Spengler Erin K, O'Leary Jacqueline G, Te Helen S, Rogal Shari, Pillai Anjana A, Al-Osaimi Abdullah, Desai Archita, Fleming James N, Ganger Daniel, Seetharam Anil, Tsoulfas Georgios, Montenovo Martin, Lai Jennifer C
1 Division of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI.2 Division of Hepatology, Baylor University Medical Center, Dallas, TX.3 Center for Liver Diseases, University of Chicago Medicine, Chicago, IL.4 VA Pittsburgh Healthcare System, Department of Surgery, University of Pittsburgh, PA.5 Division of Digestive Diseases and The Emory Transplant Center, Emory University Hospital, Atlanta, GA.6 Division of Hepatology, Temple University Health System, Philadelphia, PA.7 Division of Gastroenterology and Hepatology, Department of Medicine, University of Arizona, Tucson, AZ.8 Department of Pharmacy, Medical University of South Carolina, Charleston, SC.9 Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL.10 Transplant Institute, Banner University of Arizona College of Medicine-Phoenix, Tucson, AZ.11 Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece.12 Division of Transplantation, Department of Surgery. University of Washington. Seattle, WA.13 Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA.
Transplantation. 2017 Oct;101(10):2288-2296. doi: 10.1097/TP.0000000000001794.
Despite the rapidly increasing prevalence of obesity in the transplant population, the optimal management of obese liver transplant candidates remains undefined. Setting strict body mass index cutoffs for transplant candidacy remains controversial, with limited data to guide this practice. Body mass index is an imperfect measure of surgical risk in this population, partly due to volume overload and variable visceral adiposity. Weight loss before transplantation may be beneficial, but it remains important to avoid protein calorie malnutrition and sarcopenia. Intensive lifestyle modifications appear to be successful in achieving weight loss, though the durability of these interventions is not known. Pretransplant and intraoperative bariatric surgeries have been performed, but large randomized controlled trials are lacking. Traditional cardiovascular comorbidities are more prevalent in obese individuals and remain the basis for pretransplant cardiovascular evaluation and risk stratification. The recent US liver transplant experience demonstrates comparable patient and graft survival between obese and nonobese liver transplant recipients, but obesity presents important medical and surgical challenges during and after transplant. Specifically, obesity is associated with an increased incidence of wound infections, wound dehiscence, biliary complications and overall infection, and confers a higher risk of posttransplant obesity and metabolic syndrome-related complications. In this review, we examine current practices in the obese liver transplant population, offer recommendations based on the currently available data, and highlight areas where additional research is needed.
尽管移植人群中肥胖的患病率迅速上升，但肥胖的肝移植候选者的最佳管理仍不明确。为移植候选资格设定严格的体重指数临界值仍存在争议，指导这种做法的数据有限。体重指数在该人群中并非衡量手术风险的完美指标，部分原因是容量超负荷和内脏脂肪含量各异。移植前减重可能有益，但避免蛋白质热量营养不良和肌肉减少症仍然很重要。强化生活方式改变似乎能成功实现减重，不过这些干预措施的持久性尚不清楚。移植前和术中已开展减重手术，但缺乏大型随机对照试验。传统心血管合并症在肥胖个体中更为普遍，仍是移植前心血管评估和风险分层的基础。美国近期的肝移植经验表明，肥胖和非肥胖肝移植受者的患者及移植物存活率相当，但肥胖在移植期间及之后带来了重要的医学和手术挑战。具体而言，肥胖与伤口感染、伤口裂开、胆道并发症及总体感染的发生率增加相关，并使移植后肥胖及代谢综合征相关并发症的风险更高。在本综述中，我们研究了肥胖肝移植人群的当前做法，根据现有数据提供建议，并强调需要进一步研究的领域。
