Kidney transplantation in the morbidly obese: complicated but still better than dialysis

Bennett WM, McEvoy KM, Henell KR, Pidikiti S, Douzdjian V, Batiuk T. Kidney transplantation in the morbidly obese: complicated but still better than dialysis.
Clin Transplant 2011: 25: 401–405. © 2010 John Wiley & Sons A/S. Abstract: Obese patients are denied renal transplantation in many centers. We report results regarding obesity from a new transplant program (1999 through 2007). Six hundred and forty‐two patients were transplanted: 439 patients with BMI < 30 (Group 1), 109 patients with BMI 30.1‐34.9 (Group 2), and 89 patients with BMI > 35 (Group 3). Follow‐up was at least one yr. Medical and surgical management was performed by the same team throughout the study period. There were no demographic differences between groups except for increased diabetes in Groups 2 and 3. Actuarial graft and patient survivals were not statistically different between groups. Group 3 patients had numerical trends toward more delayed graft function and lower graft survivals but these did not reach statistical significance. Biopsy‐proven rejections did not differ between groups. Wound infections were statistically significant in Groups 2 and 3 compared to Group 1 (p < 0.01). Despite increased wound infection rates with increased BMI, transplanting patients with morbid obesity results in better survival for individual patients than dialysis. Thus, there is no a priori ethical reason for treating obese ESRD patients differently from those with other comorbidities.     

Obesity Affects Short-Term Renal Function After Renal Transplantation

BackgroundThe literature has shown a significant association between body mass index (BMI) and patient and graft outcomes after renal transplantation. The purpose of this study was to reveal the effect of obesity on graft function in a Taiwanese kidney transplant cohort.MethodsTwo hundred consecutive patients who received kidney transplantation were enrolled in our study. Eight pediatric cases were excluded due to differing definitions of BMI among children. According to the national obesity criteria, these patients were divided into underweight, normal, overweight, and obese groups. Their estimated glomerular filtration rate (eGFR) was compared accordingly using t tests. Cumulative graft and patient survivals were calculated using Kaplan-Meier analysis. A P value of ≤ .05 was considered significant.ResultsThe mean age of our cohort (105 men and 87 women) was 45.3 years. There was no significant difference comparing biopsy-proven acute rejection, acute tubular necrosis, and delayed graft function between the obese and nonobese groups (P values: .293, .787, and .304, respectively). Short-term eGFR was inferior in the overweight group, but this effect was insignificant beyond 1 month. The 1-month and 3-month eGFR were found to be correlated with BMI groups (P = .012 and P = .008, respectively) but not significant after 6 months post–kidney transplantation.ConclusionsOur study found that short-term renal function was affected by obesity and being overweight, possibly due to the higher prevalence of diabetes and dyslipidemia in obese patients and the increased surgical difficulty.     

Factors Affecting Persistent Splenomegaly After Adult-to-Adult Living Donor Liver Transplantation Using a Left Lobe

BackgroundThe aim of the present study was to evaluate spleen volume (SV) and the factors influencing it after adult-to-adult living donor liver transplantation (A2LDLT) using a left lobe.MethodsPretransplant computed tomography (CT) and post-transplant CT 2 years after A2LDLT were examined by volumetric analysis in 24 patients. We divided the recipients into the following 2 groups according to the post-transplant SV: >500 mL (Group A) and ≤500 mL (Group B). The factors affecting the change in post-transplant SV were compared between the 2 groups.ResultsThe mean pretransplant SV decreased significantly after A2LDLT. Platelet counts after living donor liver transplantation increased significantly relative to the pretransplant values. Post-transplant SV was >500 mL in 9 patients (Group A) and ≤500 mL in 15 (Group B). Pretransplant SV, platelet count, anhepatic time, operative time, intraoperative blood loss, post-transplant portal vein pressure >20 mm Hg, and post-transplant portal vein flow >250 mL/min/100 g graft weight showed significant differences between the 2 groups. Actual graft volume (GV) and GV/standard liver volume ratio showed no intergroup differences. Multivariate analysis showed that the only significant factor related to a post-transplant SV of >500 mL was the pretransplant SV. Post-transplant platelet counts were significantly increased from the pretransplant values in both Group A and Group B.ConclusionsPretransplant SV is the only significant factor predicting a SV of >500 mL after A2LDLT. However, even in patients with a SV of >500 mL, the platelet count increased significantly from the pretransplant value.     

Obesity in kidney transplant recipients: association with decline in glomerular filtration rate

Abstract

In this study we aimed to evaluate the influence of obesity in kidney and patient survival and graft function. Retrospective cohort study of kidney transplant recipients performed between 2001 and 2009. The body mass index was calculated at time of transplantation, one and five years after. The main outcomes studied were incidence of delayed graft function, new onset diabetes after transplantation, patient and graft survival, and glomerular filtration rate. The prevalence of obesity and overweight patients were 10.7% and 26.8% respectively, with an increase to 16.9% and 32.5% one year after transplantation. Underweight and obese recipients presented a higher incidence of early graft loss. The incidence of new onset diabetes after transplantation was significantly higher at one and five years in overweight or obese recipients at baseline. Overweight and obese recipients presented significantly lower estimated glomerular filtration rate at five years posttransplantation (p?=?0.002). In the Kaplan–Meier analyses no statistically significant differences in patients or grafts survivals were observed. Obese patients have a higher rate of early graft failure and a higher new onset diabetes after transplantation incidence. Also, the finding of decreased glomerular filtration rate is worrisome and perhaps longer follow-up will reveal more graft failures and patients deaths in the group of obese recipients.     

Effect of Degree of Obesity on Renal Transplant Outcome

Obesity in renal transplantation has proven to affect both patient and graft survival. The scientific community seems to be split into 2 groups: one claims similar outcomes among obese and nonobese, showing only marginally increased postoperative complications; whereas the other group report a higher rate of complications, including graft loss and mortality. These results did not provide sufficient evidence to be applied in practice. In this study we analyzed the outcomes of obese recipients of renal transplant in our institution. One hundred fourteen renal transplantations were performed between January 1993 and December 2003. To estimate the impact of various degrees of obesity, the patients were allocated into 2 cohorts: Group A (body mass index [BMI] 30-34.9) and Group B (BMI 35 and greater). We analyzed patient and donor characteristics. Wound infection rates were similar in the 2 groups. The aggregate Group A and B patient survival rate was 95.6% at 1 year and 93% at 5 years. Graft survival rate was 93.9% at 1 year and 88% at 5 years. However, the analysis of the outcomes in the 2 groups with different degrees of obesity showed that the patient survival rate at 1 year in Group A was 98.9% (1 death) and 95.6% at 5 years (4 deaths). In Group B the patient survival rate at 1 year was 87.5% (3 deaths; P = .007) and at 5 years was 79.2% (P = .006). Graft survival rate in Group A was 98.9% (1 graft loss) at 1 year and 94.5% (5 graft losses) at 5 years; in Group B the graft survival rate was 75% (6 graft loss) at 1 year and 63% (9 graft losses) at 5 years (P < .0001 both at 1 and 5 years). The present study showed that overall obese recipient outcomes were as expected when evaluating the obese as a single group of recipients with a BMI >30. The overall patient and graft survival did not show particularly different results from already published studies claiming similar outcomes. However, this series showed different outcomes when we divided them into 2 groups by BMI. There was a remarkable difference between moderate obese (Group A) and morbid obese (Group B) recipients as regards patient and graft survival. It is possible that the excellent outcome in Group A may be the result of super-selection and stringent cardiovascular risk screening that is implemented for this category of potential recipients. Obese recipients with a BMI of >35 are a high-risk category. Because of the difference in the outcomes of the 2 groups, it does not seem reasonable to address obese recipients as a single group. We believe that obese patients should not be discriminated simply on the basis of the BMI. A strict evaluation should be performed before denying the opportunity to receive a renal transplant to these patients.     

Bariatric Surgery to Target Obesity in the Renal Transplant Population: Preliminary Experience in a Single Center

During the last century, obesity has become a global epidemic. The effect of obesity on renal transplantation may occur in perioperative complications and impairment of organ function. Obese patients have metabolic derangements that can be exacerbated after transplantation and obesity directly impacts most transplantation outcomes. These recipients are more likely to develop adverse graft events, such as delayed graft function and early graft loss. Furthermore, obesity is synergic to some immunosuppressive agents in triggering diabetes and hypertension. As behavioral weight loss programs show disappointing results in these patients, bariatric surgery has been considered as a means to achieve rapid and long-term weight loss.Up-to-date literature shows laparoscopic bariatric surgery is feasible and safe in transplantation candidates and increases the rate of transplantation eligibility in obese patients with end-stage organ disease. There is no evidence that restrictive procedures modify the absorption of immunosuppressive medications. From 2013 to 2016 we performed six bariatric procedures (sleeve gastrectomy) on obese patients with renal transplantation; mean preoperative body mass index (BMI) was 39.8 kg/m². No postoperative complication was observed and no change in the immunosuppressive medications regimen was needed. Mean observed estimated weight loss was 27.6%, 44.1%, 74.2%, and 75.9% at 1, 3, 6, and 12 months follow-up, respectively. Our recommendation is to consider patients with BMI >30 kg/m² as temporarily ineligible for transplantation and as candidates to bariatric surgery if BMI >35 kg/m². We consider laparoscopic sleeve gastrectomy as a feasible, first-choice procedure in this specific population.     

Effect of Pretransplantation Body Mass Index on Allograft Function and Patient Survival After Renal Transplantation

We evaluated the effects of pretransplantation recipient body mass index (BMI) on allograft survival and on kidney function. Kidney transplant recipients were grouped according to their pretransplantation BMIs: Group I (BMI <18.5 kg/m²; n = 10); Group II (BMI 18.5-24.9 kg/m²; n = 62); Group III (BMI 25.0-29.9 kg/m²; n = 47); and Group IV (BMI >30.0 kg/m²; n = 16). Excellent 1-year patient and graft survival rates were observed in all groups. Increased BMI was associated with increased hypertension and longer hospital stays. The incidence of acute rejection episodes, slow graft function, and delayed graft function, as well as the need for antithymocyte globulin Fresenius (ATG-F) rescue therapy were comparable between the 4 patient groups. The 1-year glomerular filtration rate was markedly different between the 4 patient groups. The 1-year posttransplantation glucose level was higher among obese patients compared with the other groups. A multivariate regression analysis confirmed the association of a higher 1-year GFR with obesity (BMI >30.0 kg/m²). Overweight and obese recipients showed excellent long-term patient and graft survival rates. Accordingly, denying patients renal transplantation because of obesity may not be justified.     

Familial Incidence and Influence on the Development of Obesity

Background: The prevalence of obesity in families of patients seeking surgical treatment for their severe obesity was investigated. Methods: Patients listed for surgery (vertical gastroplasty) for severe obesity (BMI >35) were interviewed and asked for details of the numbers of members of the immediate family who were at least 6.5 kg overweight. The data collected on 87 morbidly obese patients were compared to data from a group of 50 patients, all of whom had a BMI of less than 25 and were not overweight, who were acting as controls. Results: Obese patients had significantly more overweight family members than normal weight controls (p = 0.004). Conclusion: The prevalence of overweight in the families of obese patients may be genetically and environmentally influenced.     

The weight of obesity in patients with lower extremity vascular injuries

ObjectiveClinical obesity is an epidemic problem in the United States. The impact of this disease upon traumatic lower extremity vascular injuries (LEVI) is as yet undefined. We hypothesized that clinical obesity adversely affects outcome in patients with traumatic LEVI.MethodsAll adult patients admitted over a 5-year period with a traumatic LEVI were identified. Clinical obesity was defined as body mass index (BMI) > 30. Obese and non-obese patient groups were compared for surgical management and outcome.ResultsA total of 145 patients were identified. BMI data were available for 115 (79.3%) of these patients (obese n = 47; non-obese n = 68). Obese and non-obese groups were similar. Obese patients underwent more vascular repairs but the amputation rate and mortality were not significantly different.ConclusionsWhile obese body habitus can increase the complexity of evaluation and management of patients with LEVI, we have demonstrated that equivalent outcomes to the non-obese population can be achieved for the clinically obese patient with a BMI > 30. However, patients with a BMI > 40 did reveal a significantly higher chance of amputation and death after LEVI. Due to the small number of patients in this subset, one should use caution when interpreting this data.     

Pretransplant BMI Should Be <25 in Japanese Kidney Transplant Recipients: A Single-Center Experience

BackgroundThe aim of this study was to determine the appropriate body mass index (BMI) in Japanese kidney transplant (KTx) recipients. We analyzed the effects of pre- and post-transplant (Tx) obesity on graft and patient survival, perioperative complications, post-transplant diabetes mellitus (PTDM), and cardiovascular disease (CVD) in Japanese KTx recipients.MethodsThis retrospective study included 269 recipients who underwent KTx from 2008 through 2020 at Niigata University Hospital. Obesity was defined as a body mass index (BMI) ≥25 kg/m². We examined the association between pre- and post-Tx obesity and graft survival, patient survival, the incidence of PTDM and CVD, and perioperative surgical complications.ResultsThe graft survival rate was lower in the pre-Tx BMI ≥25 kg/m² group, although there was no significant difference in patient survival. There was no difference in graft and patient survival between the post-Tx BMI ≥25 kg/m² group and the <25 kg/m² group. A pre-Tx BMI ≥25 kg/m² was an independent risk factor for biopsy-proven allograft rejection. New-onset DM after transplantation was significantly more common in the BMI ≥25 kg/m² group than in the BMI <25 kg/m² group (36% vs 13%; P = .002). The incidence of CVD was significantly higher in the post-Tx BMI ≥30 kg/m² group than in the BMI <30 kg/m² group (50% vs 11%; P = .023). There were no differences in surgical operating time, intraoperative blood loss, or perioperative complications between the obese and non-obese groups.ConclusionPre-Tx BMI ≥25 kg/m² may be a risk factor for allograft rejection and graft loss. Post-Tx BMI should be <25 kg/m² to reduce the risk for PTDM.     

Hyperparathyroidism at 1 year after kidney transplantation is associated with graft loss

BackgroundHyperparathyroidism persists in many patients after kidney transplantation. The purpose of this study was to evaluate the association between post-transplant hyperparathyroidism and kidney transplantation outcomes.MethodsWe identified 824 participants from a prospective longitudinal cohort of adult patients who underwent kidney transplantation at a single institution between December 2008 and February 2020. Parathyroid hormone levels before and after kidney transplantation were abstracted from medical records. Post-transplant hyperparathyroidism was defined as parathyroid hormone level ≥70 pg/mL 1 year after kidney transplantation. Cox proportional hazards models were used to estimate the adjusted hazard ratios of mortality and death-censored graft loss by post-transplant hyperparathyroidism. Models were adjusted for age, sex, race/ethnicity, college education, parathyroid hormone level before kidney transplantation, cause of kidney failure, and years on dialysis before kidney transplantation. A Wald test for interactions was used to evaluate the risk of death-censored graft loss by age, sex, and race.ResultsOf 824 recipients, 60.9% had post-transplant hyperparathyroidism. Compared with non-hyperparathyroidism patients, those with post-transplant hyperparathyroidism were more likely to be Black (47.2% vs 32.6%), undergo dialysis before kidney transplantation (86.9% vs 76.6%), and have a parathyroid hormone level ≥300 pg/mL before kidney transplantation (26.8% vs 9.5%) (all P < .001). Patients with post-transplant hyperparathyroidism had a 1.6-fold higher risk of death-censored graft loss (adjusted hazard ratio = 1.60, 95% confidence interval: 1.02–2.49) compared with those without post-transplant hyperparathyroidism. This risk more than doubled in those with parathyroid hormone ≥300 pg/mL 1 year after kidney transplantation (adjusted hazard ratio = 4.19, 95% confidence interval: 1.95–9.03). The risk of death-censored graft loss did not differ by age, sex, or race (all P_interaction > .05). There was no association between post-transplant hyperparathyroidism and mortality.ConclusionThe risk of graft loss was significantly higher among patients with post-transplant hyperparathyroidism when compared with patients without post-transplant hyperparathyroidism.     

Outcomes of the overweight and obese major trauma patient in the rural setting

PurposeOverweight and obese patients are more prevalent in rural and remote areas and are of major public health concern in Australia. We aimed to evaluate the mortality and morbidity of overweight and obese trauma patients in the rural Australian context.MethodThis was a retrospective cohort study on 207 major trauma patients (injury severity score [ISS] > 12) treated at the Mackay Base Hospital between 2018 and 2021. Data was extracted from the Mackay Base Hospital trauma database and hospital records. Outcomes were compared between body mass index (BMI) groups.ResultsThere were 164 males (79%) and 43 females (21%). The average BMI was 27.09 (standard deviation 5.46). 7 patients (3%) were in the underweight category (BMI < 18.5 kg/m²), 70 (34%) were of normal weight (BMI 18.5–24.9 kg/m²), 79 (38%) were overweight (BMI 25–29.9 kg/m²), and 51 (25%) were obese (BMI > 30 kg/m²). The majority of trauma was blunt (n = 203, 98%). Compared to patients with normal BMI, obese patients were significantly more likely to require intubation, intensive care unit (ICU) admission, and have a longer ICU stay. There were no significant differences in requirement for surgery, duration of surgery, hospital length of stay, ventilator time, or mortality (P > 0.05). However, subgroup analysis of the obese patient group showed an increased rate of complications (sepsis, acute kidney injury, fluid overload and pneumonia), longer ventilation times, hospital and ICU length of stay with increasing BMI in these patients.ConclusionThe majority of trauma presentations in our regional community are in overweight or obese patients. Overweight and obese patients are more likely to require intubation and have a longer intensive care unit admission than normal weight counterparts. Amongst obese patients, those with BMI > 40 (obesity class 3) are at significantly increased risk of complications.     

The impact of abnormal BMI on surgical complications after pediatric colorectal surgery

Background/PurposeWhile childhood obesity is a growing problem, the implications of BMI on elective pediatric surgery remains poorly described. This study evaluates the impact of obesity on surgical outcomes after elective colorectal procedures.MethodsChildren ages 2–18 years undergoing elective colorectal surgery for IBD were identified from the NSQIP-Pediatric database. Patients were classified as underweight (UW), normal weight (NW), overweight (OW) and obese (OB) based on their age- and sex-adjusted BMI. Postoperative complications were compared between cohorts.Results858 patients (14.8% UW, 64.3% NW, 13.1% OW, 7.8% OB) were identified, with overall complications occurring in 15.3% and SSI in 10.1%. Obese/overweight patients had higher rates of deep incisional SSI (4.5%OB, 4.5%OW, 0%NW, p = 0.002) and superficial wound disruption (5.4%OB, 5.8%OW, 1.6%NW, p = 0.04). Incremental increase in BMI by 1.0kg/m² was associated with 4.3% increased likelihood of developing deep incisional SSI and 2.3% increase of superficial wound disruption. Obese/overweight children also had increased incidence of septic shock and UTI, as well as longer operative times, days of mechanical ventilation and LOS.ConclusionsIncreasing BMI was associated with increased wound complications in IBD patients undergoing elective intestinal surgery. Preoperative optimization and weight loss strategies may potentially reduce SSI and other infectious complications.Level of EvidenceIII     

The role of obesity in kidney transplantation outcome

Background

The number of obese kidney transplant candidates has been growing. However, there are conflicting results regarding to the effect of obesity on kidney transplantation outcome. The aim of this study was to investigate the association between the body mass index (BMI) and graft survival by using continuous versus categoric BMI values as an independent risk factor in renal transplantation.

Methods

We retrospectively reviewed 376 kidney transplant recipients to evaluate graft and patient survivals between normal-weight, overweight, and obese patients at the time of transplantation, considering BMI as a categoric variable.

Results

Obese patients were more likely to be male and older than normal-weight recipients (P = .021; P = .002; respectively). Graft loss was significantly higher among obese compared with nonobese recipients. Obese patients displayed significantly lower survival compared with nonobese subjects at 1 year (76.9% vs 35.3%; P = .024) and 3 years (46.2% vs 11.8%; P = .035).

Conclusions

Obesity may represent an independent risk factor for graft loss and patient death. Careful patient selection with pretransplantation weight reduction is mandatory to reduce the rate of early posttransplantation complications and to improve long-term outcomes.     

Effect of Obesity on Clinical Outcomes of Kidney Transplant Patients

PurposeCorrelating with the obesity epidemic, the number of obese transplant candidates is increasing. This study was designed to evaluate the effect of obesity on the survival of our kidney transplant recipients.MethodsAmong 1033 kidney transplants performed during the last 7.5 years in our center, 750 adult recipients were transplanted from living donors and were evaluated, and 561 of them were included in the study. Demographic and clinical data were collected. Body mass index (BMI) values at the time of transplant and post-transplant during the first year, the presence of delayed graft function, hospitalization duration, number of readmissions within the first year post-transplant, presence of post-transplant diabetes mellitus (PTDM) and cardiovascular disease, and graft and patient survival rates at 1, 3, and 5 years were investigated.ResultsObesity (BMI >30) was observed in 148 (19.7%) at the time of the transplant (initial obesity) and in 174 (23.2%) recipients at post-transplant first year. Initial obesity was not only found to be correlated with delayed wound healing (P = .03), increased hospitalization duration (P = .03), number of readmissions within the first year (P = .04), presence of PTDM (P = .02), and cardiovascular disease (P = .03) but also with lower graft survival rate (P = .04) at the first year. On the other hand, obesity at post-transplant the first year was associated with lower 3- and 5-year grafts (P = .04 and P = .03, respectively) and 5-year patient (P = .03) survival rates.ConclusionObesity should not be considered as a contraindication for kidney transplantation; however, to achieve better results, certain precautions should be taken pre- and postoperatively.     

Nutritional status of patients with alcoholic cirrhosis undergoing liver transplantation: time trends and impact on survival

Alcoholic cirrhotics evaluated for liver transplantation are frequently malnourished or obese. We analyzed alcoholic cirrhotics undergoing transplantation to examine time trends of nutrition/weight, transplant outcome, and effects of concomitant hepatitis C virus (HCV) and/or hepatocellular carcinoma (HCC). Nutrition and transplant outcomes were reviewed for alcoholic cirrhosis with/without HCV/HCC. Malnutrition was defined by subjective global assessment. Body mass index (BMI) classified obesity. A total of 261 patients receiving transplants were separated (1988–2000, 2001–2006, and 2007–2011) to generate similar size cohorts. Mean BMI for the whole cohort was 28 ± 6 with 68% classified as overweight/obese. Mean BMI did not vary among cohorts and was not affected by HCV/HCC. While prevalence of malnutrition did not vary among cohorts, it was lower in patients with HCV/HCC (P < 0.01). One‐year graft/patient survival was 90% and not impacted by time period, HCV/HCC, or malnutrition after adjusting for demographics and model end‐stage liver disease (MELD). Alcoholic cirrhotics undergoing transplantation are malnourished yet frequently overweight/obese. Among patients selected for transplantation, 1‐year post‐transplant graft/patient survival is excellent, have not changed over time, and do not vary by nutrition/BMI. Our findings support feasibility of liver transplantation for alcoholic cirrhotics with obesity and malnutrition.     

Effect of Pretransplant Body Mass Index on Kidney Transplant Recipient and Graft Long-term Survival

BackgroundThe aim of the study was to assess the influence of pretransplant body mass index (BMI [calculated as weight in kilograms divided by height in meters squared]) to the graft and patient 5- and 10-year survival.MethodsOur study group consisted of 706 patients who received their kidney transplant after the year 2000.ResultsAlmost half, 51.9% (n = 372) of the patients had BMI < 25, and 47.6% (n = 336) had BMI ≥ 25. Patients who were overweight or obese were significantly older than other groups (P = .01). The 5-year recipient survival was significantly better in the BMI < 25 group (n = 291, 79.5%) than the BMI ≥ 25 group (n = 238, 70.2%, P < .05). In addition, 10-year recipient survival was better in the BMI < 25 group (n = 175, 47.8%) compared with the BMI ≥ 25 group (n = 127, 37.5%, P < .05). Similarly, 5-year graft survival was better in the BMI < 25 group (66.9%, n = 242) compared with the BMI ≥ 25 group (61.1%, n = 204, P < .05). However, 10-year graft survival was not statistically significant (P = .08). Regarding the impact of diabetes on survival, we found patients with diabetes mellitus to have worse survival in all groups (P = .009).ConclusionsRecipient graft survival was affected by diabetes mellitus independently from being overweight. In the current study, we demonstrated that pretransplant obesity or being overweight affects recipient and graft short-term survival, but long-term comparison of patients who were overweight or obese with patients with normal BMI revealed minimal recipient survival differences and in graft survival analysis no difference. Although in many studies obesity and being overweight predict a bad outcome for kidney transplant recipient survival, our research did not fully confirm it. Diabetes mellitus had worse outcome in all patients groups.     

Impact of Obesity on Perioperative Outcomes and Survival Following Pancreaticoduodenectomy for Pancreatic Cancer: A Large Single-Institution Study

Background

To examine the effect of body mass index (BMI) on clinicopathologic factors and long-term survival in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma.

Methods

Data on BMI, weight loss, operative details, surgical pathology, and long-term survival were collected on 795 patients who underwent pancreaticoduodenectomy. Patients were categorized as obese (BMI?>?30 kg/m²), overweight (BMI 25 to <30 kg/m²), or normal weight (BMI?<?25 kg/m²) and compared using univariate and multivariate analyses.

Results

At the time of surgery, 14% of patients were obese, 33% overweight, and 53% normal weight. Overall, 32% of patients had preoperative weight loss of >10%. There were no differences in operative times among the groups; however, higher BMI was associated with increased risk of blood loss (P?<?0.001) and pancreatic fistula (P?=?0.01). On pathologic analysis, BMI was not associated with tumor stage or number of lymph nodes harvested (both P?>?0.05). Higher BMI patients had a lower incidence of a positive retroperitoneal/uncinate margin versus normal weight patients (P?=?0.03). Perioperative morbidity and mortality were similar among the groups. Obese and overweight patients had better 5-year survival (22% and 22%, respectively) versus normal weight patients (15%; P?=?0.02). After adjusting for other prognostic factors, as well as preoperative weight loss, higher BMI remained independently associated with improved cancer-specific survival (overweight: hazard ratio, 0.68; obese: hazard ratio, 0.72; both P?<?0.05).

Conclusion

Obese patients had similar tumor-specific characteristics, as well as perioperative outcomes, compared with normal weight patients. However, obese patients undergoing pancreaticoduodenectomy for pancreatic cancer had an improved long-term survival independent of known clinicopathologic factors.     

Pre-resection gastric bypass reduces post-resection body mass index but not liver disease in short bowel syndrome

Background

Obese patients developing short bowel syndrome (SBS) maintain a higher body mass index (BMI) and have increased risk of hepatobiliary complications. Our aim was to determine the effect of pre-resection gastric bypass (GBP) on SBS outcome.

Methods

We reviewed 136 adults with SBS: 69 patients with initial BMI < 35 were controls; 43 patients with BMI > 35 were the obese group; and 24 patients had undergone GBP before SBS.

Results

BMI at 1, 2, and 5 years was similar in control and GBP groups, whereas obese patients had a persistently increased BMI. Eight (33%) of the GBP patients had a pre-resection BMI > 35, but post-SBS BMI was similar to those <35. Obese patients were more likely to wean off PN (47% vs 20% control and 12% GBP, P < .05). Radiographic fatty liver tended to be higher in the GBP group (54% vs 19% control and 35% obese). End-stage liver disease occurred more frequently in obese and GBP patients (30% and 33% vs 13%, P < .05).

Conclusions

Pre-resection GBP prevents the nutritional benefits of obesity but does not eliminate the increased risk of hepatobiliary disease in obese SBS patients. This occurs independent of pre-SBS BMI suggesting the importance of GBP itself or history of obesity rather than weight loss.     

Is obesity still a risk factor in renal transplantation?

At our center, since 1982, a body mass index (BMI) of less than 30 has been a prerequisite for placing a patient on the waiting list for renal transplantation. This decision was made because obese transplant recipients seemed to have a less than favorable post-transplant outcome. The aim of this study was to evaluate whether this requirement is still justified. Forty-six patients with a BMI above 30 underwent primary cadaveric renal transplantation between 1972 and 1993. For each of these obese patients, five consecutive non-obese (BMI 20–25) control patients were selected. Patient and graft survival, causes of graft loss, and acute rejection rate were evaluated for the two patient groups before and after the year 1982. Within the first 30 post-transplant days, one patient (2 %) and 11 grafts (24 %) were lost in the group of obese patients whereas seven patients (3 %) and 36 grafts (16 %) were lost in the control group. Among the obese patients, renal circulatory complications were a major cause of graft loss. In the period 1973–1981, the 1-year patient survival rate was 65 % among obese patients versus 75 % among controls from 1982 to 1993, this was 90 % versus 93 %. From 1973 to 1981, the 1-year graft survival rate was 25 % among obese patients versus 53 % among controls (P < 0.05); from 1982 to 1993, it was 68 % versus 84 % (P = NS). Multivariate analysis showed that the immunosuppressive regimen, age of the patient, BMI, and cold ischemia time of the graft had a significant influence on graft survival. The acute rejection rate within the first 30 days was 28 % among obese patients and 35 % among controls (P = NS). We conclude that a BMI below or equal to 30 is still justified as a prerequisite for placement on the waiting list for renal transplantation, for despite an overall improvement, the outcome of renal transplantation in obese patients remains worse than that in non-obese patients. Received: 3 February 1997 Received after revision: 4 April 1997 Accepted: 8 April 1997