Responding to rising demand, Duke is providing patients with obesity greater access to successful kidney and liver transplants by implementing novel surgical techniques and tailored medical interventions. A collaborative team of transplant and bariatric specialists lead the effort.
 
“We’ve spent a few years now synergizing the two teams,” says Duke Center for Weight Loss Surgery bariatric surgeon Dana Portenier, MD. “These patients require multispecialty care. So we’ve streamlined our services to help ensure a patient-centered experience.”

Patients with obesity have traditionally been disadvantaged when it comes to organ transplant. “Most transplant centers have BMI [body mass index] cutoffs of 35 to 40,” says Duke Transplant Center abdominal transplant surgeon Aparna Rege, MD. “As a result, patients with a higher BMI are not considered for organ transplant. They end up either living their life on dialysis with end-stage renal disease or dying from liver disease.”
 
The BMI cutoffs can be attributed to the increased risks associated with transplanting obese patients. According to Rege, obesity, particularly truncal distribution of fat, can make surgery more challenging, delay postoperative recovery and wound healing, and increase the risk of graft dysfunction. “Obesity is also associated with sarcopenia from loss of muscle mass leading to frailty and an increased risk of postoperative complications, morbidity, and mortality,” Rege adds.
 
Duke is among a select group of U.S. transplant centers working to get obese patients the care they need. “We decided to work on a solution for obese patients and create an opportunity for them to benefit from transplantation, yet minimize the risk of postoperative morbidity related to obesity,” says Rege.  

One of the latest strategies Duke has adopted to treat obese patients with liver failure is a surgical procedure that combines liver transplantation with sleeve gastrectomy. Studies have shown that this combined approach has the best outcome compared to pre- or post-transplant bariatric surgery. The advantages include:

• A lower risk for complications compared to multiple operations
• Fewer technical challenges for the surgeon due to the presence of scar tissue from a prior procedure
• Reduction in portal hypertension risk
• A single recovery period for the patient
• More durable weight loss

Incorporating sleeve gastrectomy into a liver transplant procedure is fairly simple, according to Portenier. “The stomach is super accessible due to the large upper abdominal incision required for transplant,” he says. “Once we’ve seen that the patient is doing well and the transplant has gone smoothly, it’s pretty easy at that point for us to do the sleeve at the end.”
 
The challenges of this combined procedure arise during the pre- and postoperative period. It requires ongoing collaboration among the two teams to thoroughly evaluate patients to ensure they are good candidates for the procedure. And both teams’ combined expertise is essential in managing patients after surgery. 

Clinically, patients eligible for combined liver transplant and sleeve gastrectomy meet the following requirements:

• BMI of 40 or higher
• Obesity-related comorbidities, including liver disease
• No significant ascites

These are initial considerations, but not the only ones. “Our evaluation of eligible patients comprises multiple specialties — hepatology, surgery, nutrition, medical psychology, palliative care, finance, social work — all of these people see the patient to determine if they are good candidates,” says Rege. 
 
With the lifelong medications and dietary restrictions required after this procedure, compliance is important. Duke’s dedicated medical psychologist is experienced in evaluating patients for both procedures, and knows what characteristics to look for, such as family support and mental acuity. In addition, they work with patients on the behavioral modifications necessary to adapt to required dietary changes.  
 
Nutritionists also work with patients prior to surgery to educate them on changes they’ll need to make to their eating habits. Their role is most critical, however, in the postoperative period.
 
“Postoperative nutritional management of these patients is complex and requires the expertise of both bariatric dieticians and liver transplant dieticians to ensure patients are getting adequate protein intake and also a diet that is suitable for weight loss,” says Rege.
 
After surgery, patients are closely followed by the transplant team to assess liver function, medication management, as well as healing, which can be compromised by immunosuppression. According to Portenier, patients also lean heavily on the bariatric team to help them with maintaining their weight.

The Duke Kidney Transplant Program has a history of accepting patients with challenging comorbidities who are turned down elsewhere, including HIV, sickle cell and cardiomyopathies. With the introduction of robotic kidney transplantation, this team is also making kidney transplant more accessible to patients with truncal obesity and end-stage renal disease.
 
“By doing these cases robotically, we’re staying away from the lower abdominal pannus, so we’re minimizing the surgical risks, such as wound-related complications like infection,” says Rege.
 
Successfully performing these procedures takes expertise in robotics and transplant. Rege and her colleague, Kadiyala Ravindra, MBBS, trained extensively over the past few years to master the technology. 

In spite of taking on this and other more complex procedures, the Duke Kidney Transplant Program achieved high marks in their 1-year conditional survival with a functioning graft. Duke’s 1-year conditional survival rate for kidney was 99.34 percent against a U.S. rate of 96.71 percent, according to data from the July 2023 Scientific Registry of Transplant Recipients (SRTR).

Unlike patients with liver disease, those with renal failure have a bridge to transplant — dialysis — which helps them maintain their health and allows them more time to focus on weight loss. The Duke bariatric team evaluates patients with kidney disease and a BMI of 35 or higher to determine whether they might be candidates for medical weight loss or surgery to improve their transplant eligibility status and their chances for a successful outcome post-transplant.
 
Patients may find success with nonsurgical interventions, such as medication or lifestyle modification. If these are not effective, the bariatric team may evaluate them for surgery.
 
“In patients who are on dialysis but don't qualify for transplant because of their weight, bariatric surgery can really open up a lifeline to these patients to be able to get on the list for transplant,” says Portenier.
 
The bariatric team may also step in after kidney transplant, when some patients struggle to maintain a weight that promotes healthy organ function.

The best-case scenario for patients with life-threatening, obesity-related comorbidities is preventing disease progression so that transplant isn’t necessary. That means addressing obesity sooner.
 
Losing weight can lower the risk of diabetes and hypertension, the primary causes of kidney failure. Studies have also shown that weight-loss surgery can stop or reverse the development of chronic kidney disease.
 
The same is true of liver disease. “With weight loss, if you're able to either halt the process of fatty liver disease or reverse the process of fatty liver disease early on, I think it should definitely be implemented,” says Rege. “It's possible that we can take patients off the organ waitlist with improvement or stability of their liver disease. Or we may even avoid listing patients because, when these strategies are implemented in advance or in due time, it can prevent further damage or scarring of the liver.”