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EASL-EASD-EASO Clinical Practice Guidelines on the Management of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD). Obes Facts 2024:1-70. [PMID: 38852583 DOI: 10.1159/000539371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 05/15/2024] [Indexed: 06/11/2024] Open
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed non-alcoholic fatty liver disease (NAFLD), is defined as steatotic liver disease (SLD) in the presence of one or more cardiometabolic risk factor(s) and the absence of harmful alcohol intake. The spectrum of MASLD includes steatosis, metabolic dysfunction-associated steatohepatitis (MASH, previously NASH), fibrosis, cirrhosis and MASH-related hepatocellular carcinoma (HCC). This joint EASL-EASD-EASO guideline provides an update on definitions, prevention, screening, diagnosis and treatment for MASLD. Case-finding strategies for MASLD with liver fibrosis, using non-invasive tests, should be applied in individuals with cardiometabolic risk factors, abnormal liver enzymes, and/or radiological signs of hepatic steatosis, particularly in the presence of type 2 diabetes (T2D) or obesity with additional metabolic risk factor(s). A stepwise approach using blood-based scores (such as FIB-4) and, sequentially, imaging techniques (such as transient elastography) is suitable to rule-out/in advanced fibrosis, which is predictive of liver-related outcomes. In adults with MASLD, lifestyle modification - including weight loss, dietary changes, physical exercise and discouraging alcohol consumption - as well as optimal management of comorbidities - including use of incretin-based therapies (e.g. semaglutide, tirzepatide) for T2D or obesity, if indicated - is advised. Bariatric surgery is also an option in individuals with MASLD and obesity. If locally approved and dependent on the label, adults with non-cirrhotic MASH and significant liver fibrosis (stage ≥2) should be considered for a MASH-targeted treatment with resmetirom, which demonstrated histological effectiveness on steatohepatitis and fibrosis with an acceptable safety and tolerability profile. No MASH-targeted pharmacotherapy can currently be recommended for the cirrhotic stage. Management of MASH-related cirrhosis includes adaptations of metabolic drugs, nutritional counselling, surveillance for portal hypertension and HCC, as well as liver transplantation in decompensated cirrhosis.
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Tacke F, Horn P, Wai-Sun Wong V, Ratziu V, Bugianesi E, Francque S, Zelber-Sagi S, Valenti L, Roden M, Schick F, Yki-Järvinen H, Gastaldelli A, Vettor R, Frühbeck G, Dicker D. EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). J Hepatol 2024:S0168-8278(24)00329-5. [PMID: 38851997 DOI: 10.1016/j.jhep.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 06/10/2024]
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed non-alcoholic fatty liver disease (NAFLD), is defined as steatotic liver disease (SLD) in the presence of one or more cardiometabolic risk factor(s) and the absence of harmful alcohol intake. The spectrum of MASLD includes steatosis, metabolic dysfunction-associated steatohepatitis (MASH, previously NASH), fibrosis, cirrhosis and MASH-related hepatocellular carcinoma (HCC). This joint EASL-EASD-EASO guideline provides an update on definitions, prevention, screening, diagnosis and treatment for MASLD. Case-finding strategies for MASLD with liver fibrosis, using non-invasive tests, should be applied in individuals with cardiometabolic risk factors, abnormal liver enzymes, and/or radiological signs of hepatic steatosis, particularly in the presence of type 2 diabetes (T2D) or obesity with additional metabolic risk factor(s). A stepwise approach using blood-based scores (such as FIB-4) and, sequentially, imaging techniques (such as transient elastography) is suitable to rule-out/in advanced fibrosis, which is predictive of liver-related outcomes. In adults with MASLD, lifestyle modification - including weight loss, dietary changes, physical exercise and discouraging alcohol consumption - as well as optimal management of comorbidities - including use of incretin-based therapies (e.g. semaglutide, tirzepatide) for T2D or obesity, if indicated - is advised. Bariatric surgery is also an option in individuals with MASLD and obesity. If locally approved and dependent on the label, adults with non-cirrhotic MASH and significant liver fibrosis (stage ≥2) should be considered for a MASH-targeted treatment with resmetirom, which demonstrated histological effectiveness on steatohepatitis and fibrosis with an acceptable safety and tolerability profile. No MASH-targeted pharmacotherapy can currently be recommended for the cirrhotic stage. Management of MASH-related cirrhosis includes adaptations of metabolic drugs, nutritional counselling, surveillance for portal hypertension and HCC, as well as liver transplantation in decompensated cirrhosis.
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Terrault NA, Francoz C, Berenguer M, Charlton M, Heimbach J. Liver Transplantation 2023: Status Report, Current and Future Challenges. Clin Gastroenterol Hepatol 2023; 21:2150-2166. [PMID: 37084928 DOI: 10.1016/j.cgh.2023.04.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/29/2023] [Accepted: 04/04/2023] [Indexed: 04/23/2023]
Abstract
Liver transplantation offers live-saving therapy for patients with complications of cirrhosis and stage T2 hepatocellular carcinoma. The demand for organs far outstrips the supply, and innovations aimed at increasing the number of usable deceased donors as well as alternative donor sources are a major focus. The etiologies of cirrhosis are shifting over time, with more need for transplantation among patients with alcohol-associated liver disease and nonalcoholic/metabolic fatty liver disease and less for viral hepatitis, although hepatitis B remains an important indication for transplant in countries with high endemicity. The rise in transplantation for alcohol-associated liver disease and nonalcoholic/metabolic fatty liver disease has brought attention to how patients are selected for transplantation and the strategies needed to prevent recurrent disease. In this review, we present a status report on the most pressing topics in liver transplantation and future challenges.
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Affiliation(s)
- Norah A Terrault
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California.
| | - Claire Francoz
- Liver Intensive Care and Liver Transplantation Unit, Hepatology, Hospital Beaujon, Clichy, France
| | - Marina Berenguer
- Hepatology and Liver Transplantation Unit, Hospital Universitario la Fe - IIS La Fe Valencia; CiberEHD and University of Valencia, Valencia, Spain
| | - Michael Charlton
- Transplantation Institute, University of Chicago, Chicago, Illinois
| | - Julie Heimbach
- William von Liebig Center for Transplantation, Mayo Clinic Rochester, Minnesota
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Yeoh A, Wong R, Singal AK. The Role Bariatric Surgery and Endobariatric Therapies in Nonalcoholic Steatohepatitis. Clin Liver Dis 2023; 27:413-427. [PMID: 37024216 DOI: 10.1016/j.cld.2023.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide. Disease spectrum varies from steatosis, steatohepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma. Currently, there are no approved medical therapies, and weight loss through lifestyle modifications remains a mainstay of therapy. Bariatric surgery is the most effective therapy for weight loss and has been shown to improve liver histology. Recently, endoscopic bariatric metabolic therapies have also emerged as effective treatments for patients with obesity and NAFLD. This review summarizes the role of bariatric surgery and endoscopic therapies in the management of patients with NAFLD.
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Affiliation(s)
- Aaron Yeoh
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Robert Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA, USA; Gastroenterology Section, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Ashwani K Singal
- University of South Dakota Sanford School of Medicine; Avera Medical Group Liver Disease and Transplant Institute, Avera McKennan University Hospital, Clinical Research Affairs Avera Transplant Institute, 1315 South Cliff Avenue, Sioux Falls, SD 57105, USA; VA Medical Center, Sioux Falls, SD, USA.
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5
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Alqahtan SA, Brown RS. Management and Risks Before, During, and After Liver Transplant in Individuals With Obesity. Gastroenterol Hepatol (N Y) 2023; 19:20-29. [PMID: 36865816 PMCID: PMC9972654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Obesity has become a global epidemic, adding to the burden of chronic diseases and disabilities. Metabolic syndrome, especially obesity, is a significant risk factor for nonalcoholic fatty liver disease, which is the most common indication for liver transplant (LT). The prevalence of obesity among the LT population is growing. Obesity increases the necessity of LT by playing a role in the development of nonalcoholic fatty liver disease, decompensated cirrhosis, and hepatocellular carcinoma, and it can also coexist with other diseases requiring LT. Therefore, LT teams must identify key aspects required to manage this high-risk population, but there are currently no defined recommendations for managing obesity in LT candidates. Although body mass index is often used to assess the weight of patients and classify them as overweight or obese, this measure may be inaccurate to use in patients with decompensated cirrhosis, as fluid overload or ascites can significantly add to the weight of patients. Diet and exercise remain the cornerstone of obesity management. Supervised weight loss before LT, without worsening frailty and sarcopenia, may be beneficial in reducing surgical risks and improving long-term LT outcomes. Bariatric surgery is another effective treatment for obesity, with sleeve gastrectomy currently conferring the best outcomes in LT recipients. However, evidence supporting the timing of bariatric surgery is lacking. Long-term patient and graft survival data in individuals with obesity following LT are scarce. Class 3 obesity (body mass index ≥40) further complicates the treatment of this patient population. This article discusses the impact of obesity on the outcome of LT.
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Affiliation(s)
- Saleh A. Alqahtan
- 1Liver Transplant Center, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia,2Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Robert S. Brown
- 3Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine, New York, New York
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CHIERICI A, ALROMAYAN M, DEFATICO S, DRAI C, VINCI D, ANTY R, SCHIAVO L, IANNELLI A. Is bariatric surgery safer before, during, or after liver transplantation? A systematic review and meta-analysis. JOURNAL OF LIVER TRANSPLANTATION 2023. [DOI: 10.1016/j.liver.2023.100139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Sarno G, Schiavo L, Calabrese P, Álvarez Córdova L, Frias-Toral E, Cucalón G, Garcia-Velasquez E, Fuchs-Tarlovsky V, Pilone V. The Impact of Bariatric-Surgery-Induced Weight Loss on Patients Undergoing Liver Transplant: A Focus on Metabolism, Pathophysiological Changes, and Outcome in Obese Patients Suffering NAFLD-Related Cirrhosis. J Clin Med 2022; 11:jcm11185293. [PMID: 36142939 PMCID: PMC9503676 DOI: 10.3390/jcm11185293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/28/2022] [Accepted: 09/05/2022] [Indexed: 11/30/2022] Open
Abstract
Because of their condition, patients with morbid obesity develop several histopathological changes in the liver, such as non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), cirrhosis, and end-stage liver disease (ESLD). Hence, a liver transplant (LT) becomes an opportune solution for them. Due to many challenges during the perioperative and postoperative periods, these patients are recommended to lose weight before the surgery. There are many proposals to achieve this goal, such as intragastric balloons and many different bariatric surgery (BS) procedures in combination with a preparation diet (very-low-calorie diet, ketogenic diet, etc.). All the interventions focus on losing weight and keeping the continuity and functionality of the digestive tract to avoid postoperative complications. Thus, this review analyzes recent publications regarding the metabolic and pathophysiological impacts of BS in LT patients suffering from NAFLD-related cirrhosis, the effect of weight loss on postoperative complications, and exposes the cost-effectiveness of performing BS before, after, and at liver transplantation. Finally, the authors recommend BS before the LT since there are many positive effects and better outcomes for patients who lose weight before the procedure. Nevertheless, further multicentric studies are needed to determine the generalizability of these recommendations due to their impact on public health.
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Affiliation(s)
- Gerardo Sarno
- San Giovanni di Dio e Ruggi D’Aragona University Hospital, Scuola Medica Salernitana, 84131 Salerno, Italy
| | - Luigi Schiavo
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, P.O. Gaetano Fucito Mercato San Severino, 84085 Salerno, Italy
- Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, 84081 Baronissi, Italy
- Correspondence: ; Tel.: +39-089-965062
| | - Pietro Calabrese
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, P.O. Gaetano Fucito Mercato San Severino, 84085 Salerno, Italy
- Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, 84081 Baronissi, Italy
| | - Ludwig Álvarez Córdova
- Carrera de Nutrición y Dietética, Facultad de Ciencias Médicas, Universidad Católica De Santiago de Guayaquil, Av. Pdte. Carlos Julio Arosemena Tola, Guayaquil 090615, Ecuador
| | - Evelyn Frias-Toral
- School of Medicine, Universidad Católica Santiago de Guayaquil, Av. Pdte. Carlos Julio Arosemena Tola, Guayaquil 090615, Ecuador
- Universidad de Especialidades Espìritu Santo, Samborondòn 0901952, Ecuador
| | - Gabriela Cucalón
- Lifescience Faculty, ESPOL Polytechnic University, Escuela Superior Politécnica del Litoral (ESPOL), Campus Gustavo Galindo Km. 30.5 Vía Perimetral, Guayaquil 090615, Ecuador
| | | | | | - Vincenzo Pilone
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, P.O. Gaetano Fucito Mercato San Severino, 84085 Salerno, Italy
- Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, 84081 Baronissi, Italy
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Roeb E, Canbay A, Bantel H, Bojunga J, de Laffolie J, Demir M, Denzer UW, Geier A, Hofmann WP, Hudert C, Karlas T, Krawczyk M, Longerich T, Luedde T, Roden M, Schattenberg J, Sterneck M, Tannapfel A, Lorenz P, Tacke F. Aktualisierte S2k-Leitlinie nicht-alkoholische Fettlebererkrankung der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – April 2022 – AWMF-Registernummer: 021–025. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:1346-1421. [PMID: 36100202 DOI: 10.1055/a-1880-2283] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- E Roeb
- Gastroenterologie, Medizinische Klinik II, Universitätsklinikum Gießen und Marburg, Gießen, Deutschland
| | - A Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - H Bantel
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - J Bojunga
- Medizinische Klinik I Gastroent., Hepat., Pneum., Endokrin., Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - J de Laffolie
- Allgemeinpädiatrie und Neonatologie, Zentrum für Kinderheilkunde und Jugendmedizin, Universitätsklinikum Gießen und Marburg, Gießen, Deutschland
| | - M Demir
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum und Campus Charité Mitte, Berlin, Deutschland
| | - U W Denzer
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Marburg, Deutschland
| | - A Geier
- Medizinische Klinik und Poliklinik II, Schwerpunkt Hepatologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - W P Hofmann
- Gastroenterologie am Bayerischen Platz - Medizinisches Versorgungszentrum, Berlin, Deutschland
| | - C Hudert
- Klinik für Pädiatrie m. S. Gastroenterologie, Nephrologie und Stoffwechselmedizin, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Berlin, Deutschland
| | - T Karlas
- Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - M Krawczyk
- Klinik für Innere Medizin II, Gastroent., Hepat., Endokrin., Diabet., Ern.med., Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - T Longerich
- Pathologisches Institut, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - T Luedde
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - M Roden
- Klinik für Endokrinologie und Diabetologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - J Schattenberg
- I. Medizinische Klinik und Poliklinik, Universitätsmedizin Mainz, Mainz, Deutschland
| | - M Sterneck
- Klinik für Hepatobiliäre Chirurgie und Transplantationschirurgie, Universitätsklinikum Hamburg, Hamburg, Deutschland
| | - A Tannapfel
- Institut für Pathologie, Ruhr-Universität Bochum, Bochum, Deutschland
| | - P Lorenz
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - F Tacke
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum und Campus Charité Mitte, Berlin, Deutschland
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Updated S2k Clinical Practice Guideline on Non-alcoholic Fatty Liver Disease (NAFLD) issued by the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - April 2022 - AWMF Registration No.: 021-025. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e733-e801. [PMID: 36100201 DOI: 10.1055/a-1880-2388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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Ahmed Z, Khan MA, Vazquez-Montesino LM, Ahmed A. Bariatric surgery, obesity and liver transplantation. Transl Gastroenterol Hepatol 2022; 7:25. [PMID: 35892056 PMCID: PMC9257534 DOI: 10.21037/tgh-2020-14] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 07/06/2020] [Indexed: 06/01/2024] Open
Abstract
The obesity epidemic has profoundly impacted the epidemiology and trends of liver disease. In the current era, non-alcoholic fatty liver disease (NAFLD) progressing to non-alcoholic steatohepatitis (NASH) has emerged as the second leading indication for liver transplant (LT) and has been associated with the rising rates of hepatocellular carcinoma (HCC) with and without underlying cirrhosis. Obesity has been associated with poor post-transplant outcomes including lower patient and graft survival; higher risk of post-operative metabolic complications; poor wound healing; and higher infection rates. Bariatric surgery is currently the most effective management of morbid obesity and has been offered to patients both in the pre and post LT setting. The techniques attempted in LT recipients most commonly include sleeve gastrectomy (SG), gastric bypass surgery with few cases of gastric banding and biliopancreatic diversion. However, there is lack of evidence-based data on the optimal management for patients with obesity and who are liver transplant candidates and/or recipients. In the following discussion, we present the highlights from a review of the literature.
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Affiliation(s)
| | - Muhammad Ali Khan
- Division of Gastroenterology and Hepatology, University of Alabama Birmingham, AL, USA
| | | | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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Safavi D, Creavin B, Gallagher TK, Kelly ME. The role of bariatric surgery in liver transplantation: timing and type. Langenbecks Arch Surg 2022; 407:3249-3258. [DOI: 10.1007/s00423-022-02606-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/09/2022] [Indexed: 11/29/2022]
Abstract
Abstract
Introduction
The rise in obesity worldwide has shifted the indications for liver transplantation (LT), with non-alcoholic steatohepatitis (NASH) being the second most common indication for transplantation. There remains an underestimation of cirrhosis being attributed to NASH. Bariatric surgery (BS) is a reliable solution to overcome obesity and its associated comorbidities. The role of BS in LT has been investigated by different studies; however, the type of BS and timing of LT need further investigation.
Methods
A systemic review examining the role of BS in LT patients was performed. After selection of the studies based on inclusion and exclusion criteria, data extraction was performed by two independent reviewers. Primary outcomes included patient and graft survival.
Results
From a total of 2374 articles, five met the prefined criteria. One hundred sixty-two patients had both BS + LT and 1426 underwent LT alone. The percentage of female patients in the BS + LT and LT cohorts was 75% and 35% respectively. The average age in BS + LT and LT cohorts was 43.05 vs. 56.22 years respectively. Patients undergoing BS had comparable outcomes in terms of overall patient survival, graft survival and post-operative morbidity compared to LT alone. When comparing BMI change in patients with prior versus simultaneous BS + LT, no significant difference was found.
Conclusion
BS and LT patients achieve comparable outcomes to general LT populations. Further studies examining simultaneous BS + LT are needed to answer questions concerning patient selection and timing of surgery.
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Khajeh E, Aminizadeh E, Eslami P, Ramouz A, Kulu Y, Billeter AT, Nickel F, Müller-Stich BP, Mehrabi A. Outcomes of Bariatric Surgery in Obese Patients with Compensated Liver Cirrhosis. Surg Obes Relat Dis 2022; 18:727-737. [DOI: 10.1016/j.soard.2022.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/10/2022] [Accepted: 03/13/2022] [Indexed: 12/21/2022]
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Combined liver transplantation with sleeve gastrectomy: a pioneer case series from Brazil. Updates Surg 2022; 74:81-86. [PMID: 35103918 DOI: 10.1007/s13304-021-01230-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 12/23/2021] [Indexed: 02/07/2023]
Abstract
The association of a bariatric operation during liver transplantation may benefit patients with liver failure and obesity and sleeve gastrectomy emerges as the procedure of choice. The aim of this study is to present our experience with combined liver transplantation and sleeve gastrectomy. During an 18-month period, seven patients were submitted to simultaneous liver transplant and sleeve gastrectomy (LTSG). There were four male and three female, and the mean recipient age was 60.5 years, mean BMI was 38.2 kg/m2, and mean MELD score was 25 points. The indication for liver transplantation was nonalcoholic steatohepatitis (NASH) with hepatocellular carcinoma (HCC) in four cases, hepatitis C with HCC in one case, pure NASH in one case and alcoholic cirrhosis with HCC in one case. Six patients are alive with normal allograft function. There were no biliary complications.
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Abstract
Currently, there are no approved medications to treat patients with nonalcoholic steatohepatitis (NASH) with fibrosis or cirrhosis. Although the management goal in these patients is weight reduction by 7-10% with lifestyle modifications, only less than 10% of patients achieve this target at 1-year, and fewer maintain the weight loss at 5 years. Bariatric surgery is an option that may be considered in those who fail to lose weight by lifestyle changes. Bariatric surgery has been shown to improve liver histology including fibrosis secondary to NASH, in addition to other benefits including an improvement or resolution of type 2 diabetes mellitus, dyslipidemia, and hypertension, and a reduction of cardiovascular morbidity or mortality. There are no guidelines of bariatric surgery indications for the management of NASH. The purpose of this review is to critically appraise the current knowledge of the role of bariatric surgery and the potential mechanisms for its perceived benefits in the management of patients with NASH-related liver disease.
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Anselmo A, Siragusa L, Sensi B, Bacchiocchi G, Pellicciaro M, Manzia TM, Gentileschi P, Tisone G. High-priority liver transplantation and simultaneous sleeve gastrectomy in MELD 32 end-stage liver disease: a case report with long-term follow-up. Obes Res Clin Pract 2022; 16:91-94. [PMID: 35016856 DOI: 10.1016/j.orcp.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/05/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Morbid obesity is a worldwide epidemic closely linked to Non-Alcoholic Fatty Liver Disease (NAFLD), an ever more relevant indication for Liver Transplantation (LT). Obesity affects an increasing number of LT recipients, but the ideal management of these patients remain unclear. Bariatric surgery (BS) in LT setting is challenging but feasible, although the debate is still open about the best timing of bariatric surgery. Herein we report a case of high-priority LT and simultaneous sleeve gastrectomy (SG) in an obese young adult. CASE REPORT A 45 years old man with morbid obesity (BMI 46 kg/m2) and severe NAFLD-related end-stage liver disease (ESLD) underwent simultaneous LT and sleeve gastrectomy (SG) in an emergency setting, due to a MELD score of 32. He had substantial weight loss during long-term follow-up and enjoyed resolution of diabetes and hypertension. At 4 years follow-up, he has normal allograft function with appropriate immunosuppressant blood levels and no ultrasound evidence of steatosis. CONCLUSION In selected patients, combined LT and SG present several advantages in terms of transplant outcomes, weight loss and resolution of obesity-related comorbidities. In addition, it can be performed in the high-priority setting in case of severe ESLD with good results in the short- and long-term.
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Affiliation(s)
| | - Leandro Siragusa
- Department of Surgery, University of Rome Tor Vergata, Rome, Italy.
| | - Bruno Sensi
- Department of Surgery, University of Rome Tor Vergata, Rome, Italy
| | | | | | | | | | - Giuseppe Tisone
- Department of Surgery, University of Rome Tor Vergata, Rome, Italy
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16
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Villeret F, Dumortier J, Erard-Poinsot D. How will NAFLD change the liver transplant landscape in the 2020s? Clin Res Hepatol Gastroenterol 2022; 46:101759. [PMID: 34311133 DOI: 10.1016/j.clinre.2021.101759] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/21/2021] [Indexed: 02/04/2023]
Abstract
Liver steatosis is the hepatic manifestation of the metabolic syndrome, and is now the leading cause of chronic liver disease worldwide. The treatment of metabolic cirrhosis with liver failure and/or hepatocellular carcinoma is liver transplantation (LT). During the past decade, metabolic cirrhosis represented an increasing cause for LT, especially in the United States. At listing, patients with metabolic cirrhosis are older, with numerous cardiovascular (CV) and renal comorbidities, and this requires multidisciplinary pre-transplant assessment. After LT, 5-year survival is similar to other indications. The leading causes of death are infectious, cancers and CV. The recurrence of the initial disease is very frequent, and a significant part of the patients progress towards graft cirrhosis. No specific immunosuppressive regimen is recommended, but the toxicity profiles must probably be taken into account. In these patients, the only etiological treatment is that of obesity, in the absence of specific therapy for non-alcoholic steatohepatitis. The place of bariatric surgery has to be defined, probably sleeve gastrectomy, in a stable patient, 6-12 months after LT.
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Affiliation(s)
- François Villeret
- Hepatology Department, Croix Rousse Hospital, Hospices Civils de Lyon, Lyon, France; University Claude Bernard Lyon 1, Lyon, France
| | - Jérôme Dumortier
- Hepatogastroenterology Department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France; University Claude Bernard Lyon 1, Lyon, France.
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17
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Mendoza YP, Becchetti C, Watt KD, Berzigotti A. Risks and Rewards of Bariatric Surgery in Advanced Chronic Liver Diseases. Semin Liver Dis 2021; 41:448-460. [PMID: 34243194 PMCID: PMC8492193 DOI: 10.1055/s-0041-1731705] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The burden of obesity and metabolic syndrome has determined a sharp increase in bariatric surgery (BS) procedures, which lead to marked weight loss, improved metabolic syndrome, reduced cardiovascular risk, and even improvement in nonalcoholic steatohepatitis (NASH). Despite these promising results, BS in patients with chronic liver disease can rarely lead to worsening of liver function, progression to cirrhosis and its complications, and even liver transplantation. On the other hand, since obesity in patients with cirrhosis is a major cofactor for progression to a decompensated stage of the disease and a risk factor for hepatocellular carcinoma, BS has been used to achieve weight loss in this population. In this review, we critically analyze the existing data on outcomes of BS in patients with cirrhosis and the possible mechanisms leading to fibrosis progression and worsening liver function in patients undergoing BS. Finally, we propose a set of measures that could be taken to improve the multidisciplinary management of liver disease in patients undergoing BS, including early recognition of malnutrition and alcohol misuse.
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Affiliation(s)
- Yuly P. Mendoza
- Department of Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland,Hepatology, Department of Biomedical Research, University of Bern, Switzerland,Graduate School for Health Sciences (GHS), University of Bern, Switzerland
| | - Chiara Becchetti
- Department of Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland,Hepatology, Department of Biomedical Research, University of Bern, Switzerland
| | - Kymberly D. Watt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Annalisa Berzigotti
- Department of Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland,Hepatology, Department of Biomedical Research, University of Bern, Switzerland,Address for correspondence Annalisa Berzigotti, MD, PhD Hepatology, University Clinic for Visceral Surgery and Medicine, Bern University Hospital, University of BernSwitzerland, Murtenstrasse 35, 3008 BerneSwitzerland
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18
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Sharpton SR, Terrault NA, Tavakol MM, Posselt AM. Sleeve gastrectomy prior to liver transplantation is superior to medical weight loss in reducing posttransplant metabolic complications. Am J Transplant 2021; 21:3324-3332. [PMID: 33780129 DOI: 10.1111/ajt.16583] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 02/23/2021] [Accepted: 03/15/2021] [Indexed: 01/25/2023]
Abstract
Strategies to optimize the management of obesity-related metabolic complications after liver transplantation (LT) are needed. We examined the effect of pre-LT sleeve gastrectomy (SG), as compared to medical weight loss (MWL), on post-LT outcomes. This is a cohort study of adults (≥18 years) with medically complicated obesity who were eligible for pre-LT SG and underwent LT from January 1, 2006 to June 1, 2016. Logistic regression models evaluated the association of SG on post-LT diabetes and hypertension, defined as new-onset or progressive disease post-LT. Cox regression models evaluated the association of SG on recurrent and de novo nonalcoholic fatty liver disease (NAFLD). Among 70 LT recipients who were eligible for pre-LT SG, 14 (20%) underwent SG and 56 (80%) underwent MWL only. Mean follow-up was 5.2 years post-LT. The SG cohort sustained higher % total body weight loss at 3 years post-LT (28.9% vs. 5.4%, p < .001). In multivariable analyses, SG was associated with significantly lower risk of post-LT diabetes (OR 0.04, 95% CI 0.00-0.41, p = .01), hypertension (OR 0.15, 95% CI 0.04-0.67, p = .01), and recurrent and de novo NAFLD (HR 0.19, 95% CI 0.04-0.91, p = .04). When compared to MWL, SG resulted in sustained weight loss and significantly lower risk of diabetes, hypertension, and recurrent and de novo NAFLD post-LT.
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Affiliation(s)
- Suzanne R Sharpton
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Norah A Terrault
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine at the University of Southern California, Los Angeles, California, USA
| | - Mehdi M Tavakol
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Andrew M Posselt
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
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19
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Iannelli A, Bulsei J, Debs T, Tran A, Lazzati A, Gugenheim J, Anty R, Petrucciani N, Fontas E. Clinical and Economic Impact of Previous Bariatric Surgery on Liver Transplantation: a Nationwide, Population-Based Retrospective Study. Obes Surg 2021; 32:55-63. [PMID: 34499293 PMCID: PMC8752569 DOI: 10.1007/s11695-021-05684-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/18/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023]
Abstract
Purpose The present study aims to determine the impact of previous bariatric surgery (BS) on the length of hospital stay; the incidence of mortality, re-transplantation, and re-hospitalization after LT; and the related economic costs, through the analysis of the French National Health Insurance Information System. Materials and Methods All patients aged > 18 years who underwent LT in France in the period from 2010 to 2019 were included. Thirty-nine patients with a history of BS (study group) were compared with 1798 obese patients without previous BS (control group). Results At the time of LT, patients with a history of BS were significantly younger than those of the control group and had lower Charlson comorbidity index. Female sex was significantly more represented in the study group. No significant differences were detected between the two groups regarding the postoperative mortality rate after LT (10.3% in the study group versus 8.0% in the control group), long-term mortality (0.038 versus 0.029 person-year of follow-up, respectively), re-transplantation (adjusted hazard ratio (HR) = 2.15, p = 0.2437), re-hospitalization (adjusted analysis, IRR = 0.93, p = 0.7517), and costs of LT hospitalization (73,515 € in the study group versus 65,878 € in the control group). After 1:2 propensity score matching, the duration of the LT hospital stay was significantly longer in the study group (58.3 versus 33.4 days, p = 0.0172). Conclusion No significant differences were detected between patients with previous BS versus obese patients without history of BS undergoing LT concerning the rates of mortality, re-LT, re-hospitalization after LT, and costs of hospitalization and re-hospitalizations. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s11695-021-05684-4.
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Affiliation(s)
- Antonio Iannelli
- Université Côte D'Azur, Nice, France. .,Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France. .,Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", Nice, France.
| | - Julie Bulsei
- Centre Hospitalier Universitaire de Nice, Department of Clinical Research and Innovation, Université Côte D'Azur, Nice, France
| | - Tarek Debs
- Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France
| | - Albert Tran
- Université Côte D'Azur, Nice, France.,Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France.,Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", Nice, France
| | - Andrea Lazzati
- Department of General Surgery, Centre Hospitalier Intercommunal de Creteil, Creteil, France
| | - Jean Gugenheim
- Université Côte D'Azur, Nice, France.,Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France.,Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", Nice, France
| | - Rodolphe Anty
- Université Côte D'Azur, Nice, France.,Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France.,Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", Nice, France
| | - Niccolo Petrucciani
- Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France.,Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, St. Andrea Hospital, Sapienza University, Rome, Italy
| | - Eric Fontas
- Centre Hospitalier Universitaire de Nice, Department of Clinical Research and Innovation, Université Côte D'Azur, Nice, France
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20
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Lefere S, Onghena L, Vanlander A, van Nieuwenhove Y, Devisscher L, Geerts A. Bariatric surgery and the liver-Mechanisms, benefits, and risks. Obes Rev 2021; 22:e13294. [PMID: 34002452 DOI: 10.1111/obr.13294] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/01/2021] [Accepted: 05/03/2021] [Indexed: 12/18/2022]
Abstract
The prevalence of obesity and metabolic diseases such as type 2 diabetes and nonalcoholic fatty liver disease (NAFLD) has risen dramatically over the past decades. At present, bariatric surgery is the most effective treatment for this global health problem, through effects on food intake, gut hormone secretion, metabolic signaling pathways, and adipose tissue dysfunction. The liver occupies a central role in carbohydrate, protein, and lipid metabolism. Notably, a reduction in hepatic fat content and an improvement in hepatic insulin resistance are among the earliest beneficial effects of bariatric surgery, which has therefore emerged as an attractive treatment option for NAFLD. However, as the scope and popularity of weight loss surgery have expanded, new questions have arisen regarding its safety in patients with liver cirrhosis, the outcome of liver transplantation in patients with a history of bariatric surgery, and over incidental reports of liver failure following surgery. Studies in humans and rodents have also linked bariatric surgery to an increased risk of developing alcohol use disorder, a major risk factor for liver disease. This review integrates data from clinical and translational research to delineate both the beneficial impact of bariatric surgery on the liver and the potential risks involved.
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Affiliation(s)
- Sander Lefere
- Hepatology Research Unit, Department of Internal Medicine and Pediatrics, Liver Research Center Ghent, Ghent University, Ghent, Belgium.,Gut-Liver Immunopharmacology Unit, Department of Basic and Applied Medical Sciences, Liver Research Center Ghent, Ghent University, Ghent, Belgium
| | - Louis Onghena
- Department of Gastrointestinal Surgery, Ghent University, Ghent, Belgium.,Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University, Ghent, Belgium
| | - Aude Vanlander
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University, Ghent, Belgium
| | | | - Lindsey Devisscher
- Gut-Liver Immunopharmacology Unit, Department of Basic and Applied Medical Sciences, Liver Research Center Ghent, Ghent University, Ghent, Belgium
| | - Anja Geerts
- Hepatology Research Unit, Department of Internal Medicine and Pediatrics, Liver Research Center Ghent, Ghent University, Ghent, Belgium
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21
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Yemini R, Nesher E, Braun M, Cohen M, Carmeli I, Mor E, Keidar A. Long-term outcomes of Roux-en-Y gastric bypass or sleeve gastrectomy in patients with cirrhosis; before, during or after liver transplantation: A single center's experience. Clin Transplant 2021; 35:e14374. [PMID: 34043840 DOI: 10.1111/ctr.14374] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/18/2021] [Accepted: 05/16/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND The increasing prevalence of morbid obesity (MO) results in parallel growth of obesity-associated liver diseases necessitating liver transplantation (LT). OBJECTIVE To examine the feasibility and safety of Roux-en-Y gastric bypass or sleeve gastrectomy in the setting of LT. METHODS This retrospective chart review included the data on all the MO candidates before and after LT who underwent bariatric surgery (BS) in our institution between 04/2013-09/2016. The reported outcomes were weight change and early and late postoperative complications (mean follow-up: 43 ± 11.1 months). RESULTS Eighteen MO peri-LT patients (10 females, 8 males, average age 48 years) were included in the study. Ten had cirrhosis (mean Model of End-stage Liver Disease [MELD] score of 12.5 ± 6.42), three underwent concurrent LT and BS (mean MELD score 23.7 ± 0.58), and five had LT (mean of 56 months from LT). The mean percentage of total and excess weight loss was 31% and 81%, respectively. Six of the eight patients with type 2 diabetes mellitus became normoglycemic after BS. Three patients sustained perioperative complications. Two cirrhotic patients died 1 and 4.5 years after BS with decompensation. CONCLUSIONS Bariatric surgery appears to effectively address obesity in cirrhotic and LT patients. The surgical risk is higher than that of the regular BS population.
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Affiliation(s)
- Renana Yemini
- Division of Surgery, Assuta University Medical Center Ashdod, Ashdod, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eviatar Nesher
- Department of Transplant Surgery, Beilinson Medical Center, Petach-Tikva, Israel
| | - Marius Braun
- Liver Diseases Institute, Beilinson Medical Center, Petach-Tikva, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michal Cohen
- Liver Diseases Institute, Beilinson Medical Center, Petach-Tikva, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Idan Carmeli
- Division of Surgery, Assuta University Medical Center Ashdod, Ashdod, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eytan Mor
- Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Surgery B, Transplant Center, Sheba Medical Center, Ramat-Gan, Israel
| | - Andrei Keidar
- Division of Surgery, Assuta University Medical Center Ashdod, Ashdod, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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22
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Pomenti S, Mehta S, Guo A, Wattacheril J. Bariatric Surgery in the Peritransplant Period. Clin Liver Dis (Hoboken) 2021; 17:282-291. [PMID: 33968390 PMCID: PMC8087907 DOI: 10.1002/cld.1052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/04/2020] [Accepted: 10/11/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Sydney Pomenti
- Division of Digestive and Liver DiseasesDepartment of MedicineColumbia University Irving Medical Center
| | - Sanket Mehta
- Columbia University Vagelos College of Physicians and Surgeons
| | - Averill Guo
- Department of MedicineColumbia University Irving Medical CenterNew YorkNY
| | - Julia Wattacheril
- Division of Digestive and Liver DiseasesDepartment of MedicineColumbia University Irving Medical Center
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23
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AGA Clinical Practice Update on Bariatric Surgery in Cirrhosis: Expert Review. Clin Gastroenterol Hepatol 2021; 19:436-445. [PMID: 33393473 PMCID: PMC8872426 DOI: 10.1016/j.cgh.2020.10.034] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023]
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24
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Harrington CR, Soghikian M, Gregory D, Wilcox JE, Shetty A, Rinella ME, Ladner DP, VanWagner LB. Association between history of bariatric surgery and graft rejection among solid organ transplant recipients. TRANSPLANTATION REPORTS 2021. [DOI: 10.1016/j.tpr.2020.100071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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25
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Vyhmeister R, Enestvedt CK. The Changing Liver Transplant Recipient: From Hepatitis C to Nonalcoholic Steatohepatitis and Alcohol. Clin Liver Dis 2021; 25:137-155. [PMID: 33978575 DOI: 10.1016/j.cld.2020.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hepatitis C virus has historically been the leading indication for liver transplant, followed by nonalcoholic steatohepatitis (NASH) and alcoholic liver disease. Severe alcoholic hepatitis has become a growing indication for liver transplant, and overall alcohol use rates continue to increase in the United States. Rates of obesity and NASH in the United States continue to increase and are expected to place increasing demand on liver transplant infrastructure. In the current absence of robust pharmacologic therapy for NASH, the use of bariatric procedures and surgeries is being explored, as are other innovative approaches to curtail this upward trend.
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Affiliation(s)
- Ross Vyhmeister
- Department of Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - C Kristian Enestvedt
- Division of Abdominal Organ Transplantation and HPB Surgery, School of Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
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26
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Abstract
Obesity is increasing in prevalence in liver transplant candidates and recipients. The rise in liver transplantation for nonalcoholic steatohepatitis reflects this increase. Management of obesity in liver transplant candidates can be challenging due to the presence of decompensated cirrhosis and sarcopenia. Obesity may increase peritransplant morbidity but does not have an impact on long-term post-transplant survival. Bariatric surgery may be a feasible option in select patients before, during, or after liver transplantation. Use of weight loss drugs and/or endoscopic therapies for obesity management ultimately may play a role in liver transplant patients, but more research is needed to determine safety.
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27
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Puri P, Dhiman RK, Taneja S, Tandon P, Merli M, Anand AC, Arora A, Acharya SK, Benjamin J, Chawla YK, Dadhich S, Duseja A, Eapan C, Goel A, Kalra N, Kapoor D, Kumar A, Madan K, Nagral A, Pandey G, Rao PN, Saigal S, Saraf N, Saraswat VA, Saraya A, Sarin SK, Sharma P, Shalimar, Shukla A, Sidhu SS, Singh N, Singh SP, Srivastava A, Wadhawan M. Nutrition in Chronic Liver Disease: Consensus Statement of the Indian National Association for Study of the Liver. J Clin Exp Hepatol 2021; 11:97-143. [PMID: 33679050 PMCID: PMC7897902 DOI: 10.1016/j.jceh.2020.09.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023] Open
Abstract
Malnutrition and sarcopenia are common in patients with chronic liver disease and are associated with increased risk of decompensation, infections, wait-list mortality and poorer outcomes after liver transplantation. Assessment of nutritional status and management of malnutrition are therefore essential to improve outcomes in patients with chronic liver disease. This consensus statement of the Indian National Association for Study of the Liver provides a comprehensive review of nutrition in chronic liver disease and gives recommendations for nutritional screening and treatment in specific clinical scenarios of malnutrition in cirrhosis in adults as well as children with chronic liver disease and metabolic disorders.
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Key Words
- ACLF, acute on chronic liver failure
- ASM, appendicular skeletal muscle mass
- BCAA, branched chain amino acids
- BIA, bioimpedance analysis
- BMD, bone mineral densitometry
- BMI, body mass index
- CLD, chronic liver disease
- CS, corn-starch
- CT, computed tomography
- CTP, Child–Turcotte–Pugh
- DEXA, dual-energy X-ray absorptiometry
- EASL, European Association for the Study of the Liver
- ESPEN, European society for Clinical Nutrition and Metabolism
- GSD, glycogen storage disease
- HGS, hand-grip strength
- IBW, ideal body weight
- IEM, inborn error of metabolism
- INASL, Indian National Association for Study of the Liver
- L3, third lumbar
- LFI, Liver Frailty Index
- MCT, medium-chain triglyceride
- MELD, model for end-stage liver disease
- MLD, metabolic liver disease
- MRI, magnetic resonance imaging
- RDA, recommended daily allowance
- REE, NASH
- RFH-NPT, Royal Free Hospital-Nutritional Prioritizing Tool
- SMI, skeletal muscle index
- Sarcopenia
- TEE, total energy expenditure
- chronic liver disease
- cirrhosis
- malnutrition
- non-alcoholic liver disease, resting energy expenditure
- nutrition
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Affiliation(s)
- Pankaj Puri
- Fortis Escorts Liver & Digestive Diseases Institute, New Delhi, 110025, India
| | - Radha K. Dhiman
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, 00185, Italy
| | - Anil C. Anand
- Kalinga Institute of Medical Sciences, Bhubhaneswar, 751024, Odisha, India
| | - Anil Arora
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences of Sir Ganga Ram Hospital, New Delhi, 110060, India
| | - Subrat K. Acharya
- Fortis Escorts Liver & Digestive Diseases Institute, New Delhi, 110025, India
| | - Jaya Benjamin
- Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, 110070, India
| | - Yogesh K. Chawla
- Kalinga Institute of Medical Sciences, Bhubhaneswar, 751024, Odisha, India
| | - Sunil Dadhich
- Department of Gastroenterology SN Medical College, Jodhpur, 342003, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - C.E. Eapan
- Department of Gastroenterology, Christian Medical College, Vellore, 632004, India
| | - Amit Goel
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Naveen Kalra
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Dharmesh Kapoor
- Department of Gastroenterology, Global Hospital, Hyderabad, 500004, India
| | - Ashish Kumar
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences of Sir Ganga Ram Hospital, New Delhi, 110060, India
| | - Kaushal Madan
- Max Smart Super Speciality Hospital, New Delhi, India
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital, Mumbai, 400026, India
| | - Gaurav Pandey
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Padaki N. Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, 500082, India
| | - Sanjiv Saigal
- Department of Hepatology, Medanta Hospital, Gurugram, 122001, India
| | - Neeraj Saraf
- Department of Hepatology, Medanta Hospital, Gurugram, 122001, India
| | - Vivek A. Saraswat
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110016, India
| | - Shiv K. Sarin
- Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, 110070, India
| | - Praveen Sharma
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences of Sir Ganga Ram Hospital, New Delhi, 110060, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110016, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GSMC & KEM Hospital, Mumbai, 400022, India
| | - Sandeep S. Sidhu
- Department of Gastroenterology, SPS Hospital, Ludhiana, 141001, India
| | - Namrata Singh
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110016, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, 753007, India
| | - Anshu Srivastava
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Manav Wadhawan
- Institute of Liver & Digestive Diseases, BL Kapur Memorial Hospital, New Delhi, 110005, India
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28
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Jamal MH, El-Abd R. Sleeve Gastrectomy in Non-alcoholic Steatohepatitis (NASH) and Liver Cirrhosis. LAPAROSCOPIC SLEEVE GASTRECTOMY 2021:115-137. [DOI: 10.1007/978-3-030-57373-7_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Agarwal L, Sahu AK, Baksi A, Agarwal A, Aggarwal S. Safety of metabolic and bariatric surgery in obese patients with liver cirrhosis: a systematic review and meta-analysis. Surg Obes Relat Dis 2020; 17:525-537. [PMID: 33339694 DOI: 10.1016/j.soard.2020.11.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/23/2020] [Accepted: 11/01/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND With the pandemic of obesity and the growing experience in metabolic and bariatric surgery (MBS), the number of patients with obesity and liver cirrhosis undergoing MBS is increasing. OBJECTIVE To analyze the morbidity and mortality following MBS in patients with obesity and liver cirrhosis. SETTING Systematic review and meta-analysis. METHODS The published literature was systematically reviewed, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, for studies reporting outcomes of MBS among patients with liver cirrhosis. The predetermined endpoints were the overall complication after MBS, intraoperative complications, liver-related complications after MBS, all-cause 90-day mortality after MBS, and liver-related mortality post-MBS. The pooled weighted proportions for each of the endpoints was calculated using random effect meta-analysis. RESULTS A total of 18 studies, including 471 patients with obesity and liver cirrhosis undergoing MBS, qualified for the final quantitative analysis. The mean age and mean body mass index (BMI) of the pooled patient cohort were 50.2 years and 47.2 kg/m2. The pooled weighted proportions of the overall post-MBS complications, intraoperative complications, liver-related complications, overall 90-day mortality, and liver failure related mortality post MBS were 22.14% (CI95%: 15.43%-29.55%), .08% (CI95%: 0%-1.02%), 4.62% (CI95%: 1.27%-9.30%), 0% (CI95%: 0%-.44%), .08% (CI95%: 0%-1.03%), respectively. Significantly lower postoperative complications were noted with sleeve gastrectomy (10.08% [95%CI: 5.14%-16%]) compared with Roux-en-Y gastric bypass (31.53% [95%CI: 18.62%-45.68%]; (P = .02). CONCLUSION We found an overall low postoperative surgical and liver-related mortality post MBS among patients with obesity and liver cirrhosis. The overall postoperative complications and liver-related complications were higher among patients with liver cirrhosis than in noncirrhotic patients. Sleeve gastrectomy showed lower postoperative complications compared with Roux-en-Y gastric bypass.
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Affiliation(s)
- Lokesh Agarwal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Ankit Kumar Sahu
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Baksi
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Ayushi Agarwal
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Aggarwal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.
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Lee Y, Tian C, Lovrics O, Soon MS, Doumouras AG, Anvari M, Hong D. Bariatric surgery before, during, and after liver transplantation: a systematic review and meta-analysis. Surg Obes Relat Dis 2020; 16:1336-1347. [DOI: 10.1016/j.soard.2020.05.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/09/2020] [Accepted: 05/13/2020] [Indexed: 12/18/2022]
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Orandi BJ, Purvis JW, Cannon RM, Smith AB, Lewis CE, Terrault NA, Locke JE. Bariatric surgery to achieve transplant in end-stage organ disease patients: A systematic review and meta-analysis. Am J Surg 2020; 220:566-579. [PMID: 32600846 PMCID: PMC7484004 DOI: 10.1016/j.amjsurg.2020.04.041] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND As obesity prevalence grows, more end-stage organ disease patients will be precluded from transplant. Numerous reports suggest bariatric surgery in end-stage organ disease may help patients achieve weight loss sufficient for transplant listing. METHODS We performed a systematic review/meta-analysis of studies of bariatric surgery to achieve solid organ transplant listing. RESULTS Among 82 heart failure patients, 40.2% lost sufficient weight for listing, 29.3% were transplanted, and 8.5% had sufficient improvement with weight loss they no longer required transplantation. Among 28 end-stage lung disease patients, 28.6% lost sufficient weight for listing, 7.1% were transplanted, and 14.3% had sufficient improvement following weight loss they no longer required transplant. Among 41 cirrhosis patients, 58.5% lost sufficient weight for listing, 41.5% were transplanted, and 21.9% had sufficient improvement following weight loss they no longer required transplant. Among 288 end-stage/chronic kidney disease patients, 50.3% lost sufficient weight for listing and 29.5% were transplanted. CONCLUSIONS Small sample size and publication bias are limitations; however, bariatric surgery may benefit select end-stage organ disease patients with obesity that precludes transplant candidacy.
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Affiliation(s)
- Babak J Orandi
- University of Alabama at Birmingham Schools of Medicine, Department of Surgery, United States.
| | - Joshua W Purvis
- University of Alabama at Birmingham Schools of Medicine, Department of Surgery, United States
| | - Robert M Cannon
- University of Alabama at Birmingham Schools of Medicine, Department of Surgery, United States
| | - A Blair Smith
- University of Alabama at Birmingham Schools of Medicine, Department of Anesthesia, United States
| | - Cora E Lewis
- University of Alabama at Birmingham Schools of Medicine, Department of Medicine, United States; University of Alabama at Birmingham Schools of Medicine, Public Health, United States
| | - Norah A Terrault
- University of Southern California Keck School of Medicine, Department of Medicine, United States
| | - Jayme E Locke
- University of Alabama at Birmingham Schools of Medicine, Department of Surgery, United States
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Benmassaoud A, Deschenes M, Chen T, Ghali P, Sebastiani G. Optimizing patients with non-alcoholic fatty liver disease pre-transplant. CANADIAN LIVER JOURNAL 2020; 3:237-250. [PMID: 35992526 PMCID: PMC9202706 DOI: 10.3138/canlivj-2019-0025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/17/2019] [Indexed: 06/01/2024]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in Western countries. Non-alcoholic steatohepatitis (NASH), which is the progressive counterpart of the disease, is becoming the leading indication for liver transplantation in North America. Owing to the lack of symptoms, NASH is often an incidental diagnosis, resulting in a significant proportion of patients being diagnosed when advanced liver disease has already developed. NAFLD has recently been characterized as the hepatic manifestation of metabolic syndrome. Consequently, it is a multisystem disease that often co-exists with several other conditions, such as obesity, diabetes, cardiovascular diseases, and extra-hepatic malignancy, which have an impact on selection of transplant recipients. The complexity of diagnostic approach, need for multidisciplinary clinical management, and lack of a specific treatment further complicate the picture of this extremely prevalent liver condition. NAFLD patients with advanced liver disease should be considered for early referral to liver transplant clinics for careful metabolic and cardiovascular risk stratification because they have worse survival rates after liver transplantation than other patients with chronic liver disease. Early referral will also facilitate optimization of metabolic comorbidities before proceeding with transplantation. This review provides an overview of strategies to identify patients with advanced NAFLD, with an emphasis on the management of associated comorbidities and optimal timing of pre-transplant evaluation. Other topics that have been shown to affect recipient optimization, such as the role of lifestyle changes and bariatric surgery in the management of obesity, as well as sarcopenia in decompensated NASH-related cirrhosis, are addressed.
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Affiliation(s)
- Amine Benmassaoud
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marc Deschenes
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tianyan Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Peter Ghali
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Gastroenterology, Department of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Chronic Viral Illness Service, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Obesity in the Liver Transplant Setting. Nutrients 2019; 11:nu11112552. [PMID: 31652761 PMCID: PMC6893648 DOI: 10.3390/nu11112552] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/23/2019] [Accepted: 09/25/2019] [Indexed: 12/12/2022] Open
Abstract
The obesity epidemic has resulted in an increased prevalence of obesity in liver transplant (LT) candidates and in non-alcoholic fatty liver disease (NAFLD) becoming the fastest growing indication for LT. LT teams will be dealing with obesity in the coming years, and it is necessary for them to recognize some key aspects surrounding the LT in obese patients. Obesity by itself should not be considered a contraindication for LT, but it should make LT teams pay special attention to cardiovascular risk assessment, in order to properly select candidates for LT. Obese patients may be at increased risk of perioperative respiratory and infectious complications, and it is necessary to establish preventive strategies. Data on patient and graft survival after LT are controversial and scarce, especially for long-term outcomes, but morbid obesity may adversely affect these outcomes, particularly in NAFLD. The backbone of obesity treatment should be diet and exercise, whilst being careful not to precipitate or worsen frailty and sarcopenia. Bariatric surgery is an alternative for treatment of obesity, and the ideal timing regarding LT is still unknown. Sleeve gastrectomy is probably the procedure that has the best evidence in LT because it offers a good balance between safety and efficacy.
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Selzner N, Grant D. Obesity: Weighty Challenges for the Liver Transplant Community. Liver Transpl 2019; 25:531-532. [PMID: 30811874 DOI: 10.1002/lt.25437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 02/22/2019] [Indexed: 01/12/2023]
Affiliation(s)
- Nazia Selzner
- Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David Grant
- Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
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