Obesity-Related Glomerulopathy with Kidney Function Improvement Following Bariatric Surgery and Lisinopril Therapy

Introduction: Obesity-related glomerulopathy (ORG), characterized by glomerulomegaly ± focal segmental glomerulosclerosis, is a rising cause of chronic kidney disease (CKD) in obesity (BMI ≥30 kg/m2). It presents with proteinuria and declining GFR, accounting for 15-30% of CKD. Pathogenesis involves glomerular hyperfiltration, RAAS overactivation, insulin resistance, inflammation, and ectopic lipid deposition. Case Description: A 35-year-old woman with class 3 obesity (BMI 43), hypertension, OSA, and CKD 3b (serum creatinine(sCr) 1.6 mg/dL, eGFR: 43) underwent Roux-en-Y gastric bypass. Five months postoperatively, she was referred to nephrology for evaluation of CKD3. At her initial renal clinic visit, she lost 17.2 with improved renal function (sCr 1.4 mg/dL; eGFR 50) and normotension (108/60) but had proteinuria (UPCR: 688 mg/g). Renal ultrasound demonstrated renal atrophy (right 9.2 cm, left 8.5 cm) with increased cortical echogenicity. Serological workup was unremarkable. Renal biopsy showed glomerulomegaly, focal global glomerulosclerosis, and moderate interstitial fibrosis (50%), confirming ORG. After starting lisinopril (2.5 mg/day), 18-month follow-up showed: BMI decreased to 29 kg/m2, sCr improved to 1.2 mg/dL (eGFR 60), and proteinuria (UPCR) decreased to 287 mg/g. Discussion: ORG management prioritizes weight loss and RAAS inhibition, with emerging roles for SGLT2 inhibitors and GLP-1 agonists. Bariatric surgery improves GFR and proteinuria by reducing hyperfiltration and metabolic dysfunction. The case highlights that combined bariatric surgery and RAAS blockade can significantly improve renal function and potentially halt ORG progression. Early intervention is crucial for patients with class 3 obesity (BMI ≥40) unresponsive to conventional medical therapy.A: Glomerulosclerosis; B: Glomerulomegaly