*Purpose: Morbid obesity is a barrier to kidney transplantation in patients with end-stage renal disease (ESRD) and is associated with progression of chronic kidney disease (CKD). Despite previous studies showing the efficacy of sleeve gastrectomy (SG) in this population, the safety of operating on these high-risk patients is of concern. Moreover, the long-term outcomes after SG among patients with kidney disease is unknown.

*Methods: We reviewed prospectively collected data on patients with ESRD and CKD undergoing SG from 2012 to 2018. During the study period, 195 patients with ESRD and 45 patients with CKD (stages 1 to 4) met NIH guidelines for metabolic surgery and underwent SG by a single surgeon. Average follow-up period was 2.3±1.5 years.

*Results: Mean age was 54.1±11.1 with a preoperative BMI of 44.0±6.3 kg/m². At most recent follow-up, mean BMI decreased to 36.7±6.6 (p<0.01). A total of 172 patients (71.7%) achieved a BMI ≤40 with 117 (48.1%) achieving a BMI ≤35. The mean percentage of total weight loss was 18.9±10.8 and the mean percentage of excess weight loss was 38.2±20.3. SG decreased the prevalence of HTN (85.8% vs 52.1%) and lowered the total anti-hypertensive medications required (1.6 vs 1.0) (p<0.01 each). Similarly, the prevalence of DM decreased after SG (59.6% vs 32.5%, p<0.01). Insulin requirements decreased by 51.7% for long-acting (59.6 to 29.4 units) and 57.6% for short-acting use (45.7 to 19.4 units) (p<0.05 each). Seventy-one ESRD patients (36.4%) achieved a BMI ≤40 and were waitlisted for KT, with 45 (63.4%) of these patients receiving KT and 10 (14.1%) remaining on the waitlist. Sixteen patients (22.5%) were removed for worsening comorbidities. Mortality rate among waitlisted patients after SG was 1.8 deaths per 100 patient-years, compared to 7.3 at our institution and 5.5 nationally. Subset analysis of the 45 patients with CKD showed improved estimated GFR in patients who were classified as stage 3a or 3b pre-operatively (43.5 vs 58.4 ml/min, p=0.01). Eight of the 13 patients with CKD stage 3 (61.5%) had improvement in their staging while none progressed.

*Conclusions: This is the largest prospective case series involving SG in patients with ESRD and CKD. SG has significant, sustainable effects on weight loss and medical comorbidities in this high-risk population. SG improves transplant candidacy safely and effectively, without increasing patient morbidity and mortality. Additionally, SG may be the only known way to improve renal function in patients with CKD, helping decrease progression to ESRD.

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