‘Amazing’ outcomes for liver transplants in obese patients despite challenges

Obesity brings a higher risk of perioperative complications during liver transplantation but despite that, obese patients appear to have similar survival to other transplant patients.

Dr Caroline Tallis, a gastroenterologist and hepatologist at Brisbane’s Princess Alexandra Hospital, told AGW 2018 that it was certainly ‘a brave new world’ when both donors and recipients were getting heavier.

“We’ve got a rising number of obese patients, a steady rise in the number of patients who require a liver transplant for NASH, and a rising incidence of NASH-related hepatocellular carcinoma.

She said an obese transplant recipient had an increased risk of metabolic complications, cardiovascular disease, malignancy, respiratory problems like sleep apnoea, musculoskeletal, gastrointestinal and renal problems.

“Our donors are also getting heavier and the data shows our donors have increased [in weight] by at least 10 kg over the last decade or two. So if we have a donor that has a steatotic liver, this impacts on primary non-function, and particularly if there is greater than 30% steatosis in a donor liver there is a risk of the graft not functioning.”

“We also need to bear in mind when there is obesity with metabolic issues in the donor there is a likelihood of atherosclerotic disease in the donor vessels.”

“So that’s a problem for us in liver transplantation, although we’re at the pointy end of things, the impact of obesity is certainly an increasing problem.”

Dr Tallis said some of the documented risks for patients with BMI above 40 were longer operating times, increased requirements for transfusion, perioperative complications including wound infections, more time in ICU and longer hospital stays.

“But again through all these studies we see a trend for graft survival similar to other patients. We do need a cautious assessment – the right patient for the right procedure – but the outcomes are amazing.”

“Five-year survival is greater than 80%, they have great quality of life, they go on to have their careers and families, but we need to deal with the metabolic syndrome like we do in non-transplant patients and treat it aggressively with a multidisciplinary team.”

“A lot of our patients are at risk of putting on weight after a transplant and at significant risk of metabolic syndrome and diabetes and so they need aggressive therapies immediately after the transplant, education and interactions with dieticians, exercise physiologists and their specialists.”

She said it was patients at the extremes of BMI that required more care and precaution and would ultimately require the use of more resources.

There was a role for intensive, medically-supervised weight loss programs ahead of transplantation, but it was difficult to achieve fat loss in end-stage liver disease in part because patients had low muscle mass and poor endurance.

In patients who failed to reduce their BMI to 35 before surgery, there was the option of simultaneous sleeve gastrectomy and liver transplant, said Dr Tallis.

This procedure resulted in similar perioperative outcomes but superior weight loss and metabolic outcomes.

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