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Listing practices for Morbidly Obese Patients at Liver Transplant Centers in the United States Dina Halegoua-De Marzio, MD1, She-Yan Wong, MD1, Jonathan M. Fenkel, MD1, Cataldo Doria, MD, PhD2, David A. Sass, MD1 1 Department of Medicine, Division of Gastroenterology and Hepatology; 2 Department of S urger y, Division of Transplantation, Thomas Jefferson University, Philadelphia, Pennsylvania, US A INTRODUCTION • Obesity affects more than one third of Americans. • Morbid obesity (body mass index (BMI) >35 kg/m2) has been associated with multiple co-morbidities and perioperative complications. • Figure 1: Regional Map with Number of Respondents from each Region Transplant Center Location The effect of morbid obesity on liver transplant outcomes has yielded mixed results. AIM To determine listing practices for morbidly obese patients at United States (U.S.) liver transplant centers. 70.0% 64.2% 60.7% 60.0% METHODS 50.0% A 19 item survey was created to assess liver transplant evaluation and listing practices for morbidly obese patients. All U.S. adult liver transplant medical and surgical directors were contacted by email with a cover letter describing the study and an internet link to the SurveyMonkey® website. A few questions had a free-text section which allowed for comment. Five follow-up emails were sent to encourage participation. 40.0% RESULTS • • • • • • • A policy on evaluation and listing of obese patients was present at 70.5% of institutions with the majority (54.5%) reporting their BMI cut off for transplant was 40 but a range of 35 to unlimited was noted. (Figure 2) The majority (61.4%) of respondents agreed that there has been an increase in the number of obese patients they have listed for liver transplant 75% of respondents’ reported that patients with high BMI were less likely to be evaluated for transplantation. 65.9% of respondents reported experiencing an increased complication rate, with the most frequently cited complications being poor wound healing and increased infection rates. (Figure 3) 34.1% reported they had experienced worse survival rates with obese patients. 62.5% 56.3% 4 (8.7%) Region 2 6 (13.0%) Region 3 5 (10.9%) Region 4 1 (2.2%) Region 5 5 (10.9%) Region 7 Region 8 60.0% 32.1% 31.3% 30.0% 64.3% 1 (2.2%) 53.6% 4 (8.7%) 43.8% 56.3% 10.0% 5 (10.9%) 0.0% 4 (8.7%) University-Affiliated Medical Center Region 10 6 Region 11 5 (10.9%) 17.3% 25-50 21.7% 50-75 15.2% 75-100 19.5% >100 26.0% Graft Failure CON25% CLUSIONS Infection Respiratory failure Longer hospital admissions 9% 9% BMI 35 The majority of medical and surgical liver transplant directors 38 have a strong appreciation of the possible morbidity risks 40 associated with morbidly obese patients post-transplant and 4% have policies in effect to minimize these risks. This is of 45 specific concern due to the need to provide more high Unlimited quality and cost effective transplant care in the current 55% data examining morbidly obese healthcare climate. More cirrhotic patient outcomes perioperatively, stratified by other co-morbidities, is needed. 7% BMI 35 38 40 78.2% <25 Poor wound healing 7% 4% Number of Transplant Performed Yearly Cardiac complications Listed Complications Figure 2: What is the upper limit of BMI allowed Cardiac Poor wound Graft Failure Infection Respiratory Longer hospital complications healing failure admissions for liver transplant listing at your institution? 25% Type of Transplant Program 7.1% 32.1% 31.3% (13.0%) 0.0% Academic Role 37% 18.8% 20.0% 7.1% 87% Surgical Transplant Director 56.3% 53.6% 40.0% Gender 63% Medical Director 56.3% 43.8% % of Responses Medical Transplant Director Surgical Director 50.0% Listed Complications Men 64.3% 62.5% 18.8% 10.0% Responders Characteristics 64.2% 60.7% Surgical Director Region 9 20.0% Table 1: Characteristics of Respondents from U.S. Liver Transplant Programs 70.0% Number of Respondents (% of total) Region 1 Medical Director 6 Region 30.0% A total of 187 surveys were emailed with responses received from 46 physicians (24.7% response rate). The responding cohort consisted of 29 (63%) medical directors and 17 (37%) surgical directors, including respondents from all United Network Organ Sharing (UNOS) regions, though regions 4 and 6 had the fewest respondents (n=2). (Table 1 and Figure 1) Figure 3: For what reason do you exclude obese patients for liver transplant listing? 55% 45 REFERENCES Unlimited 1. Nair S, Verma S, Thuluvath PJ. Obesity and its effect on survival in patients undergoing orthotopic liver transplantation in the United States. Hepatology. 2002 Jan;35(1):105-9. 2. Segev DL, Thompson RE, Locke JE, Simpkins CE, Thuluvath PJ, Montgomery RA, Maley WR. Prolonged waiting times for liver transplantation in obese patients. Ann Surg 2008;248:863-870. 3. Perez-Protto SE, Quintini C, Reynolds LF, You J, Cywinski JB, Sessler DI, Miller C. Comparable graft and patient survival in lean and obese liver transplant recipients. Liver Transpl. 2013 Aug;19(8):907-15. None of the authors have any relevant disclosures to report