Sleeve gastrectomy versus tirzepatide to improve survival among patients with stage 5 CKD: A Markov decision analysis.

BACKGROUND: With the increasing use of glucagon-like peptide receptor agonists and declining bariatric surgery referrals for patients with morbid obesity and chronic kidney disease (CKD), it is unclear whether this strategy optimizes long-term survival. STUDY DESIGN: A Markov state transition model simulated the life of 30,000 patients with morbid obesity and stage 5 CKD after three weight loss interventions: diet and exercise (DE), sleeve gastrectomy (SG), and tirzepatide treatment. Base case patients were 45 years old with a pre-intervention body mass index (BMI) of 45 kg/m. SG patients were exposed to a mortality risk in the first three months. Sensitivity analysis was conducted on pre-intervention BMI. RESULTS: Patients who underwent SG or treatment with tirzepatide experienced similar survival for pre-intervention BMIs below 38 kg/m. However, as baseline BMI increased, SG was associated with progressively greater projected survival compared with tirzepatide. At a BMI of 40 kg/m, SG was associated with an additional 0.6 life-years relative to tirzepatide, increasing to 3.2 life-years at a BMI of 50 kg/m. For all BMIs above 37 kg/m, SG and tirzepatide improved survival over DE. CONCLUSION: In this decision-analytic model, greater and more sustained weight loss was the primary driver of improved long-term survival among patients with stage 5 CKD and morbid obesity. While tirzepatide may offer comparable outcomes at lower BMIs, sleeve gastrectomy was associated with significantly increased survival benefit for those with BMIs above 40 kg/m. These findings highlight the importance of individualized, weight loss-focused strategies when counseling patients with advanced CKD.