AASLD: Liver Transplants Okay in Superobese Patients

AASLD: Liver Transplants Okay in Superobese Patients
By John Gever, Senior Editor, MedPage Today
Published: November 03, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner Earn CME/CE credit
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Action Points

* Explain to interested patients that some transplant centers have excluded extremely obese patients as candidates for liver transplant. These two studies reported that overall outcomes are similar for superobese and normal BMI patients, although the surgery and recovery can be more complicated to manage in cases of obsesity.


* Note that these studies were published as abstracts and presented at a conference. These data and conclusions should be considered preliminary until published in a peer-reviewed journal.

BOSTON -- Liver transplants can work as well in extremely fat patients as in anyone else, although the surgery itself and post-transplant management are more complex, researchers said here.

Outcome studies at two major liver transplant centers, the Ochsner Clinic in New Orleans and the University of Wisconsin in Madison, found that rates of patient survival and graft loss were virtually identical in patients with body mass index (BMI) values of 40 or more compared with nonobese recipients, according to presentations at the American Association for the Study of Liver Diseases' annual meeting.

In the Wisconsin study, covering all transplants performed from 1997 to 2008, the 10-year survival rate among 47 patients with BMI of at least 40 was 79%, compared with 73% among 216 patients with BMI of less than 25, said John C. LaMattina, MD.

Graft survival rates at 10 years post-transplant were also very similar between the superobese and those of normal weight, at 66% versus 70%, he reported.

Patient mortality and graft loss rates after one year and five years also appeared unrelated to BMI.

The Ochsner study, meanwhile, analyzed short-term outcomes at the institution for 255 transplants performed from 2005 to 2008.

After one year, 92% of the 34 recipients with BMI of 40 or more were alive, compared with 96% of those with lower BMI values, according Scott Seals, MD.

Second surgeries within 30 days of transplant were needed only half as often in the superobese patients, the Ochsner study found: reoperations were performed in 12% of them versus 23% of control cases.

On the other hand, both studies found that extreme obesity was associated with much longer post-transplant hospital stays.

At Ochsner, the median stay for the superobese was 13 days, compared with nine in the control group (P not reported).

At Wisconsin, LaMattina reported mean stays of 29.9 for the superobese and 17.2 for those with normal BMI (P=0.002).

He said the average for the superobese was skewed by one patient who remained hospitalized for more than 500 days. However, the mean for other patients was still considerably longer than in the nonobese recipients, he said.

Infections and deep vein thrombosis were significantly more common in the obese patients, he said.

The actual surgery also took longer in patients with higher BMI, LaMattina said, noting the following mean times (P=0.0002 for trend):

* 8.2 hours (range 5.0 to 14.7) in those with BMI of 40 or more
* 7.9 hours in those with BMI of 35 to 39.9 (range 4.2 to 15.0)
* 7.2 hours for those with BMI less than 30 (range 3.5 to 18.1)

The Ochsner researchers did not report specific data, but called the surgery "technically challenging."

"Morbid obesity, in and of itself, should not be an absolute contraindication to liver transplantation," LaMattina said. He explained that some centers have excluded extremely obese patients as candidates for liver transplant.

Scott Friedman, MD, president of AASLD and a hepatologist at Mount Sinai School of Medicine in New York City, said the chronic diseases that go with obesity are the major challenge in extremely fat patients after transplant.

"It's not just about the liver, it's about the comorbidities," Friedman said.

In the Wisconsin cohort, 43% of the superobese patients had diabetes prior to transplant and 53% had hypertension, compared with 17% and 27%, respectively, of those with BMI less than 25.

Friedman pointed out that liver transplant recipients are routinely treated with steroids as part of the immunosuppressive regimen, which can worsen their diabetes.

"It makes post-transplant management more difficult," he said.

No external funding was reported for either study.

LaMattina reported no potential conflicts of interest.

Seals reported no potential conflicts. One co-author reported relationships with Roche, 3 Rivers Pharmaceuticals, Gilead, Eisai, and Schering-Plough.

Friedman reported relationships with Exalenz, sanofi-aventis, Axcan, Angion, Intercept, 7TM, Stromedix, and Celera.

Primary source: Hepatology
Source reference:
Seals S, et al "Liver transplantation in the super morbidly obese: A single center experience" Hepatology 2009; 50: 584A-585A.

Additional source: Hepatology
Source reference:
LaMattina J, et al "Class III obesity is not a contraindication to liver transplantation" Hepatology 2009; 50: 583A.