Endoscopic Sleeve Gastroplasty as Facilitator for Renal Transplantation in Patients with Obesity: Rationale and Protocol

Abstract Introduction: Obesity is a major barrier to kidney transplantation, associated with increased perioperative complications and reduced graft survival. Traditional bariatric surgeries have shown effectiveness in weight reduction but present challenges in pharmacokinetics and nutritional status. Endoscopic sleeve gastroplasty has emerged as a less invasive alternative, potentially suitable as a bridge to renal transplantation in obese patients. This study aims to evaluate the efficacy and safety of ESG in patients with end-stage kidney disease and obesity as a preparatory step to kidney transplantation. Primary endpoints include weight loss, BMI change, and transplant-related complications. Secondary endpoints address ESG failure, need for adjunct therapy, and procedural safety. Methods: A prospective, single-center cohort trial will include 13 adult end-stage kidney disease patients with BMI 30-42 kg/m² undergoing ESG. Outcomes will be compared with a case matched retrospective control cohort of previously transplanted obese patients who received no structured weight loss intervention. Patients will undergo ESG and follow a 6-month monitored weight loss program. Those who do not reach a BMI <35 kg/m² may receive GLP-1 agonists, repeat ESG or undergo surgical sleeve conversion. Results: Preliminary institutional data show ESG achieves moderate weight loss with lower severe adverse event rates (1.8% vs 3.5%) and shorter hospital stay compared to laparoscopic sleeve gastrectomy. Study enrollment begins in May 2025. Conclusion: ESG may represent a safe and effective strategy to optimize transplant eligibility in obese ESKD patients, with potential for integration into pre-transplant assessment pathways.