Obesity and metabolic complications of liver transplantation

Abstract

Foundation, Rochester, MNKey Points 1. The body mass index is not an adequate measure of obesity in patients with cirrhosis. It is necessary to account for the contributions of ascites and fluid overload in addition to the distribution of adipose tissue. The interpretation of the literature on the effects of the body mass index on posttransplant outcomes is difficult if adjustments are not made for these factors. 2. Survival after liver transplantation has improved over the years and appears unaffected by obesity (even class III obesity) before transplantation. 3. Obesity is even more common after liver transplantation. Weight increases occur, with the greatest gains occurring within the first 6 months of transplant. Education and lifestyle management for the prevention of weight gain are the first measures in the posttransplant management of obesity. 4. Further investigation of bariatric surgery before, during, and after transplantation is needed. 5. Metabolic syndrome and its individual components are common after liver transplantation and are associated with increased risks of cardiovascular disease, cardiovascular death, liver-related deaths, and overall mortality. 6. Recurrent or de novo steatosis in the allograft is not uncommon and is a risk for steatohepatitis and progression to cirrhosis with graft loss. Liver Transpl 16:S65-S71, All aspects of liver transplantation (LT)-pretransplant, perioperative, and posttransplant-are affected by obesity and metabolic syndrome. Both obesity and metabolic syndrome are extremely prevalent in the general population and thus in transplant patients. Nonalcoholic fatty liver disease, a manifestation of metabolic syndrome, is an increasingly common indication for LT, but obesity is also commonly noted in many other patients with underlying chronic liver disease.This discussion concerns the clinical relevance of obesity and metabolic syndrome specifically with respect to LT and is not meant to be a thorough review of the literature. OBESITYObesity is categorized according to the body mass index (BMI): overweight, BMI ¼ 25-29.9 kg/m 2 ; class I obesity, BMI ¼ 30-34.9 kg/m 2 ; class II obesity, BMI ¼ 35-39.9 kg/m 2 ; and class III obesity, BMI 40 kg/ m 2 . BMI, however, is not an accurate measure of true body fat versus lean muscle mass, for which waist circumference measures may better account. Central adipose tissue, typically manifesting as increased abdominal girth, is more metabolically active than peripheral adipose tissue and confers a greater risk factor for metabolic syndrome and cardiovascular disease (CVD). In our patient population (patients with end-stage cirrhosis), even waist circumference

What is the long-term outcome of the liver allograft?

“…Liver transplant patients are at risk for developing a number of features of the metabolic syndrome, such as diabetes mellitus, weight gain, hypertension, and hyperlipidaemia and are thus predisposed to the development of NAFLD [119,120]. Steatosis in the donor liver has also been identified as a risk factor for the development of steatosis in late post-transplant biopsies, although the mechanism for this is uncertain [121].…”

Metabolic Syndrome After Liver Transplantation

“…Obesity can also be differentiated between peripheral or central obesity, with the latter having more implication in the metabolism (Watt, 2010).…”

“…Within this group of drugs, diltiazem, verapamil or nicardipine interfere in the hepatic metabolism of calcineurin whilst amlodipine does not, and this latter is thus the most used (Watt, 2010). Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) produce vasodilation of the efferent arteriole, reducing glomerular pressure and hyperfiltration (Desai et al, 2010).…”

Excesso de peso em pacientes submetidos ao transplante hepático

“…All these drugs are implicated in the genesis of posttransplant excessive weight gain and obesity 18,19 . Although this gain can not affect the statistics of survival of patients in the short term, it is certainly involved in the incidence of diabetes mellitus, dyslipidemia, hypertension and metabolic syndrome in this population 20 . This morbidity exposes patients to increased risk of heart and kidney diseases, as well as nonalcoholic graft steatohepatitis.…”

“…In addition, excessive weight gain and excess weight are certainly related to comorbidities, such as diabetes, dyslipidemia, hypertension, metabolic syndrome, osteoarthritis and sleep apnea. They expose patients to increased risk of cardiovascular and renal diseases, and graft steatohepatitis 20 , as it happens in the general population. Moreover, higher rates of such conditions are found in patients moderately (BMI between 35-40kg/m 2 ) and severely obese (BMI > 40kg/m 2 ) after five years of operation 45 .…”