Obese Liver Transplant Recipients Research Articles

Macrosteatotic Allografts and Obese Recipients Have Nearly Equal Negative Impact on Liver Transplant Survival.

Our aim was to evaluate liver transplant outcomes involving donors with high macrosteatosis grafts in the obese modern liver transplant recipient population. A high-steatosis graft was defined as donor graft macrosteatosis ≥30% on biopsy. Recipient obesity was defined as body mass index (BMI) >35 adjusted for ascites. Raw and adjusted recipient liver transplant survival were evaluated and compared between 4 cohorts: (1) high-steatosis graft in high-BMI recipient; (2) low-steatosis graft in high-BMI recipient; (3) high-steatosis graft in normal-BMI recipient; and (4) low-steatosis graft in normal-BMI recipient. After adjustment for multiple factors, recipient high-BMI remained an independent predictor of posttransplant mortality at 30 days (P < 0.0001) and persisted at 1 year (P = 0.009). A high-steatosis graft was the strongest independent predictor of mortality at 30 days (hazard ratio 2.05, 1.66-2.53; P < 0.0001) and that effect was diminished but persistent at 1 year (1.27, 1.10-1.46; P = 0.001). Recipient high-BMI and a high-steatosis graft are both significant independent and equally powerful predictors of mortality after modern liver transplant. High-steatosis grafts transplanted into obese recipients have the highest mortality. The increase in mortality associated with a high-steatosis graft into a normal-BMI recipient is similar in magnitude to a low-steatosis graft placed into a high-BMI recipient.

Minimally Invasive Sleeve Gastrectomy as a Surgical Treatment for Nonalcoholic Fatty Liver Disease in Liver Transplant Recipients

BackgroundObesity is a major public health burden that affects the transplant community because of its key role in fatty liver disease and transplantation outcomes. ObjectivesTo evaluate the role of sleeve gastrectomy in treating recurrent and de novo nonalcoholic fatty liver disease (NAFLD) in liver transplant recipients. SettingA university hospital. MethodsWe describe 2 obese liver transplant recipients with recurrent and de novo NAFLD who underwent minimally invasive metabolic and bariatric surgery. ResultsThe surgery was performed successfully, with much of the operative time consumed by enterolysis. There were no intraoperative or postoperative complications. At last follow-up appointment (16 months postoperatively), there was a mean reduction in weight (31.98 kg), body mass index (10.2 kg/m2), glycosylated hemoglobin (1.05%), alanine aminotransferase (38 IU/L), steatosis score (0.34), and fibrosis score (0.05). The mean decrease in 6-month postoperative hepatic fat quantification was 6%. ConclusionsThese cases show that metabolic and bariatric surgery in obese, posttransplant recipients with recurrent and de novo nonalcoholic steatohepatitis lead to improved steatosis and reduced obesity and obesity-associated comorbidities.

Liver Transplant Candidates With Obesity and High MELD Are Not at Increased Risk for Post Transplant Death or Graft Failure.

The prevalence of obesity is increasing among patients undergoing liver transplant (LT). It has been proposed that an elevated BMI in the setting of higher MELD scores may confer increased risk for poor post-LT outcomes. Aims: To investigate the impact of BMI on post-LT outcomes in the context of pre-LT liver disease severity as assessed by MELD score. Methods: We identified all adult (≥18 yrs) primary LT recipients from 3/1/02-9/30/11 in the UNOS dataset. BMI was categorized as: underweight, normal, overweight, Obese Class I, II, or III (<18.5; 18.5-24.9; 25-29.9; 30-34.9; 35-39.9; ≥40 kg/m2, respectively). 1-year post-LT death and graft loss were modeled using Cox regression and included an interaction term between BMI category and MELD. Results: Of the 45551 LT recipients identified, 68% were male, median [IQR] age=55 [49-60] yrs, MELD=19 [13-26], DRI=1.39 [1.12-1.69] and BMI categories were: Underweight (n=863, 1.9%), Normal (n=13262, 29%), Overweight (n=16329, 36%), Obese Class I (n=9639, 21%), Class II (n=4062, 9%), and Class III (n=1396, 3%). In adjusted multivariate analyses, increasing BMI was not associated with increased risk for post-LT death or graft loss at 1-yr. There were statistically significant interactions between BMI and MELD with respect to risk for 1-yr post-LT death (p=0.02) and graft loss (p=0.01) in the underweight BMI category only. Obesity (Class I, II, or III) was not associated with increased risk for 1-yr death or graft loss, regardless of MELD. However, there was increased risk for death (Figure 1) and graft loss (trend similar to patient death, data not shown) at 1-yr post-LT in patients with very low BMI (<18.5 kg/m2) who were transplanted at lower MELD scores. Conclusions: Obese LT recipients do not have increased risk of death or graft loss post-LT, even in the setting of higher MELD scores. LT recipients with the lowest BMIs (<18.5 kg/m2) are at increased risk for death and graft loss at lower MELD scores, with the specific mechanisms underlying this phenomenon requiring further investigation.Figure: No Caption available.

Comparable graft and patient survival in lean and obese liver transplant recipients

Obesity is among the great health problems facing Americans today. More than 32% of the US population is considered obese on the basis of a body mass index (BMI) exceeding 30 kg/m(2) . Obesity increases the risk for numerous perioperative complications, but how obesity affects the outcome of liver transplantation remains unclear. We compared graft/patient survival after orthotopic liver transplantation performed at the Cleveland Clinic between April 2005 and June 2011 in 2 groups: obese patients with a BMI ≥ 38 kg/m(2) and lean patients with a BMI between 20 and 26 kg/m(2) . We included 47 obese patients and 183 lean patients, whose demographics and baseline characteristics were well balanced after weighting with the inverse propensity score. After we controlled for observed confounding, no significant differences were observed in graft/patient survival between obese and lean patients (P = 0.30). The estimated hazard ratio for obese patients to experience graft failure or death was 1.19 [95% confidence interval (CI) = 0.85-1.67]. There were 134 patients who had follow-up for more than 3 years, and they included 27 obese patients and 107 lean patients. Within this subset, the odds of having metabolic syndrome were significantly greater for obese patients (46%) versus lean patients (21%; odds ratio = 4.76, 99.5% CI = 1.66-13.7, P < 0.001). However, no significant association between obesity and any other long-term adverse outcomes was found. In conclusion, this study shows that transplant outcomes were comparable for lean and obese recipients. We thus recommend that even morbid obesity per se should not exclude patients from consideration for transplantation.

Increased morbidity in overweight and obese liver transplant recipients: A single-center experience of 1325 patients from the United Kingdom

Obesity levels in the United Kingdom have risen over the years. Studies from the United States and elsewhere have reported variable outcomes for obese liver transplant recipients in terms of post-liver transplant morbidity, mortality, and graft survival. This study was designed to analyze the impact of the body mass index (BMI) on outcomes following adult liver transplantation. Data from 1994 to 2009 were retrieved from a prospectively maintained database. Patients were stratified into 5 World Health Organization BMI categories: underweight (<18.5 kg/m(2)), normal weight (18.5-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), obese (30.0-34.9 kg/m(2)), and morbidly obese (≥35.0 kg/m(2)). The primary outcome was an evaluation of graft and patient survival, and the secondary outcome was an assessment of postoperative morbidity. Bonferroni correction was applied with statistical significance set at P < 0.012. Kaplan-Meier curves were used to study the effects of BMI on graft and patient survival. A total of 1325 patients were included in the study: underweight (n = 47 or 3.5%), normal-weight (n = 643 or 48.5%), overweight (n = 417 or 31.5%), obese (n = 145 or 10.9%), and morbidly obese patients (n = 73 or 5.5%). The rate of postoperative infective complications was significantly higher in the overweight (60.7%, P < 0.01) and obese recipients (65.5%, P < 0.01) versus the normal-weight recipients (50.4%). The morbidly obese patients had a longer mean intensive care unit (ICU) stay than the normal-weight patients (4.7 versus 3.2 days, P = 0.03). The mean hospital stay was longer for the overweight (22.4 days, P < 0.001), obese (21.3 days, P = 0.04), and morbidly obese recipients (22.4 days, P = 0.047) versus the normal-weight recipients (18.0 days). There was no difference in death-censored graft survival or patient survival between the groups. In conclusion, this is the largest and only reported UK series on BMI and outcomes following liver transplantation. Overweight and obese patients have significantly increased morbidity in terms of infective complications after liver transplantation and, consequently, longer ICU and hospital stays.

Increased Morbidity in Overweight and Obese Liver Transplant Recipients - A Single Centre Experience with 1325 Patients

Introduction: Various studies from US and elsewhere have reported either similar outcome between obese and non-obese liver transplant recipients, or increased morbidity and overall poor patient and graft survival in obese patients. We aim to study the impact of BMI following adult liver transplantation. Methods: Data was retrieved from a prospectively maintained institutional database from 1994-2009. Patients were stratified into 4 BMI categories established by the WHO: underweight (< 18.5 kg/m2), normal weight (18.5 to < 25.0 kg/m2), over weight (>25.0 to < 30.0 kg/m2) and obese (>30.0 kg/m2). Primary outcome was to evaluate post-operative morbidity and secondary measures were overall patient and graft survival. Categorical variables were analysed by Χ2, and continuous variables by one-way ANOVA (p value < 0.05 was considered statistically significant). Kaplan Meier curves with log-rank comparison were used to study the effect of BMI categories on patient and graft survival. Results: 1400 adult transplants were identified. 1325 patients with available date were included, of which there were 47 underweight (3.5%), 643 normal weight (48.5%), 417 overweight (31.5%) and 218 obese (16.5%) patients. Post-operative chest infections were much more common in obese (14.2% vs 9.0%, p=0.038) and overweight recipients (17.7% vs 9.0%, p < 0.001) in comparison to normal weight recipients. Obese patients had significantly longer intensive care stay than normal weight patients (mean 4.1 vs 3.2 days, p=0.043). The length of post-operative hospital stay was significantly longer in obese (mean 21.5 days, p=0.009) and overweight patients (mean 22.4 days, p=0.000) in comparison to normal weight patients (mean 18.0 days). Similarly, ascitic or drain fluid sepsis was common in overweight patients in comparison to normal weight recipients (16.5 % vs 2.2%, p< 0.001). Overall, post-operative septic events were common in overweight (60.6%, p=0.001) and obese patients (61.0%, p=0.007) in comparison to normal weight patients (50.4%). There was no difference in overall graft survival (p=0.222) and patient survival (p=0.196) between the four groups by log-rank (Mantel-Cox). Conclusions: This is the largest and the only reported UK series on BMI and outcome following liver transplantation. Liver transplantation does lead to increased morbidity in terms of septic complications in overweight and obese patients, with consequent increased length of intensive care and hospital stay. Identifying these patients early and reducing BMI appropriately should be an important consideration to improve outcomes and for appropriate use of scarce resources.

OC-058 Increased morbidity in overweight and obese liver transplant recipients—a single centre experience with 1325 patients

IntroductionObesity levels in the UK have risen over the years. Studies from the US and elsewhere have reported variable outcomes in terms of post liver transplant morbidity, mortality and graft...

Surgical morbidity in severely obese liver transplant recipients - A single Canadian Centre Experience

The prevalence of obesity is increasing globally, with nearly half of a billion of the world’s population now considered to be overweight or obese. Obesity and overweight patients are one of the major health issues in Canada, resulting in approximately 57,000 deaths related to obesity over the last 15 years. The effect of obesity on outcomes following liver transplantation remains largely unclear. To determine the effect of obesity on outcome we reviewed 167 liver transplants, performed at the Vancouver General Hospital, between February 1999 and October 2003. Severe obesity was defined as body mass index (BMI) > 35 kg/m2 and moderate obesity as BMI of 30 – 34 kg/m2. One hundred forty three transplants were performed in patients with a body mass index (BMI) < 30 kg/m2, 14 in patients with a BMI of 30 – 34 kg/m2, and 10 in patients with a BMI > 35 kg/m2. Non-weight related patient demographics were similar between the groups. A very high proportion of Hepatitic C patients (7/10) were observed in the severely obese group. In the early postoperative course severely obese patients had a higher rate of wound infection (20% vs. 4%, p = 0.0001) and wound dehiscence (40% vs. 1.2%, p = 0.0001). Within the first twelve postoperative months severely obese liver transplant recipients had a higher rate of ventral wound herniation (30% vs. 2.8%, p = 0.0001) when compared to obese or non-obese recipients. The one-year graft and patient survival were similar to non-obese patients. An increased BMI in liver transplant recipients in our centre did not increase the risk of early postoperative mortality, but did increase surgical complications, such as wound infection and wound dehis-cence. The 1-year patient and graft survival however was indistinguishable from those of non-obese patients.

Orlistat treatment is safe in overweight and obese liver transplant recipients: a prospective, open label trial

Obesity is a frequent complication following liver transplantation and is insufficiently responsive to dietary and life style advice. We studied the safety of orlistat treatment in obese and overweight liver transplant recipients (n = 15) on a stable tacrolimus-based immunosuppressive regimen. For safety reasons, the treatment period was restricted (6 months 120 mg t.i.d., 3 months 120 mg daily). Three patients dropped out, tacrolimus dose was adjusted in six of 12 remaining patients (dose reduction in 4, increase in 2, P = N.S.). All dose adjustments occurred during the 6 months of orlistat 120 mg t.i.d. therapy. No drug intolerance, adverse events or episodes of rejection occurred during the study. Efficacy of orlistat treatment in this population could not be shown, because a formal control population was not included in this safety trial. Moreover, only a significant decrease of waist circumference (P < 0.01 versus start of the study), but not of weight or body mass index, was achieved in the treated group. Orlistat treatment is well tolerated in liver transplant recipients and can be started safely, provided immunosuppressive drug levels and dietary adherence are closely monitored.

Obese and morbidly obese liver transplant recipients fare as well as non-obese recipients

Obese and morbidly obese liver transplant recipients fare as well as non-obese recipients