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1
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Larson EL, Ellias SD, Blezek DJ, Klug J, Hartman RP, Ziller NF, Bamlet H, Mao SA, Perry DK, Nimma IR, Badurdeen D, Yang L, Leise MD, Watt KD, Diwan TS, Taner T, Rosen CD, Elli EF, Madura JA, Jadlowiec CC, Lizaola-Mayo B, Kellogg TA, Heimbach JK. Simultaneous liver transplant and sleeve gastrectomy provides durable weight loss, improves metabolic syndrome and reduces allograft steatosis. J Hepatol 2025:S0168-8278(25)00139-4. [PMID: 40089069 DOI: 10.1016/j.jhep.2025.02.030] [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: 08/14/2024] [Revised: 02/06/2025] [Accepted: 02/18/2025] [Indexed: 03/17/2025]
Abstract
BACKGROUND AND AIMS The prevalence of obesity and metabolic syndrome (MetS) is rising among liver transplant (LT) candidates, many of whom have Metabolic-Associated Steatotic Liver Disease (MASLD). Following LT, untreated obesity often causes recurrent MASLD. We treated patients with obesity with LT and concurrent sleeve gastrectomy (LTSG), aiming to determine long-term impact on obesity, MetS and recurrent MASLD after transplantation. METHODS A multicenter retrospective cohort study analyzed patients undergoing LTSG using a single clinical protocol (n=72), and patients with BMI >30 who underwent LT alone for MASLD (n=185). Follow-up duration was 4-153 (median 41) months for LTSG and 12-161 (median 75) months for LT. Outcomes included mortality, graft loss, BMI, MetS components, allograft steatosis and fibrosis. RESULTS Mortality and graft loss were not significantly different between LT and LTSG patients. Post-LTSG patients had significantly lower prevalence of diabetes for >8 years (p<0.05); hypertension decreased from 61.1% to 35.8% (p<0.01). LTSG patients, with average starting BMI of 45.5, had significant weight loss compared to baseline for >9 years (p<0.001). LT-alone patients, average starting BMI 34.0, experienced no significant change in BMI or diabetes. Development of allograft steatosis was significantly lower in LTSG vs LT patients (p=0.004). Fibrosis prevalence was reduced in LTSG vs LT patients 3-10 years postoperatively; although not statically significant, relative risk ratio was 0.46 (p=0.09). One LTSG patient had a gastric sleeve leak; one required hiatal hernia repair. Severe GERD occurred in 11.1% of LTSG patients; risk factors included pre-existing diabetes and GERD. CONCLUSIONS LTSG results in sustained weight loss, resolution of diabetes and hypertension, and reduced recurrence of steatosis and possibly fibrosis compared to LT alone. It confers no increase in mortality or graft loss.
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Affiliation(s)
- Ellen L Larson
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Samia D Ellias
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Daniel J Blezek
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Jason Klug
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Robert P Hartman
- Department of Radiology, Mayo Clinic College of Medicine Rochester MN USA
| | - Nickie Francisco Ziller
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Heather Bamlet
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Shennen A Mao
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Dana K Perry
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Induja R Nimma
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Dilhana Badurdeen
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Liu Yang
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Michael D Leise
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Kymberly D Watt
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Tayyab S Diwan
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Timucin Taner
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Charles D Rosen
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Enrique F Elli
- Department of Surgery, Division of General Surgery, Mayo Clinic Arizona
| | - James A Madura
- Department of Surgery, Division of General Surgery, Mayo Clinic Arizona
| | | | - Blanca Lizaola-Mayo
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic Arizona
| | - Todd A Kellogg
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Julie K Heimbach
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA.
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2
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Manzia TM, Sensi B, Gentileschi P, Quaranta C, Toti L, Baiocchi L, Dauri M, Angelico R, Tisone G. Safety and efficacy of simultaneous liver transplantation and sleeve gastrectomy in morbid obese patients with end-stage liver disease: The LT-SG study. Liver Transpl 2024:01445473-990000000-00500. [PMID: 39451118 DOI: 10.1097/lvt.0000000000000522] [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: 03/25/2024] [Accepted: 09/30/2024] [Indexed: 10/26/2024]
Abstract
In obese patients, metabolic dysfunction-associated steatotic liver disease is becoming a leading etiology of end-stage liver disease and HCC. Simultaneous liver transplantation and sleeve gastrectomy (LT-SG) have been proposed in the United States, but the safety and efficacy of the procedure have not been widely explored in Europe. Between January 2016 and December 2022, morbidly obese patients listed for liver transplantation at Tor Vergata University were enrolled in the LT-SG study. Primary outcomes were (1) safety expressed as 30- and 90-day overall survival and (2) major postoperative complications (Clavien-Dindo >IIIa). The secondary outcome was efficacy expressed as a 3-year %excess body mass index (BMI) loss. Eleven patients were enrolled in the study. The median BMI at transplantation was 42 (IQR 38-48). Indications of LT-SG were HCC (63.6%) and cirrhosis (36.4%). In 54% of cases, donors had high-risk characteristics (eurotransplant donor risk index >1.6). The 30- and 90-day overall survival were 63.6% and 54.5%, respectively. All deaths occurred in patients with P-SOFT >15 or in patients who had at least 3 of the following characteristics: >60 years, BMI >45, metabolic syndrome, MELD >25 or eurotransplant donor risk index >1.6. The 6 months, 1, 2, and 3 years %excess BMI loss was 73%, 60%, 50%, and 43%, respectively. LT-SG is a complex procedure that may carry excess risk in an unselected population. It should be considered only in highly selected patients. Standard donors are recommended, and prioritization of severely obese patients on the waiting list should be considered.
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Affiliation(s)
- Tommaso Maria Manzia
- Department of Surgical Science, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | - Bruno Sensi
- Department of Surgical Science, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | - Paolo Gentileschi
- Department of Surgical Science, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
- Department of Surgery, Bariatric and Metabolic Surgery Unit, Maria Cecilia Hospital, Cotignola, Italy
| | - Claudia Quaranta
- Department of Surgical Science, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | - Luca Toti
- Department of Surgical Science, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | - Leonardo Baiocchi
- Department of Medical Science, Hepatology Unit, University of Rome Tor Vergata, Rome, Italy
| | - Mario Dauri
- Department of Surgical Science, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | - Roberta Angelico
- Department of Surgical Science, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | - Giuseppe Tisone
- Department of Surgical Science, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
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3
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Onghena L, Geerts A, Berrevoet F, Pirenne J, Verbeek J, Bonaccorsi-Riani E, Dahlqvist G, Vonghia L, Detry O, Delwaide J, Lefere S, van Nieuwenhove Y. Bariatric surgery post-liver transplantation: A Belgian nationwide study. Liver Transpl 2024; 30:1050-1057. [PMID: 38551388 DOI: 10.1097/lvt.0000000000000372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/10/2024] [Indexed: 06/28/2024]
Abstract
Weight gain poses a rising concern post-liver transplantation (LT), and metabolic dysfunction-associated steatotic liver disease might impair graft health. The timing is crucial when considering bariatric surgery (BS) in a population with liver disease or transplantation. BS can be considered for post-LT weight gain, although the evidence is limited and the long-term outcome still uncertain. We conducted a national retrospective analysis in 5 Belgian transplant centers and included 25 patients with an LT followed by a bariatric procedure. A total of 187 LT patients without BS were included for comparison. Clinical, biochemical, and outcome data were retrospectively retrieved. In our nationwide cohort, 25 patients had undergone BS post-LT, at a median 3.5 years after LT. Twenty-one (84.0%) patients received a sleeve gastrectomy (SG). Patients were predominantly male (72.0%), with a lower age at time of transplantation compared with the non-BS population (54.5 vs. 60.6, p <0.001). Weight loss was significant and sustained, with a decrease in body mass index from 41.0±4.5 pre-BS to 32.6±5.8 1-3 years post-BS ( p <0.001) and 31.1±5.8 3-5 years post-BS ( p <0.001). Three pre-BS (12.0%) patients presented with recurrent and one (4.0%) de novo metabolic dysfunction-associated steatotic liver disease after LT, with 100% resolution post-BS ( p =0.016). Notable reductions were observed in alanine transaminase levels (40.5±28.5 U/L to 27.1±25.1 U/L post-BS, p =0.05) and HbA1c levels (6.9±1.6 to 6.0±1.4 post-BS, p <0.001). Three patients were re-transplanted, and eight patients died, of which five (20.0%) due to a nonhepatic malignancy and one (4.0%) due to liver failure. SG is the favored BS post-LT and has proven to be safe and feasible in a post-LT setting with favorable metabolic consequences. SG post-LT is a valid treatment for de novo and recurrent metabolic dysfunction-associated steatotic liver disease post-LT. Although we report on the largest cohort to date, there is still a need for larger cohorts to examine the effect of BS on patient and graft survival.
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Affiliation(s)
- Louis Onghena
- Department for Human Structure and Repair, Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
- Department for Human Structure and Repair, Department of General and Hepatobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Hepatology Research Unit, Ghent University, Ghent, Belgium
- Liver Research Center Ghent, Ghent University, Ghent University Hospital, Ghent, Belgium
| | - Anja Geerts
- Department of Internal Medicine and Pediatrics, Hepatology Research Unit, Ghent University, Ghent, Belgium
- Liver Research Center Ghent, Ghent University, Ghent University Hospital, Ghent, Belgium
| | - Frederik Berrevoet
- Department for Human Structure and Repair, Department of General and Hepatobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Jacques Pirenne
- Department for Abdominal Transplant Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Jef Verbeek
- Department of Gastroenterology & Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Eliano Bonaccorsi-Riani
- Abdominal Transplant Unit, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
- Pôle de Chirurgie Expérimentale et Transplantation, Institute de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Geraldine Dahlqvist
- Department of Hepatogastroenterology and Liver Transplantation, University Hospitals Saint-Luc, Brussels, Belgium
| | - Luisa Vonghia
- Division of Gastroenterology and Hepatology, University Hospital Antwerp, Antwerp, Belgium
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liege, Liege, Belgium
| | - Jean Delwaide
- Department of Hepatogastroenterology, CHU Liege, Liege, Belgium
| | - Sander Lefere
- Department of Internal Medicine and Pediatrics, Hepatology Research Unit, Ghent University, Ghent, Belgium
- Liver Research Center Ghent, Ghent University, Ghent University Hospital, Ghent, Belgium
| | - Yves van Nieuwenhove
- Department for Human Structure and Repair, Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
- Department for Human Structure and Repair, Department of General and Hepatobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
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4
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Sugawara Y, Hibi T. Recent trends and new developments in liver transplantation. Biosci Trends 2024; 18:206-211. [PMID: 38945855 DOI: 10.5582/bst.2024.01176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Liver transplantation (LT) has been an established treatment for end-staged liver disease for acute, chronic, metabolic diseases and liver cancer. Advanced surgical techniques, refined indications and contraindications for LT, improvements of donor selection, prognostic scorings system and immunosuppressive regimens have contributed to the improved outcomes of liver transplantation. The etiologies of cirrhosis have been shifting from viral hepatitis to metabolic associated fatty liver disease. New indications include peripheral or mass forming bile duct cancer, metastases from bowel cancers or neuroendocrine tumors. Resection and partial liver segments 2-3 transplantation with delayed total hepatectomy has been performed to the limited cases, which was the explored technique of auxiliary partial orthotopic LT. Minimally invasive donor hepatectomy (laparoscopic or robotic) has been increasingly done. In this review are described the recent pressing topics in LT.
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Affiliation(s)
- Yasuhiko Sugawara
- Department of Transplantation/Pediatric Surgery, Postgraduate School of Life Science, Kumamoto University, Kumamoto, Japan
| | - Taizo Hibi
- Department of Transplantation/Pediatric Surgery, Postgraduate School of Life Science, Kumamoto University, Kumamoto, Japan
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5
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Bhalla S, Mcquillen B, Cay E, Reau N. Preoperative risk evaluation and optimization for patients with liver disease. Gastroenterol Rep (Oxf) 2024; 12:goae071. [PMID: 38966126 PMCID: PMC11222301 DOI: 10.1093/gastro/goae071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/24/2024] [Accepted: 06/14/2024] [Indexed: 07/06/2024] Open
Abstract
The prevalence of liver disease is rising and more patients with liver disease are considered for surgery each year. Liver disease poses many potential complications to surgery; therefore, assessing perioperative risk and optimizing a patient's liver health is necessary to decrease perioperative risk. Multiple scoring tools exist to help quantify perioperative risk and can be used in combination to best educate patients prior to surgery. In this review, we go over the various scoring tools and provide a guide for clinicians to best assess and optimize perioperative risk based on the etiology of liver disease.
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Affiliation(s)
- Sameer Bhalla
- Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | | | - Edward Cay
- Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Nancy Reau
- Internal Medicine, Division of Digestive Diseases, Section of Hepatology, Rush University Medical Center, Chicago, IL, USA
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6
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Vogel AS, Roediger R, von Ahrens D, Fortune BE, Schwartz JM, Frager S, Chacko KR, Tow CY. The Impact of Metabolic Health and Obesity on Liver Transplant Candidates and Recipients. Life (Basel) 2024; 14:685. [PMID: 38929668 PMCID: PMC11204519 DOI: 10.3390/life14060685] [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: 03/18/2024] [Revised: 04/12/2024] [Accepted: 05/21/2024] [Indexed: 06/28/2024] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | - Clara Y. Tow
- Correspondence: ; Tel.: +1-888-795-4837; Fax: +1-602-563-8224
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7
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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: 1.0] [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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8
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Fearon N, Pournaras DJ. Effect of Metabolic Surgery on Non-Alcoholic Steatohepatitis. OBESITY, BARIATRIC AND METABOLIC SURGERY 2023:1005-1011. [DOI: 10.1007/978-3-030-60596-4_107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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9
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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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10
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Kheirvari M, Goudarzi H, Hemmatizadeh M, Anbara T. Bariatric surgery outcomes following organ transplantation: A review study. World J Exp Med 2022; 12:92-99. [PMID: 36196436 PMCID: PMC9526996 DOI: 10.5493/wjem.v12.i5.92] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/29/2022] [Accepted: 08/16/2022] [Indexed: 02/05/2023] Open
Abstract
Weight gain is a frequent postoperative complication following a solid organ transplant which can be solved by bariatric surgery. The outcomes of bariatric surgery among patients with an organ transplant history are always a challengeable subject for surgeons and surgery candidates. In this review article, we aim to investigate the existence literature about the rates of morbidity and mortality, frequent complications in terms of graft function, remission in diabetes, hypertension, pulmonary and cardiovascular disorders, hepatic and renal functions, and immunosuppressive stability, as well as the safety of bariatric surgery among patients.
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Affiliation(s)
- Milad Kheirvari
- Microbiology Research Center, Pasteur Institute of Iran, Tehran 14758-94433, Iran
| | | | | | - Taha Anbara
- Department of Surgery, Erfan Niayesh Hospital, Tehran 14758-94433, Iran
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11
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Clinical and Economic Impact of Bariatric Surgery Post Liver Transplantation: a Nationwide, Population-Based Retrospective Study. Obes Surg 2022; 32:2548-2555. [PMID: 35668279 DOI: 10.1007/s11695-022-06120-x] [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: 03/06/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Prevalence of obesity in liver transplant recipients is increasing with the overall epidemic augmentation of severe obesity, the effects of immunosuppressive drugs, and lifestyle changes which are responsible for de novo obesity development or aggravation of pre-existing obesity. The aim of this study is to analyze the differences in overall mortality, re-hospitalization rate, and hospitalization-related costs between patients undergoing bariatric surgery after liver transplantation and patients undergoing bariatric surgery alone. MATERIALS AND METHODS Twenty patients with history of liver transplantation who underwent bariatric surgery were analyzed from the French National Hospital Discharge Database. Overall mortality, re-hospitalization rate, length of stay for bariatric procedure, and the costs of bariatric surgery hospitalization and eventual re-hospitalizations were compared to a group of 360,846 patients who underwent bariatric surgery alone from 2010 to 2019. Furthermore, a 1:1 propensity score matching analysis was conducted. RESULTS Patients with a history of liver transplantation showed an increased risk of overall mortality (HR: 7.66, p = 0.0047) and increased costs of hospitalization for bariatric surgery (8250 ± 4822€ vs 5583 ± 3398€, p = 0.0005). No differences in length of stay, re-hospitalization rate, and costs were found after multivariate analysis. After propensity score matching analysis, a significant increased cost of hospitalization (8250 ± 4822€ vs 6086 ± 1813€, p = 0.0195) still resulted for the liver transplantation group. CONCLUSION Bariatric surgery represents the best treatment for obesity and its related associated medical problems. Our study highlights an increased risk of overall all-cause mortality and increased costs of hospitalization in this population compared to patients undergoing bariatric surgery alone.
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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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13
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Tan EK, Heimbach JK. Obesity and Liver Transplantation. TEXTBOOK OF LIVER TRANSPLANTATION 2022:73-84. [DOI: 10.1007/978-3-030-82930-8_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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14
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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: 0.7] [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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15
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Han MAT, Olivo R, Choi CJ, Pyrsopoulos N. De novo and recurrence of metabolic dysfunction-associated fatty liver disease after liver transplantation. World J Hepatol 2021; 13:1991-2004. [PMID: 35070003 PMCID: PMC8727208 DOI: 10.4254/wjh.v13.i12.1991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 07/27/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
Metabolic dysfunction-associated fatty liver disease (MAFLD) is a new acronym adopted from the consensus of international experts. Given the increasing prevalence of MAFLD in pre-transplant settings, de novo and recurrent graft steatosis/MAFLD are common in post-transplant settings. The impact of graft steatosis on long-term outcomes is unclear. The current knowledge of incidence rate, risk factors, diagnosis, long-term outcomes, and management of graft steatosis (both de novo and recurrent) is discussed in this review.
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Affiliation(s)
- Ma Ai Thanda Han
- Department of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
| | - Raquel Olivo
- Department of Gastroenterology and Hepatology, Rutgers University, New Jersey Medical School, Newark, NJ 07103, United States
| | - Catherine J Choi
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07101, United States
| | - Nikolaos Pyrsopoulos
- Department of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
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Kermansaravi M, Davarpanah Jazi AH, Talebian P, Rokhgireh S, Kabir A, Pazouki A. Bariatric surgery in transplant recipients: A narrative review. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2021; 26:44. [PMID: 34484376 PMCID: PMC8384002 DOI: 10.4103/jrms.jrms_631_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/20/2020] [Accepted: 02/09/2021] [Indexed: 11/11/2022]
Abstract
Morbidity and mortality rates are increased due to obesity after organ transplantation; in this regards, bariatric surgery (BS) is believed to be an effective treatment for posttransplant obese patients. Nevertheless, some studies are doubtful in terms of the effectiveness of BS, the most suitable bariatric procedure, and management of immunosuppressant drugs in some kinds of organ transplants. We evaluated nonsurgical therapies, weight reduction, adjustment of immunosuppressants, comorbidities, and the recommended surgical procedures for posttransplant BS for different types of organ transplantations.
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Affiliation(s)
- Mohammad Kermansaravi
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.,Center of Excellence of European Branch of International Federation for Surgery of Obesity, Hazrat-e-Rasool Hospital, Tehran, Iran
| | - Amir Hossein Davarpanah Jazi
- Department of Surgery, Minimally Invasive Surgery Research Center, Al Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran.,Department of General Surgery, Shariati Hospital, Isfahan, Iran
| | - Pedram Talebian
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Samaneh Rokhgireh
- Endometriosis Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Kabir
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Abdolreza Pazouki
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.,Center of Excellence of European Branch of International Federation for Surgery of Obesity, Hazrat-e-Rasool Hospital, Tehran, Iran
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17
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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: 28] [Impact Index Per Article: 7.0] [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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18
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Nilles KM, Levitsky J. Current and Evolving Indications for Simultaneous Liver Kidney Transplantation. Semin Liver Dis 2021; 41:308-320. [PMID: 34130337 DOI: 10.1055/s-0041-1729969] [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] [Indexed: 02/01/2023]
Abstract
This review will discuss the etiologies of kidney disease in liver transplant candidates, provide a historical background of the prior evolution of simultaneous liver-kidney (SLK) transplant indications, discuss the current indications for SLK including Organ Procurement and Transplantation Network policies and Model for End Stage Liver Disease exception points, as well as provide an overview of the safety net kidney transplant policy. Finally, the authors explore unanswered questions and future research needed in SLK transplantation.
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Affiliation(s)
- Kathy M Nilles
- Division of Gastroenterology and Hepatology, Department of Medicine, MedStar Georgetown Transplant Institute, Georgetown University School of Medicine, Washington, District of Columbia
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Department of Medicine, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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19
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de Barros F, Cardoso Faleiro Uba PH. Liver transplantation and bariatric surgery: a new surgical reality: a systematic review of the best time for bariatric surgery. Updates Surg 2021; 73:1615-1622. [PMID: 34118015 DOI: 10.1007/s13304-021-01106-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/26/2021] [Indexed: 12/11/2022]
Abstract
Non-alcoholic fatty liver disease has increased in parallel with the obesity. This situation represents a new reality for patients with an indication for liver transplant (LT) and bariatric surgery (BS). We undertook a systematic review of BS and LT using the terms 'liver transplant', 'obesity' and 'bariatric surgery'. The variables analyzed were number of patients, technique and timing of BS, surgical complications, follow-up and mortality. A total of 190 papers were identified and, 28 articles were discussed (6 papers with BS before a LT, 6 with both procedures simultaneously and 16 studies with BS after a LT). In the last 7 years, 22 of the 28 papers (78.6%) were published on this subject. A total of 144 patients had both procedures: 27 (18.8%) before, 42 (29.1%) simultaneously and 75 (52.1%) after. Sleeve gastrectomy was the most performed BS (121 cases-84%) followed by a Roux-en-Y gastric bypass (20 cases-13.9%). The number of publications has increased substantially in recent years. The majority papers of BS after LT could be explained because of commodity of the flow of these patients. The best moment to perform BS in these patients has yet to be established.
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Affiliation(s)
- Fernando de Barros
- Professor of the Department of General Surgery, Fluminense Federal University, Niterói, RJ, Brazil. .,, Niteroi, Brazil, Rio de Janeiro.
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20
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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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21
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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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22
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Singhal V, Dhampalwar S, Saigal S, Choudhary N, Saraf N, Chaudhary A, Soin A. Successful Outcome of Bariatric Surgery in Living Donor Liver Transplant Recipients With Multidisciplinary Approach: A Preliminary Experience. J Clin Exp Hepatol 2021; 11:144-148. [PMID: 33679051 PMCID: PMC7897857 DOI: 10.1016/j.jceh.2020.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Liver transplant recipients may develop weight gain, metabolic syndrome, and subsequent nonalcoholic steatohepatitis of the transplanted liver which impairs graft function. Bariatric surgery is an effective modality for management of morbid obesity and metabolic syndrome. Our aim is to review the role of bariatric surgery in such high-risk posttransplant patients not responding to medical management and highlight the important considerations. METHODOLOGY We review the management of two cases with posttransplant metabolic syndrome not responding to medical management and discuss the literature available on bariatric surgery in organ transplant patients. RESULTS The first patient was a 51-year-old man who underwent living donor liver transplantation 3 years prior, and follow-up ultrasound and fibroscan was suggestive of steatohepatitis of the graft. After liver transplantation, he had gained 30 Kg weight and was on oral hypoglycemic agents with HbA1c of 8%. The second patient was a 65-year-old man, who gained 30 Kg weight with risk of graft impairment 4 years after of combined liver and kidney transplant. Both patients were evaluated thoroughly preoperatively for risk stratification including an upper gastro-intestinal (GI) endoscopy. The immunosuppression was reduced and monitored closely perioperatively. Both patients underwent laparoscopic sleeve gastrectomy (LSG) and were discharged on postoperative day 3. The first patient was evaluated a year after surgery with body mass index (BMI) reduction from 42 to 34 and second at 2 months with BMI reduction from 38 to 33; both patients were free of diabetes and had stable graft functions. CONCLUSION Bariatric surgery in liver transplant recipients has significant challenges with higher complication rates as patients are on immunosuppression which often impairs wound healing. LSG is safe and effective in such patients which often requires good coordination between the bariatric team and liver transplant team.
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Affiliation(s)
- Vikas Singhal
- Department of GI Surgery, GI Oncology & Bariatric Surgery, Medanta- The Medicity, Gurugram, India
| | - Swapnil Dhampalwar
- Institute of Liver Transplantation & Regenerative Medicine, Medanta- The Medicity, Gurugram, India
| | - Sanjiv Saigal
- Institute of Liver Transplantation & Regenerative Medicine, Medanta- The Medicity, Gurugram, India,Address for correspondence: Sanjiv Saigal, Director – Transplant Hepatology, Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Sector 38, Gurgaon, Delhi (NCR), India.
| | - Narendra Choudhary
- Institute of Liver Transplantation & Regenerative Medicine, Medanta- The Medicity, Gurugram, India
| | - Neeraj Saraf
- Institute of Liver Transplantation & Regenerative Medicine, Medanta- The Medicity, Gurugram, India
| | - Adarsh Chaudhary
- Department of GI Surgery, GI Oncology & Bariatric Surgery, Medanta- The Medicity, Gurugram, India
| | - Arvinder Soin
- Institute of Liver Transplantation & Regenerative Medicine, Medanta- The Medicity, Gurugram, India
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23
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Lopez-Lopez V, Ruiz-Manzanera JJ, Eshmuminov D, Lehmann K, Schneider M, von der Groeben M, de Angulo DR, Gajownik U, Pons JA, Sánchez-Bueno F, Robles-Campos R, Ramírez-Romero P. Are We Ready for Bariatric Surgery in a Liver Transplant Program? A Meta-Analysis. Obes Surg 2020; 31:1214-1222. [PMID: 33225408 DOI: 10.1007/s11695-020-05118-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/30/2020] [Accepted: 11/10/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Obesity-related non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are two main causes of end-stage liver disease requiring a liver transplantation. Studies exploring bariatric surgery in the liver transplantation setting have increased in recent years; however, a systematic analysis of the topic is lacking to date. This meta-analysis was conducted to explore the perioperative and long-term outcomes of bariatric surgery in obese patients undergoing liver transplantation. METHODS Electronic databases were systematically searched for studies reporting bariatric surgery in patients undergoing liver transplantation. The primary outcomes were postoperative complications and mortality. We also extracted data about excess weight loss, body mass index, and improvement of comorbidities after bariatric surgery. RESULTS A total of 96 patients from 8 articles were included. Bariatric surgery-related morbidity and mortality rates were 37% (95% CI 0.27-0.47) and 0.6% (95% CI 0.02-0.13), respectively. Body mass index at 24 months was 31.02 (95% CI 25.96-36.09) with a percentage excess weight loss at 12 and 24 months of 44.08 (95% CI 27.90-60.26) and 49.2 (95% CI 31.89-66.66), respectively. After bariatric surgery, rates of improvement of arterial hypertension and diabetes mellitus were 61% (95% CI 0.45-0.75) and 45% (95% CI 0.25-0.66), respectively. In most patients, bariatric surgery was performed after liver transplant and the most frequent technique was sleeve gastrectomy. CONCLUSIONS Bariatric surgery can be performed safely in the setting of liver transplantation resulting in improvement of obesity-related comorbidities. The optimal timing and technique require further studies.
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Affiliation(s)
- Víctor Lopez-Lopez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain.
| | - Juan José Ruiz-Manzanera
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland
| | - Kuno Lehmann
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland
| | - Marcel Schneider
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland
| | | | - David Ruiz de Angulo
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Ursula Gajownik
- Department of Hepatology, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Jose Antonio Pons
- Department of Hepatology, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Francisco Sánchez-Bueno
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Ricardo Robles-Campos
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Pablo Ramírez-Romero
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
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24
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Tan EK, Taner T, Heimbach JK, Gores GJ, Rosen CB. Liver Transplantation for Peri-hilar Cholangiocarcinoma. J Gastrointest Surg 2020; 24:2679-2685. [PMID: 32671802 DOI: 10.1007/s11605-020-04721-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/28/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Liver transplantation for peri-hilar cholangiocarcinoma (pCCA) following neoadjuvant chemoradiation achieves excellent long-term survival in carefully selected patients with early-stage unresectable pCCA and patients with primary sclerosing cholangitis (PSC)-associated pCCA. Strict adherence to selection criteria, aggressive neoadjuvant therapy, operative staging prior to transplantation, and several technical accommodations during the transplant operation are necessary for success. In this review, we provide a contemporaneous overview of liver transplantation for pCCA, including selection criteria, neoadjuvant therapy, operative staging, and technical aspects of liver transplantation unique to patients with pCCA and an irradiated operative field. We also discuss several evolving trends intended to improve patient outcomes. RESULTS AND CONCLUSION Intention-to-treat and patient outcomes after liver transplantation for PSC-associated pCCA are superior to de novo pCCA. Outcomes between living donor liver transplantation (LDLT) and deceased donor liver transplantation are similar for patients with PSC-associated pCCA. However, LDLT for de novo pCCA shows a trend toward more disease recurrence and worse patient survival. A period of waiting time before transplant may be beneficial in selecting for patients with superior outcomes after transplant. Compared with liver transplantation for other indications, there is an increased risk of late arterial and portal vein complications, presumably due to the radiation. However, with close follow-up and prompt intervention for vascular complications, graft loss can be avoided. Neoadjuvant therapy and liver transplantation can achieve results comparable with resection for patients with early-stage unresectable pCCA and is the treatment of choice for patients with pCCA arising in the setting of PSC.
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Affiliation(s)
- Ek Khoon Tan
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN, USA
| | - Timucin Taner
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN, USA.,Department of Immunology, Mayo Clinic, Rochester, MN, USA
| | - Julie K Heimbach
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN, USA
| | - Gregory J Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Charles B Rosen
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN, USA.
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25
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Jorgenson MR, Gracon AS, Hanlon B, Leverson GE, Parajuli S, Smith JA, Al‐Adra DP. Pre‐transplant bariatric surgery is associated with increased fungal infection after liver transplant. Transpl Infect Dis 2020; 23:e13484. [PMID: 33012079 DOI: 10.1111/tid.13484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/18/2020] [Accepted: 09/26/2020] [Indexed: 01/11/2023]
Affiliation(s)
| | - Adam S. Gracon
- Department of Surgery University of Wisconsin‐Madison School of Medicine and Public HealthUniversity of Wisconsin Hospital and Clinics Madison WI USA
| | - Bret Hanlon
- Department of Surgery University of Wisconsin‐Madison School of Medicine and Public HealthUniversity of Wisconsin Hospital and Clinics Madison WI USA
| | - Glen E. Leverson
- Department of Surgery University of Wisconsin‐Madison School of Medicine and Public HealthUniversity of Wisconsin Hospital and Clinics Madison WI USA
| | - Sandesh Parajuli
- Department of Medicine University of Wisconsin‐Madison School of Medicine and Public HealthUniversity of Wisconsin Hospital and Clinics Madison WI USA
| | - Jeannina A. Smith
- Department of Medicine University of Wisconsin‐Madison School of Medicine and Public HealthUniversity of Wisconsin Hospital and Clinics Madison WI USA
| | - David P. Al‐Adra
- Department of Surgery University of Wisconsin‐Madison School of Medicine and Public HealthUniversity of Wisconsin Hospital and Clinics Madison WI USA
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26
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Sharma H, Banerjee A, Lominchar PL, Nair A, Chasiotis D, Intzepogazoglou D, Osman M, Bogatu D, Boumpoureka C, Shahdoost-Rad A, Unnikrishan R, Skaro A. Bariatric surgery and transplantation: A bridge not so far. Am J Transplant 2020; 20:2621-2622. [PMID: 32337842 DOI: 10.1111/ajt.15946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Hemant Sharma
- Department of Multi-Organ Transplantation, University of Western Ontario, London, Canada.,Liver & HPB Surgery Unit, Kings College Hospital, London, UK
| | - Amlan Banerjee
- Department of Bariatric Surgery, York Teaching Hospital, York, UK
| | - Pablo L Lominchar
- General Surgery Department, Liver Transplant Unit, Hospital General Universitario Gregorio Maranon, Madrid, Spain
| | - Ashitha Nair
- Liver & HPB Surgery Unit, Kings College Hospital, London, UK
| | | | | | - Mohamed Osman
- Liver & HPB Surgery Unit, Kings College Hospital, London, UK
| | - Diana Bogatu
- Liver & HPB Surgery Unit, Kings College Hospital, London, UK
| | | | | | - R Unnikrishan
- Department of Surgery, Lourdes Hospital, Cochin, India
| | - Anton Skaro
- Department of Multi-Organ Transplantation, University of Western Ontario, London, Canada
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27
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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: 3.2] [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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28
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Kaufmann B, Reca A, Wang B, Friess H, Feldstein AE, Hartmann D. Mechanisms of nonalcoholic fatty liver disease and implications for surgery. Langenbecks Arch Surg 2020; 406:1-17. [PMID: 32833053 PMCID: PMC7870612 DOI: 10.1007/s00423-020-01965-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 08/09/2020] [Indexed: 02/08/2023]
Abstract
Background Nonalcoholic fatty liver disease (NAFLD) has become the most common form of chronic liver disease in both adults and children worldwide. Understanding the pathogenic mechanisms behind NAFLD provides the basis for identifying risk factors, such as metabolic syndrome, pancreatoduodenectomy, and host genetics, that lead to the onset and progression of the disease. The progression from steatosis to more severe forms, such as steatohepatitis, fibrosis, and cirrhosis, leads to an increased number of liver and non-liver complications. Purpose NAFLD-associated end-stage liver disease (ESLD) and hepatocellular carcinoma (HCC) often require surgery as the only curative treatment. In particular, the presence of NAFLD together with the coexisting metabolic comorbidities that usually occur in these patients requires careful preoperative diagnosis and peri-/postoperative management. Bariatric surgery, liver resection, and liver transplantation (LT) have shown favorable results for weight loss, HCC, and ESLD in patients with NAFLD. The LT demand and the increasing spread of NAFLD in the donor pool reinforce the already existing lack of donor organs. Conclusion In this review, we will discuss the diverse mechanisms underlying NAFLD, its implications for surgery, and the challenges for patient management.
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Affiliation(s)
- Benedikt Kaufmann
- Department of Pediatric Gastroenterology, University of California San Diego (UCSD), La Jolla, CA, USA.,Department of Surgery, TUM School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675, Munich, Germany
| | - Agustina Reca
- Department of Pediatric Gastroenterology, University of California San Diego (UCSD), La Jolla, CA, USA
| | - Baocai Wang
- Department of Surgery, TUM School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675, Munich, Germany
| | - Helmut Friess
- Department of Surgery, TUM School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675, Munich, Germany
| | - Ariel E Feldstein
- Department of Pediatric Gastroenterology, University of California San Diego (UCSD), La Jolla, CA, USA
| | - Daniel Hartmann
- Department of Surgery, TUM School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675, Munich, Germany.
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29
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Diwan TS, Lee TC, Nagai S, Benedetti E, Posselt A, Bumgardner G, Noria S, Whitson BA, Ratner L, Mason D, Friedman J, Woodside KJ, Heimbach J. Obesity, transplantation, and bariatric surgery: An evolving solution for a growing epidemic. Am J Transplant 2020; 20:2143-2155. [PMID: 31965711 DOI: 10.1111/ajt.15784] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 01/05/2020] [Accepted: 01/08/2020] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Andrew Posselt
- University of California at San Francisco, San Francisco, California, USA
| | | | | | | | - Lloyd Ratner
- Columbia University Medical Center, New York, New York, USA
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30
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Becchetti C, Dirchwolf M, Banz V, Dufour JF. Medical management of metabolic and cardiovascular complications after liver transplantation. World J Gastroenterol 2020; 26:2138-2154. [PMID: 32476781 PMCID: PMC7235200 DOI: 10.3748/wjg.v26.i18.2138] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/26/2020] [Accepted: 04/28/2020] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation represents the only curative option for patients with end-stage liver disease, fulminant hepatitis and advanced hepatocellular carcinoma. Even though major advances in transplantation in the last decades have achieved excellent survival rates in the early post-transplantation period, long-term survival is hampered by the lack of improvement in survival in the late post transplantation period (over 5 years after transplantation). The main etiologies for late mortality are malignancies and cardiovascular complications. The latter are increasingly prevalent in liver transplant recipients due to the development or worsening of metabolic syndrome and all its components (arterial hypertension, dyslipidemia, obesity, renal injury, etc.). These comorbidities result from a combination of pre-liver transplant features, immunosuppressive agent side-effects, changes in metabolism and hemodynamics after liver transplantation and the adoption of a sedentary lifestyle. In this review we describe the most prevalent metabolic and cardiovascular complications present after liver transplantation, as well as proposing management strategies.
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Affiliation(s)
- Chiara Becchetti
- Hepatology, Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Bern CH-3008, Switzerland
- Department of Biomedical Research, University of Bern, Bern CH-3008, Switzerland
| | - Melisa Dirchwolf
- Hepatology, Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Bern CH-3008, Switzerland
- Department of Biomedical Research, University of Bern, Bern CH-3008, Switzerland
- Hepatology, Hepatobiliary Surgery and Liver Transplant Unit, Hospital Privado de Rosario, Rosario S2000GAP, Santa Fe, Argentina
| | - Vanessa Banz
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Bern CH-3008, Switzerland
- Department of Clinical Research, University of Bern, Bern CH-3008, Switzerland
| | - Jean-François Dufour
- Hepatology, Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Bern CH-3008, Switzerland
- Department of Biomedical Research, University of Bern, Bern CH-3008, Switzerland
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31
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Risk factors for the metabolic syndrome components of hypertension, diabetes mellitus, and dyslipidemia after living donor liver transplantation. HPB (Oxford) 2020; 22:511-520. [PMID: 31561946 DOI: 10.1016/j.hpb.2019.08.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 08/11/2019] [Accepted: 08/12/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Metabolic syndrome (MS) is the most common long-term complication after liver transplantation, and it has been increasing in incidence. The aim of this study was to clarify the risk factors for each MS component -hypertension, diabetes mellitus, and dyslipidemia-after living-donor liver transplantation (LDLT), including characteristics of living-donors. METHODS Data related to clinicopathological parameters including MS components in 461 consecutive patients who underwent LDLT were analyzed retrospectively. RESULTS Prevalence of all MS components (hypertension, diabetes mellitus, and dyslipidemia) increased from 9.3%, 16.5%, and 7.2% before LDLT to 44.9%, 45.3%, and 50.8% after LDLT, respectively. By multivariate logistic regression analysis, the three factors, cyclosporine use (OR 2.086, P = 0.001), recipient age (OR 1.036, P = 0.001), and BMI (OR 1.072, P = 0.026) were independent predictors for post-LDLT hypertension. Next, the three factors, male recipient (OR 2.471, P < 0.001), recipient age (OR 1.039, P = 0.002), and donor BMI (OR 1.124, P = 0.012) were independent for post-LDLT diabetes mellitus. The four factors, cyclosporine use (OR 2.015, P = 0.001), prolonged prednisolone use (OR 1.928, P = 0.002), recipient age (OR 1.019, P = 0.037), and GRWR (OR 0.316, P = 0.037) were independent for post-LDLT dyslipidemia as well. CONCLUSIONS Not only recipient-related factors but also donor-related factors were independently associated with each targeted post-LDLT MS component.
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32
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Understanding and managing cardiovascular outcomes in liver transplant recipients. Curr Opin Organ Transplant 2020; 24:148-155. [PMID: 30676402 DOI: 10.1097/mot.0000000000000614] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Cardiovascular disease (CVD) is a common cause of mortality after liver transplantation. The transplant community is focused on improving long-term survival. Understanding the prevalence of CVD in liver transplant recipients, precipitating factors as well as prevention and management strategies is essential to achieving this goal. RECENT FINDINGS CVD is the leading cause of death within the first year after transplant. Arrhythmia and heart failure are the most often cardiovascular morbidities in the first year after transplant which could be related to pretransplant diastolic dysfunction. Pretransplant diastolic dysfunction is reflective of presence of cirrhotic cardiomyopathy which is not as harmless as it was thought. Multiple cardiovascular risk prediction models have become available to aid management in liver transplant recipients. SUMMARY A comprehensive prevention and treatment strategy is critical to minimize cardiovascular morbidity and mortality after liver transplant. Weight management and metabolic syndrome control are cornerstones to any prevention and management strategy. Bariatric surgery is an underutilized tool in liver transplant recipients. Awareness of 'metabolic-friendly' immunosuppressive regimens should be sought. Strict adherence to the cardiology and endocrine society guidelines with regard to managing metabolic derangements post liver transplantation is instrumental for CVD prevention until transplant specific recommendations can be made.
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33
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Angeles PC, Robertsen I, Seeberg LT, Krogstad V, Sandbu R, Åsberg A, Hjelmesaeth J. Reply to letter: "What about drug bioavailability in patients who had bariatric surgery and dependent on immunosuppressives?". Obes Rev 2020; 21:e12954. [PMID: 31746506 DOI: 10.1111/obr.12954] [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: 09/08/2019] [Accepted: 09/09/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Philip Carlo Angeles
- Morbid Obesity Centre, Department of Medicine, Vestfold Hospital Trust, Tønsberg, Norway.,Department of Surgery, Vestfold Hospital Trust, Tønsberg, Norway.,Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ida Robertsen
- Section of Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | | | | | - Rune Sandbu
- Department of Surgery, Vestfold Hospital Trust, Tønsberg, Norway
| | - Anders Åsberg
- Section of Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway.,Department of Transplantation, Oslo University Hospital, Oslo, Norway
| | - Jøran Hjelmesaeth
- Morbid Obesity Centre, Department of Medicine, Vestfold Hospital Trust, Tønsberg, Norway.,Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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34
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Morris MC, Jung AD, Kim Y, Lee TC, Kaiser TE, Thompson JR, Bari K, Shah SA, Cohen RM, Schauer DP, Smith EP, Diwan TS. Delayed Sleeve Gastrectomy Following Liver Transplantation: A 5-Year Experience. Liver Transpl 2019; 25:1673-1681. [PMID: 31518478 DOI: 10.1002/lt.25637] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/02/2019] [Indexed: 12/31/2022]
Abstract
Obesity has become an epidemic in the United States over the past decade, and recent studies have shown this trend in the liver transplantation (LT) population. These patients may be candidates for laparoscopic sleeve gastrectomy (LSG) to promote significant and sustained weight loss to prevent recurrence of nonalcoholic steatohepatitis. However, safety remains a concern, and efficacy in this setting is uncertain. A single-institution database from 2014 to 2018 was queried for patients undergoing LSG following LT. The selection criteria for surgery were consistent with National Institutes of Health guidelines, and patients were at least 6 months after LT. A total of 15 patients (median age, 59.0 years; Caucasian, 86.7%; and female, 60%) underwent LSG following LT. Median time from LT to LSG was 2.2 years with a median follow-up period of 2.6 years. The median hospital length of stay (LOS) was 2 days after LSG. Mortality and rate of liver allograft rejection was 0, and there was 1 postoperative complication (a surgical site infection). Following LSG, body mass index (BMI) decreased from 42.7 to 35.9 kg/m2 (P < 0.01), and in 12 patients with at least 1 year of follow-up, the total body weight loss was 20.6%. Following LSG in patients with diabetes, the median daily insulin requirements decreased from 98 (49-118) to 0 (0-29) units/day (P = 0.02), and 60% discontinued insulin. Post-LT patients had a similar decrease in BMI and reduction in comorbidities at 1 year compared with a matched non-LT patient cohort. In the largest patient series to date, we show that LSG following LT is safe, effective, and does not increase the incidence of liver allograft rejection. Larger longer-term studies are needed to confirm underlying metabolic changes following LSG.
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Affiliation(s)
- Mackenzie C Morris
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Andrew D Jung
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Young Kim
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Tiffany C Lee
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Tiffany E Kaiser
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Jonathan R Thompson
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Khurram Bari
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Robert M Cohen
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Daniel P Schauer
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Eric P Smith
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Tayyab S Diwan
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
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35
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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: 4.2] [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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36
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Germani G, Laryea M, Rubbia-Brandt L, Egawa H, Burra P, OʼGrady J, Watt KD. Management of Recurrent and De Novo NAFLD/NASH After Liver Transplantation. Transplantation 2019; 103:57-67. [PMID: 30335694 DOI: 10.1097/tp.0000000000002485] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Nonalcoholic steatohepatitis (NASH) is a growing indication for liver transplant whether the primary or secondary cause of liver disease, and it is expected to be the leading indication in the years to come. Nonalcoholic steatohepatitis recurs after transplant but the impact of the recurrence on allograft and patient outcomes is unclear. A group of multidisciplinary transplant practice providers convened at the International Liver Transplantation Society NASH consensus conference with the purpose of determining the current knowledge and future directions for understanding the recurrence rates, risk and management of NASH in the transplant allograft. Specific questions relating to posttransplant NASH were proposed and reviewed in detail with recommendations on future actions to fill the knowledge gaps.
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Affiliation(s)
- Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Marie Laryea
- University of Rochester Medical Center, Rochester NY
| | | | - Hiroto Egawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - John OʼGrady
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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37
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Northup PG, Friedman LS, Kamath PS. AGA Clinical Practice Update on Surgical Risk Assessment and Perioperative Management in Cirrhosis: Expert Review. Clin Gastroenterol Hepatol 2019; 17:595-606. [PMID: 30273751 DOI: 10.1016/j.cgh.2018.09.043] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/18/2018] [Accepted: 09/24/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Patrick G Northup
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
| | - Lawrence S Friedman
- Departments of Medicine, Harvard Medical School, Tufts University School of Medicine, Newton-Wellesley Hospital, Rochester, Minnesota; Massachusetts General Hospital, Boston, Massachusetts, Rochester, Minnesota
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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38
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International Liver Transplantation Society Consensus Statement on Immunosuppression in Liver Transplant Recipients. Transplantation 2019; 102:727-743. [PMID: 29485508 DOI: 10.1097/tp.0000000000002147] [Citation(s) in RCA: 178] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Effective immunosupression management is central to achieving optimal outcomes in liver transplant recipients. Current immunosuppression regimens and agents are highly effective in minimizing graft loss due to acute and chronic rejection but can also produce a substantial array of toxicities. The utilization of immunosuppression varies widely, contributing to the wide disparities in posttransplant outcomes reported between transplant centers. The International Liver Transplantation Society (ILTS) convened a consensus conference, comprised of a global panel of expert hepatologists, transplant surgeons, nephrologists, and pharmacologists to review the literature and experience pertaining to immunosuppression management to develop guidelines on key aspects of immunosuppression. The consensus findings and recommendations of the ILTS Consensus guidelines on immunosuppression in liver transplant recipients are presented in this article.
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39
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Choudhary NS, Saigal S. Preventive Strategies for Nonalcoholic Fatty Liver Disease After Liver Transplantation. J Clin Exp Hepatol 2019; 9:619-624. [PMID: 31695252 PMCID: PMC6823688 DOI: 10.1016/j.jceh.2019.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/22/2019] [Indexed: 12/12/2022] Open
Abstract
Post-transplant nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH) is common and can be recurrent or de novo. The available data suggest that progression of fibrosis is accelerated in these patients compared to NASH in general population. The long-term data suggest more risk of metabolic syndrome and associated metabolic comorbidities and cardiovascular disease in these patients. The current review focuses on prevalence and prevention/treatment of post-transplant NAFLD or NASH.
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Affiliation(s)
| | - Sanjiv Saigal
- Address for correspondence: Sanjiv Saigal, Director, Hepatology & Liver Transplant, Medanta Institute of Digestive & Hepatobiliary Sciences &Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, PIN 122001, India.
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40
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Yemini R, Nesher E, Winkler J, Carmeli I, Azran C, Ben David M, Mor E, Keidar A. Bariatric surgery in solid organ transplant patients: Long-term follow-up results of outcome, safety, and effect on immunosuppression. Am J Transplant 2018; 18:2772-2780. [PMID: 29569341 DOI: 10.1111/ajt.14739] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 03/09/2018] [Accepted: 03/11/2018] [Indexed: 01/25/2023]
Abstract
The surgical risk of transplanted patients is high, and the modified gastrointestinal anatomy after bariatric surgery (BS) may lead to pharmacokinetic alterations in the absorption of immunosuppressive drugs. Data on outcomes of BS and the safety and feasibility of maintaining immunosuppression and graft safety among solid organ transplanted patients are scarce. In the current study, weight loss, improvement in comorbidities, and changes in dosage and trough levels of immunosuppression drugs before and after BS were analyzed for all transplanted patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) in our institution between November 2011 and January 2017. Thirty-four patients (13 females, 21 males, average age 53 years) were included in the study. A successful weight loss (>50% excess weight loss in 28 of them [82%]) was recorded at the last follow-up. Comorbidities improved significantly. Immunosuppressive stability increased from 39% to 47% among all patients. The tacrolimus blood trough levels declined slightly, but remained within therapeutic range. These data suggest that LSG and LRYGB ensure good immunosuppressive maintenance together with significant weight loss and improvement in comorbidities without serious graft rejection or dysfunction. The surgical risk is higher than in the regular BS population.
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Affiliation(s)
- Renana Yemini
- Bariatric Clinic, Department of Surgery, Beilinson Medical Center, Petach-Tikva, Israel
| | - Eviatar Nesher
- Department of Transplant Surgery, Beilinson Medical Center, Petach-Tikva, Israel
| | - Janos Winkler
- Department of Nephrology, Beilinson Medical Center, Petach-Tikva, Israel
| | - Idan Carmeli
- Bariatric Clinic, Department of Surgery, Beilinson Medical Center, Petach-Tikva, Israel
| | | | - Matan Ben David
- Bariatric Clinic, Department of Surgery, Beilinson Medical Center, Petach-Tikva, Israel
| | - Eytan Mor
- Department of Transplant Surgery, Beilinson Medical Center, Petach-Tikva, Israel
| | - Andrei Keidar
- Bariatric Clinic, Department of Surgery, Beilinson Medical Center, Petach-Tikva, Israel
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41
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Yu JW, Gupta G, Kang L, Bandyopadhyay D, Siddiqui MS, Bhati CS, Stravitz RT, Levy M, Reichman TW. Obesity does not significantly impact outcomes following simultaneous liver kidney transplantation: review of the UNOS database - a retrospective study. Transpl Int 2018; 32:206-217. [DOI: 10.1111/tri.13352] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/19/2018] [Accepted: 09/13/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Jonathan W. Yu
- Department of Biostatistics; Virginia Commonwealth, University; Richmond VA USA
| | - Gaurav Gupta
- Division of Nephrology; Department of Medicine; Virginia Commonwealth, University; Richmond VA USA
| | - Le Kang
- Department of Biostatistics; Virginia Commonwealth, University; Richmond VA USA
| | | | - Mohammed S. Siddiqui
- Division of Hepatology; Department of Medicine; Virginia Commonwealth, University; Richmond VA USA
| | - Chandra S. Bhati
- Division of Transplantation; Department of Surgery; Virginia Commonwealth University; Richmond VA USA
| | - Richard T. Stravitz
- Division of Hepatology; Department of Medicine; Virginia Commonwealth, University; Richmond VA USA
| | - Marlon Levy
- Division of Transplantation; Department of Surgery; Virginia Commonwealth University; Richmond VA USA
| | - Trevor W. Reichman
- Division of Transplantation; Department of Surgery; Virginia Commonwealth University; Richmond VA USA
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42
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Impact of Allograft Steatosis on Cardiovascular Outcomes. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0205-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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43
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Diwan TS, Rice TC, Heimbach JK, Schauer DP. Liver Transplantation and Bariatric Surgery: Timing and Outcomes. Liver Transpl 2018; 24:1280-1287. [PMID: 30080949 DOI: 10.1002/lt.25303] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 06/18/2018] [Indexed: 12/12/2022]
Abstract
Nonalcoholic steatohepatitis (NASH) is projected to become the leading indication for liver transplantation (LT) in the next decade in the United States. Strategies to treat the underlying etiology of NASH, which is almost always obesity, are being pursued. One such strategy is the utilization of bariatric surgery (BS) in the peritransplant period. The use of BS prior to LT could prevent the progression of NASH and abrogate the need for LT. BS at the time of LT or postoperatively has the potential to not only improve obesity-associated conditions such as diabetes, but also the potential to influence the incidence of NASH in the post-LT setting. However, there continues to be no consensus on the use and timing of BS in this patient population. This review aims to discuss the current literature and possible future action.
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Affiliation(s)
- Tayyab S Diwan
- Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati Collaborative on Obesity Research, Cincinnati, OH
| | - Teresa C Rice
- Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati Collaborative on Obesity Research, Cincinnati, OH
| | - Julie K Heimbach
- Division of Transplantation Surgery, Mayo Clinic College of Medicine, Rochester, MN
| | - Daniel P Schauer
- Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati Collaborative on Obesity Research, Cincinnati, OH
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44
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Schiavo L, Busetto L, Cesaretti M, Zelber-Sagi S, Deutsch L, Iannelli A. Nutritional issues in patients with obesity and cirrhosis. World J Gastroenterol 2018; 24:3330-3346. [PMID: 30122874 PMCID: PMC6092576 DOI: 10.3748/wjg.v24.i30.3330] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/15/2018] [Accepted: 06/25/2018] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Luigi Schiavo
- Department of Translational Medical Science, University of Campania “Luigi Vanvitelli”, Naples 80131, Italy
- IX Division of General Surgery, Vascular Surgery and Applied Biotechnology, Naples University Policlinic, Naples 80131, Italy
| | - Luca Busetto
- Department of Medicine, University of Padua, Padua 35128, Italy
- Center for the Study and the Integrated Management of Obesity, University Hospital of Padua, Padua 35128, Italy
| | - Manuela Cesaretti
- Department of HPB Surgery and Liver Transplantation, Hôpital Beaujon, AP-HP, Clichy 92110, France
- Department of Nanophysics, Italian Institute of Technology, Genova 16163, Italy
| | - Shira Zelber-Sagi
- School of Public Health, University of Haifa, Haifa 3498838, Israel
- Department of Gastroenterology and Liver disease, Tel Aviv Medical Center, 62431, Tel-Aviv 62431, Israel
| | - Liat Deutsch
- Department of Gastroenterology and Liver disease, Tel Aviv Medical Center, 62431, Tel-Aviv 62431, Israel
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 62431, Israel
| | - Antonio Iannelli
- Digestive Unit, Archet 2 Hospital, University Hospital of Nice, F-06202, Nice, France; Inserm, U1065, Team 8 “Hepatic complications of obesity”, Nice F-06204, France
- University of Nice Sophia-Antipolis, Nice F-06107, France
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45
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Osseis M, Lazzati A, Salloum C, Gavara CG, Compagnon P, Feray C, Lim C, Azoulay D. Sleeve Gastrectomy After Liver Transplantation: Feasibility and Outcomes. Obes Surg 2018; 28:242-248. [PMID: 28776154 DOI: 10.1007/s11695-017-2843-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Michael Osseis
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, 51 Avenue de Lattre de Tassigny, 94010, Creteil, France
| | - Andrea Lazzati
- Department of Digestive Surgery, Centre Hospitalier Intercommunal de Créteil, Creteil, France
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, 51 Avenue de Lattre de Tassigny, 94010, Creteil, France
| | - Concepcion Gomez Gavara
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, 51 Avenue de Lattre de Tassigny, 94010, Creteil, France
| | - Philippe Compagnon
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, 51 Avenue de Lattre de Tassigny, 94010, Creteil, France
- UNITE INSERM 955, Creteil, France
| | - Cyrille Feray
- UNITE INSERM 955, Creteil, France
- Department of Hepatology, Henri Mondor Hospital, Creteil, France
| | - Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, 51 Avenue de Lattre de Tassigny, 94010, Creteil, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, 51 Avenue de Lattre de Tassigny, 94010, Creteil, France.
- Department of Digestive Surgery, Centre Hospitalier Intercommunal de Créteil, Creteil, France.
- UNITE INSERM 955, Creteil, France.
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Dziodzio T, Biebl M, Öllinger R, Pratschke J, Denecke C. The Role of Bariatric Surgery in Abdominal Organ Transplantation-the Next Big Challenge? Obes Surg 2018; 27:2696-2706. [PMID: 28791580 DOI: 10.1007/s11695-017-2854-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Obesity is linked to inferior transplant outcome. Bariatric surgery (BS) is an established treatment of morbid obesity. We provide an overview on BS in the field of kidney (KT) and liver transplantation (LT). In end-stage renal disease (ESRD) and KT patients, BS seems safe and feasible. Complication rates were slightly higher compared to the non-transplant population, whereas weight loss and improvement of comorbidities were comparable. Sleeve gastrectomy (SG) was the preferred procedure before KT and superior to gastric bypass (GB) in regard to mortality and morbidity. If conducted after KT, both procedures showed comparable results. BS before LT was associated with high complication rates, in particular after GB. Albeit distinct complications, SG conducted after LT showed the best results. Immunosuppression (IS) changes after BS were rare.
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Affiliation(s)
- Tomasz Dziodzio
- Department of Surgery, Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13352, Berlin, Germany.
| | - Matthias Biebl
- Department of Surgery, Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13352, Berlin, Germany
| | - Robert Öllinger
- Department of Surgery, Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13352, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13352, Berlin, Germany
| | - Christian Denecke
- Department of Surgery, Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13352, Berlin, Germany
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Tsamalaidze L, Elli EF. Solid Organ Transplantation and Bariatric Surgery. THE SAGES MANUAL OF BARIATRIC SURGERY 2018:615-633. [DOI: 10.1007/978-3-319-71282-6_45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Mahawar KK, Parmar C, Graham Y, De Alwis N, Carr WRJ, Jennings N, Small PK. Monitoring of Liver Function Tests after Roux-en-Y Gastric Bypass: An Examination of Evidence Base. Obes Surg 2017; 26:2516-22. [PMID: 27381560 DOI: 10.1007/s11695-016-2280-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
There is no consensus on the monitoring of liver function tests after Roux-en-Y gastric bypass (RYGB). Since the main objective of such monitoring would be to diagnose early those who will eventually develop liver failure after RYGB, we performed a systematic review on this topic. An extensive search of literature revealed only 10 such cases in 6 published articles. It would hence appear that liver failure is a rare problem after RYGB. Routine lifelong monitoring of liver function tests is therefore unnecessary for otherwise asymptomatic individuals. Such monitoring should hence be reserved for high-risk groups, such as patients with liver cirrhosis, those undergoing extended limb/distal RYGB, patients with new illnesses, those abusing alcohol, those on hepatotoxic drugs and those presenting with a surgical complication.
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Affiliation(s)
- Kamal K Mahawar
- Bariatric Unit, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK.
- Department of Pharmacy, Health and Well-being, University of Sunderland, Sunderland, SR1 3SD, UK.
| | - Chetan Parmar
- Bariatric Unit, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK
| | - Yitka Graham
- Bariatric Unit, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK
- Department of Pharmacy, Health and Well-being, University of Sunderland, Sunderland, SR1 3SD, UK
| | | | - William R J Carr
- Bariatric Unit, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK
| | - Neil Jennings
- Bariatric Unit, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK
| | - Peter K Small
- Bariatric Unit, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK
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