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Impact of Prior Bariatric Surgery on Perioperative Liver Transplant

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Impact of Prior Bariatric Surgery on Perioperative Liver Transplant ORIGINAL ARTICLE IDRISS ET AL. Impact of Prior Bariatric Surgery on Perioperative Liver Transplant Outcomes Rajab Idriss,1 Jeanette Hasse,1 Tiffany Wu,2 Fatima Khan,1 Giovanna Saracino,1 Greg McKenna,1 Giuliano Testa,1 James Trotter,1 Goran Klintmalm,1 and Sumeet K. Asrani1 1 Baylor University Medical Center, Dallas, TX; and 2 Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA Bariatric surgery (BS) is effective in treating morbid obesity, but the impact of prior BS on candidacy for liver transplantation (LT ) is unclear. We examined 78 patients with cirrhosis with prior BS compared with a concurrent cohort of 156 patients matched by age, Model for End-Stage Liver Disease score, and underlying liver disease. We compared rates of transplant denial after evaluation, delisting on the waiting list, and survival after LT. The median time from BS to LT evaluation was 7 years. Roux-en-Y gastric bypass was the most common BS procedure performed (63% of cohort). Nonalcoholic fatty liver disease was the leading etiology for liver cirrhosis (47%). Delisting/death on the waiting list was higher among patients with BS (33.3% versus 10.1%; P = 0.002), and the transplantation rate was lower (48.9% versus 65.2%; P = 0.03). Intention-to-treat (ITT) survival from listing to 1 year after LT was lower in the BS cohort versus concurrent cohort (1-year survival, 84% versus 90%; P = 0.05). On adjusted analysis, a history of BS was associated with an increased risk of death on the waiting list (hazard ratio [HR], 5.7; 95% confidence interval [CI], 2.2-15.1), but this impact was attenuated (HR, 4.9; 95% CI, 1.8-13.4) by the presence of malnutrition. When limited to matched controls by sex, mortality attributed to BS was no longer significant for females (P = 0.37) but was significant for males (P = 0.046). Sarcopenia, as captured by skeletal muscle index, was calculated in a subset of patients (n = 49). The total skeletal surface area was lower in the BS group (127 [105-141] cm2 versus 153 [131-191] cm2; P = 0.005). Rates of sarcopenia were higher among patients delisted after listing (71.4% versus 16.7%; P = 0.04). In conclusion, a history of BS was associated with higher rates of delisting on the waiting list as well as lower survival from the time of listing on ITT analysis. Presence of malnutrition and sarcopenia among patients with BS may contribute to worse outcomes. Liver Transplantation 25 217‒227 2019 AASLD. Received June 8, 2018; accepted October 18, 2018. SEE EDITORIAL ON PAGE 203 (HTN), cardiovascular disease, and nonalcoholic fatty liver disease (NAFLD).(3) Bariatric surgery (BS) is considered one of the most effective options to treat Obesity is a major health burden worldwide. More than (1,2) severe obesity and reduces obesity-related comorbidi- one-third of the US population is considered obese. ties, such as NAFLD,(4,5) induces the disappearance of Morbid obesity is associated with an increased prev- steatohepatitis, reduces fibrosis, and improves relevant alence of diabetes mellitus (DM), hypertension metabolic comorbidities.(6-8) Increasingly, patients with decompensated cirrhosis Abbreviations: ALD, alcoholic liver disease; BMI, body mass index; who underwent BS are encountered for consideration of BS, bariatric surgery, CC, cryptogenic cirrhosis; CI, confidence liver transplantation (LT). The short-term and longterm interval; CKD, chronic kidney disease; CT, computed tomography; surgical complications of BS are well documented, DM, diabetes mellitus; HCV, hepatitis C virus; HR, hazard ratio; (7,9) HTN, hypertension; IQR, interquartile range; ITT, intention- including infection and nutrient deficiencies. Over to-treat; LT, liver transplantation; MELD, Model for End-Stage the last decade, several case series have described liver Liver Disease; NAFLD, nonalcoholic fatty liver disease; NASH, failure after BS.(10-13) In most of the reports, liver fail- nonalcoholic steatohepatitis; RYGB, Roux-en-Y gastric bypass; SGA, subjective global assessment; SMI, skeletal muscle index. ure occurred early postoperatively, presented with quick deterioration of liver function, and may have been asso- Address reprint requests to Sumeet K. Asrani, M.D., M.Sc., Baylor (12,14) University Medical Center, 3410 Worth Street, Suite 860, Dallas, ciated with rapid weight loss and malnutrition. TX 75246. Telephone: 214-820-8500; FAX: 214-820-0993; However, the effect of BS on liver function and the nutri- E-mail: [email protected] tion consequences in patients with cirrhosis, regardless of etiology, years after BS are not completely clear. ORIGINAL ARTICLE | 217 IDRISS ET AL. LIVER TRANSPLANTATION, February 2019 Malnutrition occurs frequently in patients undergo- (MELD) score at evaluation, and etiology of disease. ing LT and adversely affects transplant outcomes.(15) Patients undergoing retransplant as well as those with Sarcopenia defined as the loss of muscle mass and hepatocellular carcinoma were also excluded to create function(16,17) has also been recognized in recent years a cohort of patients with decompensated liver disease as a predictor of pre- and post-LT outcomes.(18,19) being considered for primary LT. Sarcopenic obesity, characterized by loss of muscle mass and preservation of fat, is a condition that can be DATA SOURCE present in patients with cirrhosis who have undergone BS, and this sarcopenia may play a role in the outcomes We examined center-specific data using a prospec- of this group of patients.(20-22) tively maintained locked database capturing inpatient, We hypothesized that compared with matched outpatient, and nontransplant-related encounters in all patients who had not undergone BS, patients with evaluated patients before and after LT with seamless cirrhosis who had undergone BS would have worse linkage to clinical data and longterm outcomes. We outcomes on the waiting list as well as increased compli- extracted data on characteristics of liver disease (eg, cations and reduced graft and patient survival post-LT decompensation), demographics, characteristics of partially driven by malnutrition and sarcopenia. weight loss (amount of weight loss, time of BS relative to evaluation for LT, and stage of fibrosis). In addition, the type of BS was noted: Rou x-en-Y gastric bypass (RYGB), sleeve gastrectomy, adjustable gastric band, Patients and Methods or biliopancreatic diversion with duodenal switch. The primary aim of this study was to identify the in- dependent impact of prior BS on outcomes among pa- NUTRITION STATUS tients on the LT waiting list as well as after LT. The Given that patient outcomes may be impacted by secondary outcome was to identify the effect of mal- numerous factors, we examined the role of nutrition nutrition and sarcopenia on outcomes before and after status as well as the presence of sarcopenia. The pres- LT among patients with prior BS. ence of malnutrition was assessed using the validated subjective global assessment (SGA) tool, and patients PATIENTS were classified as well-nourished or moderately or se- verely malnourished by trained registered dietitians We examined adult patients who were evaluated for LT (23-25) specializing in transplantation. The moderately between 1985 and 2017 at Baylor Simmons Transplant Institute. We identified adult patients who had a his- and severely malnourished patients were combined into a single group and identified as malnourished. tory of BS prior to evaluation for consideration of pri- mary LT. Patients were matched (2:1) to a concurrent SGA has been consistently used at our institution since (26) To assess sarcopenia, abdominal computed cohort on age, Model for End-Stage Liver Disease 1987. tomography (CT) images within the 12 months prior to the date of LT evaluation among patients in the BS Authors had access to all the study data, take responsibility for cohort and concurrent cohort were analyzed for body the accuracy of the analysis, and had authority over manuscript composition. For the 2 study groups, transverse CT preparation and the decision to submit the manuscript for publication. images at the third lumbar vertebra were downloaded All authors approve the manuscript. as a digital imaging and communications in medicine Funding is provided by a Baylor foundation grant. file and were analyzed using a novel software, Slice- James Trotter is on the speaker’s bureau for Gilead. O-Matic, version 4.3 (Tomovision, Montreal, Canada) Additional supporting information may be found in the online version by a trained investigator (R.I.) according to previously (27) of this article. published protocols. Data extracted included total abdominal muscle area, intramuscular adipose tissue, Copyright © 2018 by the American Association for the Study of Liver Diseases. subcutaneous adipose tissue, and visceral adipose tis- sue. Sarcopenia was defined according to the following View this article online at wileyonlinelibrary.com. equation for the skeletal muscle index (SMI): (total ab- DOI 10.1002/lt.25368 dominal muscle area in cm2)/(height in m2). The cut- off points for sarcopenia were determined according to 218 | ORIGINAL ARTICLE LIVER TRANSPLANTATION, Vol. 25, No. 2, 2019 IDRISS ET AL. the previously reported values for patients with cirrho- with 63% maintaining their weight loss by self-report; sis: males, <50 cm2/m2 and females, <39 cm2/m2.(28) 83% of BS patients had a previous history of abdominal surgeries (other than the BS). The date of liver cirrhosis STATISTICAL ANALYSIS diagnosis was available for 51% (40/78) of the patients from the BS cohort. Liver cirrhosis was diagnosed after The primary outcomes when comparing the BS co- BS in 27 patients, 9 were diagnosed at time of BS, and hort with the concurrent cohort included denial for 4 patients were diagnosed before BS. The median time LT, listing for LT transplantation, delisting due to between the BS and evaluation for LT was 7 years. The death or deterioration in condition on the waiting list, demographics and clinical characteristics of all the pa- intention-to-treat (ITT) survival (from listing), and tients are shown in Table 1.
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