Severe Hypoalbuminemia Following Roux-En-Y Gastric Bypass in a Patient with Type 1 Diabetes

Patients with diabetes mellitus are at risk for several long-term complications due to insufficient diabetes control. Increased albuminuria is considered to be an early sign of diabetic nephropathy and is associated with an elevated risk for cardiovascular disease and early mortality [1,2]. Albuminuria usually occurs in association with poor glycemic control, elevated blood pressure and longer diabetes duration [3]. 30-40% of patients with type 1 diabetes develop microalbuminuria [4,5]. In type 2 diabetes, ten years from diagnosis the prevalence of microalbuminuria is 24.9% [6]. During the last decades bariatric surgery for morbid obese patients became more and more frequent. Between 2014 and 2018 there were 190.177 of primary bariatric surgeries performed worldwide [7]. 69.2% of these patients were diagnosed with diabetes [7]. Besides significant weight reduction, beneficial effects of bariatric surgery comprise (transient) remission of type 2 diabetes and improvement of other risk factors such as hypertension and hyperlipidemia [8]. Therefore, bariatric surgery is mentioned as a potential treatment in obese, type 2 diabetic subjects in current guidelines [9,10]. Regarding albuminuria, data from the Swedish Obese Subjects Study (SOS) showed a reduction in its incidence after bariatric surgery [8,11,12].

On the other hand, malabsorptive procedures such as Rouxen- Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) carry the risk of protein malabsorption due to changes in gut anatomy and physiology, since the small intestine as the major site of protein absorption is partly bypassed. It is characterized by hypoalbuminemia, edema, alopecia, and asthenia. Protein malnutrition is a complication mainly seen in patients undergoing BPD with an occurrence rate of 7-21% [13], has, however, also been reported after RYGB with an incidence of 13% at the 2-year follow-up [14]. While the typical patient with type 1 diabetes is not commonly regarded as overweight or obese, there is a growing number of patients with type 1 diabetes and morbid obesity who seek treatment by bariatric surgery [15]. In this case report we describe the consequences of bariatric surgery in such a patient.

A 49 year-old woman was first seen in our internal medicine outpatient clinic 3 months ago. Her past medical history included diabetes mellitus type 2 (DM2) for 5 years, seronegative rheumatoid arthritis (RA) for 4 years and hypertension. Her long-standing medications at that time included leflunomide (LE) 10mg daily, HCQ 200mg twice a day, prednisone 10mg daily, irbesartan 150mg daily, sitagliptin (SITA) 100mg daily, metformin 1000mg twice a day. Four months before our meeting her hemoglobin A1c was 5, 8%, while it raised to 8% at her last control 10 days before she came to us. After the last result she referred to her general practitioner and he added SITA 100mg to her previous antidiabetic treatment that included only metformin 1000mg twice a day (morning and dinner time). After a week she referred to out clinic worried due to some recent high blood glucose (BG) levels during the morning and persistent high during the day. She referred no symptoms of hypoglycemia (HYPO) at that time. After controlling her glucometer data I confirmed the high BG levels during the day. Repaglinide (RE) 1mg twice a day before lunch and dinner was administered to her, while she continued also her previous medications. A schedule with three times per day BG measurement for a week was given to the patient prior to discharge. Our next appointment was programmed after a week.

On admission, A1C was 10.8%, serum albumin 40% (normal range: 55.8-66.1%) and ACR was 1336.1mg/g, Creatinine 2.07mg/ dl, and GFR 25ml/min/1.7m2. Subsequently, the patient was substituted intravenously with albumin which caused only a slow regression of edema only. She was advised about the appropriate protein intake for bariatric patients by a trained dietologist and prescribed “Ressource Protein”® (a protein-rich, high-calorie drinking food, containing 18.8gms of protein per bottle) twice a day. During in-hospital treatment a very good diabetes control was achieved. After nearly four weeks of in-hospital treatment the patient could be discharged in good general health. Regular checkups were planned. One year after hospital admission ACR was 1522mg/g, albumin was 32.9g/l, Creatinine was 1.14mg/dl, and GFR 50ml/min/1.7m2.

Although the SOS study demonstrated that patients undergoing bariatric surgery show an improvement of albuminuria [8], these results cannot be generalized. This case report describes the deleterious consequences of malabsorptive bariatric surgery in a poorly controlled patient with type 1 diabetes and already preoperatively existing albuminuria. Regarding the long diabetes duration, persistent poor diabetes control and the already substantially increased albumin excretion, a further worsening of albuminuria and the development of macroalbuminuria and overt renal insufficiency should have been anticipated. In addition, poor diabetes control might indicate a lack of compliance which is necessary for the required follow-up consultations after bariatric surgery. In this patient, hypalbuminemia is most likely the consequence of deterioration of kidney function with development of macroalbuminuria and protein malabsorption following a malabsorptive procedure. In addition, reduced protein intake might be an additional contributing factor.

The course of the disease highlights the need for interdisciplinary consultation between internists/endocrinologists, surgeons, dietitians and psychologists. While there is no absolute contraindication for bariatric surgery in morbidly obese patients with type 1 diabetes, a careful preoperative evaluation is mandatory. This includes screening for diabetes complications, especially nephropathy with increased albumin excretion, and information on patient’s compliance regarding regular follow-up and appropriate substitution of macro- and micronutrients as well as vitamins. In patients at risk for hypoalbuminemia due to albuminuria a nonmalabsorptive method such as the sleeve gastrectomy should be considered. This, however, does not preclude hypalbuminemia, taking into account a possibly decreased protein intake due to gastric restriction or loss of appetite.

E-Ch K-made the research and wrote the manuscript. JMBcontributed to the interpretation of the results. BL-supervised the findings of this work. All authors provided critical feedback and contributed to the final version of the manuscript.

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