Expired CME Article

Challenges of Abdominal Organ Transplant in Obesity

Authors: Mary Killackey, MD, Rubin Zhang, MD, Kelly Sparks, RD, Anil Paramesh, MD, Douglas Slakey, MD, MPH, Sander Florman, MD

Abstract


Obesity is a worldwide epidemic and public health crisis associated with severe comorbidity leading to end organ dysfunction and poorer transplant outcome. Large population studies show decreased patient and graft survival in obese kidney transplant patients. Despite the poorer outcomes, kidney transplant is considered because of the survival benefit as compared to the wait-listed dialysis patients. In liver transplantation, the benefit of transplant as compared to remaining on the list is obvious because there is no viable liver dialysis at this time.


Obesity in potential organ donors impacts both medical and surgical issues. Obesity-related kidney disease affects both the remaining and transplanted kidney. Pancreas donor organs are associated with decreased early graft survival. Liver donor organs with significant steatosis lead to an increased risk for delayed function or nonfunction of the organ.


Immunosuppressive drugs with variable lipophilicity and altered volume of distribution can greatly affect the therapeutic usefulness of these drugs.


Transplant candidates benefit from a multidisciplinary team approach to their care. As the epidemic progresses and less invasive treatments for metabolic surgery evolve, we are likely to see more patients lose weight before transplant as we continue to strive for improved outcomes.



This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1.World Health Organization. Obesity and overweight. Geneva: WHO, September 2007.
 
2.Flegal K, Carroll M, Ogden C, et al. Prevalence and trends in obesity among US adults, 1999–2000. JAMA 2002;288:1723–1727.
 
3.Hedley A, Ogden C, Johnson C, et al. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999–2002. JAMA 2004;297:2847–2850.
 
4.Ogden C, Yanovski S, Carroll M, et al. The epidemiology of obesity. Gastroenterology 2007;132:2087–2102.
 
5.Louisiana Department of Health and Hospitals, Baton Rouge, 2007.
 
6.World Health Organization. The international classification of adult underweight, overweight and obesity according to BMI. Adapted from WHO 1995, WHO 2000, and WHO 2004.
7.Sturm R. Increases in clinically severe obesity in the United States, 1986–2000. Arch Intern Med 2003;163:2146–2148.
8.Wang Y, Beydoun M. The obesity epidemic in the United State—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: A systematic review and meta-regression analysis. Epidem Rev 2007;29:6–28.
9.Olshansky S, Passaro D, Hershow R, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med 2005;352:1138–1145.
10.Fabricatore A, Wadden T. Obesity. Annu Rev Clin Psychol 2006;2:357–377.
11.Calle E, Thun M, Petrelli J, et al. Body-mass index and mortality in a prospective cohort of US adults. N Engl J Med 1999;341:1097–1105.
12.Kenchaiah S, Evans J, Levy D, et al. Obesity and the risk of heart failure. N Engl J Med 2002;347:305–313.
13.Mathier M, Ramanathan R. Impact of obesity and bariatric surgery on cardiovascular disease. Med Clin North Am 2007;91:415–431.
14.McGill H Jr, McMahan C, Herderick E, et al. Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Obesity accelerates the progression of coronary atherosclerosis in young men. Circulation 2002;105:2712–2718.
15.Quan S, Gersh B. National Center of Sleep Disorders Research; National Heart, Lung and Blood Institute Cardiovascular consequences of sleep-disordered breathing: past, present and future: report of a workshop from the National Center on Sleep Disorders Research and the National Heart, Lung and Blood Institute. Circulation 2004;109:951–957.
16.Frey W, Pilcher J. Obstructive sleep-related breathing disorders in patients evaluated for bariatric surgery. Obes Surg 2003;13:676–683.
17.Zimmet P, Alberti K, Shaw J. Global and societal implications of the diabetes epidemic. Nature 2001;414:782–787.
18.Weinbrenner T, Schroder H, Escurriol V, et al. Circulating oxidized LDL is associated with increased waist circumference independent of body mass index in men and women. Am J Clin Nutr 2006;83:30–35.
19.Zhang R, Lia J, Morse S, et al. Kidney disease in the metabolic syndrome. Am J Med Sci 2005;330(6):319–325.
20.Zhang R, Thakur V, Reisin E. Renal and cardiovascular considerations for the nonpharmacological and pharmacological therapies of obesity-hypertension. J Human Hypertens 2002;16(12):819–827.
21.Kambham N, Markowitz G, Valeri A, et al. Obesity related glomeruplopathy: An emerging epidemic. Kidney Int 2001;59(4):1498–1509.
22.Jones R, Nzekwu M. The effects of body mass index on lung volumes. Chest 2006;130:827–833.
23.Benumof J. Obesity, sleep apnea and anesthesia. Curr Opin Anaesthesiol 2004;17:21–30.
24.Nguyen N, Silver M, Robinson M, et al. Result of a national audit of bariatric surgery performed at academic centers: a 2004 University Health System Consortium Benchmarking Project. Arch Surg 2006;141:445–449.
25.Hamad G, Bergqvist D. Venous thromboembolism in bariatric surgery patients: an update of risk and prevention. Surg Obes Relat Dis 2007;3:97–102.
26.DeMaria E, Carmody B. Perioperative management of special populations: obesity. Surg Clin North Am 2005;85:1283–1289.
27.Dindo D, Muller M, Weber M, et al. Obesity in general elective surgery. Lancet 2003;361:2032–2035.
28.Meier-Kriesche H, Arndorfer J, Kaplan B. The impact of body mass index on renal transplant outcomes: a significant independent risk factor for graft failure and patient death. Transplantation 2002;73:70–74.
29.Yamamoto S, Hanley E, Hahn A, et al. The impact of obesity in renal transplantation: an analysis of paired cadaver kidneys. Clin Transplant 2002;16:252–256.
30.Glanton C, Kao T, Cruess D, et al. Impact of renal transplantation on survival in end-stage renal disease with elevated body mass index. Kidney Int 2003;63:647–653.
31.Pelletier S, Maraschio M, Schaubel D, et al. Survival benefit of kidney and liver transplantation for obese patients on the waiting list. Clin Transplant 2003;77–88.
32.Marks W, Florence L, Chapman P, et al. Morbid obesity is not a contraindication to kidney transplantation. Am J Surg 2204;187:635–638.
33.Massarweh N, Clayton J, Mangum C, et al. High body mass index and short- and long-term renal allograft survival in adults. Transplantation 2005;80:1430–1434.
34.Alexander J, Goodman H. Gastric bypass in chronic renal failure and renal transplant. Nutr Clin Pract 2007;22:16–21.
35.Sawyer R, Pelletier S, Pruett T. Increased early morbidity and mortality with acceptable long-term function in severely obese patients undergoing liver transplantation. Clin Transplant 1999;13:126–130.
36.Heimbach J, Taler S, Prieto M, et al. Obesity in living kidney donors: clinical characteristics and outcomes in the era of laparoscopic donor nephrectomy. Am J Transplant 2005;5:1057–1064.
37.Chagnac A, Weinstein T, Korzets A, et al. Glomerular hemodynamics in severe obesity. Am J Physiol Renal Physiol 2000;278:F817–F822.
38.Bagby S. Obesity-initiated metabolic syndrome and the kidney: a recipe for chronic kidney disease? J Am Soc Nephrol 2004;15:2775–2791.
39.Wisse B. The inflammatory syndrome: The role of adipose tissue cytokines in metabolic disorders linked to obesity. J Am Soc Nephrol 2004;15:2792–2800.
40.Kamijo A, Kimura, Sugaya T, et al. Urinary free fatty acids bound to albumin aggravate tubulointerstitial damage. Kidney Int 2002;62: 1623–1637.
41.Morales E, Valero A, Leon M, et al. Beneficial effects of weight loss in overweight patients with chronic proteinuric nephropathies. Am J Kidney Dis 2003;41:319–327.
42.Humar A, Ramcharan T, Kandaswamy R, et al. The impact of donor obesity on outcomes after cadaver pancreas transplant. Am J Transplant 2004;4:605–610.
43.Escartin A, Castro E, Dopazo C, et al. Analysis of discarded livers for transplantation. Transplant Proc 2005;37:3859–3860.
44.Hong J, Busuttil R. Cold ischemia time and liver graft survival. Am J Transplant 2008;8:481–482.
45.Selzner M, Rudiger H, Sindram D, et al. Mechanisms of ischemic injury are different in the steatotic and normal rat liver. Hepatology 2000;32:1280–1288.
46.Imber C, St Peter S, Handa A, et al. Hepatic steatosis and its relationship to transplantation. Liver Transpl 2002;8:415–423.
47.Fishbein T, Fiel M, Emre S, et al. Use of livers with microvesicular fat safely expands the donor pool. Transplantation 1997;64:248–251.
48.Cheymol G. Effects of obesity on pharmacokinetics implications for drug therapy. Clin Pharmacokin 2000;39:215–231.
49.Angulo P. Nonalcoholic fatty liver disease. N Engl J Med 2002;346:1221–1231.
50.Miller A, Smith K. Medication and nutrient administration considerations after bariatric surgery. Am J Health-Syst Pharm 2006;63:1852.
51.Rogers C, Alloway R, Alexander J, et al. Pharmacokinetics of mycophenolic acid, tacrolimus and sirolimus after gastric bypass surgery in end-stage renal disease and transplant patients: a pilot study. Clin Transpl 2008;22:281–291.