Complications associated with liver transplantation in the obese recipient

The Impact of Metabolic Health and Obesity on Liver Transplant Candidates and Recipients

Poor metabolic health and obesity have significant impacts on the outcomes of patients suffering from chronic liver disease, particularly those with metabolic dysfunction-associated steatotic liver disease. Patients with such comorbidities who require liver transplant evaluation for advancing liver disease or liver failure require special consideration due to increased risk of cardiovascular disease, renal dysfunction, sarcopenic obesity, and cancer. Those who have had a history of prior bariatric surgery pose specific anatomical constraints and may also be at increased risk of alcohol use disorder. Pre-operative risk assessment as well as strict control of metabolic risk factors are essential to reduce intra-operative and post-liver transplant complications. As immunosuppressive therapy exacerbates metabolic dysfunction and risk for cancer, post-liver transplant care must focus on balancing the need to prevent rejection and the impact of progressive metabolic dysfunction in this unique, but growing, patient population.

[The Role of the Anaesthesiologist in Liver Transplantation - Preoperative Evaluation]

Preoperative evaluation prior to listing for orthotopic liver transplantation (LT) requires a careful multidisciplinary approach with specialized teams including surgeons, hepatologists and anesthesiologists in order to improve short- and long-term clinical outcomes. Due to inadequate supply of donor organs and changing demographics, patients listed for LT have become older, sicker and share more comorbidities. As cardiovascular events are the leading cause for early mortality precise evaluation of risk factors is mandatory. This review focuses on the detection and management of coronary artery disease, cirrhotic cardiomyopathy, portopulmonary hypertension and hepatopulmonary syndrome in patients awaiting LT. Further insights are being given into scoring systems, patients with Acute-on-chronic-liver-failure (ACLF), frailty, NASH cirrhosis and into psychologic evaluation of patients with substance abuse.

Perceptions of surgical difficulty in liver transplantation: A European survey and development of the Pitié-Salpêtrière classification

BACKGROUND

Significant variations exist regarding the definition of difficult liver transplantation. The study goals were to investigate how liver transplant surgeons evaluate the surgical difficulty of liver transplantation and to use the identified factors to classify liver transplantation difficulty.

METHODS

A Web-based online European survey was presented to liver transplant surgeons. The survey was divided into 3 parts: (1) participant demographics and practices; (2) various situations based on recipient, liver disease, tumor treatment, and technical factors; and (3) 8 real-life clinical vignettes with different levels of complexity. In part 3 of the survey, respondents were asked whether they would perform liver transplantation but were not aware that these patients eventually underwent liver transplantation.

RESULTS

A total of 143 invites were sent out, and 97 (67.8%) participants completed the survey. Most participants considered previous spontaneous bacterial peritonitis, previous supra-mesocolic surgery, hypertrophy of segment I, and obesity to be recipient factors for high-difficulty liver transplantation. Most participants considered liver transplantation to be challenging in patients with Budd-Chiari syndrome, Kasai surgery, polycystic liver disease, diffuse portal vein thrombosis, and a history of open hepatectomy. The proportion of participants indicating that liver transplantation was warranted varied across the 8 cases, from 69% to 100%. Our classification of the surgical difficulty of liver transplantation employed these recipient-related, surgical history-related, and liver disease-related variables and 3 difficulty groups were identified: low, intermediate, and high difficulty groups.

CONCLUSION

This survey provides an overview of the surgical difficulty of various situations in liver transplantation that could be useful for further benchmark and textbook outcome studies.

The impact of obesity on postoperative complications and short-term survival after liver transplantation

BACKGROUND AND AIMS

Obesity is considered a risk factor for perioperative complications, but its effect on patients undergoing liver transplantation (LT) remains unclear. This study was conducted to analyze the impact of obesity on early morbidity and mortality risk following LT.

METHODS

A multicenter study of outcomes in patients submitted to LT between 2009 and 2019 was conducted. Recipients were stratified into obese (BMI ≥ 30 kg/m2) and nonobese patients (BMI < 30 kg/m2). Early postoperative complications were compared and 30-day and 1-year patient and graft survival were assessed by Kaplan-Meier method. Primary graft nonfunction (PGNF) was defined as the presence of total bilirubin > 10 mg/dl, INR > 1.6 or ALT > 2000 U/l within the first week after LT.

RESULTS

A total of 1608 patients were included after applying exclusion criteria, nonobese (1149, 71.46%) and obese patients (459, 28.54%). There were no significant differences in age, sex, Model for End-stage Liver Disease, Charlson comorbidity score, ethnicity, waiting list time and ischemia time. There were significantly higher rates of vascular (17.58% vs 23.53%, P = 0.021) and biliary complications (27.68% vs 35.73%, P = 0.006) and PGNF (11.40% vs 12.20%, P = 0.021) in obese patients. There was a significantly increased risk for long-term graft failure; however, there was no significant difference in patient survival after LT.

CONCLUSION

Obese patients have significantly increased morbidity in terms of vascular and biliary complications and PGNF after LT. They have a higher risk for worse 1-year graft survival in comparison to controls.

CT-quantified sarcopenic visceral obesity is associated with poor transplant waitlist mortality in patients with cirrhosis

Sarcopenic obesity is associated with higher rates of morbidity and mortality than seen with either sarcopenia or obesity alone. We aimed to define sarcopenic visceral obesity (SVO) using CT-quantified skeletal muscle index and visceral-to-subcutaneous adipose tissue ratio and to examine its association with waitlist mortality in patients with cirrhosis. Included were 326 adults with cirrhosis awaiting liver transplantation in the ambulatory setting with available abdominal CT within 6 months from enrollment between February 2015 and January 2018. SVO was defined as patients with sarcopenia (skeletal muscle index <50 cm 2 /m 2 in men and <39 cm 2 /m 2 in women) and visceral obesity (visceral-to-subcutaneous adipose tissue ratio ≥1.21 in men and ≥0.48 in women). The percentage who met criteria for sarcopenia, visceral obesity, and SVO were 44%, 29%, and 13%, respectively. Cumulative incidence of waitlist mortality was higher in patients with SVO compared to patients with sarcopenia without visceral obesity or visceral obesity without sarcopenia at 12 months (40% vs. 21% vs. 12%) (overall logrank p =0.003). In univariable Cox regression, SVO was associated with waitlist mortality (HR: 3.42, 95% CI: 1.58-7.39), which remained significant after adjusting for age, sex, diabetes, ascites, encephalopathy, MELDNa, liver frailty index, and different body compositions (HR: 2.64, 95% CI: 1.11-6.30). SVO was associated with increase waitlist mortality in patients with cirrhosis in the ambulatory setting awaiting liver transplantation. Concurrent loss of skeletal muscle and gain of adipose tissue seen in SVO quantified by CT may be a useful and objective measurement to identify patients at risk for suboptimal pretransplant outcomes.

Management and Risks Before, During, and After Liver Transplant in Individuals With Obesity

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.

Bariatric surgery in liver cirrhosis

Introduction

Obesity is frequently associated with its hepatic manifestation, the nonalcoholic fatty liver disease (NAFLD). The most effective treatment for morbid obesity is bariatric surgery (BS) also improving NAFLD and liver function. In patients where NAFLD has already progressed to liver cirrhosis, BS can be considered a high-risk procedure. Hence, consideration of the procedure and the most appropriate timing is crucial.

Material and Methods

Obese patients suffering from NAFLD who underwent BS from two German University Medical Centers were retrospectively analyzed.

Results

Twenty-seven patients underwent BS. Most common procedures were laparoscopic Roux-en-Y-gastric (RYGB) and laparoscopic sleeve gastrectomy (SG). All patients suffered from liver cirrhosis Child A. A preoperative transjugular portosystemic shunt (TIPS) was established in three patients and failed in another patient. Postoperative complications consisted of wound healing disorders (n = 2), anastomotic bleeding (n = 1), and leak from the staple line (n = 1). This patient suffered from intraoperatively detected macroscopic liver cirrhosis. Excess weight loss was 73% and 85% after 1 and 2 years, respectively. Two patients suffered from postoperative aggravation of their liver function, resulting in a higher Child-Pugh score, while three could be removed from the waiting list for a liver transplantation.

Conclusion

BS leads to weight loss, both after SG and RYGB, and potential improvement of liver function in liver cirrhosis. These patients need to be considered with care when evaluated for BS. Preoperative TIPS implantation may reduce the perioperative risk in selected patients.

2021 Clinical Update in Liver Transplantation

In 2021, the United States performed 9,236 liver transplantations, an increase of 3.7% from 2020. As the specialty of transplant anesthesiologist continues to grow, so does the body of evidence-based research to improve patient care. New technology in organ preservation offers the possibility of preserving marginal organs for transplant or improving the graft for transplantation. The sequalae of end-stage liver disease have wide-ranging consequences that affect neurologic outcomes of patients both during and after transplantation that anesthesiologists should monitor. Obesity presents several challenges for anesthesiologists. As an increasing number of patients with nonalcoholic steatohepatitis are listed for transplant, managing their multiple comorbidities can be challenging. Finally, the rebalanced hemostasis of end-stage liver disease can cause both bleeding and thrombus. Often, bleeding risks predominate as a concern, but anesthesiologists should be aware of risks of intracardiac thrombus and review therapeutic options for prevention and treatment.

Sarcopenic visceral obesity is associated with increased post-liver transplant mortality in acutely ill patients with cirrhosis

"Sarcopenic obesity" refers to a condition of low muscle mass in the context of obesity, though may be difficult to assess in patients with cirrhosis who are acutely ill. We aimed to define sarcopenic visceral obesity (SVO) using CT-based skeletal muscle index (SMI) and visceral-to-subcutaneous adipose tissue ratio (VSR) to examine its association with post-transplant mortality. We analyzed 116 adult inpatients with cirrhosis who were urgently listed and transplanted between 1/2005 and 12/2017 at 4 North American transplant centers. SVO was defined as patients with sarcopenia (SMI <50 cm2 /m2 in men and <39 cm2 /m2 in women) and visceral obesity (VSR ≥ 1.54 in men and ≥1.37 in women). The percentage who met criteria for sarcopenia, visceral obesity, and SVO were 45%, 42%, and 20%, respectively. Cumulative rates of post-transplant mortality were higher in patients with SVO compared to patients with sarcopenia or visceral obesity alone at 36 months (39% vs. 14% vs. 8%) [logrank p = .01]. In univariable regression, SVO was associated with post-transplant mortality (HR 2.92, 95%CI 1.04-8.23) and remained significant after adjusting for age, sex, diabetes, encephalopathy, hepatocellular carcinoma, and MELD-Na (HR 3.50, 95%CI 1.10-11.15). In conclusion, SVO is associated with increased post-transplant mortality in acutely ill patients with cirrhosis.

Evaluation of liver transplant candidates with non-alcoholic steatohepatitis

Non-alcoholic steatohepatitis (NASH) is anticipated to become the leading indication for liver transplantation (LT) in the United States in the near future. LT is indicated in patients with NASH-related cirrhosis who have medically refractory hepatic decompensation, synthetic dysfunction, and hepatocellular carcinoma (HCC) meeting certain criteria. The objective of LT evaluation is to determine which patient will derive the most benefit from LT with the least risk, thus maximizing the societal benefits of a limited resource. LT evaluation is a multidisciplinary undertaking involving several specialists, assessment tools, and diagnostic testing. Although the steps involved in LT evaluation are relatively similar across different liver diseases, patients with NASH-related cirrhosis have unique demographic and clinical features that affect transplant outcomes and influence their LT evaluation. LT candidates with NASH should be assessed for metabolic syndrome and obesity, malnutrition and sarcopenia, frailty, and cardiovascular disease. Interventions that treat cardiometabolic co-morbidities and improve patients' nutrition and functionality should be considered in order to improve patient outcomes in the waitlist and after LT.

The role of bariatric surgery in liver transplantation: timing and type

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.

Bariatric Surgery in NAFLD

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.

How will NAFLD change the liver transplant landscape in the 2020s?

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.

Multidirectional facets of obesity management in the metabolic syndrome population after liver transplantation

The obesity pandemic has resulted in an increasing demand for liver transplantation and has significantly altered the profile of liver transplant candidates in addition to affecting posttransplantation outcomes. In this review, we discuss a broad range of clinical approaches that warrant attention to provide comprehensive and patient‐centred medical care to liver transplant recipients, and to be prepared to confront the rapidly changing clinical challenges and ensuing dilemmas. Adipose tissue is a complex and metabolically active organ. Visceral fat deposition is a key predictor of overall obesity‐related morbidity and mortality. Limited pharmacological options are available for the treatment of obesity in the liver transplant population. Bariatric surgery may be an alternative in eligible patients. The rapidly increasing prevalence of nonalcoholic fatty liver disease (NAFLD) is a global concern; NAFLD affects both pre‐ and posttransplantation outcomes. Numerous studies have investigated pharmacological and nonpharmacological management of NAFLD and some of these have shown promising results. Liver transplant recipients are constantly exposed to numerous factors that result in intestinal microbiota alterations, which were linked to the development of obesity, diabetes type 2, metabolic syndrome (MS), NAFLD, and hepatocellular cancer. Microbiota modifications with probiotics and prebiotics bring gratifying results in the management of metabolic complications. Fecal microbiota transplantation (FMT) is successfully performed in many medical indications. However, the safety and efficacy profiles of FMT in immunocompromised patients remain unclear. Obesity together with immunosuppressive treatment, may affect the pharmacokinetic and/or pharmacodynamic properties of coadministered medications. Individualized immunosuppressive regimens are recommended following liver transplantation to address possible metabolic concerns. Effective and comprehensive management of metabolic complications is shown to yield multiple beneficial results in the liver transplant population and may bring gratifying results in improving long‐term survival rates.

The impact of race and comorbid conditions on adult liver transplant outcomes in obese recipients

Many prior studies comparing liver transplant outcomes between obese and nonobese recipients found no significant differences in survival. However, obesity is intrinsically associated with demographic factors such as race and comorbidities. Thus, this work aimed to analyze the effects of obesity, in conjunction with these factors, on liver transplant outcomes. OPTN data was analyzed to identify adult-only, first-time liver transplants between 1995 and 2019. Obesity was defined by the CDC obesity classification. Race, insurance status, age, and comorbidities were analyzed together with patient survival and graft survival using a multivariable Cox Proportional-Hazards model and long-term survival with Kaplan-Meier curves. The multivariable models found that being black, older than 50 years, having diabetes, or having nonprivate insurance were all risk factors for both patient survival and graft survival after liver transplant. Adjusting for obesity class, black recipients had a 20% lower patient survival and 23% lower graft survival compared with nonblack recipients. Survival curves verified that obese black liver transplant recipients had poorer long-term patient survival and graft survival compared with both obese nonblack and nonobese recipients. In conclusion, obesity compounds known factors associated with poor outcomes after liver transplantation. Further work is critical to understand why these discrepancies persist.

Individualized treatment options for patients with non-cirrhotic and cirrhotic liver disease

The obesity pandemic has led to a significant increase in patients with metabolic dysfunction-associated fatty liver disease (MAFLD). While dyslipidemia, type 2 diabetes mellitus and cardiovascular diseases guide treatment in patients without signs of liver fibrosis, liver related morbidity and mortality becomes relevant for MAFLD's progressive form, non-alcoholic steatohepatitis (NASH), and upon development of liver fibrosis. Statins should be prescribed in patients without significant fibrosis despite concomitant liver diseases but are underutilized in the real-world setting. Bariatric surgery, especially Y-Roux bypass, has been proven to be superior to conservative and/or medical treatment for weight loss and resolution of obesity-associated diseases, but comes at a low but existent risk of surgical complications, reoperations and very rarely, paradoxical progression of NASH. Once end-stage liver disease develops, obese patients benefit from liver transplantation (LT), but may be at increased risk of perioperative infectious complications. After LT, metabolic comorbidities are commonly observed, irrespective of the underlying liver disease, but MAFLD/NASH patients are at even higher risk of disease recurrence. Few studies with low patient numbers evaluated if, and when, bariatric surgery may be an option to avoid disease recurrence but more high-quality studies are needed to establish clear recommendations. In this review, we summarize the most recent literature on treatment options for MAFLD and NASH and highlight important considerations to tailor therapy to individual patient's needs in light of their risk profile.

NAFLD: a multi-faceted morbid spectrum with uncertain diagnosis and complicated management. Where do we stand? Review of the literature

NASH can be considered the "contemporary era pandemic", because of its global widespread in parallel with obesity, diabetes and metabolic dysfunction. It is a disease that often poses many difficulties, since making a early diagnosis is often impossible since specific diagnostic tests and criteria are missing: so, it needs a high degree of suspicion. Most of the times the evolution to its more severe and terminal step, NASH cirrhosis, is unavoidable and so are the social pressure on health sistem and economic consequences it brings back. In this work we aim to review the literature about both NAFLD and NASH, thus structuring a wide, comprehensive, 360 degree work with a focus on all major aspects of NAFLD, spanning from diagnosis, physiopathology and its repercussions on liver transplantation. Moreover we also focused on patients related issues both in pre- and post-transplant management (when these patients are listed for liver transplant). NAFLD and NASH are a contemporary plague, and an exaustive knowledge of the problem throughout all its aspects is necessary in order to lower economic weight that metabolic issues bring back and to have a open view to possible solutions to all management issues that NASH patients have and that are oten prohibitive to a definitive cure (for example cardiovascular risk in patients otherwise eligible to liver transplantation). We aim to offer a complete view on the actual knowledge about NAFLD and NASH, by an extensive review of the literature.

Changing Trends in Liver Transplantation: Challenges and Solutions

Despite improvements in postliver transplant outcomes through refinements in perioperative management and surgical techniques, several changing trends in liver transplantation have presented challenges. Mortality on the waitlist remains high. In the United States, Europe, and the United Kingdom, there is an increasing need for liver transplantation, primarily as a result of increased incidence of nonalcoholic steatohepatitis-related cirrhosis and cancer indications. Meanwhile, donor suitability has decreased, as donors are often older and have more comorbidities. Despite a mismatch between organ need and availability, many organs are discarded. Notwithstanding this, many solutions have been developed to overcome these challenges. Innovative techniques in allograft preservation, viability assessment, and reconditioning have allowed the use of suboptimal organs with adequate results. Refinements in surgical procedures, including live donor liver transplantations, have increased the organ pool and are decreasing the time and mortality on the waitlist. Despite many challenges, a similar number of solutions and prospects are on the horizon. This review seeks to explore the changing trends and challenges in liver transplantation and highlight possible solutions and future directions.

Obesity Management of Liver Transplant Waitlist Candidates and Recipients

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.

Metabolic associated fatty liver disease: Addressing a new era in liver transplantation

Metabolic associated fatty liver disease (MAFLD), previously termed non-alcoholic fatty liver disease, is the leading global cause of liver disease and is fast becoming the most common indication for liver transplantation. The recent change in nomenclature to MAFLD refocuses the conceptualisation of this disease entity to its metabolic underpinnings and may help to spur a paradigm shift in the approach to its management, including in the setting of liver transplantation. Patients with MAFLD present significant challenges in the pre-, peri- and post-transplant settings, largely due to the presence of medical comorbidities that include obesity, metabolic syndrome and cardiovascular risk factors. As the community prevalence of MAFLD increases concurrently with the obesity epidemic, donor liver steatosis is also a current and future concern. This review outlines current epidemiology, nomenclature, management issues and outcomes of liver transplantation in patients with MAFLD.

NAFLD and liver transplantation: Disease burden, current management and future challenges

Non-alcoholic fatty liver disease (NAFLD), specifically its progressive form non-alcoholic steatohepatitis (NASH), represents the fastest growing indication for liver transplantation in Western countries. Diabetes mellitus, morbid obesity and cardiovascular disease are frequently present in patients with NAFLD who are candidates for liver transplantation. These factors require specific evaluation, including a detailed pre-surgical risk stratification, in order to improve outcomes after liver transplantation. Moreover, in the post-transplantation setting, the incidence of cardiovascular events and metabolic complications can be amplified by immunosuppressive therapy, which is a well-known driver of metabolic alterations. Indeed, patients with NASH are more prone to developing early post-transplant complications and, in the long-term, de novo malignancy and cardiovascular events, corresponding to higher mortality rates. Therefore, a tailored multidisciplinary approach is required for these patients, both before and after liver transplantation. Appropriate candidate selection, lifestyle modifications and specific assessment in the pre-transplant setting, as well as pharmacological strategies, adjustment of immunosuppression and a healthy lifestyle in the post-transplant setting, play a key role in correct management.

Obesity, transplantation, and bariatric surgery: An evolving solution for a growing epidemic

The increasing obesity epidemic has major implications in the realm of transplantation. Patients with obesity face barriers in access to transplant and unique challenges in perioperative and postoperative outcomes. Because of comorbidities associated with obesity, along with the underlying end-stage organ disease leading to transplant candidacy, these patients may not even be referred for transplant evaluation, much less be waitlisted or actually undergo transplant. However, the use of bariatric surgery in this population can help optimize the transplant candidacy of patients with obesity and end-stage organ disease and improve perioperative and postoperative outcomes. We review the impact of obesity on kidney, liver, and cardiothoracic transplant candidates and recipients and explore potential interventions to address obesity in these populations.

Visceral adiposity is an independent risk factor for high intra-operative blood loss during living-donor liver transplantation; could preoperative rehabilitation and nutritional therapy mitigate that risk?

BACKGROUND & AIMS

Blood loss during liver transplantation (LT) is one of the major concerns of the transplant team, given the potential negative post-transplant outcomes related to it. Blood loss was reported to be higher in certain body compositions, such as obese patients, undergoing LT. Therefore, we aimed to study the risk factors for high blood loss (HBL) during adult living donor liver transplant (ALDLT) including the body composition markers; visceral-to-subcutaneous adipose tissue area ratio (VSR), skeletal muscle index and intramuscular adipose tissue content. In June 2015, an aggressive perioperative rehabilitation and nutritional therapy (APRNT) program was prescribed in our institute for the patients with abnormal body composition.

METHODS

We retrospectively analyzed 394 patients who had undergone their first ALDLT between 2006 and 2019. Risk factors for HBL were analyzed in the total cohort. Differences in blood loss and risk factors were analyzed in relation to the APRNT.

RESULTS

Multivariate risk factor analysis in the total cohort showed that a high VSR (odds ratio (OR): 1.98, 95% confidence interval (CI): 1.19-3.29, P = 0.009), was an independent risk factor for HBL during ALDLT, as well as a history of upper abdominal surgery, simultaneous splenectomy and the presence of a large amount of ascites. After the introduction of the APRNT, a significantly lower blood loss was observed during the ALDLT recipient operation (P = 0.003). Moreover, the significant difference in blood loss observed between normal and high VSR groups before the application of the APRNT (P < 0.001), was not observed with the APRNT (P = 0.85). Likewise, before the APRNT, only high VSR was a risk factor for HBL by multivariate analysis (OR: 2.34, CI: 1.33-4.09, P = 0.003). Whereas with the APRNT, high VSR was no longer a significant risk factor for HBL even by univariate analysis (OR: 0.89, CI: 0.26-3.12, P = 0.86).

CONCLUSION

Increased visceral adiposity was an independent risk factor for high intraoperative blood loss during ALDLT recipient operation. With APRNT, high VSR was not associated with high blood loss. Therefore, APRNT might have mitigated the risk of high blood loss related to high visceral adiposity.

Body Weight Parameters are Related to Morbidity and Mortality After Liver Transplantation: A Systematic Review and Meta-analysis

BACKGROUND

Weight gain and obesity are well-known clinical issues in liver transplantation (LTx). However, their impacts on patient outcomes remain unclear, as only the impact of pre-LTx body mass index (BMI) on survival has been meta-analyzed. We summarized and synthesized the evidence on pre- and post-LTx body weight parameters' relations with post-LTx outcomes such as survival, metabolic and cardiovascular comorbidities, and healthcare utilization.

METHODS

We followed the Cochrane Handbook for Systematic Reviews of Interventions' recommendations. Quality was assessed via a 19-item instrument. Odds ratios and 95% confidence intervals were calculated for outcomes investigated in ≥5 studies.

RESULTS

Our meta-analysis included 37 studies. Patients with pre-LTx BMI ≥ 30 kg/m and BMI ≥ 35 kg/m had lower overall survival rates than those with pre-LTx normal weight (72.6% and 69.8% versus 84.2%; P = 0.02 and P = 0.03, respectively). Those with pre-LTx BMI ≥ 30 kg/m had worse overall graft survival than normal weight patients (75.8% and 85.4%; P = 0.003). Pre-LTx BMI and pre-LTx overweight were associated with new-onset diabetes (P < 0.001 and P = 0.015, respectively), but post-LTx BMI showed no relationship. No associations were evident with healthcare utilization.

CONCLUSIONS

Patients with BMI values ≥30 kg/m had worse patient and graft survival than those with normal weight. Few of the reviewed studies examined post-LTx body weight parameters or other relevant outcomes such as cardiovascular comorbidities. High heterogeneity as well as diverse definitions and operationalizations of measurement and outcomes severely impeded comparability.

Post-transplant obesity impacts long-term survival after liver transplantation

BACKGROUND

Short-term survival after orthotopic liver transplantation (OLT) has improved over the past decades, but long-term survival remains impaired. The effects of obesity on long-term survival after OLT are controversial. Because pre-transplant body mass index (BMI) can be confounded by ascites, we hypothesized that post-transplant BMI at 1 year could predict long-term survival.

METHODS

A post-hoc analysis was performed of an observational cohort study consisting of adult recipients of a first OLT between 1993 and 2010. Baseline BMI was measured at 1-year post-transplantation to represent a stable condition. Recipients were stratified into normal weight (BMI < 25 kg/m²), overweight (25 ≤ BMI ≤ 30 kg/m²), and obese (BMI > 30 kg/m²). Kaplan-Meier survival analyses were performed with log-rank testing, followed by multivariable Cox proportional hazards regression analysis.

RESULTS

Out of 370 included recipients, 184 had normal weight, 136 were overweight, and 50 were obese at 1-year post-transplantation. After median follow-up for 12.3 years, 107 recipients had died, of whom 46 (25%) had normal weight, 39 (29%) were overweight, and 22 (44%) were obese (log-rank P = 0.020). Obese recipients had a significantly increased mortality risk compared to normal weight recipients (HR 2.00, 95% CI 1.08-3.68, P = 0.027). BMI was inversely associated with 15 years patient survival (HR 1.08, 95% CI 1.03-1.14, P = 0.001 per kg/m²), independent of age, gender, muscle mass, transplant characteristics, cardiovascular risk factors, kidney- and liver function.

CONCLUSION

Obesity at 1-year post-transplantation conveys a 2-fold increased mortality risk, which may offer potential for interventional strategies (i.e. dietary advice, lifestyle modification, or bariatric surgery) to improve long-term survival after OLT.

Factors Associated With Length of Hospital Stay Following Liver Transplant Surgery

OBJECTIVES

Length of stay is considered an important surrogate for transplant survival rate and resource utilization. Therefore, in the present study, our aim was to determine factors affecting length of hospital stay.

MATERIALS AND METHODS

We retrospectively analyzed records of patients who underwent liver transplant at the Tehran University of Medical Sciences Liver Transplantation Center from March 2014 to March 2016.

RESULTS

For our final analyses, there were 161 adult recipients, including 106 males (65.8%) and 55 females (34.1%). Univariate analyses showed that body mass index, Modelfor End-Stage Liver Disease score, duration of surgery, number of administered packed red blood cells and fibrinogen during surgery, reoperation, retransplant, bacterial infection, pleural effusion, ascites, renal failure that required dialysis, and wound infection were risk factors for length of hospital stay. After multivariate linear regression analysis, only body mass index (β = 0.016; P = .028), Model for End-Stage Liver Disease score (β = 0.017; P = .002), surgical duration (β = 0.002; P = .001), reoperation (β = 0.016; P < .001), presence of pleural effusion (β = 0.212; P = .042), and management of bacterial infection (β = 0.21; P = .03) and psychiatric problems after liver transplant (β = 0.213; P = .025) were independent risk factors for length of hospital stay.

CONCLUSIONS

The present study showed that multiple preoperative, intraoperative, and postoperative variables could have an impact on length of hospitalization. Therefore, methods for assessing these factors could improve patient outcomes and resource savings in liver transplant centers.

Peri-transplant management of nonalcoholic fatty liver disease in liver transplant candidates

The incidence of non-alcoholic fatty liver disease (NAFLD) is rapidly growing, affecting 25% of the world population. Non-alcoholic steatohepatitis (NASH) is the most severe form of NAFLD and affects 1.5% to 6.5% of the world population. Its rising incidence will make end-stage liver disease (ESLD) due to NASH the number one indication for liver transplantation (LT) in the next 10 to 20 years, overtaking Hepatitis C. Patients with NASH also have a high prevalence of associated comorbidities such as type 2 diabetes, obesity, metabolic syndrome, cardiovascular disease, and chronic kidney disease (CKD), which must be adequately managed during the peritransplant period for optimal post-transplant outcomes. The focus of this review article is to provide a comprehensive overview of the unique challenges these patients present in the peritransplant period, which comprises the pre-transplant, intraoperative, and immediate postoperative periods.

Nonalcoholic Steatohepatitis After Liver Transplantation

Currently, nonalcoholic steatohepatitis (NASH) is the second leading indication for liver transplantation (LT), behind alcohol-related liver disease. After transplant, both recurrent and de novo nonalcoholic fatty liver disease are common; however, recurrence rates of NASH and advanced fibrosis are low. Identification of high-risk groups and optimizing treatment of metabolic comorbidities both before and after LT is paramount to maintaining a healthy allograft, especially with the additional consequences of longterm immunosuppression. In addition, NASH LT recipients are at an increased risk of cardiovascular events and malignancy, and their condition warrants a tailored approach to management. The optimal approach to NASH LT recipients including metabolic comorbidities management, tailored immunosuppression, the role of bariatric surgery, and nutritional and pharmacotherapy of NASH are discussed in this review. Overall, aggressive management of metabolic syndrome after LT via medical and surgical modalities and a minimalist approach to immunosuppression is advised.

Medical Contraindications to Transplant Listing in the USA: A Survey of Adult and Pediatric Heart, Kidney, Liver, and Lung Programs

INTRODUCTION

Listing practices for solid organ transplantation are variable across programs in the USA. To better characterize this variability, we performed a survey of psychosocial listing criteria for pediatric and adult heart, lung, liver, and kidney programs in the USA. In this manuscript, we report our results regarding listing practices with respect to obesity, advanced age, and HIV seropositivity.

METHODS

We performed an online, forced-choice survey of adult and pediatric heart, kidney, liver, and lung transplant programs in the USA.

RESULTS

Of 650 programs contacted, 343 submitted complete responses (response rate = 52.8%). Most programs have absolute contraindications to listing for BMI > 45 (adult: 67.5%; pediatric: 88.0%) and age > 80 (adult: 55.4%; pediatric: not relevant). Only 29.5% of adult programs and 25.7% of pediatric programs consider HIV seropositivity an absolute contraindication to listing. We found that there is variation in absolute contraindications to listing in adult programs among organ types for BMI > 45 (heart 89.8%, lung 92.3%, liver 49.1%, kidney 71.9%), age > 80 (heart 83.7%, lung 76.9%, liver 68.4%, kidney 29.2%), and HIV seropositivity (heart 30.6%, lung 59.0%, kidney 16.9%, liver 28.1%).

CONCLUSIONS

We argue that variability in listing enhances access to transplantation for potential recipients who have the ability to pursue workup at different centers by allowing different programs to have different risk thresholds. Programs should remain independent in listing practices, but because these practices differ, we recommend transparency in listing policies and informing patients of reasons for listing denial and alternative opportunities to seek listing at another program.

Obesity in the Liver Transplant Setting

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.

Obesity in Liver Transplantation: A Risk Factor for Unplanned Reoperation and Prolonged Operative Time

Selection of orthotopic liver transplantation (OLT) candidates is increasingly inclusive of patients with high BMI. We aim to characterize the influence of obesity on the surgical outcome measures of prolonged operative time and unplanned reoperation. We reviewed the records of obese and normal weight OLT recipients over a 10-year period from a single institution. Variables that trended ( P < 0.1) with endpoints on univariate analysis were put into multivariate logistic regression models to determine independent association ( P < 0.05). We included 195 obese and 171 normal weight OLT recipients in our study. On multivariate analysis, obesity was the only preoperative risk factor that trended with unplanned reoperation (odds ratio 2, P = 0.05). Similarly, only obesity remained independently associated with prolonged length of operation (defined as ≥275 minutes) on multivariate analysis (odds ratio 1.7, P = 0.04). In summary, obesity may make OLT more technically challenging and, thus, represents an independent risk factor for unplanned reoperations and prolonged operative time.

Recipient body mass index and infectious complications following liver transplantation

BACKGROUND

Nutritional problems are common in patients requiring liver transplantation. Recipient obesity or malnutrition are thought to increase postoperative complications. Body mass index (BMI) is commonly used prior to major surgery but its value specifically in liver transplant assessment has not been established. This is a retrospective study assessing the correlation between the BMI of individuals undergoing liver transplant and the development of postoperative infectious complications.

METHODS

Data were collected from a prospectively maintained database regarding all consecutive patients over a period of 23 years. Preoperative recipient BMI was correlated with the number, nature and outcome of postoperative infective complications.

RESULTS

Of a total of 1156 consecutive patients, 13.2% developed infectious complications. Thirty-day mortality was 7.2% and 90-day mortality was 10%. Higher BMI was associated with higher risk of infections (p = 0.002). Wound infections occurred predominantly in obese patients (p = 0.001) while other types of infections were more common in malnourished patients (p < 0.001).

CONCLUSION

Extremes of BMI are associated with increased infectious complications following liver transplantation. Patients with lower BMI had a higher rate of overall infectious complications whereas those with a higher BMI had increased general and wound complications.

International Liver Transplantation Consensus Statement on End-stage Liver Disease Due to Nonalcoholic Steatohepatitis and Liver Transplantation

Nonalcoholic steatohepatitis (NASH)-related cirrhosis has become one of the most common indications for liver transplantation (LT), particularly in candidates older than 65 years. Typically, NASH candidates have concurrent obesity, metabolic, and cardiovascular risks, which directly impact patient evaluation and selection, waitlist morbidity and mortality, and eventually posttransplant outcomes. The purpose of these guidelines is to highlight specific features commonly observed in NASH candidates and strategies to optimize pretransplant evaluation and waitlist survival. More specifically, the working group addressed the following clinically relevant questions providing recommendations based on the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system supported by rigorous systematic reviews and consensus: (1) Is the outcome after LT similar to that of other etiologies of liver disease? (2) Is the natural history of NASH-related cirrhosis different from other etiologies of end-stage liver disease? (3) How should cardiovascular risk be assessed in the candidate for LT? Should the assessment differ from that done in other etiologies? (4) How should comorbidities (hypertension, diabetes, dyslipidemia, obesity, renal dysfunction, etc.) be treated in the candidate for LT? Should treatment and monitoring of these comorbidities differ from that applied in other etiologies? (5) What are the therapeutic strategies recommended to improve the cardiovascular and nutritional status of a NASH patient in the waiting list for LT? (6) Is there any circumstance where obesity should contraindicate LT? (7) What is the optimal time for bariatric surgery: before, during, or after LT? (8) How relevant is donor steatosis for LT in NASH patients?

The Association of obesity with vascular complications after liver transplantation

Background

Because of the growing number of obese patients undergoing liver transplantation (LT), it is important to investigate the impact of obesity on post-transplant outcomes. Vascular complications are rare, but serious causes of morbidity and mortality after LT. It is not known if pre-transplant obesity is associated with an increased incidence of post-LT vascular complications.

Methods

Medline, Embase, and Cochrane Library databases were searched in September 2017. The primary outcome was the impact of obesity on the vascular complication rate in adult LT recipients. Survival and biliary complications rates were also analyzed. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated to compare pooled data between groups with a body mass index (BMI) ≥ 30 kg/m² and < 30 kg/m².

Results

Six retrospective cohort studies with a total of 987 patients with a BMI ≥ 30 kg/m² (high BMI group) and 2911 patients with a BMI < 3 0 kg/m² (control group) were included in the analysis. All studies had Newcastle-Ottawa Scale scores ≥4. The vascular complication rates were similar between the high BMI group and control group (RR = 1.13, 95% CI: 0.87–1.47, P = 0.27), as were the patient survival, graft survival, and biliary complication rates. In subgroup analysis, there was no difference in the vascular complication rates between BMI ≥ 35 vs. BMI < 25 kg/m²; BMI 30–35 vs. BMI 18–25 kg/m²; BMI ≥ 30 vs. BMI 18–25 kg/m²; and BMI ≥ 35 vs. BMI < 35 kg/m². No difference was found in subgroup analysis when BMI was adjusted for ascites. However, recipients whose primary disease was alcoholic liver disease, those with a BMI ≥ 30 kg/m² had higher incidence of vascular complications than those with a BMI < 30 kg/m² (RR = 1.55, 95% CI: 1.07–2.25, P = 0.02) .

Conclusions

BMI does not affect incidence of vascular complications after LT. High pre-transplant BMI is not a risk factor for patient survival and biliary complications after LT.

Electronic supplementary material

The online version of this article (10.1186/s12876-019-0954-8) contains supplementary material, which is available to authorized users.

Vascular and Biliary Complications Following Deceased Donor Liver Transplantation: A Meta-analysis

OBJECTIVE

To assess biliary and vascular complications after liver transplantations (LTs) sourced from deceased donors.

METHODS

This study reviewed potentially relevant English-language articles gathered from PubMed and Medline published from 2012 to 2017. One additional study was carried out using our institution's database for articles published from 2013 to 2017. Biliary and vascular complications from adult patients receiving their first deceased-donor LT were included. This meta-analysis was performed using Review Manager version 5.2 (Cochrane Collaboration, Copenhagen, Denmark) and the study quality was evaluated using the Newcastle-Ottawa Scale.

RESULTS

Ten studies met our inclusion criteria. Heterogeneity in donation after cardiac death (DCD) and donation after brain death (DBD) recipients was observed and minimized after pooling a subgroup analysis. This latter analysis focused on biliary stricture, biliary leaks and stones, and vascular thrombosis and stenosis. Meta-analyses showed that patients receiving DCD organs have a greatly increased risk of biliary complications compared to those receiving DBD organs, particularly the following: biliary leaks and stones (odds ratio [OR] = 1.69, 95% confidence interval [CI] 1.22-2.34); and biliary stricture (OR = 1.58, 95% CI 1.21-2.06). DCD grafts tended to be but were not significantly associated with DBD regarding vascular thrombosis (OR = 1.62, 95% CI 1.05-2.50), and the risk of vascular stenosis in DCD grafts was not statistically significant (OR = 1.25, 95% CI, .70-2.25).

CONCLUSION

DCD was associated with an increased risk of biliary complications after LT, tended to indicate an increased risk of vascular thrombosis versus, and was not associated with an increased risk of vascular stenosis compared to DBD. There was no significant difference between the grafts.

Nutritional issues in patients with obesity and cirrhosis

Obesity and metabolic syndrome are considered as responsible for a condition known as the non-alcoholic fatty liver disease that goes from simple accumulation of triglycerides to hepatic inflammation and may progress to cirrhosis. Patients with obesity also have an increased risk of primary liver malignancies and increased body mass index is a predictor of decompensation of liver cirrhosis. Sarcopenic obesity confers a risk of physical impairment and disability that is significantly higher than the risk induced by each of the two conditions alone as it has been shown to be an independent risk factor for chronic liver disease in patients with obesity and a prognostic negative marker for the evolution of liver cirrhosis and the results of liver transplantation. Cirrhotic patients with obesity are at high risk for depletion of various fat-soluble, water-soluble vitamins and trace elements and should be supplemented appropriately. Diet, physical activity and protein intake should be carefully monitored in these fragile patients according to recent recommendations. Bariatric surgery is sporadically used in patients with morbid obesity and cirrhosis also in the setting of liver transplantation. The risk of sarcopenia, micronutrient status, and the recommended supplementation in patients with obesity and cirrhosis are discussed in this review. Furthermore, the indications and contraindications of bariatric surgery-induced weight loss in the cirrhotic patient with obesity are discussed.

Specific issues concerning the management of patients on the waiting list and after liver transplantation

The present document is a second contribution collecting the recommendations of an expert panel of transplant hepatologists appointed by the Italian Association for the Study of the Liver (AISF) concerning the management of certain aspects of liver transplantation, including: the issue of prompt referral; the management of difficult candidates; malnutrition; living related liver transplants; hepatocellular carcinoma; and the role of direct acting antiviral agents before and after transplantation. The statements on each topic were approved by participants at the AISF Transplant Hepatology Expert Meeting organized by the Permanent Liver Transplant Commission in Mondello on 12-13 May 2017. They are graded according to the GRADE grading system.

Morbidly Obese Patients Awaiting Liver Transplantation-Sleeve Gastrectomy: Safety and Efficacy From a Liver Transplant Unit Experience

BACKGROUND

The prevalence of obesity has increased dramatically, even in the population awaiting a liver transplantation. Despite their associated complications, we cannot consider morbid obesity any longer as an absolute contraindication to liver transplantation. Dietary approaches alone are usually completely ineffective. Bariatric surgery is the gold-standard treatment for morbid obesity and can be performed before, during, or after transplantation.

MATERIALS AND METHODS

At our Liver Transplantation Unit, a single surgeon performed a sleeve gastrectomy in 8 patients with liver cirrhosis due to nonalcoholic steatohepatitis, alcohol, or HCV. The Child score was A in 6 patients and B in the remaining 2 patients. Two of our patients had portal hypertension with mild esophageal varices. The procedure was performed laparoscopically in 7 cases (87.5%); in the other case, it was performed by open approach due to portal hypertension and according to patient preferences.

RESULTS

Patients showed no postoperative morbidity or mortality. The mean postoperative body mass index of our patients was 37.4, 33.3, and 30.3 kg/m² at 3, 6, and 12 months after surgery, respectively. The mean percentage excess weight loss of our patients was 42.9%, 62.2%, and 76.3% at 3, 6, and 12 months. Two of the patients have already undergone a successful liver transplant.

CONCLUSION

Bariatric surgery in selected patients with compensated cirrhosis and without significative portal hypertension is reasonable. There are not clear guidelines on the use of bariatric surgery in patients with cirrhosis. In our experience, the sleeve gastrectomy is safe and effective in the treatment of patients with compensated cirrhosis; in a short time, the sleeve gastrectomy can improve candidacy in morbidly obese patients awaiting transplantation.

Sleeve Gastrectomy After Liver Transplantation: Feasibility and Outcomes

BACKGROUND

Knowledge regarding the feasibility and safety of sleeve gastrectomy (SG) in obese liver transplant recipients is scarce. We report our experience of sleeve gastrectomy following liver transplantation (LT).

METHODS

All patients who had undergone LT and subsequently underwent SG at our institution were retrospectively reviewed. Surgical outcomes, liver and kidney function tests, outcomes of obesity-related comorbidities, and excess weight loss were analyzed.

RESULTS

Between May 2008 and February 2015, six consecutive patients underwent SG after LT. Three procedures (50%) were performed totally by laparoscopy, and three by upfront laparotomy for concomitant incisional hernia complex repair. Within the first 30 days, one complication occurred: early gastric fistula that required multiple endoscopic procedures and re-intervention, followed by death 19 months after SG due to multi-organ failure. Another patient had one late complication: chronic infection on a parietal mesh successfully controlled by mesh removal. Excess weight loss averaged 76% at 2 years with a median BMI of 28 (21-39) kg/m². Median follow-up was 37.2 months (range 13-101 months). Median length of stay was 9 days (range: 6-81 days).

CONCLUSIONS

SG is technically feasible after LT and resulted in weight loss without adversely affecting graft function and immunosuppression. However, morbidity and mortality are high.

Nonalcoholic fatty liver disease and liver transplantation - Where do we stand?

Nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH) is a challenging and multisystem disease that has a high socioeconomic impact. NAFLD/NASH is a main cause of macrovesicular steatosis and has multiple impacts on liver transplantation (LT), on patients on the waiting list for transplant, on post-transplant setting as well as on organ donors. Current data indicate new trends in the area of chronic liver disease. Due to the increased incidence of metabolic syndrome (MetS) and its components, NASH cirrhosis and hepatocellular carcinoma caused by NASH will soon become a major indication for LT. Furthermore, due to an increasing incidence of MetS and, consequently, NAFLD, there will be more steatotic donor livers and less high quality organs available for LT, in addition to a lack of available liver allografts. Patients who have NASH and are candidates for LT have multiple comorbidities and are unique LT candidates. Finally, we discuss long-term grafts and patient survival after LT, the recurrence of NASH and NASH appearing de novo after transplantation. In addition, we suggest topics and areas that require more research for improving the health care of this increasing patient population.

Systematic review with meta-analysis: de novo non-alcoholic fatty liver disease in liver-transplanted patients

BACKGROUND

De novo non-alcoholic fatty liver disease (NAFLD) in liver-transplanted patients for cirrhosis not due to non-alcoholic steatohepatitis (NASH) is becoming a growing phenomenon.

AIMS

We performed a systematic review and evaluated the prevalence of this event and possible associated factors.

METHODS

A literature search in medical databases (PubMed, MEDLINE/OVIDSP, Science Direct and EMBASE) was performed in March 2017. Relevant publications were identified in most important databases. We estimated the pooled prevalence of NAFLD and NASH in patients with liver transplant. The data have been expressed as proportions/percentages, and 95% confidence intervals (CI) were calculated, using the inverse variance method. Odd ratios (OR) and 95% confidence intervals (95% CI) were estimated.

RESULTS

Twelve studies were selected, enrolling 2166 subjects overall undergoing post-liver transplant biopsy. The pooled weighted prevalence of de novo NAFLD was 26% (95% CI 20%-31%). The pooled weighted prevalence of NASH was 2% (95% CI 0%-3%). The highest prevalences of de novo NAFLD were found for patients transplanted for alcoholic cirrhosis (37%) and cryptogenic cirrhosis (35%) and for patients taking tacrolimus (26%). Tacrolimus showed a risk of NAFLD similar to ciclosporin (OR = 1.02, 95% CI 0.3-3.51).

CONCLUSIONS

Patients undergoing liver transplant are more prone to experience diabetes, hypertension or dyslipidaemia, and NAFLD may be an important element in this context. In this study, we show how the prevalence of NASH tends to remain significant and similar to the general population. Moreover, this study suggests a possible association with specific transplant indications. Further studies are required to confirm these findings.

Nonalcoholic Fatty Liver Disease/Nonalcoholic Steatohepatitis in Liver Transplantation

The number of transplants caused by nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NASH) has been progressively increasing and this is expected to become the most common indication for liver transplant in the United States. Patients with NASH show many features of the metabolic syndrome and, as a result, are at higher risk for postoperative cardiovascular morbidity and mortality. Despite this, patients with NASH have long-term graft and patient survival rates comparable with other causes of chronic liver disease. Posttransplant metabolic syndrome is a common occurrence that increases the risk of steatosis in the graft liver.

Impact of body mass index in liver transplantation for nonalcoholic fatty liver disease and alcoholic liver disease

BACKGROUND

This study evaluates long-term outcomes and body mass index (BMI) following liver transplantation (LT) for non-alcoholic fatty liver disease (NAFLD) in comparison with alcoholic liver disease (ALD).

METHODS

Patient and graft survival were compared using Kaplan Meier curves and log rank test. Multivariable analysis of recipient and donor characteristics was performed as determinants of patient survival. BMI at listing was compared with BMI post-LT.

RESULTS

Patient survival at 1-, 3-, 5- and 10 years post-LT was similar in the ALD group (n = 195) compared with the NAFLD group (n = 84) (93% vs. 93%, 91% vs. 89%, 86% vs. 77%, 64% vs. 66% respectively, p = 0.21). One patient in the NAFLD group was re-transplanted and none in the ALD group therefore graft survival was also similar (p = 0.20). Multivariable analysis didn't identify any significant predictors of reduced survival. In comparison with the ALD group, BMI was significantly higher in the NAFLD group at listing (31 vs. 27, p < 0.001), 3-months post-LT (28 vs. 26, p < 0.05) and 6-months post-LT (29 vs. 27, p < 0.05) but was equivalent by 5-years post-LT (29 vs. 30, p = 0.80).

CONCLUSIONS

NAFLD patients had similar patient and graft survival post-LT compared to ALD. NAFLD patients returned to listing BMI by one-year post-LT but by 5-years post-LT there was no difference in BMI between the groups.

Outcome of liver transplantation in patients with prior bariatric surgery

Nonalcoholic fatty liver disease is becoming the leading cause of disease resulting in liver transplantation (LT). As a result of this trend, more LT candidates are presenting with prior history of bariatric surgery (BS). Over the last decade, 960 patients underwent LT at our institution; 11 (1.1%) had prior BS. The most common type of BS was Roux-en-Y gastric bypass (n = 9) with 1 sleeve gastrectomy and 1 jejunoileal bypass. A total of 9 patients underwent LT alone, and 2 underwent simultaneous liver-kidney transplantation. The most common indication for LT was nonalcoholic steatohepatitis (n = 10) with 5 having additional diagnosis of alcoholic liver disease. The 30-day reoperation rate was 36.4% (n = 4); indications were bile duct repair (n = 3) and wound repair (n = 1). In the first 6 months after LT, biliary complications were seen in 54.5% (n = 6) of the patients. Both patient and graft survival rates at 1 and 2 years were 81.8% (n = 9) and 72.7% (n = 8), respectively. A total of 8 patients (72.7%) had indications for liver biopsy after LT; significant macrovesicular steatosis was found in 2 (18.2%). In patients with a history of alcohol consumption, 2 (40.0%) relapsed after LT. Two patients (18.2%) had a history of diet-controlled diabetes before LT; 1 of these patients became insulin dependent after LT. Mean body mass index (BMI) at LT was 31.0 ± 5.7 kg/m² . Mean BMI at 1, 6, and 12 months after LT was 28.3 ± 5.8, 28.0 ± 3.2, and 31.0 ± 6.6 kg/m² , respectively. Mean preoperative albumin was 2.6 ± 0.6 mg/dL. Patients showed improvement in albumin after LT, with mean albumin of 2.7 ± 0.6 and 3.2 ± 0.5 mg/dL at 1 and 3 months, respectively. The liver profile was stable after LT, with mean aspartate aminotransferase of 32.9 ± 18.4 and 26.6 ± 19.8 IU/L and alanine aminotransferase of 28.0 ± 17.5 and 30.2 ± 17.0 IU/L at 6 and 12 months, respectively. In conclusion, outcomes of LT patients with prior BS are comparable with other transplant recipients with regards to patient and graft survival and post-LT complication rates. Liver Transplantation 23 1415-1421 2017 AASLD.

Liver Transplantation in the Obese Cirrhotic Patient

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.