Clinical

Obese patients face longer waits for liver transplantation

Last Updated: 2008-12-17 15:55:04 -0400 (Reuters Health)

By Will Boggs, MD

NEW YORK (Reuters Health) - Obese patients face prolonged waiting times for liver transplantation, reflecting a possible "reluctance to transplant obese patients," according to a report in the November issue of the Annals of Surgery.

"In transplantation, outcomes are available online to the general public, and compared from hospital to hospital," Dr. Dorry L. Segev from Johns Hopkins University School of Medicine, Baltimore, told Reuters Health. "The side effect is that centers might become too reluctant to take on challenging cases, in fear that a bad outcome would be misinterpreted as poor quality of care."

Dr. Segev and colleagues determined the association between body mass index (BMI) and access to transplantation in more than 25,000 consecutive patients, using the model for end-stage liver disease exceptions, provider turndowns of organ offers, and time-to-transplantation.

After adjusting for other factors, severely obese patients had 30% lower odds and morbidly obese patients had 38% lower odds of receiving model of end-stage liver disease exceptions than did nonobese patients, the authors report.

Similarly, severely obese patients had 10% higher likelihood and morbidly obese patients had 16% higher likelihood of being turned down for an organ offer.

Overall, after adjustments for many factors related to transplantation rate, severely obese patients had 11% lower rates and morbidly obese patients 29% lower rates of being transplanted.

Among centers listing patients on the waiting list during this study period, 11% listed none who were severely obese and 19% listed none who were morbidly obese, the investigators report.

"Our findings suggest a reluctance to perform liver transplantation on obese patients," the authors conclude. "If indeed as a community we feel that liver allografts should not be distributed to patients with excessive postoperative risk, we should consider expressing this as a formal change to our allocation policy rather than through informal practice patterns."

"I believe that liver allografts should be allocated fairly to patients who are determined by their providers to be good candidates," Dr. Segev said. "Many obese patients are predicted to derive a significant survival benefit from liver transplantation."

"All patients in our study were already on the waiting list, in other words, already determined to be good candidates," Dr. Segev continued. "I believe that there should be no disparities past that hurdle, especially under the current allocation scheme which specifically allocates based on disease severity score and no other characteristics."

Ann Surg 2008;248:863-870.