肥胖和不肥胖病患的肝臟移植結果類似


  June 3, 2008 (多倫多) — 根據在此間發表的回溯研究,病態肥胖病患不應被排除在肝臟移植候選名單之外,因為這些病患的移植結果不會比非肥胖病患差。
  
  在美國移植醫學會以及美國移植外科學會聯合年會的美國移植研討會中,克里夫蘭診所的移植外科醫師Federico Aucejo指出,肥胖與病態肥胖病患接受肝臟移植手術的結果有不同之處 ,美國有些移植中心選擇不對這些病患進行此種手術。
  
  Aucejo醫師在口頭發表之後向Medscape Transplantation表示,有些中心不願意對這些病患進行移植,因為有些資料顯示在移植後有較高的併發症比率。
  
  【回溯研究】
  研究者比較25名肥胖(身體質量指數 (BMI)大於等於38 kg/m2 )病患和50名非肥胖病患(BMI 小於等於26 kg/m2)進行正位肝臟移植手術前後的臨床結果,手術在2005年6月至2007年10月間進行。
  
  Aucejo醫師指出,BMI為40 kg/m2 者通常定義為病態肥胖,但是研究人員將此數值降低到BMI為38 kg/m2,以提供適當的研究強度。
  
  研究者就病患的年紀、種族、性別與捐贈者身高進行配對,肥胖與非肥胖病患之間的各種特徵沒有顯著差異,除了非酒精性脂性肝炎(42%比10%; P = .002) 以及第2型糖尿病(50% 比20%; P = .01)。
  
  他們檢視住院天數、手術時間、6個月內死亡或者再度移植、紅血球細胞計數、使用呼吸器於加護病房的住院天數、加護病房住院天數、加護病房感染件數等;他們發現,肥胖與非肥胖病患之間只有手術時間有統計上的顯著差異:526 分鐘比631分鐘; P < .003;平均追蹤期間為23.1個月,範圍從6-45個月 。
  
  Aucejo醫師向Medscape Transplantation表示,我們從實際手術前開始誘導麻醉時,即開始計算時間;在肥胖病患身上比較難找到血管。
  
  運用統計分析 (指數系列法),研究者發現,肥胖與非肥胖病患之間,病患存活(0.93)或移植器官存活(0.44)都沒有統計上的顯著差異。
  
  【移植後BMI明顯改變】
  不過,在手術之後3個月,肥胖病患的BMI有統計上的顯著改變 (P = .001);結果顯示,BMI分類為肥胖的病患,實際上並沒有真正肥胖;根據Aucejo醫師表示,移植後大量減重主要可能是因為體液狀態改變之故。
  
  Aucejo醫師向Medscape Transplantation表示,我們要表達的是,一些中心無法移植的病患很多是因為體液多導致BMI高所致;體液留置是因為腎臟功能,有肝硬化的病患,在移植前有時候會有肝腎症狀,腎功能不正常而導致體液留置;移植之後,腎臟和肝臟都比較好,而可以排除多餘的液體。
  
  Aucejo醫師表示,資料支持美國許多中心考量為病態肥胖病患移植。
  
  南卡羅來納醫學大學肝膽胃腸科肝臟服務小組主任Adrian Reuben醫學教授表示,研究者並未考量肥胖病患可能是因為其他因素,如共病症等原因而被排除在移植候選名單之外。
  
  【影響移植的共病症】
  Reuben醫師向Medscape Transplantation表示,有許多BMI在40 kg/m2左右的病患被排除是因為共病症,例如糖尿病、感染、冠狀動脈疾病。
  
  Reuben 醫師指出,醫師應將液體排除納入篩選移植病患的考量中;如果BMI高是因為過多體液,可以估計排除液體之後的 BMI,不可以將滯留的體液也當作體重。
  
  Reuben醫師指出,除了BMI,在病態肥胖病患中,體重的分布也應在決定進行肝臟移植與否時納入考量,那些主要是腹部肥胖的病患應被視為有併發症的高風險。
  
  該研究為獨立進行。Aucejo 醫師和 Reuben 醫師宣稱沒有相關資金上的往來。

Liver Transplant Outcomes Similar in Obese and Nonobese Patients

By Louise Gagnon
Medscape Medical News

June 3, 2008 (Toronto) — Morbidly obese patients should not be excluded as candidates for liver transplantation because outcomes with these patients are no worse than in nonobese patients undergoing liver transplantation, according to retrospective esearch presented here.

Speaking at the American Transplant Congress, the joint annual meeting of the American Society of Transplant Surgeons and the American Society of Transplantation, Federico Aucejo, MD, a staff transplant surgeon at the Cleveland Clinic in Ohio, indicated that there had been inconsistent data on the outcomes with obese and morbidly obese patients undergoing liver transplantation and that some transplant centers in the United States are choosing not to perform these procedures in these patients.

"Some centers are reluctant to transplant these patients because of some data showing higher complications following transplantation," Dr. Aucejo told Medscape Transplantation after presenting his team's data in an oral session.

Retrospective Study

The investigators compared perioperative and clinical outcomes after orthotopic liver transplantation in 25 obese patients, defined as having a body mass index (BMI) of 38 kg/m2 or more, and 50 nonobese subjects, defined as having a BMI of 26 kg/m2 or less. The procedures had been performed between June 2005 and October 2007.

Dr. Aucejo noted that a BMI of 40 kg/m2 is often used a criterion for morbid obesity, but investigators reduced the threshold to a BMI of 38 kg/m2 to provide adequate power to the study.

Researchers matched the patients for various characteristics, such as age, race, sex, and donor height. There were no statistically significant differences in any patient characteristics for obese vs nonobese patients other than nonalcoholic steatohepatitis (42% vs 10%; P = .002) and presence of type 2 diabetes mellitus (50% vs 20%; P = .01).

They looked at various measurements including hospital length of stay, case duration, death or retransplant within 6 months, red blood cell count, days in the intensive care unit (ICU) on mechanical ventilation, length of stay in the ICU, and episodes of ICU infection. They found a statistically significant difference only in case duration between the nonobese patients and the obese patients: 526 min vs 631 min; P < .003. Median follow-up time was 23.1 months, with a range of 6 to 45 months.

"We start counting the minutes from the time the induction of anesthesia starts, which is before actual surgery," Dr. Aucejo told Medscape Transplantation. "It is harder to find intravenous access [in obese patients] than in patients that are not obese."

Employing statistical analysis (log rank tests), researchers found no statistically significant differences in either patient survival (0.93) or graft survival (0.44) for obese vs nonobese patients.

Significant Difference in BMI After Transplant

However, there was a statistically significant difference (P = .001) reported in BMI among obese patients 3 months after surgery. The results suggest that patients with a BMI that categorizes them as obese may in fact not have real obesity; those who experience substantive weight loss after transplantation may simply have substantial fluid retention, according to Dr. Aucejo.

"We wanted to show that a significant number of patients that might not be transplanted at some centers actually have a high BMI due to total fluid retention," Dr. Aucejo told Medscape Transplantation. "That fluid retention is due to kidney function. The pretransplant patients with cirrhosis sometimes have hepatorenal syndrome, where kidney function is not normal and they tend to retain fluid. Immediately after transplantation, both the kidney and the liver get better and they get rid of the excess fluid."

Dr. Aucejo said the data support that more centers in the United States consider liver transplantation in morbidly obese patients.

Adrian Reuben, MBBS, FRCP, FACG, professor of medicine and director of liver service in the Division of Gastroenterology and Hepatology at the Medical University of South Carolina in Charleston, said the investigators did not consider that obese patients might be ruled out as candidates for transplantation for other reasons, such as associated illnesses.

Comorbidities May Rule Out Transplant

"There are a lot of patients who are excluded with that BMI [around 40 kg/m2] because of comorbidities that go along with morbid obesity, such as...diabetes, infections, and coronary artery disease," Dr. Reuben told Medscape Transplantation.

Dr. Reuben indicated that physicians should be taking fluid excess into account when screening patients for transplantation. "If the BMIs were artificially inflated because of fluid excess, you can make an estimate of what their BMI would be without the fluid," he said. "It's wrong to include fluid retention as part of their weight."

Dr. Reuben added the distribution of weight, and not the BMI alone, in morbidly obese patients is a factor to consider when deciding whether to perform liver transplantation, noting those patients with predominantly abdominal obesity would be regarded as higher risk for complications.

The study was independently conducted. Dr. Aucejo and Dr. Reuben have disclosed no relevant financial relationships.

American Transplant Congress 2008: Abstract 309. Presented June 2, 2008.

    
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