differences in perioperative, weight loss, or graft outcomes were observed between sequencing strategies and may suggest that operative timing can be individualized based on patient-specific factors, transplant candidacy, metabolic disease severity, and multidisciplinary care considerations rather than a universally preferred sequence.