Severe insulin-resistant diabetes associated with better metabolic surgery outcomes

Patients with severe insulin-resistant diabetes (SIRD) may particularly benefit from metabolic surgery, a study found.

Researchers retrospectively compared diabetes disease states and response to metabolic surgery in participants with type 2 diabetes from independent cohorts in France and Brazil. Participants underwent Roux-en-Y gastric bypass or sleeve gastrectomy. Study outcomes were type 2 diabetes remission and improvement of estimated glomerular filtration rate (eGFR). Results were published Feb. 8 by The Lancet Diabetes & Endocrinology.

Of 368 patients in a French cohort, 34 (9%) were classified as having SIRD, 314 (85%) with mild obesity-related diabetes (MOD), and 17 (5%) with severe insulin-deficient diabetes (SIDD). In a Brazilian cohort of 121 patients, 10 (8%) had SIRD, 83 (69%) had MOD, and 25 (21%) had SIDD. At one year, type 2 diabetes remission was reported in 81% and 90% of French and Brazilian patients with SIRD, compared to 55% and 51% of patients with MOD, and 13% and 36% of patients with SIDD, respectively. Multivariable analysis showed SIRD was associated with more frequent type 2 diabetes remission (odds ratio, 4.3 [95% CI, 1.8 to 11.2]; P=0.0015) and with an increase in eGFR (mean effect size, 13.1 mL/min per 1.73 m² [95% CI, 3.6 to 22.7 mL/min per 1.73 m²]; P=0.0070).

Overall, 35 (83%) of 42 patients with SIRD had complete or partial diabetes remission at one year, compared with 219 (51%) of 430 patients with non-SIRD. Odds of type 2 diabetes remission remained significantly higher in patients with SIRD after adjustment for each of the five clinical or biological primary traits used to determine diabetes type (body mass index, age at diagnosis, baseline HbA1c, fasting blood glucose, and fasting plasma C-peptide). Analysis of postop changes in eGFR found that it increased after surgery in the subgroup of patients with SIRD, resulting in a decrease in the number of patients in stage 2 and stage 3 chronic kidney disease. In contrast, eGFR remained stable postop in patients with MOD and SIDD. There was no difference in surgical complications by SIRD, MOD, or SIDD status.

Data-driven classification might help to refine the indications for metabolic surgery, the authors said. “The precise mechanisms that contribute to better postoperative glucose control and eGFR improvement in SIRD require further investigation. More generally, this approach might represent a step towards the implementation of precision medicine in metabolic surgery,” they wrote.