Obesity, hyperlipidemia, and metabolic syndrome.
ABSTRACT 1. Obesity is increasingly common among liver transplantation (LT) recipients and donors. Outcomes following LT for selected patients with class I-III obesity are similar to those for nonobese recipients. In patients who are otherwise satisfactory candidates for LT, a high body mass index, as long as it does not present a technical barrier, should not be considered to be an absolute contraindication to LT. 2. The most common causes of death beyond the first year of LT are, in descending order of frequency, graft failure (especially secondary to hepatitis C virus recurrence), malignancy, cardiovascular disease, infections, and renal failure. Metabolic syndrome is an important risk factor for each of these etiologies of posttransplant death. Posttransplant diabetes, posttransplant hypertension, and an original diagnosis of cryptogenic cirrhosis, which is commonly associated with metabolic syndrome, are all associated with an increased risk of post-LT mortality. Features of metabolic syndrome should be screened for and treated in LT recipients. 3. Because of the physiological mechanism of post-LT hypertension, which includes renal arteriolar constriction secondary to calcineurin inhibition, calcium channel blocking agents are a good pharmacological treatment modality and have been shown to be effective in renal protection in randomized controlled trials of posttransplant hypertension. 4. It is rare for dietary changes and weight reduction to result in normalization of the lipid profile. Statins should thus be initiated early in the course of management of post-LT dyslipidemia. Forty milligrams of simvastatin per day, 40 mg of atorvastatin per day, and 20 mg of pravastatin per day are reasonable starting doses for post-LT hypercholesterolemia. It is important to remember that the effects of statin therapy are additive to those of a controlled diet (eg, a Mediterranean diet rich in omega-3 fatty acids, fruits, vegetables, and dietary fiber). 5. Nonalcoholic steatohepatitis, an increasingly common etiology of cirrhosis and liver failure, recurs commonly after LT and may also arise de novo. Treatment should be directed at managing obesity and complications of metabolic syndrome. Optimal immunosuppression in patients with nonalcoholic steatohepatitis is still evolving but should include steroid minimization.
- SourceAvailable from: InTech02/2012; , ISBN: 978-953-51-0015-7
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ABSTRACT: BACKGROUND: Obesity, steroid-induced diabetes, hypercholesterolemia, and steatohepatitis can occur after liver transplantation and may respond to bariatric surgery. The safety and feasibility of bariatric surgery after liver transplantation is unknown. METHODS: Nine morbidly obese patients with prior liver transplants underwent sleeve gastrectomy in a pilot program. Sleeve gastrectomy was chosen over gastric banding to avoid foreign body implantation, and over gastric bypass to maintain endoscopic access to the biliary system and reduce surgical complexity. We reviewed patient demographics, operative details, 30-day complications, weight loss, postoperative hepatic and renal functions, and resolution of comorbidities. RESULTS: Sleeve gastrectomy was performed laparoscopically in eight patients and as an open procedure in one patient. The mean operative time was 165 min and mean postoperative length of stay was 5 days. Follow-up ranged from 3 to 36 months. In the first 30 days, there were three complications in three patients: mesh dehiscence after a synchronous incisional hernia repair, bile leak from the liver surface requiring laparoscopic drainage, and postoperative dysphagia that required reoperation. Calcineurin inhibitor levels and hepatic and renal functions remained stable. There were no episodes of graft rejection. At 3 months liver function tests remained stable. Excess weight loss averaged 55.5 % at 6 months. CONCLUSION: Sleeve gastrectomy is technically feasible after liver transplantation and resulted in weight loss without adversely affecting graft function and immunosuppression. Early complications may be more frequent as a result of adhesions of the left upper quadrant. Late complications were rare.Surgical Endoscopy 06/2012; · 3.43 Impact Factor
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ABSTRACT: Obesity is among the great health problems facing Americans today. More than 32% of the United States population is considered obese based on a Body Mass Index (BMI) exceeding 30 kg/m(2) . Obesity increases the risk for numerous perioperative complications; but how obesity affects the outcome of liver transplantation remains unclear. We compared graft/patient survival after orthotopic liver transplant performed at the Cleveland Clinic from April 2005 to June 2011 in 2 groups: obese patients with a BMI >38 kg/m(2) and lean patients with a BMI between 20 and 26 kg/m(2) . We included 47 obese patients and 183 lean patients, whose demographics and baseline characteristics were well balanced after weighting by the inversed propensity score. After controlling for the observed confounding, no significant difference was observed in graft/patient survival between obese and lean patients (P = 0.30). The estimated hazard ratio was 1.19 (95% CI: 0.85, 1.67) for obese patients to experience graft failure/death. There were 134 patients who had follow-up for more than 3 years, including 27 obese patients and 107 lean patients. Within this subset, the odds of having metabolic syndrome was significantly greater in obese (46%) than lean patients (21%) [OR: 4.76 (99.5% CI: 1.66, 13.7); P = 0.0001]. However, no significant association between obesity and any other long-term adverse outcomes was found. This study shows that transplant outcomes were comparable in lean and obese recipients. We thus recommend that even morbid obesity per se should not exclude patients from consideration for transplant. Liver Transpl , 2013. © 2013 AASLD.Liver Transplantation 06/2013; · 3.94 Impact Factor