Postoperative morbidity, mortality, costs, and long-term survival in severely obese patients undergoing orthotopic liver transplantation

Nair, Satheesh; Cohen, David B.; Cohen, Charles D.; Tan, Henkie P.; Maley, Warren R.; Thuluvath, Paul J.

doi:10.1016/s0002-9270(00)02422-9

Cited by 73 publications

(97 citation statements)

References 12 publications

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“…Because LDLT recipients are generally younger and less likely to be obese than cadaveric recipients, the occurrence of wound complications in LDLT recipients may be lower than in historic controls. [16][17][18] The lower rate of obesity in the sirolimus cohort and trend toward lower body mass index (25.5 v 26.1 kg/m 2 ) likely is caused by the greater proportion of LDLT recipients in the sirolimus cohort.…”

Section: Discussionmentioning

confidence: 98%

Sirolimus as primary immunosuppression in liver transplantation is not associated with hepatic artery or wound complications

Dunkelberg

Trotter

Wachs

et al. 2003

Liver Transplantation

115

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Sirolimus is a new immunosuppressive agent increasingly being used in liver transplant recipients. There is concern that sirolimus may be associated with wound complications and hepatic artery thrombosis (HAT). We have used sirolimus as primary immunosuppression in 170 liver transplant recipients and therefore reviewed our experience with wound complications and HAT in our cohort of patients. Records of all 170 patients administered sirolimus as primary immunosuppression and 180 historic controls were reviewed. Numbers of wound and hepatic artery complications were recorded, as well as the prevalence of obesity, reoperation, diabetes, and OKT3 use, all of which are risk factors for wound complications. The prevalence of wound complications was 12.4% in sirolimus-treated patients compared with 13. S irolimus, a new immunosuppressive agent, is being used increasingly in liver transplantation. 1-4 Sirolimus and tacrolimus are structurally related macrolides that bind the same intracellular receptor (FK506-binding protein-12 [FKBP12]) and potently inhibit T-cell proliferation. 5,6 The tacrolimus-FKBP12 complex, like the cyclosporine-cyclophilin complex, binds to and inhibits the Ca 2ϩ -dependent serine-threonine phosphatase calcineurin, thereby inhibiting cytokine-induced T-cell gene transcription and G 0 to G 1 transition. Conversely, the sirolimus-FKBP12 complex inhibits the target of rapamycin kinase, thereby inhibiting protein synthesis, G 1 to S transition, and cytokinedriven T-cell proliferation.Sirolimus has shown benefit in renal transplant recipients and therefore was approved for use in renal transplantation by the Food and Drug Administration in 1999. In two recent studies, a fixed dose of 2 or 5 mg/d of sirolimus in combination with cyclosporine decreased the acute rejection rate in the first year by 50% without an increase in immunosuppressant-related side effects. 7,8 Wound infection rates were not increased with sirolimus.Two recent trials have shown that liver transplantation may be performed successfully with minimal use of corticosteroids by using sirolimus and either tacrolimus or cyclosporine A. Low-dose sirolimus in the absence of prednisone in liver transplant recipients at our center was associated with a 50% decreased incidence of rejection, and the incidence of steroid-resistant rejection was decreased by 90% (compared with historic controls). 4 Similar efficacy was reported by McAlister et al 2 in an open-label report of 56 patients administered low-dose tacrolimus and sirolimus with prednisone up to 6 months after transplantation. The acute cellular rejection rate was 14%, which was approximately 50% lower than the historic rejection rate. None of the patients had steroid-resistant rejection.The well-established side-effect profile of sirolimus includes dose-dependent hyperlipidemia, thrombocytopenia, anemia, and leukopenia with an absence of neurotoxicity, nephrotoxicity, and diabetogenesis. There are anecdotal reports from some centers that sirolimus is associated with an increased incid...

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Section: Discussionmentioning

confidence: 98%

Sirolimus as primary immunosuppression in liver transplantation is not associated with hepatic artery or wound complications

Dunkelberg

Trotter

Wachs

et al. 2003

Liver Transplantation

115

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“…Results of other studies suggest that obese patients have higher post-transplant complications, longer hospital stays and higher hospital costs. [101][102][103][104][105][106] Obesity may also exaggerate the negative impact of risk factors such as donor graft cold ischemia time. 107 Patients with diabetes or coronary artery disease, both commonly associated with obesity, are approximately 40% more likely to die within 5 years of liver transplantation compared to non-diabetics or to patients without coronary artery disease.…”

Section: Malnutrition and Outcome Following Liver Transplantationmentioning

confidence: 99%

Reprint of: Nutrition in the Management of Cirrhosis and its Neurological Complications

Bémeur

Butterworth

2015

Journal of Clinical and Experimental Hepatology

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“…[11][12][13][14] Single center studies on liver transplantation have shown inconsistent results mainly because of the differences in the definition of obesity, sample size, reporting, and selection bias. [15][16][17][18][19] These studies, however, showed a trend toward higher postoperative complications, length of hospital stay, and hospital costs for obese recipients. 17,19 In many of the above single center studies, patients with BMI Ͼ30 kg/m 2 were grouped together and therefore, the impact of severe or morbid obesity on sold organ transplantation could not be assessed independently.…”

Section: See Article On Page 1678mentioning

confidence: 99%

“…[15][16][17][18][19] These studies, however, showed a trend toward higher postoperative complications, length of hospital stay, and hospital costs for obese recipients. 17,19 In many of the above single center studies, patients with BMI Ͼ30 kg/m 2 were grouped together and therefore, the impact of severe or morbid obesity on sold organ transplantation could not be assessed independently. Moreover, the sample size of these studies was inadequate to assess the independent effect of severe or morbid obesity on liver transplant outcomes.…”

Section: See Article On Page 1678mentioning

confidence: 99%

“…[1][2][3]5 Collective outcome data from liver and renal transplantation also indicate that morbidly obese patients have an increased morbidity and mortality compared to less obese patients. [6][7][8][9][10][11][12][13][14][16][17][18][19][20] These cumulative data mandate that morbidly obese patients be carefully evaluated for other serious comorbid illnesses before listing. Once listed, they should undergo careful surveillance and health maintenance programs to improve the outcomes.…”

Section: See Article On Page 1678mentioning

confidence: 99%

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Morbid obesity with one or more other serious comorbidities should be a contraindication for liver transplantation

Thuluvath

2007

Liver Transpl

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The prevalence of obesity is increasing in the United States and the rest of the world. The World Health Organization reported last year that over a billion people in the world are obese, surpassing 600 million malnourished people. In some ways, this is a reassuring sign that we are combating poverty in the world, but the impact of obesity on long-term morbidity, mortality, and utilization of health resources is similar or higher. [1][2][3][4][5] The reports from the Centers for Disease Control and the National Health and Nutrition Examination Surveys suggest that Ͼ20% of the U.S. population is obese as defined by a body mass index (BMI) Ͼ30 kg/ m 2 . Whereas infections are the most common causes of death in the malnourished, degenerative and vascular diseases are the common causes of death in obese people. [1][2][3][4][5] The Centers for Disease Control estimates that approximately 100 billion dollars are spent every year in the United States on obesity-related type 2 diabetes mellitus and 22 billion on obesity-related osteoarthritis.The United Network for Organ Sharing database from 1988 to 1996 showed that 16.8% of liver transplant recipients had BMI Ն30 kg/m 2 and of these 5.3% were severely obese (BMI Ն35 kg/m 2 ) and 2.1% were morbidly obese (BMI Ն40 kg/m 2 ). 6 The study reported in this issue of Liver Transplantation by Pelletier et al. 7 shows that the prevalence of obesity has increased significantly in more recent years. Of those who underwent transplantation between 2001 and 2004, 32.5% were obese, and among them, 8.4% were severely obese and 3.2% were morbidly obese. Within a decade, it appears that the prevalence of obesity (BMI Ն30 kg/m 2 ) has increased by 93% among liver transplant recipients, and moreover, there was 58% increase in severe obesity and 52% increase in morbid obesity. This increase is mostly a reflection of the changes in the general population. Fluid overload and inactivity, probably related to the advanced liver disease, may have contributed to the increased prevalence of obesity in this population, but it is difficult to assume that these factors have changed in the past decade. 4 Nevertheless, these data indicate that we need to continue to monitor the outcomes of obese patients on a continuous basis as the epidemiology is rapidly shifting in the wrong direction.The impact of obesity on renal transplantation has been studied more extensively than liver transplantation. 8,9 An analysis of 51,927 renal transplant recipients showed that extremes of BMI (Ͻ18 and Ͼ36) were associated with worse graft and patient survival. 8 In addition, higher BMI was associated with delayed graft function and chronic graft failure. Registry data (from 1987 to 2002) on 6,658 children aged 2 to 17 yr who received renal transplantation showed that BMI Ͼ95 percentile (9.7% of the study population) for age was associated with a higher risk of death (relative risk 2.9 for cadaver and 3.7 for living donor) and graft loss (19% vs. 10% for nonobese) due to thrombosis. 10 Obesity has also been described a...

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Postoperative morbidity, mortality, costs, and long-term survival in severely obese patients undergoing orthotopic liver transplantation

Cited by 73 publications

References 12 publications

Sirolimus as primary immunosuppression in liver transplantation is not associated with hepatic artery or wound complications

Sirolimus as primary immunosuppression in liver transplantation is not associated with hepatic artery or wound complications

Reprint of: Nutrition in the Management of Cirrhosis and its Neurological Complications

Morbid obesity with one or more other serious comorbidities should be a contraindication for liver transplantation

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