2444 Beyond Weight Loss: Bariatric Surgery as Treatment for NAFLD in the Post-Transplant Patient

Abstract

INTRODUCTION: Bariatric surgery, including Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG), has previously demonstrated reversal of abnormal liver histology in non-alcoholic fatty liver disease (NAFLD). However, bariatric surgery following orthotopic liver transplant (OLT) performed for non-alcoholic steatohepatitis (NASH) cirrhosis is less well studied, with only a few retrospective studies cited in the literature. We present the case of bariatric surgery performed in a patient status post OLT with successful reversal of NAFLD. CASE DESCRIPTION/METHODS: The patient is a 69-year-old female with past medical history of metabolic syndrome (diabetes, hypertension, dyslipidemia, obesity) and cirrhosis secondary to NASH and alcohol who underwent deceased donor OLT. Eighteen months postoperatively, the patient had gained 20 pounds and required multiple medications to control her blood pressure and diabetes. Subsequent abdominal ultrasound with doppler demonstrated hepatic steatosis, patent transplant vasculature and no ascites. Despite dietary and lifestyle modifications, the patient could not lose weight. She continued to have elevated transaminases (up to aspartate aminotransferase 58, alanine aminotransferase 82) prompting suspicion for recurrent NASH. The patient was ultimately referred for LSG. Her BMI prior to LSG was 37; seven weeks postoperatively it decreased to 32. Her liver function test normalized, and she no longer required Metformin. DISCUSSION: NAFLD is the most common chronic liver disorder in developed countries, and NASH cirrhosis is the second most common cause for liver transplant in the United States. Approximately 3-5% of the population in the United States lives with NASH, and this number is expected to rise with the obesity epidemic. Further troubling is NASH and cryptogenic cirrhosis seen in post-OLT patients, with one study citing 39% of those transplanted for NAFLD-related cirrhosis show steatosis on biopsy six months after transplant. Bariatric surgery, both RYGB and LSG, can reverse NAFLD histology, and only recently have retrospective reviews examined bariatric surgery as a successful means of halting and reversing NAFLD in the post-transplant patient. As with the case of our patient, bariatric surgery can provide an effective means of treating NAFLD in the post-OLT patient with metabolic syndrome. More research is currently needed to establish optimal patient selection criteria and long term efficacy in this regard.