The role of bariatric surgery in solid organ transplantation

Although controversial, many organ transplant centers use BMI as one of many criteria to determine if a patient is eligible for a transplant. Why? Research shows better outcomes with those patients whose BMIs are within an appropriate range for their respective transplanted organ type.

In some cases, BMI itself may be a contraindication for organ transplant. However, these contraindications occur at different BMI ranges and depend on the type of solid organ transplant.^1-7 With these considerations in mind, many patients, physicians, and researchers are looking to bariatric surgery either before, during, or after organ transplant.

Why bariatric surgery for organ transplant patients?

Obesity remains a public health concern, even in the organ transplant patient population. Twenty percent of lean patients develop obesity within two years of transplantation.⁸ Meta analyses support superior efficacy of bariatric surgery compared to non-surgical therapy in achieving sustained weight loss in morbidly obese patients.^9,10 

Gastric bypass (GBP) and vertical sleeve gastrectomy (VSG) are the two types of bariatric surgery considered in solid organ transplant candidates. The choice between the two procedures should be determined on a case-by-case basis.

On one hand, VSG may be better for post-transplant recipients, as it is purely restrictive and doesn’t incorporate a malabsorptive component, thus minimizing interference with medication absorption.^3,4 A single institution study found the VSG to be a faster procedure, have lower complication rates, and was less traumatic.⁵ 

On the other hand, VSG’s irreversibility may potentially harm those who lose too much weight. Plus, VSG often results in a lower percentage of excess body weight loss, is less effective in the long term, and if leaks occur, they heal slower than GBP.^3-5

Timing is everything

If bariatric surgery is considered, the optimal timing of the procedure in relation to organ transplantation is difficult to determine. Should bariatric surgery occur before, during, or after transplantation of the solid organ? This remains a controversial issue and requires more study to determine the answer.

Bariatric surgery before transplant may reduce or resolve obesity-related complications¹¹ and in fact, organ function may increase once excess weight is lost.^1,2 If a patient is not a candidate for transplant due to excess weight, it may be feasible for the patient to have bariatric surgery first so the patient can qualify for transplant.

Concurrent bariatric surgery and organ transplantation has shown decreased length of stay, decreased levels of patient stress, and risk reduction of new onset diabetes after transplant and steatosis. However, it involves high perioperative risk and high potential of initial poor organ function.15

In addition, increased incidence of delayed graft function, primary graft non-function, surgical site infections, and overall inferior graft outcomes in those who are obese when transplanted have been noted versus those who are at a normal weight or are overweight.^1,12-14

Concurrent bariatric surgery and organ transplantation has shown decreased length of stay, decreased levels of patient stress, and risk reduction of new onset diabetes after transplant and steatosis. However, it involves high perioperative risk and high potential of initial poor organ function.¹⁵

A systematic review of the role of bariatric surgery in solid organ transplantation found waiting until after transplant to perform bariatric surgery led to decreased mortality risk (2.5 percent vs. 3.9 percent mortality risk for bariatric surgery before transplant).^16,17  Thus, perhaps it’s slightly safer to wait until after transplant to perform bariatric surgery.

In the case of the post-transplant patient who did not have obesity before transplant but developed obesity after transplant, bariatric surgery is recommended to improve survival and increase the lifetime of the organ graft.^1-7 One point in which all studies seem to agree is that bariatric surgery should not be performed until patient is at least one year post-transplant.^1-6

Is bariatric surgery the best choice?

Obesity is strongly associated with inferior outcomes, increased surgical risk, and decreased graft survival both before and after solid organ transplant.^1-7 Bariatric surgery is effective and safe in selected patients although the patient population with organ failure vs. insufficiency is higher risk.

Conventional weight loss methods can still be recommended for those who are determined and healthy enough to do it, but the likelihood of success isn’t as high as with bariatric surgery. Whether transplant or bariatric surgery should come first remains elusive, despite promising research on both sides of the issue, since most sample sizes are too small to result in a change of practice or develop into a standard of care.

Want to learn more about nutrition therapy for organ transplantation? Check out the webinar MNT for Solid Organ Transplant

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References:

Suraweera D, Saab EG, Choi G, Saab S. Bariatric Surgery and Liver Transplantation. Gastroenterology & Hepatology. 2017;13(3):170-175.

Portenier D, Jain-Spangler K. Bariatric Surgery in the Transplant Patient. Bariatric Times. July 2012.

Dziodzio T, Biebl M, Öllinger R, Pratschke J, Denecke C. The Role of Bariatric Surgery in Abdominal Organ Transplantation—the Next Big Challenge? Obesity Surgery. 2017;27(10):2696-2706. doi:10.1007/s11695-017-2854-8.

Modanlou KA, Muthyala U, Xiao H, et al. Bariatric Surgery Among Kidney Transplant Candidates and Recipients: Analysis of the United States Renal Data System and Literature Review. Transplantation. 2009;87(8):1167-1173. doi:10.1097/tp.0b013e31819e3f14.

Kim Y, Jung AD, Dhar VK, et al. Laparoscopic sleeve gastrectomy improves renal transplant candidacy and posttransplant outcomes in morbidly obese patients. American Journal of Transplantation. 2018;18(2):410-416. doi:10.1111/ajt.14463.

Yemini R, Nesher E, Winkler J, et al. Bariatric surgery in solid organ transplant patients: Long-term follow-up results of outcome, safety, and effect on immunosuppression. American Journal of Transplantation. 2018;18(11):2772-2780. doi:10.1111/ajt.14739.

Szomstein S, Rojas R, Rosenthal RJ. Outcomes of Laparoscopic Bariatric Surgery after Renal Transplant. Obesity Surgery. 2009;20(3):383-385. doi:10.1007/s11695-009-9969-5.

Everhart JE, Lombardero M, Lake JR, Wiesner RH, Zetterman RK, Hoofnagle JH. Weight change and obesity after liver transplantation: incidence and risk factors. Liver Transplantation and Surgery. 1998;4(4):285-296.

Watt KD, Charlton MR. Metabolic syndrome and liver transplantation: A review and guide to management. Journal of Hepatology. 2010;53(1):199-206. doi:10.1016/j.jhep.2010.01.040.

Heredia FPD, Gómez-Martínez S, Marcos A. Obesity, inflammation and the immune system. Proceedings of the Nutrition Society. 2012;71(2):332-338. doi:10.1017/s0029665112000092.

Takata MC, Campos GM, Ciovica R, et al. Laparoscopic bariatric surgery improves candidacy in morbidly obese patients awaiting transplantation. Surgery for Obesity and Related Diseases. 2008;4(2):159-164. doi:10.1016/j.soard.2007.12.009.

Nicoletto BB, Fonseca NKO, Manfro RC, Gonçalves LFS, Leitão CB, Souza GC. Effects of Obesity on Kidney Transplantation Outcomes. Transplantation. 2014;98(2):167-176. doi:10.1097/tp.0000000000000028.

Cannon RM, Jones CM, Hughes MG, Eng M, Marvin MR. The Impact of Recipient Obesity on Outcomes After Renal Transplantation. Annals of Surgery. 2013;257(5):978-984. doi:10.1097/sla.0b013e318275a6cb.

Molnar MZ, Kovesdy CP, Mucsi I, et al. Higher recipient body mass index is associated with post-transplant delayed kidney graft function. Kidney International. 2011;80(2):218-224. doi:10.1038/ki.2011.114.

Heimbach JK, Watt KDS, Poterucha JJ, et al. Combined Liver Transplantation and Gastric Sleeve Resection for Patients With Medically Complicated Obesity and End-Stage Liver Disease. American Journal of Transplantation. 2012;13(2):363-368. doi:10.1111/j.1600-6143.2012.04318.x.

Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. Trends in mortality in bariatric surgery: A systematic review and meta-analysis. Surgery. 2007;142(4):621-635. doi:10.1016/j.surg.2007.07.018.

Morino M, Toppino M, Forestieri P, Angrisani L, Allaix ME, Scopinaro N. Mortality After Bariatric Surgery. Annals of Surgery. 2007;246(6):1002-1009. doi:10.1097/sla.0b013e31815c404e.