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.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
Obesity is becoming a major challenge in developed countries and is likewise affecting the population of patients either awaiting or recipients of an organ transplantation (OT). In 2014, Ogden et al. reported 35% of the adult US population as obese, defined by a body mass index (BMI) ≥30 kg/m2 [1]. At the same time, the prevalence of obesity in KT recipients amounted 23% [2]. Obesity is associated with a multitude of concomitant health problems, such as metabolic syndrome and cardiovascular diseases (CVDs), therefore impairing transplant outcome [3, 4].
Obesity and metabolic syndrome manifest as non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) in the liver [5]. Rates of end-stage liver disease (ESLD) caused by NAFLD and NASH are increasing in developed countries [5, 6]. Further, recent data suggest a deep interaction between adipose tissue and the immune system [7].
Materials and Methods
We conducted a systematic review of PubMed, Embase, and Cochrane Library databases by using combinations of following search terms: “kidney transplantation,” “liver transplantation,” “obesity,” “obesity surgery,” “bariatric surgery,” “gastric bypass,” “sleeve gastrectomy,” and “gastric banding.” All original full-text studies submitted in English reporting BS in adults were included. Proof-of-concept publications and studies missing follow-up data were excluded.
Impact of Obesity on Immunological Function After Transplantation
Obesity as a chronic proinflammatory disease is very likely to alter the immune response after OT. The majority of studies underlined an increased incidence of acute rejection in high BMI patients, while an extensive review by Nicoletto et al. did not find a correlation between obesity and acute rejection rates [3, 8]. Interestingly, studies by Meier-Kriesche et al. and Chang et al. showed that the major cause for graft failure in obese patients was chronic rejection, implying an ongoing immunological activation beyond the short-term risk of acute rejection [9, 10]. None of the available studies did examine the potential of BS to decrease proinflammatory state and its consequences on alloimmune activation, cardiovascular status, or concomitant diseases after OT.
Effects of Obesity on Kidney Transplantation Outcome
Obesity-associated effects, such as glomerular hyperfiltration, proteinuria, and metabolic syndrome, play important roles in the development of ESRD. Albeit KT being associated with a survival advantage compared to dialysis patients, the benefits of KT in obese patients are subject to controversial discussion [11]. Increased rates of delayed graft function (DGF), primary non-function (PNF), and inferior graft outcomes are reported in morbidly obese KT recipients [12, 13]. Data suggest that a BMI of >36 kg/m2 is associated with DGF rates up to 51%, while a BMI >40 kg/m2 increases the odds of DGF threefold [8, 14]. Furthermore, a BMI of ≥35 kg/m2 was reported to significantly increase graft failure rates [11]. The effects of obesity on mortality in the setting of KT are less pronounced [4, 15]. Nevertheless, obesity remains an independent risk factor for death caused by CVD in KT recipients [16]. Additionally, an increase in surgical site infections (SSIs) from 8.5% in non-obese to 40% in morbidly obese KT recipients was reported [17]. As a consequence, many transplant centers tend to restrict access to the KT waiting list by establishing BMI-linked thresholds (range 35–45 kg/m2). Considering the poor outcome of KT in morbidly obese patients, existing guidelines recommend a supervised weight loss regimen, targeting a BMI of less than 30 kg/m2 prior to KT [18, 19]. In reality, the majority of patients gain weight on dialysis and the recommended weight goals are rarely achieved [20]. Furthermore, weight gain after KT is a pronounced side effect of most IS regimes, and was shown to propagate pre-existing metabolic malconditions and negatively affects graft and patient survival [21].
Effect of Obesity on Liver Transplantation Outcome
The prevalence of NAFLD has doubled in the last 20 years, while incidences of other chronic liver diseases have remained stable or decreased (e.g., hepatitis C) [22, 23]. The progression of NAFLD to NASH dramatically increases the risks of cirrhosis, liver failure, and hepatocellular carcinoma (HCC) [47]. In LT, obesity and concomitant diseases are associated with increased perioperative morbidity and SSIs, resulting in higher resource utilization [24, 25]. However, data on the outcome of LT in obese patients is heterogeneous [26,27,28,29]. Older long-term series report an increased likelihood of death due to CVD in LT recipients with a BMI >35 kg/m2 [28, 30], whereas in more recent mid- and short-term studies, these effects are less pronounced or non-existent [31, 32].
After transplantation, the impact of obesity on graft survival is still a matter of discussion. Singhal et al. recently observed comparable patient and graft survival rates of obese vs non-obese LT recipients, even though morbidly obese patients were sicker at time of LT [33]. However, obesity was observed to play a major role in recurrence of NAFLD and NASH in LT recipients with an increase of the risk of HCC after LT twofold higher than in non-obese LT recipients [34,35,36].
Bariatric Surgery and Kidney Transplantation
Bariatric Surgery in ESRD and Kidney Waiting List Patients
Regarding BS prior to KT, eight retrospective studies were identified including 154 patients (102 SGs, 42 GBs, four adjustable gastric bandings [AGB], and six other procedures). Half of the retrieved studies (n = 4) were case reports/series, while the others were single-center series, reporting between 21 and 52 patients (Table 1). Seven authors reported a follow-up up to 12 months or longer. Weight loss was observed in all reported series (EWL range 21–68%). In these series, GB was the most effective procedure (EWL 64.3 vs 48.9% after SG), and AGB showed the least weight loss (EWL 35.3 ± 3.5%). Three authors reported a total of eight complications (5.1%) [37,38,39]. Six major complications, including anastomotic leakage, strictures, and ulcers, occurred in GB patients (12%). One major (reversible organ insufficiency) and one minor complication (2%) were observed after SG. Overall mortality was 4.2% in GB patients and 3.9% in SG patients. Improvement of comorbid conditions like diabetes, hypertension, and renal function were reported by three authors [37, 40, 41]. Two studies reported adequate post-transplant kidney function in 42 of the 154 patients after BS [38, 42, 43]. One group from Innsbruck recently reported prospective data on SG in eight patients before KT. No surgical complications occurred and seven patients (87.5%) underwent KT after the procedure [44].
In conclusion, BS appears safe in the reported patient series and provided good weight loss before KT. GB was associated with a slightly higher mortality and distinct higher morbidity (12 vs 2%) compared to SG.
Bariatric Surgery After Kidney Transplantation
Seven studies focused on BS after KT, including a total of 119 patients (88 GBs, 15 SGs, and 16 other procedures; Table 1). All but one study were small case series. The largest cohort up to date was published in 2009 [45] with GB performed in 70 patients. The percent of EWL ranged from 31 to 61%. Thirty-day mortality was equal to patients on the waiting list with 3.5%. Overall, the %EWL in studies referring to BS after ranged from 30 to 87%, with SG showing the best weight loss and AGB being the least effective. All authors reported follow-up data up to 12 months or longer. Three major complications (2.5%) were reported [45,46,47]. Two patients needed a reoperation after SG (13.3%) and one acute reversible rejection (1.1%) occurred after GB. No mortality was observed after SG, whereas three patients died within 1 year after GB (3.3%) [40, 45]. Four authors observed improvement of comorbidities [46,47,48,49]. Furthermore, three out of four studies containing 20 patients observed improvement in graft function [46, 47, 49, 50]. One kidney graft loss after GB was reported [48]. After BS, no or only minor modifications in IS dosages were reported which were independent of the procedure [47, 50].
In summary, GB and SG showed comparable results with low mortality and complication rates.
Bariatric Surgery and Liver Transplantation
Bariatric Surgery Prior to or Simultaneously with Liver Transplantation
Three publications with a total of 29 patients reported BS prior to LT, including one single-center series with 20 patients (Table 2). Sufficient weight loss was observed by all authors (EWL range 40–66%). Two studies reported follow-up data up to 2 years. The major complication rate after SG was 17.9%, including two bleedings, one leakage, and one liver insufficiency [37, 51]. Three patients died within 1 year after SG [37]. Improvements of obesity-associated comorbidities were observed in all patients after SG. Regarding GB prior to LT, only one case report was identified. The patient with a BMI of 50.9 kg/m2 underwent GB followed by LT due to cirrhosis [52]. Post-operative bleeding, requiring a reoperation, and renal failure requiring renal replacement therapy were documented. One year after LT, a stable graft and renal function and remission of DM were observed.
Three groups reported BS simultaneously with LT in 11 patients. Weight loss was satisfactory (EWL 28–45%). One group placed an AGB during LT and observed amelioration of hypertension and DM [53]. A similar approach with SG in seven patients with a mean MELD score of 32 at LT reported three early complications (42.9%), including one leakage from the gastric staple line causing severe early graft dysfunction [54]. Recently, another group presented similar results with good amelioration of concomitant diseases. However, two complications needed treatment (one biliary leakage and one transient kidney failure) [55]. No mortality and no metabolic complications were observed.
The available data suggest that BS prior to LT is associated with high morbidity and mortality.
Bariatric Surgery After Liver Transplantation
Concerning BS after LT, six single-center reports including 25 patients were identified (15 SGs, 10 GBs) (Table 2). Weight loss was observed in all reported series (EWL range 21–75%). The highest weight loss was achieved in patients after SG (EWL 54.9 vs 37.9% after GB). Long-term follow-up was reported by one study containing seven patients after GB. Overall, a high complication rate (40%) was documented with substantial major complications (20%). Following SG, major complications (26.7%) included one bile leakage, one early reoperation due to dysphagia, and one bleeding [46, 56], whereas after GB, major complications occurred in 10% [57, 58]. No mortality was observed after SG, while two patients died within 1 year after GB (septic shock, esophageal carcinoma; 20%) [58]. All authors reported improvement of obesity-related comorbidities. Stable graft functions and unaltered IS regimes were observed. Two series reported improvement of graft function after GB (i.e., biopsy-proven regression of steatosis) [57, 58].
In summary, only case series were available. Complications occurred more often after SG, while mortality was higher after GB. Immunosuppression regimen was reported to be unaffected of the BS procedure.
Discussion
Only few data are available on surgical treatment of morbid obesity in the setting of OT. However, an increasing clinical interest is reflected by a growing number of publications on this subject. While 503 publications dealt with this topic between 2000 and 2010, the number of original publications and reviews has more than doubled within the last 5 years [59, 60].
In the field of KT, available data suggest that BS is a reasonable, feasible, and safe option in the treatment of morbidly obese ESRD patients and KT recipients, regardless of the timing related to the OT. Aside from the less effective AGB, all surveys demonstrated weight loss comparable to the non-transplant population [61, 62]. Unfortunately, medium- and long-term follow-ups were only reported by five studies. In contrast to KT waiting list patients (SG), GB was the preferred procedure after KT (79%). This may be explained by a better health condition of KT patients compared to the waiting list population and the willingness of surgeons of performing a more complex procedure in a stable patient setting. Patients undergoing GB showed markedly lower major complication rates after than before KT (1.1 vs 12%). The post-KT complication rates were comparable to a non-transplant population [63]. Albeit the reported overall 30-day mortality was low (0.8%), the 1-year mortality of BS of 3.9% before KT and 2.5% after KT was above the rates of the non-transplant setting (<1%) [64, 65]. In contrast, average 1-year mortality on the waiting list is 7% and falls to 3% after KT [11, 66]. After KT, the association between obesity and mortality is unclear; however, most authors report no apparent association [67]. Hence, taking into account the impaired health condition of the ESRD and KT patients, the reported rates seem acceptable. Nonetheless, two deaths in ESRD patients were directly BS-related and a total of five out of nine deaths were caused by cardiovascular events. In the general population, the long-term Swedish Obese Subjects trial reported a 33% reduction in cardiovascular events by BS, compared to patients without surgery [62]. Therefore, given the substantial time on the waiting list, the long-term effects of weight loss prior to KT may positively influence perioperative surgical and CVD risk profiles in these patients. Additionally, improvements of obesity-related comorbidities before and after KT were observed [46, 47, 49].
Regarding the timing, data suggest that BS is safest when conducted after KT. However, certain patients seem to benefit from an early access to BS before KT and it has been shown that complication rates of BS prior to KT are acceptable and BS does help to meet weight-based waiting list thresholds. Especially the recent prospective publication by Kienzl-Wagner and colleagues showed that SG can be performed with low complication rates before KT. In this publication, seven out of eight patients reached KT criteria and were transplanted successfully with good organ function in the follow-up period. Thus, the application of BS before KT may be justified. Here, SG may be the procedure of choice, being a shorter and less traumatic procedure with mid-term weight loss comparable to GB (Fig. 1).
Only few data on the effects of BS in the setting of LT were available and most of the publications were case reports. In contrast to ESRD and KT patients, the benefits of BS in the setting of LT seem less clear. Regardless of the procedure and strategy, all patients showed a sustainable weight reduction. Despite amelioration of comorbidities, substantial effects on graft function and post-transplant survival have not been reported so far. Most surgeons preferred SG in favor of GB due a shorter operative time and lower technical complexity, and the preservation of the access to the biliary tree, together with presumed unclear effects of GB on IS absorption. Hereby, only one patient received a GB ahead of LT, whereas 28 received a SG. The overall major complication rate of 27.6% was distinctly higher than in the general population. Three authors performed SG simultaneously with LT to reduce trauma. However, the procedures were associated with unfavorable complications and prolonged hospital stay, albeit no deaths were reported. Consequently, this concept should be seen critically.
In BS applied after LT, major adverse events, requiring reoperations or further interventions, were lower than before LT. No mortality was observed after SG, whereas two patients died within 1 year after GB (26%). Despite the low patient numbers and high complication rates, the results imply a slight trend in favor for SG. Nevertheless, due to short observation periods, long-term effects and late complications have not been analyzed, and thus, the role of this technique remains unclear.
Regarding GB, the situation in ESLD patients is further more difficult. While a potential liver transplantation is burdened by high complication rates, recent series however did not find an increase of perioperative mortality in morbidly adipose patients [32]. Any surgery under general anesthesia except of the liver transplant itself has a considerable risk of death in patients with decompensated cirrhosis, ranging from 8.3 to 25% [68]. Consequently, advanced liver diseases with the presence of portal hypertension are usually considered as contraindications for any elective surgery [69].
Therefore, any BS needs to be carefully balanced against its risks in liver cirrhosis patients. The few reports of concomitant BS at the time of transplantation showed high complication rates, and given the increasing paucity of good liver grafts with a therefore high potential of initial poor organ function, such a combined procedure cannot be recommended.
After successful liver transplantation, obese patients have a high potential to further gain weight. The very limited international experience with BS after LT shows good weight control after such a procedure. However, several concerns regarding especially GB after LT need to be considered. First, the GB excludes the possibility for easy retrograde access to the biliary system in a patient cohort, which eventually requires such an intervention in about 30% of all cases after LT [70]. Further, concerns have been raised regarding the kinetic of the enteral absorption of the immunosuppression after a malabsorptive procedure. Unlike this assumption, no relevant effects on IS uptake were observed and most reports refuted this strong argument [58]. Further, the extent of dissection after liver transplantation required for GB results is a higher surgical risk for the LT patients compared to a SG, which however does not seem to translate in higher complication rates in the reported selected patient cohorts.
Considering the available literature, we suggest that BS should be recommended only after exhaustion of all conservative therapies and recovery from LT. If performed in these patients, SG should be favored (Fig. 1).
At least, the perception of BS in the transplant community is changing. Albeit still being a maverick, BS is more often performed as most transplant centers are confronted with the complex situations of morbidly obese patients. However, the variety of approaches and lack of prospective data reflect the current disunity in the transplant community and the lack of treatment guidelines in this growing complex inhomogeneous cohort. Since BS has been proven well effective in the non-transplant population, it is likely to have similar benefits in OT patients (Table 3).
Limitations
The main limitations of the study are the small sample sizes of the reported cohorts and the modest number of prospective data. All original full-text studies published in English reporting BS in adult abdominal transplantation were initially included. However, to achieve comparability throughout the manuscript, we had to exclude proof of concept publications, case studies, and studies missing follow-up data. Thus, not all publications dealing with the topic were discussed. We also excluded journals that publish primarily in a language other than English, especially if only an abstract was available. Further many manuscripts varied widely in methodology and homogeneity of the cohorts, which made a sound comparability difficult. However, we tried to pick out the most valid ones to make our conclusions comprehensive.
BMI body mass index, BS bariatric surgery, CKD chronic kidney disease, CNI calcineurin inhibitor, CsA cyclosporine A, CVD cardiovascular disease, DGF delayed graft function, DM diabetes mellitus, eGFR estimated glomerular filtration rate, ESLD end-stage liver disease, ESRD end-stage renal disease, GERD gastroesophageal reflux disease, GS gastric sleeve, HCC hepatocellular carcinoma, IDDM insulin-dependent diabetes mellitus, IS immunosuppression, LAGB laparoscopic gastric banding, LGB laparoscopic gastric bypass, LSG laparoscopic sleeve gastrectomy, MELD model for end-stage liver disease, NAFTLD non-alcoholic fatty liver disease, NASH non-alcoholic steatohepatitis, OT organ transplantation, SSI surgical site infection, WHO World Health Organization
References
Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA [Internet]. American Medical Association; 2014 Feb 26 [cited 2014 Jul 9];311(8):806–14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24570244.
Lentine KL, Delos Santos R, Axelrod D, Schnitzler MA, Brennan DC, Tuttle-Newhall JE, et al. Obesity and kidney transplant candidates: how big is too big for transplantation? Am J Nephrol [Internet]. Karger Publishers; 2012 Jan [cited 2015 Jun 8];36(6):575–86. Available from: http://www.karger.com/Article/FullText/345476.
Curran SP, Famure O, Li Y, et al. Increased recipient body mass index is associated with acute rejection and other adverse outcomes after kidney transplantation. Transplantation [Internet]. 2013;97(1):64–70. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24056619
Kovesdy CP, Czira ME, Rudas A, Ujszaszi A, Rosivall L, Novak M, et al. Body mass index, waist circumference and mortality in kidney transplant recipients. Am J Transplant [Internet]. 2010 Dec [cited 2015 Jun 8];10(12):2644–51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21087417.
Ong JP, Younossi ZM. Epidemiology and natural history of NAFLD and NASH. Clin Liver Dis [Internet]. 2007 Feb [cited 2015 Apr 6];11(1):1–16. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17544968.
Watt KDS, Charlton MR. Metabolic syndrome and liver transplantation: a review and guide to management. J Hepatol [Internet]. 2010 Jul [cited 2015 Jul 7];53(1):199–206. Available from: http://www.sciencedirect.com/science/article/pii/S0168827810001960.
de Heredia FP, Gómez-Martínez S, Marcos A. Obesity, inflammation and the immune system. Proc Nutr Soc [Internet]. Cambridge University Press; 2012 May 1 [cited 2015 May 25];71(2):332–8. Available from: http://journals.cambridge.org/abstract_S0029665112000092.
Nicoletto BB, Fonseca NKO, Manfro RC, et al. Effects of obesity on kidney transplantation outcomes: a systematic review and meta-analysis. Transplantation [Internet]. 2014;98(2):167–76. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24911038
Meier-Kriesche HU, Vaghela M, Thambuganipalle R, Friedman G, Jacobs M, Kaplan B. The effect of body mass index on long-term renal allograft survival. Transplantation [Internet]. 1999 Nov 15 [cited 2016 Mar 13];68(9):1294–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10573066.
Chang SH, Coates PTH, McDonald SP. Effects of body mass index at transplant on outcomes of kidney transplantation. Transplantation [Internet]. 2007 Oct 27 [cited 2016 Mar 13];84(8):981–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17989603.
Cannon RM, Jones CM, Hughes MG, et al. The impact of recipient obesity on outcomes after renal transplantation. Ann Surg [Internet]. 2013;(5):257, 978–84. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23295317
Prasad GVR, Huang M, Silver SA, Al-Lawati AI, Rapi L, Nash MM, et al. Metabolic syndrome definitions and components in predicting major adverse cardiovascular events after kidney transplantation. Transpl Int [Internet]. 2015 Jan [cited 2015 Nov 10];28(1):79–88. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25207680.
Aalten J, Christiaans MH, de Fijter H, et al. The influence of obesity on short- and long-term graft and patient survival after renal transplantation. Transpl Int. 2006;19(11):901–7.
Molnar MZ, Kovesdy CP, Mucsi I, Bunnapradist S, Streja E, Krishnan M, et al. Higher recipient body mass index is associated with post-transplant delayed kidney graft function. Kidney Int [Internet]. International Society of Nephrology; 2011 Jul [cited 2015 Jul 7];80(2):218–24. Available from: doi:10.1038/ki.2011.114.
Meier-Kriesche H-U, Arndorfer JA, Kaplan B. The impact of body mass index on renal transplant outcomes: a significant independent risk factor for graft failure and patient death. Transplantation [Internet]. 2002 Jan 15 [cited 2015 Jul 7];73(1):70–4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11792981.
Hill CJ, Courtney AE, Cardwell CR, Maxwell AP, Lucarelli G, Veroux M, et al. Recipient obesity and outcomes after kidney transplantation: a systematic review and meta-analysis. Nephrol Dial Transplant. 2015;30:1403–11. doi:10.1093/ndt/gfv214.
Lynch RJ, Ranney DN, Shijie C, et al. Obesity, surgical site infection, and outcome following renal transplantation. Ann Surg. 2009;250(6):1014–20.
Kasiske BL, Zeier MG, Chapman JR, Craig JC, Ekberg H, Garvey CA, et al. Resumen de las Guías de práctica clínica KDIGO sobre el cuidado del receptor de trasplante renal. Rev Nefrol Dial y Traspl [Internet]. Nature Publishing Group; 2011;31(1):6–21. Available from: doi:10.1038/ki.2009.377
Knoll G, Cockfield S, Blydt-Hansen T, Baran D, Kiberd B, Landsberg D, et al. Canadian Society of Transplantation consensus guidelines on eligibility for kidney transplantation. Cmaj [Internet]. 2005 Nov 8 [cited 2015 Jun 28];173(10):1181–4. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1330435&tool=pmcentrez&rendertype=abstract.
Lee MJ, Doh FM, Kim CH, Koo HM, Oh HJ, Park JT, et al. Interdialytic weight gain and cardiovascular outcome in incident hemodialysis patients. Am J Nephrol [Internet]. Karger Publishers; 2014 Jan [cited 2015 Jul 7];39(5):427–35. Available from: http://www.karger.com/Article/FullText/362743.
Thoma B, Grover VK, Shoker A. Prevalence of weight gain in patients with better renal transplant function. Clin Nephrol [Internet]. 2006 Jun [cited 2015 Aug 4];65(6):408–14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16792135.
Takahashi Y, Fukusato T, Inui A, et al. Pediatric nonalcoholic fatty liver disease/nonalcoholic steatohepatitis. Nihon Rinsho [Internet]. 2012;70(10):1827–34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23971751%5Cnhttp://www.ncbi.nlm.nih.gov/pubmed/23198569%5Cnhttp://www.ncbi.nlm.nih.gov/pubmed/23971751%5Cnhttp://www.ncbi.nlm.nih.gov/pubmed/23198569
Brunt EM, Tiniakos DG. Histopathology of nonalcoholic fatty liver disease. World J Gastroenterol [Internet]. 2010 Nov 14 [cited 2015 Jun 3];16(42):5286–96. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2980677&tool=pmcentrez&rendertype=abstract.
Hakeem AR, Cockbain AJ, Raza SS, Pollard SG, Toogood GJ, Attia MA, et al. Increased morbidity in overweight and obese liver transplant recipients: a single-center experience of 1325 patients from the United Kingdom. Liver Transpl [Internet]. 2013 May [cited 2015 Jul 7];19(5):551–62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23408499.
Dare AJ, Plank LD, Phillips ARJ, Gane EJ, Harrison B, Orr D, et al. Additive effect of pretransplant obesity, diabetes, and cardiovascular risk factors on outcomes after liver transplantation. Liver Transpl [Internet]. 2014 Mar [cited 2015 Jul 7];20(3):281–90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24395145.
Rana A, Gruessner A, Agopian VG, Khalpey Z, Riaz IB, Kaplan B, et al. Survival benefit of solid-organ transplant in the United States. JAMA Surg [Internet]. American Medical Association; 2015 Mar 1 [cited 2015 Jul 7];150(3):252–9. Available from: http://archsurg.jamanetwork.com/article.aspx?articleid=2100153.
Pelletier SJ, Maraschio MA, Schaubel DE, Dykstra DM, Punch JD, Wolfe RA, et al. Survival benefit of kidney and liver transplantation for obese patients on the waiting list. Clin Transpl [Internet]. 2003 Jan [cited 2015 Jul 7];77–88. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15387099.
Nair S, Verma S, Thuluvath PJ. Obesity and its effect on survival in patients undergoing orthotopic liver transplantation in the United States. Hepatology [Internet]. 2002 Jan [cited 2015 Jun 1];35(1):105–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11786965.
Rustgi VK, Marino G, Rustgi S, et al. Obesity and its effect on survival in patients undergoing orthotopic liver transplantation in the United States. Hepatology. 2002;35(6):105–9.
Mazuelos F, Abril J, Zaragoza C, Rubio E, Moreno J., Turrión V., et al. Cardiovascular morbidity and obesity in adult liver transplant recipients. Transplant Proc [Internet]. 2003 Aug [cited 2015 Jul 7];35(5):1909–10. Available from: http://www.sciencedirect.com/science/article/pii/S0041134503006407.
Orci LA, Majno PE, Berney T, Morel P, Mentha G, Toso C. The impact of wait list body mass index changes on the outcome after liver transplantation. Transpl Int [Internet]. 2013;26(2):170–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23199077.
VanWagner LB, Lapin B, Levitsky J, Wilkins JT, Abecassis MM, Skaro AI, et al. High early cardiovascular mortality after liver transplantation. Liver Transpl [Internet]. 2014 Nov [cited 2015 Jul 7];20(11):1306–16. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25044256.
Singhal A, Wilson GC, Wima K, Quillin RC, Cuffy M, Anwar N, et al. Impact of recipient morbid obesity on outcomes after liver transplantation. Transpl Int [Internet]. 2015 Feb [cited 2015 Nov 13];28(2):148–55. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25363625.
Scarborough P, Bhatnagar P, Wickramasinghe KK, et al. The economic burden of ill health due to diet, physical inactivity, smoking, alcohol and obesity in the UK: an update to 2006–07 NHS costs. J Public Health (Bangkok). 2011;33(4):527–35.
Patil DT, Yerian LM. Evolution of nonalcoholic fatty liver disease recurrence after liver transplantation. Liver Transpl [Internet]. 2012 Oct [cited 2015 Jul 7];18(10):1147–53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22740341.
Mathur A, Franco ES, Leone JP, Osman-Mohamed H, Rojas H, Kemmer N, et al. Obesity portends increased morbidity and earlier recurrence following liver transplantation for hepatocellular carcinoma. HPB (Oxford) [Internet]. 2013 Jul [cited 2015 Jul 7];15(7):504–10. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3692019&tool=pmcentrez&rendertype=abstract.
Lin MYC, Tavakol MM, Sarin A, Amirkiai SM, Rogers SJ, Carter JT, et al. Laparoscopic sleeve gastrectomy is safe and efficacious for pretransplant candidates. Surg Obes Relat Dis [Internet]. Jan [cited 2015 Jun 27];9(5):653–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23701857.
Kienzl-Wagner K, Pratschke J, Öllinger R. A double challenge transplant—horseshoe kidney meets obesity. First case of horseshoe kidney transplantation after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis [Internet]. 2014 Nov [cited 2015 Aug 4];10(6):e89–91 Available from: http://www.sciencedirect.com/science/article/pii/S1550728914000641.
Jamal MH, Corcelles R, Daigle CR, Rogula T, Kroh M, Schauer PR, et al. Safety and effectiveness of bariatric surgery in dialysis patients and kidney transplantation candidates. Surg Obes Relat Dis [Internet]. Jan [cited 2015 Jun 27];11(2):419–23. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25813752.
Alexander JW, Goodman H. Gastric bypass in chronic renal failure and renal transplant. Nutr Clin Pract [Internet]. 2007 Feb [cited 2015 Aug 5];22(1):16–21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17242450.
Freeman CM, Woodle ES, Shi J, Alexander JW, Leggett PL, Shah SA, et al. Addressing morbid obesity as a barrier to renal transplantation with laparoscopic sleeve gastrectomy. Am J Transplant [Internet]. 2015. Available from: http://doi.wiley.com/10.1111/ajt.13116.
Koshy AN, Wilkinson S, Coombes JS, Fassett RG. Laparoscopic adjustable gastric band in an obese unrelated living donor prior to kidney transplantation: a case report. J Med Case Rep [Internet]. 2010 Jan [cited 2015 Aug 4];4:107. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2862044&tool=pmcentrez&rendertype=abstract.
Marszałek R, Ziemiański P, Lisik W, Wierzbicki Z, Domienik-Karłowicz J, Trzebicki J, et al. Bariatric surgery as a bridge for kidney transplantation in obese subjects. Case report. Ann Transplant [Internet]. Jan [cited 2015 Aug 4];17(1):108–12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22466915.
Kienzl-Wagner K, Weissenbacher A, Gehwolf P, Wykypiel H, Öfner D, Schneeberger S. Laparoscopic sleeve gastrectomy: gateway to kidney transplantation. Surg Obes Relat Dis [Internet]. 2017 Jan 6 [cited 2017 Jun 5]; Available from: http://linkinghub.elsevier.com/retrieve/pii/S1550728917300060.
Modanlou KA, Muthyala U, Xiao H, Schnitzler MA, Salvalaggio PR, Brennan DC, et al. Bariatric surgery among kidney transplant candidates and recipients: analysis of the United States renal data system and literature review. Transplantation [Internet]. 2009 Apr 27 [cited 2015 Aug 4];87(8):1167–73. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2833328&tool=pmcentrez&rendertype=abstract.
Khoraki J, Katz MG, Funk LM, Greenberg JA, Fernandez LA, Campos GM. Feasibility and outcomes of laparoscopic sleeve gastrectomy after solid organ transplantation. Surg Obes Relat Dis [Internet]. 2015 Apr 9 [cited 2015 Jun 27]; Available from: http://www.ncbi.nlm.nih.gov/pubmed/26048513.
Golomb I, Winkler J, Ben-Yakov A, et al. Laparoscopic sleeve gastrectomy as a weight reduction strategy in obese patients after kidney transplantation. Am J Transplant [Internet]. 2014;14(10):2384–90. Available from: http://doi.wiley.com/10.1111/ajt.12829
Marterre WF, Hariharan S, First MR, Alexander JW. Gastric bypass in morbidly obese kidney transplant recipients. Clin Transplant [Internet]. 1996 Oct [cited 2015 Aug 4];10(5):414–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8930454.
Chmura A, Ziemiański P, Lisik W, Marszałek RJ, Cieciura T, Domienik-Karłowicz J, et al. Improvement of graft function following Roux-en-Y gastric bypass surgery in a morbidly obese kidney recipient: a case report and literature review. Ann Transplant [Internet]. 2014 Jan [cited 2015 Aug 5];19:639–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25483934.
Szomstein S, Rojas R, Rosenthal RJ. Outcomes of laparoscopic bariatric surgery after renal transplant. Obes Surg [Internet]. 2009 Sep 25 [cited 2015 Aug 4];20(3):383–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19779949.
Takata MC, Campos GM, Ciovica R, Rabl C, Rogers SJ, Cello JP, et al. Laparoscopic bariatric surgery improves candidacy in morbidly obese patients awaiting transplantation. Surg Obes Relat Dis [Internet]. 2008 Jan [cited 2015 Aug 5];4(2):159–64-5. Available from: http://www.sciencedirect.com/science/article/pii/S1550728908000130.
Marszałek R, Ziemiański P, Łągiewska B, Pacholczyk M, Domienik-Karłowicz J, Trzebicki J, et al. The first Polish liver transplantation after Roux-en-Y gastric bypass surgery for morbid obesity: a case report and literature review. Ann Transplant [Internet]. 2015 Jan [cited 2015 Aug 5];20:112–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25711520.
Campsen J, Zimmerman M, Shoen J, Wachs M, Bak T, Mandell MS, et al. Adjustable gastric banding in a morbidly obese patient during liver transplantation. Obes Surg [Internet]. 2008 [cited 2015 Aug 5];18(12):1625–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18704606.
Heimbach JK, Watt KDS, Poterucha JJ, Ziller NF, Cecco SD, Charlton MR, et al. Combined liver transplantation and gastric sleeve resection for patients with medically complicated obesity and end-stage liver disease. Am J Transplant [Internet]. 2013 Feb [cited 2015 Aug 5];13(2):363–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23137119.
Nesher E, Mor E, Shlomai A, Naftaly-Cohen M, Yemini R, Yussim A, et al. Simultaneous liver transplantation and sleeve gastrectomy: prohibitive combination or a necessity? Springer US; 2017 May 9 [cited 2017 Jun 5];27(5):1387–90. Available from: http://springerlink.bibliotecabuap.elogim.com/10.1007/s11695-017-2634-5.
Lin MYC, Tavakol MM, Sarin A, Amirkiai SM, Rogers SJ, Carter JT, et al. Safety and feasibility of sleeve gastrectomy in morbidly obese patients following liver transplantation. Surg Endosc [Internet]. 2013 Jan [cited 2015 Aug 5];27(1):81–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22752278.
Duchini A, Brunson ME. Roux-en-Y gastric bypass for recurrent nonalcoholic steatohepatitis in liver transplant recipients with morbid obesity. Transplantation [Internet]. 2001 Jul 15 [cited 2015 Aug 5];72(1):156–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11468551.
Al-Nowaylati A-R, Al-Haddad BJS, Dorman RB, Alsaied OA, Lake JR, Chinnakotla S, et al. Gastric bypass after liver transplantation. Liver Transpl [Internet]. 2013 Dec [cited 2015 Aug 5];19(12):1324–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24039124.
Ayloo S, Armstrong J, Hurton S, Molinari M. Obesity and liver transplantation. World J Transplant [Internet]. 2015 Sep 24 [cited 2017 Jun 5];5(3):95–101. Available from: http://www.wjgnet.com/2220-3230/full/v5/i3/95.htm.
Lazzati A, Iannelli A, Schneck A-S, Nelson AC, Katsahian S, Gugenheim J, et al. Bariatric surgery and liver transplantation: a systematic review a new frontier for bariatric surgery. Obes Surg [Internet]. 2014 Jan 22 [cited 2017 Jun 5];25(1):134–42. Available from: http://springerlink.bibliotecabuap.elogim.com/10.1007/s11695-014-1430-8.
Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4):427–36.
Sjöström L, Peltonen M, Jacobson P, Sjöström CD, Karason K, Wedel H, et al. Bariatric surgery and long-term cardiovascular events. JAMA [Internet]. 2012 Jan 4 [cited 2016 Jan 19];307(1):56–65. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22215166.
Trastulli S, Desiderio J, Guarino S, Cirocchi R, Scalercio V, Noya G, et al. Laparoscopic sleeve gastrectomy compared with other bariatric surgical procedures: a systematic review of randomized trials. Surg Obes Relat Dis [Internet]. Jan [cited 2016 Jan 19];9(5):816–29. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23993246.
Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. Trends in mortality in bariatric surgery: a systematic review and meta-analysis. Surgery [Internet]. 2007 [cited 2017 Apr 13];142(4):621–35. Available from: http://www.sciencedirect.com/science/article/pii/S0039606007004928.
Morino M, Toppino M, Forestieri P, Angrisani L, Allaix ME, Scopinaro N. Mortality after bariatric surgery. Ann Surg [Internet]. 2007 Dec [cited 2017 Apr 13];246(6):1002–9. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00000658-200712000-00012.
Puzziferri N, Roshek TB, Mayo HG, Gallagher R, Belle SH, Livingston EH. Long-term follow-up after bariatric surgery: a systematic review. JAMA [Internet]. American Medical Association; 2014 Sep 3 [cited 2015 Nov 30];312(9):934–42. Available from: http://jama.jamanetwork.com/article.aspx?articleid=1900516.
Ladhani M, Craig JC, Irving M, Clayton PA, Wong G. Obesity and the risk of cardiovascular and all-cause mortality in chronic kidney disease: a systematic review and meta-analysis. Nephrol Dial Transplant [Internet]. 2016 May 4 [cited 2017 Apr 13];gfw075. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27190330.
Millwala F, Nguyen GC, Thuluvath PJ. Outcomes of patients with cirrhosis undergoing non-hepatic surgery: risk assessment and management. World J Gastroenterol [Internet]. 2007 Aug 14 [cited 2015 Nov 10];13(30):4056–63. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4205305&tool=pmcentrez&rendertype=abstract.
Jan A, Narwaria M, Mahawar KK. A systematic review of bariatric surgery in patients with liver cirrhosis. Obes Surg [Internet]. 2015 Aug [cited 2015 Nov 10];25(8):1518–26. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25982807.
Brown RS. Live donors in liver transplantation. Gastroenterology [Internet]. 2008 May [cited 2017 Jan 24];134(6):1802–13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18471556.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosure
The authors did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Conflict of Interest
The authors declare that they have no conflict of interest.
Ethical Approval Statement
For this type of study, formal consent is not required.
Informed Consent Statement
Does not apply.
Rights and permissions
About this article
Cite this article
Dziodzio, T., Biebl, M., Öllinger, R. et al. The Role of Bariatric Surgery in Abdominal Organ Transplantation—the Next Big Challenge?. OBES SURG 27, 2696–2706 (2017). https://doi.org/10.1007/s11695-017-2854-8
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11695-017-2854-8