Liver Transplantation in the Obese Cirrhotic Patient

Abstract

Despite the rapidly increasing prevalence of obesity in the transplant population, the optimal management of obese liver transplant candidates remains undefined. Setting strict body mass index cutoffs for transplant candidacy remains controversial, with limited data to guide this practice. Body mass index is an imperfect measure of surgical risk in this population, partly due to volume overload and variable visceral adiposity. Weight loss before transplantation may be beneficial, but it remains important to avoid protein calorie malnutrition and sarcopenia. Intensive lifestyle modifications appear to be successful in achieving weight loss, though the durability of these interventions is not known. Pretransplant and intraoperative bariatric surgeries have been performed, but large randomized controlled trials are lacking. Traditional cardiovascular comorbidities are more prevalent in obese individuals and remain the basis for pretransplant cardiovascular evaluation and risk stratification. The recent US liver transplant experience demonstrates comparable patient and graft survival between obese and nonobese liver transplant recipients, but obesity presents important medical and surgical challenges during and after transplant. Specifically, obesity is associated with an increased incidence of wound infections, wound dehiscence, biliary complications and overall infection, and confers a higher risk of posttransplant obesity and metabolic syndrome-related complications. In this review, we examine current practices in the obese liver transplant population, offer recommendations based on the currently available data, and highlight areas where additional research is needed.

Obesity and Liver Decompensation

“…It is thought that an obesity‐associated increase in proinflammatory cytokines leads to increased skeletal muscle catabolism and contributes to development of sarcopenia . Furthermore, obesity is also associated with undesirable perioperative outcomes, including longer intraoperative time during transplantation, higher rates of wound infection, wound dehiscence, biliary complications, and perioperative respiratory failure …”

“…Along with the growing epidemic of obesity, the prevalence of obesity is rapidly increasing among patients with end‐stage liver disease (ESLD) in the United States. The proportion of obese patients among liver transplant recipients increased from 20% between 1988 and 1996 to 33% between 2001 and 2011 . Obesity presents challenges before and after liver transplantation (LT) because of high rates of comorbidities and unique challenges with perioperative and postoperative care (Fig.…”

“…Obesity presents challenges before and after liver transplantation (LT) because of high rates of comorbidities and unique challenges with perioperative and postoperative care (Fig. ) . Obesity itself can cause nonalcoholic steatohepatitis, leading to ESLD, hepatocellular carcinoma, and death, and there is increasing evidence of a deleterious effect of obesity on preexisting chronic liver disease caused by hepatitis C, hepatitis B, or alcohol‐related liver disease .…”

Outcomes of Sleeve Gastrectomy in Obese Liver Transplant Candidates

“…Obesity‐related liver disease is the fastest growing indication for liver transplantation (LT) in the United States . In LT recipients, obesity is associated with an increased incidence of wound infections and dehiscence, biliary and cardiopulmonary complications, and overall infection, and confers a higher risk of post‐LT complications related to metabolic syndrome . As such, morbid obesity (body mass index [BMI] ≥40 kg/m 2 ) is considered a relative contraindication to LT at many transplant centers …”

Obesity and Liver Disease: The New Era of Liver Transplantation

“…Patients with NAFLD had the highest pretransplant mortality rates among adults wait‐listed for liver transplant . In the perioperative period, patients with obesity had higher nonoperative biliary complications, wound infection and dehiscence, overall infections, and length of stay . Interestingly, the overall and graft survival rates of obese patients (body mass index [BMI] < 40 kg/m 2 ) do not appear to differ from those of lean individuals.…”