Other Supplements

A number of studies have examined various supplements to aid in weight loss.
There are a couple of candidates with relevance to both renal disease and
weight loss.

One of these substances is acetyl L carnitine. This protein is made of two
amino acids, lysine, and methionine. It is available primarily from meat
protein, but is also synthesized in the body. However, some conditions and
medications may interfere with its metabolism and may even cause secondary
deficiency.

Carnitine is needed for metabolism of fat by the mitochondria. Insufficiency
can mean a decreased ability to burn dietary and stored fat. For any
patient, symptoms of potential insufficiency include the following: 1)
excessive fat storage, 2) low muscle tone, 3) increased appetite (unable to
make adequate ATP from food consumed), 4) poor exercise endurance, 5)
increased fatigue, 6) excessive sleeping, 7) muscle pain with exertion, [image:
8)] elevated triglycerides, 9) low or unpredictable blood sugar levels
(resulting from inability to effectively use stored fat for energy), and 10)
cardiomyopathy. Hemodialysis patients with insufficient L-carnitine may have
difficulty maintaining adequate red blood cell production.
Provision of acetyl L carnitine has been shown to help with a variety of
symptoms, including diabetic neuropathy, insulin resistance in metabolic
syndrome, improved lipid parameters, improved exercise endurance, improved
blood sugar levels, and improvement in memory.

L-carnitine has been studied in the hemodialysis population. There is tissue
depletion related to hemodialysis duration and extent of disease. In several
studies, provision of L-carnitine in hemodialysis patients decreased need
for erythropoetin to maintain hemoglobin levels. It has also been shown to
have a protein sparing effect in hemodialysis patients.

In a study of children on hemodialysis, provision of l-carnitine reduced
triglycerides, free fatty acids, total cholesterol, and increased HDL-C.
Hemodialysis patients generally require IV administration of L-carnitine;
however, a few studies have used oral L-carnitine. In addition to decreased
need for erythropoietin, quality-of life-indicators have also improved with
L-carnitine administration.

The majority of L-carnintine is found in muscle and brain tissue; thus,
serum levels of L-carnitine do not reflect muscle stores. A trial of oral
L-carnitine in doses of 50mg/kg/day[67] or a typical dosage in adults of
3,000mg per day may be worth trying to see if energy levels improve in
patients trying to lose weight. Patients may be better able to manage
appetite if they are able to effectively burn stored fat. More research
regarding acetyl-L-carnitine supplementation, specifically in post-weight loss surgery patients, would be helpful.

A second supplement showing benefit in postoperative weight loss was found
as an unexpected consequence of its use. In a study initially designed
to see the impact on intestinal bacterial overgrowth and vitamin B12 levels,
researchers found an additional impact on weight loss. Compared to control
subjects, the probiotics provided in this study not only improved bacterial
overgrowth and B12 levels compared to pre-operative levels, but also
improved initial weight loss in postoperative patients during the initial
three months after surgery.

Two small studies examined the effect probiotics have on reduction of
uremic toxins in patients with stages 3 and 4 CKD. The authors found a
reduction in blood urea nitrogen (BUN), but not creatinine. Longer duration
studies with larger numbers of CKD patients are needed to determine
effectiveness and safety of probiotics in the long term. The safety of use
of probiotics in renal post-weight loss surgical patients remains a subject
for further studies.

Medication Issues

With the unpredictability of absorption of vitamin and minerals following
weight loss surgery, it seems reasonable to be concerned about the
reliability of medication absorption for renal patients. In such a patient,
can one count on the medication absorption necessary to prevent organ
rejection after a kidney transplant?

A pilot study published in 2008 examined the pharmacokinetics of three
modern immunosupressants (mycophenoic acid, tacrolimus, and sirolimus) after
gastric bypass patients with ESRD and post-kidney transplant.They found
that significant differences in dosages were required for RYGB patients
compared with nonbypass population. There was significant interpatient
variability in the RYGB patients group.
Researchers at the University of Oslo studied pharmacokinetics of
atorvastatin in 12 patients with morbid obesity before and following gastric bypass surgery.Variable affects were seen in uptake of the statin.
Researchers concluded that retitration of atorvastatin (compared to
presurgical dose) is necessary following surgery to provide the lowest
effective dose on an individual basis.

A small study of patients who had weight loss surgery following renal
transplantation showed no alterations in the dosages of immunosuppressant
medications that were needed post-bariatric surgery.

Vitamin A

Studies of vitamin and mineral deficiencies occurring after
bariatric surgery are numerous. However, the next question to ask is “how
much is too much?” In the renal dialysis population, toxicity of vitamin A
is a concern as they may have levels higher than people without renal
disease even without supplementation.

A study published in 2010 looked at vitamin and mineral levels in gastric
sleeve patients. They noted multiple vitamin and mineral deficiencies and
hypervitaminosis A was found in 26 (48%) of their 60 study participants. In
addition, thiamine and vitamin B6 levels were elevated in about 30 percent
of participants. The levels of B vitamins were not considered to be
harmful.

High levels of preformed vitamin A (retinol) can lead to problems, such as
ataxia, alopecia, dry skin, and liver problems. They can affect bone health
by causing resorption of bone. In the study by Aarts EO et al,a
multiple vitamin that included the RDA for vitamin A was recommended three
times per day. A multiple vitamin provided three times a day is in excess of
recommended supplementation guidelines published by the ASMBS.This
study does not state how much of the vitamin A was preformed (retinol)
versus betacarotene. Serum levels of vitamin A did not did not exceed 4
µmol/L after one year of supplementation.

Calcium

Serum calcium is monitored closely in patients with ESRD. There
is a delicate interplay between serum calcium, ionized calcium, serum
phosphorus, PTH, and vitamin D. Because of this, it is desirable for the
dietitian to work with the nephrologist to determine need for and adequacy
of calcium supplementation. Some phosphate binders are calcium based and can
be a problematic by elevating serum calcium levels too much. Using a
noncalcium containing phosphate binder may be preferable in hemodialysis
patients. Monitoring bone mineralization markers may be of assistance in
this determination,


http://www.drfeiz.com/

Vitamin K

A number of studies examining vitamin K are emerging due to its
effect with bone health and prevention of vascular calcification. This
nutrient is frequently avoided in patients on warfarin therapy; however,
adequacy and consistency of vitamin K intake are important for stable
PT-INRs.PT-INR is a lab test done to determine how long it takes for
the blood to clot (prothrombin time). Variability in clotting time can put
patients at risk for excessive bleeding if on warfarin.In CKD patients,
cardiovascular disease is a risk and a significant cause of mortality.

Calcium and vitamin D have long been identified as big players in the
prevention of osteoporosis. Osteopenic changes can occur rapidly in patients
after gastric bypass. However, vitamin K is a cofactor necessary for
activation of osteocalcin, a hormone that allows calcium to get into bone.
Insufficient vitamin K and subsequently inadequate levels of osteocalcin,
could impact calcium deposits in blood vessels and even the kidney. Both
vitamin D and vitamin K deficiencies have been associated with vascular
calcification in CKD patients.

Matrix Gla protein (MGP) is vitamin K dependent. It acts as a calcification
inhibitor in the vascular system. Adequate levels of MGP may play a
significant role in prevention of vascular calcification.

In a study reported in 2004, more than half of the patients four years post
BPD were shown to be deficient in vitamin K. As noted in the ASMBS article,
prothrombin time has been used as an indicator for deficiency and patients
post RYGB had levels suggestive of deficiency compared to LAGB patients and
controls.This may not only be an issue for patients who have
malabsorptive bariatric procedures. There was a case report of fetal
cerebral hemorrhage resulting from maternal vitamin K deficiency following
gastric adjustable banding.

It is reasonable to evaluate food intake in patients with hemodialysis
following weight loss surgery, as some foods that may be discouraged due to
elevated serum potassium or phosphorus levels may also be those that are a
good sources of vitamin K.

Other minerals

Necessary for making red blood cells, copper is essential.
In addition, copper is a cofactor in enzymes involved with vascular and
skeletal tissues. It is absorbed in the duodenum and proximal jejunum.
Deficiency of this mineral can mimic symptoms of vitamin B12 deficiency,
including gait disturbances, peripheral neuropathy, muscle weakness, and
anemia.Cases of patients with optic neuropathy and myopathy due to
copper deficiency have been documented.Hemodialysis does not remove
copper; however, levels should be monitored in hemodialysis patients who
have had gastric bypass as deficiency has been reported. Measurement of not
only serum copper, but also ceruloplasm is recommended to detect
deficiencies.

Zinc is an important mineral involved in more than 300 enzyme systems in the
body and necessary for proper immune function. It has been found to be
deficient in many gastric bypass patients. Signs of deficiency include taste
acuity changes, loss of appetite, loss of hair, or skin changes. If meat
intake is low, zinc, iron, and copper may be be at risk for deficiency.
Deficiency of zinc is difficult to detect since serum zinc represents less
than 0.1 percent of total zinc stores.

Zinc is not removed during hemodialysis. Provision of too much supplemental
zinc can interfere with activity of copper in the body. Doses of 50mg or
more per day can be problematic for copper metabolism.


http://www.drfeiz.com/lap-gastric-bypass.html

B vitamins

Deficiency of vitamin B12 (cobalamin) has been recognized as a
common problem in bariatric surgery patients for many years. Increased
provision of vitamin B12 is part of the supplementation plan for gastric
bypass patients due to decreased production of intrinsic factor. In the
gastric sleeve patient, the fundus of the stomach is removed, and it is
presumed that less intrinsic factor is made with this procedure.
Deficiency of vitamin B12 can cause pernicious anemia, nerve degeneration
and peripheral neuropathy. Pernicious anemia is a condition in which the
body does not make enough of a protein called “Intrinsic Factor,” which is
required for absorption of B12. Besides weight loss surgery, other common
causes of pernicious anemia include a weakened stomach lining (atrophic
gastritis) and autoimmune conditions where the body attacks the cells of the
stomach that make intrinsic factor. Provision of 500mcg or more oral or
sublingual B12 is usually sufficient to prevent deficiency; however, some
patients may require monthly injections of B12 to maintain desirable levels.
Stomach acid is required to absorb naturally occurring cobalamin; however,
forms that are added to foods or used in supplements do not require acid for
absorption.

Thiamine (B1) can be deficient in weight loss surgery patients who have lost
weight very rapidly or who have frequent vomiting.Serious effects of
thiamine deficiency include Wernicke’s encephalopathy, affecting gait, and
peripheral neuropathy. If not caught quickly, repletion of thiamine levels
may not completely reverse the symptoms. It may take 3 to 6 months for
symptoms to resolve after repletion. Daily supplementation is advised as the
body has limited stores of thiamine. IV repletion is effective with doses of
100mg for 3 to 14 days followed by an oral supplement maintenance dose of
around 20 to 100mg per day to maintain adequate stores.

Most prescription and over-the-counter renal vitamin preparations contain B
vitamins at levels at or above the RDA. Some may also contain vitamin E,
iron, and trace minerals. These supplements do vary, so careful selection of
an appropriate product is desirable.


http://www.drfeiz.com/home.html

http://www.drfeiz.com/sleeve-gastrectomy-surgery.html

Iron

Iron deficiency is very common after gastric bypass, occurring in 33
to 50 percent of patients. Serum ferritin is the most sensitive marker for
storage iron, and thus can be used by the provider as an early indicator of
iron deficiency. Heme iron is the form found in animal protein and is the
most effectively absorbed. However, intolerance of red meats (good heme iron
sources) and other meats can be a problem in many patients. The duodenum and
proximal jejunum are the primary sites of iron absorption, and in gastric
bypass, the duodenum is bypassed.

Nonheme (plant) or inorganic forms of iron are relatively inexpensive and
readily available over the counter. Supplementation with ferrous forms of
iron is common practice in post-weight loss surgery patients. Inorganic
forms of iron can cause gastrointestinal disturbances, such as constipation
and its associated discomfort. Adequate stomach acid is needed for
absorption of nonheme iron and there is decreased hydrochloric acid
production with all of the types of bariatric surgery. Proton pump
inhibitors (PPIs) are commonly used in weight loss surgery patients, thus
decreasing stomach acid production.

It is common practice to recommend separating iron supplements from calcium
supplements by 1 to 2 hours due to competition for absorption in the
gastrointestinal tract. However, in a study examining the effect of adding a
calcium-rich food to a meal containing both heme and nonheme forms of iron,
there were several useful observations. The addition of a calcium-rich food
did not impair absorption of either heme or nonheme iron. Heme iron
absorption may take longer and continue further down the intestine than
nonheme iron. Provision of a nonheme iron supplement appears to be
effectively absorbed if given with a heme form of iron (generally a meal
consisting of meat).[40] Consumption of vitamin C (ascorbic acid) or a
source of food high in vitamin C is frequently recommended to provide an
acidic environment to improve nonheme supplement forms of iron.

In renal bariatric patients, anemia management could be an even bigger
challenge. In patients with CDK, iron deficiency is common and anemia
management is complex. In patients with CKD who are not on dialysis,
provision of either oral iron or intravenous (IV) iron may delay the need
for erythropoiesis-stimulating medications. Patients on hemodialysis are
less able to absorb oral iron due to elevated serum levels of hepcidin,
which also impairs ability to recycle iron in the normal reticuloendothelial
system. IV iron is more effective in hemodialysis patients to increase
ferritin and decrease the need for erythropoetic-stimulants.

Minerals/vitamins

The optimal supplementation of vitamins and minerals is
not really known for patients with ESRD on dialysis who have also had
bariatric surgery. However, in March 2008, the American Society for
Metabolic and Bariatric Surgery (ASMBS) published nutrition guidelines for
the surgical weight loss patient.This paper addressed optimal methods
for nutrition assessment of pre- and post-weight loss surgery patients.
Supplementation guidelines for vitamin/minerals for the three most common
types of weight loss surgery were provided based on studies available at the
time. Specific recommendations for patients following sleeve gastrectomy
were not given. The article stated, “As advances are made in the field of
bariatrics and nutrition, updates regarding supplementation suggestions are
expected.”Later that same year, a retrospective study of 137 RYGB
patients published in the American Journal of Clinical Nutrition Studies
concluded that nutritional deficiencies following bariatric surgery cannot
be prevented by provision of a standard multiple vitamin preparation.

In several studies, deficient levels of vitamins and minerals have been
found in patients prior to bariatric surgery. Vitamins identified included
vitamin B12, folate, vitamin A and vitamin D (25 OH). Minerals that were
deficient included zinc, ferritin (iron stores), selenium, and magnesium.
Additionally, low levels of albumin and hemoglobin have also been identified
preoperatively. These same nutrients were frequently deficient at one year
postoperatively, but many were improved compared to preoperative
levels.

Most weight loss surgery patients are told to take a “good” multivitamin
with mineral supplement. Some nutrients have commonly been supplemented at
higher levels than found in a multivitamin, including iron, vitamin B12, and
calcium. Vitamin D is also frequently supplemented at higher than
recommended dietary allowance (RDA). Deficient nutrients that have been
previously under-recognized include copper, magnesium, thiamine, zinc,
vitamin K, and vitamin B6.

Multiple vitamin and mineral supplements vary greatly. Standard chewable
forms may not be as “complete” as nonchewable multiple vitamins with
minerals. It is necessary to compare products, especially as new products
developed specifically for weight loss surgery patients are being developed.
Dietitians should know the contents of the supplements taken and look for
any nutrients provided in insufficient amounts.
Vitamin D. Vitamin D has been a hot topic among researchers for a number of
years. It is now recognized that patients with obesity are more likely to
have insufficient serum 25 OH vitamin D. Many patients are already deficient
in vitamin D at the time of weight loss surgery.
Hypovitaminosis D and bone loss are common in patients after gastric bypass.
In one study, to correct the serum 25 OH levels, the mean supplementation
provided was 6,472IU of vitamin D per day.31 However, the Institute of
Medicine released Dietary Reference Intakes for Calcium and Vitamin D,
2011.32 It suggested the upper safe level for vitamin D is 4,000 IU/day.
This recommendation was made for the general “healthy” population and not
specific to patients with obesity. In fact, the report does note that serum
levels of vitamin D are frequently low in individuals with obesity.

This fat-soluble vitamin can be difficult to replete and maintain adequate
levels. Serum 25-OH D3 may rise by 1ng/mL for every 100IU of additional
vitamin D provided. Some studies indicate that vitamin D3 (cholecalciferol),
derived from animal or microbial sources, is more effective for repletion
that provision of vitamin D2 (ergocalciferol), which is derived from plants.
Optimal 25-OH D3 levels are thought to be greater than 32ng/mL.[33]
Obtaining serum 25 OH vitamin D levels is the best way to know if the amount
of vitamin D being supplemented is adequate.

Patients with ESRD are no longer able to convert 25 OH vitamin D to its
active form (1-25 OH vitamin D). Routine supplementation of vitamin D (D3 or
D2) in patients with ESRD on dialysis was not common due to the assumption
that supplementation of either form of vitamin D would result in
hypercalcemia. Supplementation with vitamin D3 in order to replete 25 OH
vitamin D levels does not cause hypercalcemia. Adequate 25 OH vitamin D
levels are required to maintain normal parathyroid hormone (PTH)
levels.In addition, restoring vitamin D to normal range may also
have an epoetin-sparing effect.

Hemodialysis patients with vitamin D deficiency who were not supplemented to
reach normal levels had a higher incidence of mortality compared to those
who were supplemented, and had the highest serum 25 OH vitamin D or 1,25 D
levels.

Signs of vitamin D insufficiency or deficiency are not obvious. Rickets and
osteomalacia are two bone-related deficiency conditions. Other signs may be
more subtle, including muscle pain or arthritis pain. In the elderly
population, muscle weakness and cognitive impairment have been improved by
increased vitamin D intake

Nutrient Issues

Protein.Post weight loss surgery patients are encouraged to achieve and
maintain an adequate protein intake. This can be a challenge for any patient
with the small size of the stomach pouch and food intolerances after
surgery.For patients with ESRD on dialysis, maintenance of protein
adequacy is a common problem. For patients with CKD nearing dialysis,
predialysis diet prescriptions frequently recommend limited protein. Protein
recommendations should be individualized based on comorbid chronic
conditions and laboratory measures of protein stores.
Renal diet versus post weight loss surgery diet. Foods normally encouraged
as part of a healthy diet for bariatric patients may be limited on CKD diet.
Lab values need to be monitored frequently. For patients with CKD and/or
ESRD, recommendations for limiting protein and minerals should be adjusted
based on laboratory measures.

One common nutrition issue for CKD patients is elevated serum phosphorus.
Foods high in phosphorus include whole grains, beans/legumes, nuts, and
milk. Following weight loss surgery, patients are generally encouraged to
consume these foods to help meet protein, fiber, and some vitamins/mineral
needs.

Elevated serum potassium may necessitate a decreased intake of certain
fruits and vegetables in addition to milk/dairy products.
Thus, limiting certain foods due to high serum levels of phosphorus or
potassium may necessitate a decrease in foods also high in protein, further
contributing to potential protein inadequacy

Renal stones.

There is an increased prevalence of kidney stones following
gastric bypass procedures. Frequent kidney stones are linked with worsening
of renal function and may contribute to development of CKD in patients with
otherwise normal renal function prior to surgery.
Kidney stones are associated with higher levels of oxalate in urine. It
appears that provision of oral calcium and oral citrate supplements can
decrease risk for stone formation in weight loss surgery patients. Although
provision of calcium citrate is common in many patients post weight loss
surgery, calcium citrate is not given to and is not safe for patients with
chronic renal failure due to increased serum levels of aluminum that can
accompany this particular supplementation.

Restrictive procedures (e.g., banding and gastric sleeve) do not appear to
hold this same risk for development of kidney stones. In a recent study,
patients who had a restrictive procedure for weight loss had urinary oxalate
levels similar to levels found in nonstone forming and stone-forming
controls. Levels of urinary oxalate were significantly lower than in
patients who underwent RYGB.

Headline: New 3-D Imaging Technology Gives Patients the Confidence to Undergo Lap Band Surgery

Dr. Michael Feiz provides patients with 3-D computer images of the digestive system in order to help patients understand weight loss surgery and make a more informed decision

Beverly Hills, CA, June 15, 2011 – Within the last few years, Lap Band surgery has rapidly become the most popular weight loss surgery available today, with thousands of individuals undergoing the procedure every year. While many are thrilled to quickly shed their excess weight, some patients are reticent to undergo any surgical procedure out of fear. However with innovative 3-D imaging software, patients are able to see exactly how the surgeon will approach the surgery, allowing them to better understand how the surgery is performed and relieve their nerves in the process. Dr. Michael Feiz is one of the many surgeons who uses this innovative software to help his patients understand the risks and benefits of the Lap Band in Los Angeles.

According to an ABC7 interview with Dr. Feiz regarding weight loss in Los Angeles, “Nothing empowers a patient more than having knowledge and exactly understanding what's going to be done to them, how it's going to benefit them, and what the risks and benefits are.” Many prospective patients seek the expertise of Dr. Feiz for their weight loss concerns, in a large part due to Dr. Feiz’s outstanding reputation for compassionate and personable care for all of his patients. He takes the time to ensure that each patient is comfortable and fully knowledgeable with regards to what the Lap-Band is, how it works, and the expected results. The new 3-D imaging software is another way Dr. Feiz is able to install a sense of optimism and trust in his patients, ultimately helping them achieve the weight loss they need to lead more productive and healthy lives.

The experience and passionate care Dr. Feiz provides for his patients is unmatched, designating him as the bariatric surgeon of choice for men and women who seek weight loss in Los Angeles with the Lap Band, gastric bypass, and sleeve gastrectomy procedures. Undergoing a weight loss procedure allows patients to add 20 years to their lives, as well as relieve hazardous co-morbidities such as high blood pressure, high cholesterol, type 2 Diabetes, and obstructive sleep apnea within 6-12 months after surgery.

For more information about the sleeve gastrectomy, gastric bypass and Lap Band in Beverly Hills with Dr. Feiz, please visit www.DrFeiz.com

PR submitted by http://www.Cyberset.com

Source: Michael Feiz Medical Corp. Public Relations

Possible Issues with Various Procedures for Renal Disease

Experience with patients who have undergone LAGB has shown that it is
possible for patients to consume too many calories by consuming liquids with
meals or eating high-calorie foods. This procedure does not produce
“dumping” symptoms that are more common with RYGB patients after eating
high-sugar/fatty foods.So, for patients who have a tendency to eat
these types of foods or to snack frequently, this procedure can be less
effective than others.

With RYGB being a malabsorptive procedure, there is potential for poor
absorption of many nutrients. Additionally, some dialysis patients have
difficulty maintaining a good nutritional status (e.g., adequate serum
albumin and hemoglobin), and this type of surgery may present increased risk
for malnutrition.

Laparoscopic sleeve gastrectomy

LSG combines restrictive and hormonal
components. It is a newer procedure and is not universally covered by
third-party payers (including Medicare). The sleeve was previously reserved
as the first part of a staged operation for patients with super obesity with
the plan of converting to RYGB once a reasonable weight loss was achieved
Recent studies show weight loss with this procedure to be comparable to RYGB
with a similar percentage of EBW loss. Thus, a second surgery may not be
required for many patients

Types of surgery

The type of surgical procedure done is also an important factor to consider.
Laparoscopic adjustable gastric banding (LAGB) is a restrictive, but not
malabsorptive procedure. Laparoscopic Roux-en-Y gastric bypass (RYGB) is
both a restrictive and malabsorptive procedure. Newer on the playing field,
laparoscopic sleeve gastrectomy (LSG), is also promoted as a restrictive
procedure without malabsorption effects.
Roux-en-Y gastric bypass. Roux-en-Y gastric bypass (RYGB) surgery has the
advantage of established long-term efficacy for weight loss and reductions
of obesity-related comorbities (i.e., type 2 diabetes mellitus, lipid
abnormalities, and hypertension). It is relatively safe, and weight loss
results are reported typically as a loss of 60 to 80 percent of excess body
weight (EBW). It combines elements of restrictive, hormonal, and
malabsorptive procedures. Maximum weight loss with RYGB is usually
achieved by 12 to 18 months following surgery.

Laparoscopic adjustable gastric banding. Laparoscopic adjustable gastric
banding (LAGB) has been around for a number of years in other countries. It
was approved for use in the United States in 2001. It is strictly a
restrictive procedure. Weight loss is generally slower than gastric bypass
(an average of 2 pounds per week) and yields a decrease of approximately 44
to 68 percent of EBW at four years. Adjustments of the band require more
office visits after surgery (around 10 in the first year) and an annual
upper gastrointestinal test. Band slippage is a risk that can be serious
and may even require a second surgery for gastrectomy or conversion to RYGB.
The gastric banding option for kidney transplant patients is questionable
due to the presumed predisposition to infection presented by a foreign body
(i.e., the band) in immunosuppressed patients after transplant.

Healthcare Cost—Benefits Versus Risks

Treating ESRD is costly. As of the end of 2007, the cost of treating
patients with ESRD amounted to $35.32 billion annually from both public and
private spending. In 2006, the average annual cost for a Medicare ESRD
patient on dialysis was $43,335.[2]

Consider the potential annual healthcare cost savings if fewer patients
required dialysis.

Additionally, kidney transplantation for those approaching dialysis or
already on dialysis would certainly improve quality of life. Transplant
numbers are also increasing each year. From 2005 to 2007, there were 53,012
kidney transplants performed in the United States.3 This represents a
20-percent increase from 2000 and a 45-percent increase from 1995.

Transplant recipients without obesity tend to have better outcomes, such as
improved patient and graft survival, compared to patients with obesity. So,
potential recipients need to lose weight to meet the standard of body mass
index (BMI) of 35kg/m2 or less. Is weight loss surgery a safe and
cost-effective way to reach the desired BMI?[4,5]

Weight loss surgery costs are actually decreasing due to efficiencies and
improved outcomes. One study, which examined hospital payments for bariatric
surgery procedures, found that payments fell from $29,563 to $27,905 from
2002 to 2006. In addition, complication rates have dropped during this same
time, despite the fact that patients having the procedures were older and
sicker.[6]

For patients with CKD, weight loss has been shown to improve renal
parameters.[7] In a study done by the University of Cincinnati College of
Medicine,[8] nine out of 45 patients with established renal disease, had
resolution, improvement, or stabilization of kidney function after gastric
bypass. Two patients already on dialysis at the time of surgery were able to
discontinue dialysis for 27 and seven months, respectively. The remaining
patients had stable renal function for 2 to 5 years postoperatively. Weight
loss surgery, thus, can decrease overall healthcare costs by delaying the
progression of disease or delaying the need for dialysis or kidney
transplantation.[8] More long-term studies are needed to analyze effects of
bariatric surgery on CKD and progression to ESRD.[9]

Weight loss surgery in patients with renal disease does carry some
risks.[10] One must consider the potential for malabsorption of not only
nutrients, but also antirejection medications.[11] For patients who are
undergoing dialysis, there are no studies that have looked at the optimal
vitamin/mineral supplementation plan for patients with ESRD following
bariatric surgery.

Prevalence Important Info

According to data from The National Health and Nutrition Examination Survey
(NHANES) from 1999 to 2004, the prevalence of chronic kidney disease was
16.8 percent in the United States. Not treated or inadequately treated, CKD
can necessitate eventual dialysis or transplantation. Primary causes of CKD
are noted to be diabetes, hypertension, and obesity.[1] With the rate of
diabetes and obesity in this country increasing, it is not likely that that
we will run out of patients with CKD anytime soon

Introduction

Weight loss surgery has shown benefits to many chronic diseases, such as
diabetes, hypertension, lipid abnormalities, and also to chronic kidney
disease (CKD). But is weight loss surgery for those with end-stage renal
disease (ESRD) a good option? That was my question when I first saw a
patient in the clinic who was on dialysis, but was seeking gastric bypass to
lose weight to be able to have a kidney transplant. What would happen after
surgery? How would we modify her diet and supplements after surgery?

United Healthcare Lap Band Surgery Coverage

United Healthcare Lap Band Surgery Coverage

United Healthcare Lap Band Surgery Coverage

You may qualify automatically for full Lap Band coverage under United Healthcare if you:

• Are 100+ pounds over your ideal weight
• Have a BMI of 40+
• Have a BMI of 35+ with obesity-related medical problems such as type 2 diabetes, hypertension, cardiovascular disease, mechanical arthropathy, lower extremity lymphatic, sleep apnea, or coronary artery disease
• Have been overweight more that two years and have failed diet / exercise or other weight-loss programs

United Healthcare’s coverage depends on the insurance plan of each individual, as well as each patient’s ability to meet the criteria for bariatric coverage. Most of the time, United Healthcare will indeed cover your lap band surgery should you meet your plan’s requirements, such as having a Body Mass Index (BMI) of 35 or greater, as well as a personal letter describing your weight history and struggles through failed diets. You will also be required to have a psychological and nutritional evaluation.

If Your BMI is below 40, United Healthcare will also evaluate your weight-related medical conditions prior to granting authorization for a LAP-BAND Surgery.

To find out if your individual United Healthcare Plan covers the Lap Band surgery, call us at (310) 855-8058 or fill out our Free Insurance Verification Form for Lap Band, and one of our helpful staff members will contact you within a couple of hours with your list of benefits.

Blue Cross Blue Shield Lap Band Surgery Coverage

Blue Cross Blue Shield Lap Band Surgery Coverage

You may qualify automatically for full Lap Band coverage under Blue Cross Blue Shield if you:

• Are 100+ pounds over your ideal weight
• Have a BMI of 40+
• Have a BMI of 35+ with obesity-related medical problems such as type 2 diabetes, hypertension, cardiovascular disease, mechanical arthropathy, lower extremity lymphatic, sleep apnea, or coronary artery disease
• Have been overweight more that two years and have failed diet / exercise or other weight-loss programs

If you meet your insurance plan’s criteria for bariatric coverage, Blue Cross Blue Shield will most likely cover your Lap Band Surgery. We offer Free Insurance Verification as a quick, easy way to find out if your insurance will cover you for Lap Band Surgery. If you do not automatically qualify for coverage, one of our helpful staff members will assist you in identifying your best options.

Blue Cross Blue Shield’s coverage depends on the insurance plan of each individual, as well as each patient’s ability to meet the criteria for bariatric coverage. BCBS has thirty nine locally operated companies, so each plan may vary. Most of the time, Blue Cross Blue Shield will indeed cover your lap band surgery should you meet your plan’s requirements, such as having a Body Mass Index (BMI) of 35 or greater. In some cases, you may be required to undergo a nutritional evaluation, which involves a supervised 6-12 month nonsurgical weight-loss regime.

If Your BMI is below 40, Blue Cross Shield will also evaluate your weight-related medical conditions prior to granting authorization for a LAP-BAND Surgery.

To find out if your individual Aetna Plan covers the Lap Band surgery, call us at (310) 855-8058 or fill out our Free Insurance Verification Form for Lap Band and one of our helpful staff members will contact you within a couple of hours with your list of benefits.

Aetna Lap Band Surgery Coverage

Aetna Lap Band Surgery Coverage

You may qualify automatically for full Lap Band coverage under Aetna if you:

• Are 100+ pounds over your ideal weight
• Have a BMI of 40+
• Have a BMI of 35+ with obesity-related medical problems such as type 2 diabetes, hypertension, cardiovascular disease, mechanical arthropathy, lower extremity lymphatic, sleep apnea, or coronary artery disease
• Have been overweight more that two years and have failed diet / exercise or other weight-loss programs

If you meet your insurance plan’s criteria for bariatric coverage, Aetna will most likely cover your Lap Band Surgery. We offer a Free Insurance Verification as a quick, easy way to find out if your insurance will cover you for Lap Band Surgery. If you do not automatically qualify for coverage, one of our helpful staff members will assist you in identifying your best options.

Aetna’s coverage depends on the insurance plan of each individual, as well as each patient’s ability to meet the criteria for bariatric coverage. Most of the time, Aetna will indeed cover your lap band surgery should you meet your plan’s requirements, such as having a Body Mass Index (BMI) of 35 or greater. In some cases, you may be required to undergo a nutritional evaluation, which involves a supervised three month diet.

If your BMI is below 40, Aetna will also evaluate your weight-related medical conditions prior to granting authorization for a LAP-BAND Surgery.

To find out if your individual Aetna Plan covers the Lap Band surgery, call us at (310) 855-8058 or fill out our Free Insurance Verification Form for Lap Band and one of our helpful staff members will contact you within a couple of hours with your list of benefits.

United Healthcare Sleeve Gastrectomy Surgery Coverage

United Healthcare Sleeve Gastrectomy Surgery Coverage

United Healthcare Sleeve Gastrectomy Surgery Coverage

You may qualify automatically for full sleeve gastrectomy coverage under United Healthcare if you:

• Are 100+ pounds over your ideal weight
• Have a BMI of 40+
• Have a BMI of 35+ with obesity-related medical problems such as type 2 diabetes, hypertension, cardiovascular disease, mechanical arthropathy, lower extremity lymphatic, sleep apnea, or coronary artery disease
• Have been overweight more that two years and have failed diet / exercise or other weight-loss programs

United Healthcare’s coverage depends on the insurance plan of each individual, as well as each patient’s ability to meet the criteria for bariatric coverage. Most of the time, United Healthcare will indeed cover your sleeve gastrectomy surgery should you meet your plan’s requirements, such as having a Body Mass Index (BMI) of 35 or greater, as well as a personal letter describing your weight history and struggles through failed diets. You will also be required to have a psychological and nutritional evaluation.

If Your BMI is below 40, United Healthcare will also evaluate your weight-related medical conditions prior to granting authorization for a Sleeve Gastrectomy Surgery.

To find out if your individual United Healthcare Plan covers the Sleeve Gastrectomy surgery, call us at (310) 855-8058 or fill out our Free Insurance Verification Form for Sleeve Gastrectomy, and one of our helpful staff members will contact you within a couple of hours with your list of benefits.

Blue Cross Blue Shield Sleeve Gastrectomy Surgery Coverage

Blue Cross Blue Shield Sleeve Gastrectomy Surgery Coverage

You may qualify automatically for full Sleeve Gastrectomy coverage under Blue Cross Blue Shield if you:

• Are 100+ pounds over your ideal weight
• Have a BMI of 40+
• Have a BMI of 35+ with obesity-related medical problems such as type 2 diabetes, hypertension, cardiovascular disease, mechanical arthropathy, lower extremity lymphatic, sleep apnea, or coronary artery disease
• Have been overweight more that two years and have failed diet / exercise or other weight-loss programs

If you meet your insurance plan’s criteria for bariatric coverage, Blue Cross Blue Shield will most likely cover your Sleeve Gastrectomy surgery. We offer Free Insurance Verification as a quick, easy way to find out if your insurance will cover you for Sleeve Gastrectomy Surgery. If you do not automatically qualify for coverage, one of our helpful staff members will assist you in identifying your best options.

Blue Cross Blue Shield’s coverage depends on the insurance plan of each individual, as well as each patient’s ability to meet the criteria for bariatric coverage. BCBS has thirty nine locally operated companies, so each plan may vary. Most of the time, Blue Cross Blue Shield will indeed cover your sleeve gastrectomy surgery should you meet your plan’s requirements, such as having a Body Mass Index (BMI) of 35 or greater. In some cases, you may be required to undergo a nutritional evaluation, which involves a supervised 6-12 month nonsurgical weight-loss regime.

If Your BMI is below 40, Blue Cross Shield will also evaluate your weight-related medical conditions prior to granting authorization for a Sleeve Gastrectomy Surgery.

To find out if your individual Aetna Plan covers the Sleeve Gastrectomy surgery, call us at (310) 855-8058 or fill out our Free Insurance Verification Form for Sleeve Gastrectomy and one of our helpful staff members will contact you within a couple of hours with your list of benefits.

Aetna Sleeve Gastrectomy Surgery Coverage

Aetna Sleeve Gastrectomy Surgery Coverage

You may qualify automatically for full Sleeve Gastrectomy coverage under Aetna if you:

• Are 100+ pounds over your ideal weight
• Have a BMI of 40+
• Have a BMI of 35+ with obesity-related medical problems such as type 2 diabetes, hypertension, cardiovascular disease, mechanical arthropathy, lower extremity lymphatic, sleep apnea, or coronary artery disease
• Have been overweight more that two years and have failed diet / exercise or other weight-loss programs

If you meet your insurance plan’s criteria for bariatric coverage, Aetna will most likely cover your Sleeve Gastrectomy Surgery. We offer a Free Insurance Verification as a quick, easy way to find out if your insurance will cover you for Sleeve Gastrectomy Surgery. If you do not automatically qualify for coverage, one of our helpful staff members will assist you in identifying your best options.

Aetna’s coverage depends on the insurance plan of each individual, as well as each patient’s ability to meet the criteria for bariatric coverage. Most of the time, Aetna will indeed cover your sleeve gastrectomy surgery should you meet your plan’s requirements, such as having a Body Mass Index (BMI) of 35 or greater. In some cases, you may be required to undergo a nutritional evaluation, which involves a supervised three month diet.

If your BMI is below 40, Aetna will also evaluate your weight-related medical conditions prior to granting authorization for a Sleeve Gastrectomy Surgery.

To find out if your individual Aetna Plan covers the Sleeve Gastrectomy surgery, call us at (310) 855-8058 or fill out our Free Insurance Verification Form for Sleeve Gastrectomy and one of our helpful staff members will contact you within a couple of hours with your list of benefits.

*Abstract*

Weight loss surgery has demonstrated effectiveness for the treatment of
diabetes, obesity, and hypertension; all of which are noted to be primary
causes of chronic kidney disease and eventual end stage renal disease.
Weight loss can help limit the progression or resolve chronic kidney
disease. As the number of patients in the United States with chronic kidney
disease and end stage renal disease increases, weight loss surgery is
becoming more recognized as a treatment option either to help deminish
progression of chronic kidney disease or to prepare for kidney transplant if
weight loss is needed to qualify for transplant candidacy. This article
presents some unique considerations for renal patients with the various
weight loss procedures; both on nutrition status and potential
vitamin/mineral deficiencies or excesses. Monitoring lab values are also
recommended to help determine optimal vitamin/mineral supplementation before
and after surgery.


http://www.drfeiz.com