Bariatric Surgery and Liver Transplantation Sammy Saab, MD, MPH, AGAF, FACG, FAASLD Professor of Medicine and Surgery Head, Outcomes Research in Hepatology David Geffen School of Medicine at UCLA
Disclosures Speaker Bureau/Consultation AbbVie, Bayer, BMS, Gilead, Intercept, Merck, Salix 2
Objectives Define the prevalence of fatty liver-associated liver disease in liver transplant candidates Describe the association between metabolic syndrome and long term outcomes in liver transplant recipients Discuss the time and role of bariatric surgery in patients with liver disease 3
Classification of Fatty Liver Disease Fatty Liver Disease 5% hepatic steatosis Alcoholic (ALD) Over a 2-year period Men: >21 drinks/week Women: >14 drinks/week Nonalcoholic (NAFLD) Nonalcoholic Fatty Liver (NAFL) Nonalcoholic Steatohepatitis (NASH) Chalasani N, et al. Hepatology. 2012; EASL-EASD-EASO. J Hepatol. 2016; Goh GB, et al. Dig Dis Sci. 2016; Liu W, et al. Cell Mol Life Sci. 2016; Younossi ZM, et al. Hepatology. 2016; Wong RJ, et al. Gastroenterology. 2015.
Current and Potential Therapeutic Targets in NASH Rotman Y, et al. Gut. 2017
Global Prevalence of NAFLD Meta-analysis (n=57 studies) NAFLD diagnosed by imaging 40 NAFLD Prevalence (based on imaging criteria) Overall NAFLD prevalence 25.24% (95% CI: 22.10-28.65) Increases with age: from 22% to 34% in people 30-39 and 70-79 years of age, respectively Prevalence decreases to 13% when studies using blood tests/icd code for NAFLD diagnosis are included N values are number of studies. Exclusion criteria for studies: Review article/abstract, NAFLD not identified, other causes of liver disease not excluded, no screening of excessive alcohol consumption, only included specific metabolic subgroups, presence of pre-existing diseases, <18 years of age, postmortem diagnosis. Younossi ZM, et al. Hepatology. 2016 Prevalence (%) 30 20 10 0 25% Overall (n=57) 24% North America (n=13) 31% 24% South Europe America (n=11) (n=2) 27% Asia (n=14) 32% Middle East (n=3) 13% Africa (n=27)
CDC access july 28 th 2017 Obesity is an Epidemic
Trend of obesity over time SDI = sociodemographic index GBD 2015 Obesity Collaborators, NEjM 2017
The World View of the Hepatologist Normal Liver NAFLD Injured Liver Chronic Fibrosis NASH? Cirrhosis Liver Cancer Death or Transplant
NAFLD is the most common cause of chronic liver disease and cirrhosis Setiawan et al. Hepatology 2016
Probability of First Clinical Decompensation of Cirrhosis According to BMI Watt KD. Liver Transpl 2012.
Obesity an Independent Risk Factor for Hepatic Decompensation Berzigotti et al. Hepatology 2011
Obesity as an independent risk factor for hepatic ecompensation 48/161 (30%) experienced decompensation in a median follow up of 59 mos. The higher BMI, the higher proportion with clinical decompensation. Berzigotti et al. Hepatology 2011
Age-standardized incidence rates of liver transplantation wait-listing Flemming JA, et al. Hepatology 2017.
Age-standardized incidence rates of liver transplantation wait-listing Flemming JA, et al. Hepatology 2017.
Improvements in overall survival age after adult liver transplantation from 1987-2012 Watt KD. Gastroenterology & Hepatology 2015
Body Mass Index Since Liver Transplantation Saab S, J Clin Transl Hepatol 2017
Prevalence of metabolic risk factors and syndrome in liver transplant recipients Watt KD. Gastroenterology & Hepatology 2015
incidcence/recurrence of non-alcoholic fatty liver, non-alcoholic steatohepatitis and Cirrhosis after Liver Transplantation Khullar et al World J Transplant 2014
Incidence/Reoccurence of Non-Alcoholic Fatty Liver Disease, Non-Alcoholic Steatohepatitis and Cirrhosis in Post-Liver Transplant Population Khullar V, Dolganiuc A, Firpi RJ. World J Transplant 2014.
Factors Associated with De Novo and Recurrent Nonalcoholic Fatty Liver Disease Kappus M, Abdelmalek M. Clin Liver Dis 2017.
Factors Associated with Nonalcoholic Fatty Liver Disease Development of Recurrence After Liver Transplantat Siddiqui MS, Charlton M. Gastroenterology 2016.
Overall mortality between controls and increased BMI liver transplant recipients Saab S, et al. Liver Int 2015.
Cumulative incidence of major vascular events among liver transplant recipients with or without PTMS Laryea et al, Liver Transplantation 2007
Incidence of Major Vascular Events during Study Period Overall and for PTMS Patients and Those Without PTMS Laryea et al. Liver Transplantation 2007
Types of Bariatric Surgery Adjustable gastric band Sleeve gastrectomy Roux-en-Y gastric bypass Suraweera D, et al. Gastroenterol Hepatol 2017.
Timing of Bariatric Surgery Compensated Cirrhosis Decompensated Cirrhosis Before OLT Time of transplant After liver transplant
Summary of Bariatric Surgery Performed in Liver Transplant Recipients Before Transplant With Transplant Dziodzio et al, Obesity Surgery 2017
Summary of Bariatric Surgery Performed in Liver Transplant Recipients (continued) After Transplant Dziodzio et al, Obesity Surgery 2017
Liver Disease and Candidacy for Bariatric Surgery Suraweera D, et al. Gastroenterol Hepatol 2017.
Suggestions for bariatric surgery in organ transplantation Dziodzio T, et al. Obes Surg 2017
Conclusion Obesity and fatty liver and important medical and public health concerns Liver transplant recipients are living longer, and will be at risk of metabolic complications The role of bariatric surgery in patients with liver disease is emerging 32
Osseis et al, Obesity Surgery 2017