Next Article in Journal
Triple Procedure Long-Term Outcomes: Comparative Analysis of Penetrating Keratoplasty vs. DSAEK Combined with Cataract Surgery
Previous Article in Journal
Dynamics of the Novel Cardiac Biomarkers sST2, H-FABP, GDF-15 and suPAR in HFrEF Patients Undergoing Heart Failure Therapy, a Pilot Study
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
JCM
Volume 14
Issue 16
10.3390/jcm14165669
jcm-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Review

Synergistic Integration of Multimodal Metabolic and Bariatric Interventions Transforming Transplant Care

by
Donovan Hui
1,
Alex C. Judd
2,
Chioma Moneme
1,
Heather Passerini
1,
Stephanie Silpe
2,
Alexander Podboy
3,
Shawn J. Pelletier
2,
Peter T. Hallowell
1 and
Thomas H. Shin
1,*
1
Division of General Surgery, Department of Surgery, University of Virginia, Charlottesville, VA 22903, USA
2
Division of Transplant Surgery, Department of Surgery, University of Virginia, Charlottesville, VA 22903, USA
3
Division of Gastroenterology, Department of Medicine, University of Virginia, Charlottesville, VA 22903, USA
*
Author to whom correspondence should be addressed.
J. Clin. Med. 2025, 14(16), 5669; https://doi.org/10.3390/jcm14165669
Submission received: 4 May 2025 / Revised: 21 July 2025 / Accepted: 9 August 2025 / Published: 11 August 2025
(This article belongs to the Special Issue Innovations in Bariatric and Minimally Invasive Gastrointestinal Surgery)
Versions Notes

Abstract

Obesity presents a significant barrier to transplant eligibility due to increased morbidity associated with higher BMI. Patients with obesity who undergo transplantation face elevated risks of perioperative complications, morbidity from metabolic disease, and delayed graft function. However, recent advances in metabolic and bariatric medicine, endoscopy, and surgery offer promising opportunities for integration with transplant care. This critical review explores the potential benefits of metabolic and bariatric interventions for at-risk transplant patients. Here, we will briefly discuss the implications of obesity in transplant patients, pharmacologic, surgical, and endoscopic interventions, and ultimately, the role of bariatric surgery in different solid organ transplants. The successful implementation of these approaches could dramatically expand access to solid organ transplantation, creating life-saving opportunities for patients who would otherwise be deemed ineligible for this essential treatment. Despite the implications of metabolic and bariatric interventions in transplant care, this review is limited by the need for long-term studies of outcomes to better understand the effects of graft survival and durability of changes in metabolic syndromes.

1. Introduction

The global effect of morbid obesity has detrimental effects across all segments of patient populations, including patients requiring visceral transplant surgery. The prevalence of adult obesity in the United States, as estimated by the Centers for Disease Control and Prevention (CDC) in 2023, is 40.3%. Among individuals eligible for solid organ transplantation, the prevalence of obesity is even higher, reaching upwards of 46% [1,2]. This high prevalence significantly impacts transplant outcomes, leading to increased risks of graft failure, prolonged hospitalization, impaired healing, rejection, and mortality [3,4,5]. Consequently, many centers consider obesity a relative contraindication, particularly for candidates with a body mass index (BMI) greater than 40 kg/m2.
The severity of obesity is determined by BMI and stratified by class (class 1: 30–34.9 kg/m2, class 2: 35–39.9 kg/m2, class 3: ≥40 kg/m2) [6]. Current eligibility criteria for metabolic and bariatric surgery (MBS) are BMI > 40 kg/m2 or BMI > 35 kg/m2 with metabolic disease. Recent international consensus has reconsidered these criteria and would recommend metabolic and bariatric surgery for a BMI > 35 kg/m2, regardless of the presence of comorbidities or a BMI of 30–35 kg/m2 with metabolic disease [7]. However, BMI has limitations in transplant populations, particularly in end-stage organ dysfunction with sarcopenia, anasarca, and ascites in the setting of obesity [8]. Imaging studies such as dual-energy X-ray absorptiometry (DEXA), bioelectrical impedance assessment (BIA), and computer tomography (CT), as well as functional, muscle strength, inflammatory, and metabolic biomarkers have been studied to assess sarcopenia. Although there is no standardization of biomarkers and adjustments in BMI for ascites have shown no predictive changes in outcomes, sarcopenia in and of itself is associated with worse outcomes with longer hospital stays and worse postoperative morbidity [8,9,10,11]. Integrated metabolic and bariatric centers can help differentiate changes in muscle mass from visceral fat loss, improving metabolic health assessment [12].
While MBS effectively manages long-term obesity, its peritransplant role remains underexplored. This review examines evidence for bariatric surgery and other weight management strategies in transplant care, investigating how integrated approaches can optimize outcomes across solid organ transplantation.

2. The Impact of Obesity

Although not all end-organ dysfunction is a product of obesity, it accelerates multiple pathways to end-stage organ dysfunction, including diabetes, hypertension, cardiovascular disease, and nonalcoholic fatty liver disease (NFLD), now termed metabolic dysfunction-associated liver disease (MASLD) [13,14]. These conditions increase surgical risks, particularly wound infections, thromboembolism, renal failure, and prolonged operative times [15,16,17]. The presence of obesity in already high-risk patients poses significant considerations that can increase time on the transplant waitlist and subsequently decrease the likelihood of a timely transplant. Despite being a major contributor to organ failure, severe obesity remains a relative contraindication for transplantation, with few centers accepting candidates with a BMI > 40 kg/m2 [18]. This restriction stems from documented perioperative complications, including increased operative times, bleeding, infections, wound dehiscence, biliary, and metabolic complications. Post-transplant weight gain presents additional challenges, though metabolic and bariatric surgery can mitigate these risks by reducing weight gain and associated metabolic complications [19,20].

3. Pharmacologic Weight Loss in Transplant Patients

While various options exist for weight loss, it is essential to consider patient adherence, comorbid conditions, and insurance/financial impact on method selection. While lifestyle modifications are available for weight loss, they are less effective and surprisingly more costly long-term than medications or surgery [21,22]. GLP-1 receptor agonists (GLP1RAs), including liraglutide, semaglutide, and tirzepatide, have emerged as leading pharmacotherapy options, demonstrating superior weight loss effects compared to previous generations of anti-obesity medications and appetite suppressants [23,24,25].
Though these medications are both safe and efficacious for pre-transplant candidates, access may be limited, and all are associated with significant rates of gastrointestinal adverse reactions, including nausea, vomiting, and gastroparesis [24,26]. Other GI complications may include cholelithiasis or cholecystitis (<3.5%) or pancreatitis (<2%), with the use of GLP1RAs [24,27]. While the incidence of cholelithiasis and cholecystitis is yet undefined, it is known that gallstone formation following bariatric surgery has an incidence of 10–38%, and treatment with ursodeoxycholic acid (UDCA) may be warranted in GLP1RA use [27].
Although the data is sparse, evidence supports GLP1RA safety and efficacy across all solid transplant patients with severe obesity without significant effects on immunosuppression or post-transplant graft function [22,23,28,29,30,31]. In a study by Dotan et al., GLP1RAs significantly reduced the incidence of major cardiovascular events (MACE) and all-cause mortality in solid organ transplant recipients with diabetes, with a hazard ratio (HR) of 0.46 for MACE and 0.39 for all-cause mortality compared to non-users [32]. However, further research is needed regarding optimal dosing and effects on sarcopenia in transplant populations with larger prospective trials.

4. Synergistic Integration of Metabolic and Bariatric Surgery in Solid Organ Transplant Care

MBS offers comprehensive benefits, reducing antihypertensive and insulin requirements while potentially altering the trajectory of end-stage organ dysfunction [19]. Weight loss can be particularly difficult for patients with end-stage organ disease. Physiological reserve and exercise tolerance in transplant patients can be low, limiting the ability of high-risk obese transplant patients to lose weight. Retrospective studies have demonstrated that patients with obesity and chronic kidney disease requiring dialysis have limited pharmacologic options with a high risk of weight regain following cessation of medical therapies [33,34].
Surgical interventions can alter the trajectory of end-stage organ dysfunction by reducing multiple obesity-related risks and potentially bridge patients to improved survival following transplantation [5].
Current guidelines recommend metabolic and bariatric surgery prior to transplantation when possible, with at least 1-year post-transplant stability required for those requiring surgery after transplant [19]. MBS before transplantation is preferred, particularly as pre-transplant weight loss can improve metabolic syndrome, inflammation, hypertension, and diabetes. Significant regulated weight loss can allow for transition into transplant eligibility and even improve chronic disease states for which transplant is no longer warranted [19,35]. By mitigating underlying health conditions, MBS can not only enhance transplant eligibility but also improve long-term survival rates by improving organ function and reducing complications. Further integration between MBS and transplant evaluation is an area of significant need for further research and development to decrease morbidity and mortality for pre-transplant patients [4,36].

5. Endobariatrics in Transplant

Endoscopic bariatric therapies (EBTs) describe minimally invasive endoscopic treatments designed to manage obesity and its associated conditions. Multiple EBTs continue to be developed, including intragastric balloons, aspiration therapy, endoscopic sleeve gastroplasty, as well as small bowel devices and remodeling techniques [37,38]. While surgery remains the gold standard in the management of obesity, endobariatrics offer less invasive alternatives with potentially lower periprocedural complications and faster recovery times [39].
The American Gastroenterological Association (AGA) recommends considering EBTs in patients with severe obesity as a bridge to traditional bariatric surgery or other interventions, including organ transplantation, when weight limits are a barrier [40]. The two most commonly evaluated endobariatric therapies for the treatment of transplant-associated obesity are intragastric balloon therapy and endoscopic sleeve gastroplasty (ESG).
Intragastric balloon (IGB) therapy utilizes an endoscopically removable space-occupying balloon to promote early satiety, delayed gastric emptying, and limit caloric intake. IGB therapy has been explored in patients awaiting kidney, heart, and liver transplantation, proving safe but with potential adverse outcomes such as significant nausea, balloon migration, and esophageal tears [41,42,43,44]. Endoscopic sleeve gastroplasty reduces gastric volume through placement of full-thickness sutures to create a sleeve-like structure [39]. EBTs have shown significant improvements in hepatic dysfunction in MASLD and reversal of fibrosis [45]. However, ESG is contraindicated in end-stage liver disease due to increased portal pressures and bleeding risks [46].
Endobariatrics remains a relatively new approach in transplant care and can be a potential intervention to improve both pre- and post-transplant outcomes, especially in patients with contraindications to surgery. Given the current limitations and short-term follow-up on patients undergoing EBT, further research is needed to establish the role and long-term efficacy of endobariatrics in transplant populations.

6. Metabolic and Bariatric Surgery in Solid Organ Transplant

The published literature on this bariatric surgery population primarily consists of retrospective analyses from institutional case series or database studies, which feature a limited patient population and lack reports on long-term transplant outcomes.

6.1. Kidney Transplant

Diabetes and hypertension drive end-stage renal disease (ESRD) development, with obesity accelerating progression through multiple metabolic pathways [47,48,49]. The prevalence of obesity in ESRD reaches 39% [50]. The BMI cutoff for entering a renal transplant program varies by center, with the majority excluding patients who have a BMI > 35 kg/m2 [51]. The 2022 OPTN/SPTR database shows 140,165 candidates listed for kidney transplant, with 26,306 completing transplantation. Notably, 46.3% of listed candidates had obesity (27.4% BMI 30–34.9 kg/m2 and 18.9% BMI > 35 kg/m2) [2].
Despite the obesity paradox conferring survival advantage in ESRD patients on dialysis, kidney transplantation provides significant survival benefit even among obese patients, though with decreased advantage for BMI > 40 kg/m2 (risk reduction 48% versus 66% in other BMI groups) [52,53,54]. Multivariable analyses show that obesity alone does not independently predict decreased graft survival or rejection, though it is associated with other independent predictors like diabetes, hypertension, and expanded donor criteria [55,56,57,58,59,60,61,62,63]. A single-center analysis of transplants with a BMI ≥ 40 kg/m2 showed longer dialysis duration and lower KDPI kidneys, but no significant differences in delayed graft function, reoperations, readmissions, wound complications, survival, or renal function at 1 year [64].
Metabolic and bariatric surgery offers significant benefits, with meta-analyses showing 50.3% of ESRD patients achieve transplant-eligible weight, and 29.5% receive transplantation [4,65]. However, ESRD patients experience longer hospital stays, higher morbidity, and increased risk of dehydration affecting renal function. Sleeve gastrectomy is preferred over Roux-en-Y bypass, with no significant immunosuppression dose adjustments needed [66,67,68]. Post-transplant bariatric surgery carries additional complications, though weight loss outcomes match non-ESRD populations [69]. However, long-term outcome data is limited in this patient population. Nonetheless, limited data shows improved graft survival in the perioperative period while having comparable graft survival to non-obese patients at up to 5 years of follow-up [70,71,72].

6.2. Liver Transplant

MASLD affects up to 30% globally and 68% of obese patients in the United States [73]. MASLD with progression to metabolic dysfunction-associated steatohepatitis (MASH) can lead to cirrhosis and hepatocellular carcinoma, requiring transplantation [74]. MASH is projected to become the leading transplant indication [75]. Metabolic surgery can resolve hepatic steatosis and fibrosis in 66% and 40–50% of patients, respectively, though it is contraindicated in decompensated cirrhosis due to mortality risks [8,74,76].
The 2022 OPTN/SRTR data shows 24,186 adult candidates listed for liver transplant, with 9001 undergoing transplantation. Obesity was present in 41.3% of MASH candidates [77]. While most centers limit BMI to 35–40 kg/m2, patients with BMI > 40 kg/m2 still show overall survival benefit after transplant [78]. The obesity paradox exists in stable cirrhosis, but obese transplant candidates have higher waitlist morbidity and Model for End-Stage Liver Disease (MELD) scores [8]. Although obesity’s impact on long-term outcomes remains controversial, it increases operative times, blood loss, length of stay, and infections [3,33,59,79,80].
Bariatric surgery outperforms medical treatment alone [81]. For pretransplant candidates, eligibility requires MELD < 15 with minimal cirrhosis, varices, and encephalopathy, without significant coagulopathy or malnutrition [19]. Sleeve gastrectomy is preferred for its lower risk and preserved biliary access [19,82]. Patients achieve a mean 50% excess body weight loss without procedure-associated mortality [83]. Meta-analysis shows that 58.5% of candidates achieve transplant-eligible weight, with 21.9% receiving transplants [4]. Data on the timing of bariatric surgery before, during, or after liver transplant is limited, but meta-analysis suggests that there is no significant difference in bariatric complications such as bleeding and staple line leak rates. Further 3-year follow-up shows simultaneous surgery having more durable post-transplant weight loss and control of metabolic syndromes [8,84,85,86]. Although long-term data beyond 5 years on the benefits of bariatric surgery in liver transplant patients is limited, a combined liver transplant with sleeve gastrectomy may offer improvement in diabetes, hypertension, and hyperlipidemia [85]. Post-transplant bariatric surgery requires one-year stability but carries increased operative times and morbidity associated with increased complexity following transplant surgery [87].

6.3. Pancreas Transplant

Type 1 diabetes remains the main reason for requiring a pancreas transplant. The rate of obesity in Type 1 diabetic patients, while historically low, has increased in recent years, mirroring the trend of the general population [88]. Data from the 2022 OPTN/SRTR show that rates of pancreas transplantation for Type 2 diabetes have tripled over the past decade, now accounting for over 20% of all transplants [89]. As a result, and as seen with other solid organs, the proportion of obese patients on the waitlist for pancreas transplantation has steadily increased [83]. Selection criteria for pre-transplant bariatric surgery are particularly important for pancreas recipients as many patients have other end-organ dysfunction from long-standing diabetes, including gastroparesis and renal failure [90]. The inclusion criteria have expanded to allow for pancreas transplantation, most commonly simultaneous pancreas and kidney transplantation (SPK) or pancreas after kidney transplantation (PAK), for many patients with Type 2 Diabetes, as concomitant ESRD is associated with worse outcomes [91]. A recent review article found that patients with Type 2 Diabetes who receive pancreas transplantation have higher average BMIs and are more likely to have a BMI > 28 than those with Type 1 Diabetes, yet outcomes remain comparable [88].
Historically, pancreas transplantation excluded obese patients with a BMI > 30 kg/m2 due to higher rates of wound complications, infection, rejection, graft loss, and death [91,92]. While some studies show similar graft loss and mortality between obese and non-obese patients, obesity increases rejection risk [93,94]. Despite these risks, 23% of listed pancreas transplant candidates now have a BMI > 30 kg/m2 [89].
Robotic pancreas transplantation decreases infectious and wound complications, offering safer and expanded access to transplant candidates with obesity. A recent case-control study demonstrates that bariatric surgery prior to pancreas transplantation is feasible and safe, and expands access for patients with prohibitive obesity. Sleeve gastrectomy appeared to be the preferred surgical choice due to malabsorptive and anatomical concerns. Nevertheless, gastric bypass remains a viable option, particularly favoring allograft anastomosis located distal to the jejuno-jejunal anastomosis. Patients were able to maintain weight loss and reached an acceptable BMI threshold for transplantation, with superior 4-year graft and patient survival rates of 100% [95].

6.4. Heart Transplant

Obesity significantly impacts heart failure risk, increasing by 5–7% for each BMI point [96]. Higher BMI correlates with worse post-transplant outcomes, showing a stepwise increase in death or re-transplantation risk [97,98]. BMI > 40 kg/m2 specifically shows an increased hazard ratio for waitlist death, longer wait times, and the highest post-transplant mortality [5]. Outcomes vary for BMI 30–35 kg/m2, showing increased bypass time and early complications but no long-term survival differences [99,100]. As a result, class 2 obesity and above is considered a relative contraindication to active listing. The 2022 OPTN/SRTR data reveals 7519 adult cardiac transplant candidates with 3668 patients undergoing transplants, of which 14% are in combination with another solid organ [101]. Historical data from 2006 to 2020 showed that 32.8% of listed patients had a BMI > 30 kg/m2, with significant correlations between increasing BMI and longer cardiac transplant wait times and left ventricular assist device (LVAD) utilization [5].
Bariatric surgery effectively counters obesity’s cardiac impact, with Swedish Registry data showing a five-fold lower heart failure risk post-surgery [102]. Propensity-matched cohort studies demonstrate prior bariatric surgery was associated with a 50% reduction in mortality and a shorter length of stay during heart failure admissions, while other comparative retrospective data reveals MBS leading to improved left ventricular ejection fraction (LVEF) and New York Heart Association (NYHA) class [103,104]. The cardioprotective effects of MBS have been successfully leveraged as a bridge to heart transplantation in conjunction with LVADs for transplant candidates with severe obesity in order to achieve transplant waitlist criteria [105,106].
Meta-analyses of heart failure patients with BMI > 35 kg/m2 report extremely low 30-day mortality rates after bariatric surgery, with 40–57% of patients achieving transplantation and 8.5% of post-MBS patients showing sufficient LVEF improvement to avoid transplant in addition to decreased need for long-term post-transplant diuretic and vasodilator requirements [19,107].
Metabolic and bariatric surgery in patients with heart failure has a higher risk of morbidity and longer hospital stays, but is still considered safe [108]. Simultaneous metabolic and cardiac transplant has also been assessed in a more limited meta-analysis showing no significant long-term differences in outcomes compared to staged surgeries, but carries a mortality rate of 15%. While this is considerably higher than MBS in non-heart failure patients, it is lower than the one-year mortality risk of LVAD patients with severe obesity managed non-surgically [19,109].

6.5. Lung Transplant

Obesity significantly impacts pulmonary function through mechanical restriction and inflammatory adaptations, reducing functional residual capacity by up to 33% in severe obesity [110,111]. Obesity in and of itself may not play an important role in ventilatory outcomes, with only 15% of patients with obesity having restrictive lung disease, but it can greatly contribute to the restrictive processes affecting lung function by affecting thoracic expansion [112,113]. The 2022 OPTN/SRTR data shows that 4228 candidates were listed for lung transplant, of which 2031 patients had restrictive lung disease, and 2743 patients underwent lung transplantation [114].
Obesity in lung transplantation has had varying outcomes with mixed reports regarding its safety profile. Multiple studies identify severe obesity as an independent risk factor for primary graft dysfunction and morbidity within the first year post-lung transplant, particularly affecting 90-day and 1-year mortality for lung transplantations for restrictive lung disease [115,116]. Retrospective analysis of lung transplant recipients with severe obesity reveals that BMI > 30 kg/m2 at the time of transplant is associated with greater length of mechanical ventilation, hospital length of stay, and composite post-transplant complications, regardless of starting BMI at the time of waitlist [117].
Robust clinical evidence describing outcomes of lung transplantation in patients with severe obesity remains limited. Current consensus guidelines categorize lung transplant recipients with a BMI > 30 kg/m2 as high-risk, and limited select specialized centers accept transplant candidates with a BMI > 35 kg/m2 [118,119]. Despite the physiologic complications associated with end-stage lung disease, such as pulmonary fibrosis and pulmonary hypertension, various case series demonstrate the safety of MBS within this patient population, with the recommendation for Roux-en-Y gastric bypass as MBS of choice given the significant role of gastroesophageal reflux disease in interstitial lung disease exacerbation. Furthermore, improvement in pulmonary function tests following MBS suggests a reduction in pulmonary complications at the time of lung transplant [120,121,122].

7. Conclusions

Bariatric and metabolic surgery has transformed transplant care for patients previously excluded due to high BMIs. While obesity can worsen both pre- and post-transplant outcomes, including increased surgical complications and mortality risks, metabolic and bariatric interventions offer solutions beyond weight loss alone. These interventions can improve comorbidities like hypertension, diabetes, and cardiovascular disease, sometimes eliminating the need for transplantation entirely. The emerging integration of pharmacologic agents and endobariatrics with metabolic surgery provides new opportunities for sustainable weight management. This multifaceted approach promises to revolutionize how transplant centers manage obese candidates. Further studies in the long-term outcomes of bariatric surgery in solid organ transplant are needed to better understand differences in long-term survival, quality of life, primary and secondary graft survival, and durability of changes in metabolic syndromes (Table 1).

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
CDCCenters for Disease Control and Prevention
BMIBody mass index
DEXADual-energy X-ray absorptiometry
BIABioelectrical impedance assessment
CTComputer tomography
MBSMetabolic and bariatric surgery
NFLDNonalcoholic fatty liver disease
MASLDMetabolic dysfunction-associated liver disease
GLP1RAGLP-1 receptor agonist
UDCAUrsodeoxycholic acid
MACEMajor cardiovascular event
HRHazard ratio
EBTEndoscopic bariatric therapy
AGAAmerican Gastroenterological Association
ESGEndoscopic sleeve gastrectomy
IGBIntragastric balloon
ESRDEnd-stage renal disease
OPTNOrgan Procurement and Transplantation Network
SRTRScientific Registry of Transplant Recipients
KDPIKidney donor profile index
MASHMetabolic dysfunction-associated steatohepatitis
MELDModel for End-Stage Liver Disease
PAKPancreas after kidney transplantation
SPKSimultaneous pancreas and kidney transplantation
LVADLeft ventricular assist device
LVEFLeft ventricular ejection fraction
NYHANew York Heart Association

References

  1. Emmerich, S.; Fryar, C.; Stierman, B.; Ogden, C. Obesity and Severe Obesity Prevalence in Adults: United States, August 2021–August 2023; Centers for Disease Control and Prevention: Atlanta, GA, USA, 2024. [Google Scholar] [CrossRef]
  2. Lentine, K.L.; Smith, J.M.; Lyden, G.R.; Miller, J.M.; Dolan, T.G.; Bradbrook, K.; Larkin, L.; Temple, K.; Handarova, D.K.; Weiss, S.; et al. OPTN/SRTR 2022 Annual Data Report: Kidney. Am. J. Transplant. 2024, 24, S19–S118. [Google Scholar] [CrossRef]
  3. Lam, J.; Khan, M.Q.; Watt, K.D.; Diwan, T.S. Optimal management of obesity in transplant candidates and recipients. Curr. Transplant. Rep. 2024, 11, 84–94. [Google Scholar] [CrossRef]
  4. Orandi, B.J.; Lewis, C.E.; MacLennan, P.A.; Qu, H.; Mehta, S.; Kumar, V.; Sheikh, S.S.; Cannon, R.M.; Anderson, D.J.; Hanaway, M.J.; et al. Obesity as an isolated contraindication to kidney transplantation in the end-stage renal disease population: A cohort study. Obesity 2021, 29, 1538–1546. [Google Scholar] [CrossRef]
  5. Chouairi, F.; Milner, A.; Sen, S.; Guha, A.; Stewart, J.; Jastreboff, A.M.; Mori, M.; Clark, K.A.; Miller, P.E.; Fuery, M.A.; et al. Impact of obesity on heart transplantation outcomes. J. Am. Heart Assoc. 2021, 10, e021346. [Google Scholar] [CrossRef]
  6. Adult BMI Categories. BMI. Available online: https://www.cdc.gov/bmi/adult-calculator/bmi-categories.html (accessed on 19 March 2024).
  7. Eisenberg, D.; Shikora, S.A.; Aarts, E.; Aminian, A.; Angrisani, L.; Cohen, R.V.; De Luca, M.; Faria, S.L.; Goodpaster, K.P.S.; Haddad, A.; et al. Publisher correction: 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Indications for Metabolic and Bariatric Surgery. Obes. Surg. 2022, 33, 15–16. [Google Scholar] [CrossRef]
  8. Moctezuma-Velazquez, C.; Márquez-Guillén, E.; Torre, A. Obesity in the liver transplant setting. Nutrients 2019, 11, 2552. [Google Scholar] [CrossRef]
  9. El-Sebaie, M.; Elwakil, W. Biomarkers of sarcopenia: An unmet need. Egypt. Rheumatol. Rehabil. 2023, 50, 45. [Google Scholar] [CrossRef]
  10. Zhou, D.; Zhang, D.; Zeng, C.; Zhang, L.; Gao, X.; Wang, X. Impact of sarcopenia on the survival of patients undergoing liver transplantation for decompensated liver cirrhosis. J. Cachexia Sarcopenia Muscle 2023, 14, 2602–2612. [Google Scholar] [CrossRef] [PubMed]
  11. Vaurs, C.; Diméglio, C.; Charras, L.; Anduze, Y.; Du Rieu, M.C.; Ritz, P. Determinants of changes in muscle mass after bariatric surgery. Diabetes Metab. 2015, 41, 416–421. [Google Scholar] [CrossRef] [PubMed]
  12. Huml, A.M.; Schold, J.D. Kidney transplantation and candidate BMI: Viability is in the eye of the beholder. Am. J. Kidney Dis. 2021, 78, 484–486. [Google Scholar] [CrossRef] [PubMed]
  13. Lin, X.; Li, H. Obesity: Epidemiology, pathophysiology, and Therapeutics. Front. Endocrinol. 2021, 12, 706978. [Google Scholar] [CrossRef] [PubMed]
  14. Panuganti, K.K.; Nguyen, M.; Kshirsagar, R.K. Obesity. In StatPearls [Internet]; StatPearls Publishing: Treasure Island, FL, USA, 2025. Available online: https://www.ncbi.nlm.nih.gov/books/NBK459357/ (accessed on 4 June 2025).
  15. Madsen, H.J.; Gillette, R.A.; Colborn, K.L.; Henderson, W.G.; Dyas, A.R.; Bronsert, M.R.; Lambert-Kerzner, A.; Meguid, R.A. The association between obesity and postoperative outcomes in a broad surgical population: A 7-year American College of Surgeons National Surgical Quality Improvement analysis. Surgery 2023, 173, 1213–1219. [Google Scholar] [CrossRef] [PubMed]
  16. Waisbren, E.; Rosen, H.; Bader, A.M.; Lipsitz, S.R.; Rogers, S.O.; Eriksson, E. Percent body fat and prediction of surgical site infection. J. Am. Coll. Surg. 2010, 210, 381–389. [Google Scholar] [CrossRef]
  17. Tjeertes, E.E.; Hoeks, S.S.; Beks, S.S.; Valentijn, T.T.; Hoofwijk, A.A.; Stolker, R.J.R. Obesity—A risk factor for postoperative complications in general surgery? BMC Anesthesiol. 2015, 15, 112. [Google Scholar] [CrossRef]
  18. Lambert, E.A.; Esler, M.D.; Schlaich, M.P.; Dixon, J.; Eikelis, N.; Lambert, G.W. Obesity-Associated organ damage and sympathetic nervous activity. Hypertension 2019, 73, 1150–1159. [Google Scholar] [CrossRef]
  19. Ghanem, O.M.; Pita, A.; Nazzal, M.; Johnson, S.; Diwan, T.; Obeid, N.R.; Croome, K.P.; Lim, R.; Quintini, C.; Whitson, B.A.; et al. Obesity, organ failure, and transplantation: A review of the role of metabolic and bariatric surgery in transplant candidates and recipients. Am. J. Transplant. 2024, 24, 1534–1546. [Google Scholar] [CrossRef]
  20. Jomphe, V.; Bélanger, N.; Beauchamp-Parent, C.; Poirier, C.; Nasir, B.S.; Ferraro, P.; Lands, L.C.; Mailhot, G. New-onset obesity after lung transplantation: Incidence, risk factors, and clinical outcomes. Transplantation 2022, 106, 2247–2255. [Google Scholar] [CrossRef]
  21. Puttarajappa, C.M.; Smith, K.J.; Ahmed, B.H.; Bernardi, K.; Lavenburg, L.M.; Hoffman, W.; Molinari, M. Economic evaluation of weight loss and transplantation strategies for kidney transplant candidates with obesity. Am. J. Transplant. 2024, 24, 2212–2224. [Google Scholar] [CrossRef]
  22. Orandi, B.J. Selecting weight loss strategies for kidney transplant candidacy: Weighty decisions. Am. J. Transplant. 2024, 24, 2148–2149. [Google Scholar] [CrossRef]
  23. Zahrawi, F.; Fathma, S.; Mehal, W.Z.; Banini, B.A. Pharmacologic Management of Obesity after Liver Transplantation: A Critical Review. Ann. Gastroenterol. Dig. Disord. 2023, 6, 17–25. Available online: https://pubmed.ncbi.nlm.nih.gov/38098758 (accessed on 4 June 2025). [PubMed]
  24. Moiz, A.; Filion, K.B.; Toutounchi, H.; Tsoukas, M.A.; Yu, O.H.; Peters, T.M.; Eisenberg, M.J. Efficacy and safety of glucagon-like peptide-1 receptor agonists for weight loss among adults without diabetes: A Systematic Review of Randomized Controlled Trials. Ann. Intern. Med. 2025, 178, 199–217. [Google Scholar] [CrossRef]
  25. Wright, D.R.; Guo, J.; Hernandez, I. A Prescription for Achieving Equitable Access to Antiobesity Medications. JAMA Health Forum. 2023, 4, e230493. [Google Scholar] [CrossRef]
  26. Rubino, D.M.; Greenway, F.L.; Khalid, U.; O’Neil, P.M.; Rosenstock, J.; Sørrig, R.; Wadden, T.A.; Wizert, A.; Garvey, W.T.; Arauz-Pacheco, C.; et al. Effect of weekly subcutaneous semaglutide vs. daily liraglutide on body weight in adults with overweight or obesity without diabetes. JAMA 2022, 327, 138–150. [Google Scholar] [CrossRef]
  27. Son, S.Y.; Song, J.H.; Shin, H.J.; Hur, H.; Han, S.U. Prevention of Gallstones After Bariatric Surgery using Ursodeoxycholic Acid: A Narrative Review of Literatures. J. Metab. Bariatr. Surg. 2022, 11, 30–38. [Google Scholar] [CrossRef] [PubMed]
  28. Humberto, G.; Daniel, M.; Deepak, V. Successful Implementation of a Multidisciplinary Weight Loss Program Including GLP1 Receptor Agonists for Liver Transplant Candidates With High Body Mass Index. Transplantation 2025, 16, 2233–2237. [Google Scholar] [CrossRef]
  29. Goebel, L.; Long, M.; Paplaczyk, K.; Tomic, R.; Subramani, M.V.; Arunachalam, A.; Myers, C. Evaluating the Utility of Glucagon-Like Peptide 1 Receptor Agonists in Potential Lung Transplant Candidates Requiring Weight Loss Prior to Transplant. J. Heart Lung Transplant. 2024, 43, S642–S643. [Google Scholar] [CrossRef]
  30. Jeyakumar, S.; Jeyakumar, R.; Robson, D.; Honeysett, L.; Raven, L.; e Silva, R.C.D.; Jabbour, A.; Kotlyar, E.; Keogh, A.; Greenfield, J.; et al. Glucagon-Like Peptide-1 Receptor Agonists for Weight Loss in End Stage Heart Failure Patients Considered for Heart Transplantation. J. Heart Lung Transplant. 2024, 43, S106. [Google Scholar] [CrossRef]
  31. Richardson, S.H.; Wong, G.; Garner, E.; Izzy, M.; Srivastava, G. Utility of glucagon-like peptide 1 receptor agonists as anti-obesity medications in liver transplant recipients. Liver Transplant. 2023, 30, 226–228. [Google Scholar] [CrossRef]
  32. Dotan, I.; Rudman, Y.; Turjeman, A.; Akirov, A.; Steinmetz, T.; Calvarysky, B.; Cohen, T.D. Glucagon-like peptide 1 receptor agonists and cardiovascular outcomes in solid organ transplant recipients with diabetes mellitus. Transplantation 2024, 108, e121–e128. [Google Scholar] [CrossRef] [PubMed]
  33. Diwan, T.S.; Lee, T.C.; Nagai, S.; Benedetti, E.; Posselt, A.; Bumgardner, G.; Noria, S.; Whitson, B.A.; Ratner, L.; Mason, D.; et al. Obesity, transplantation, and bariatric surgery: An evolving solution for a growing epidemic. Am. J. Transplant. 2020, 20, 2143–2155. [Google Scholar] [CrossRef] [PubMed]
  34. Painter, P.; Zimmerman, S.W. Exercise in End-Stage Renal Disease. Am. J. Kidney Dis. 1986, 7, 386–394. [Google Scholar] [CrossRef]
  35. Verhoeff, K.; Dang, J.T.; Modasi, A.; Switzer, N.; Birch, D.W.; Karmali, S. Bariatric Surgery Outcomes in Patients with Previous Organ Transplant: Scoping Review and Analysis of the MBSAQIP. Obes. Surg. 2020, 31, 508–516. [Google Scholar] [CrossRef]
  36. Freeman, C.M.; Woodle, E.S.; Shi, J.; Alexander, J.W.; Leggett, P.L.; Shah, S.A.; Paterno, F.; Cuffy, M.C.; Govil, A.; Mogilishetty, G.; et al. Keyword Index. Am. J. Transplant. 2015, 15, 119–120. [Google Scholar] [CrossRef]
  37. Shenoy, A.; Schulman, A.R. Advances in endobariatrics: Past, present, and future. Gastroenterol. Rep. 2022, 11, goad043. [Google Scholar] [CrossRef]
  38. Jirapinyo, P.; Thompson, C.C. Endoscopic Bariatric and Metabolic therapies: Surgical analogues and mechanisms of action. Clin. Gastroenterol. Hepatol. 2016, 15, 619–630. [Google Scholar] [CrossRef] [PubMed]
  39. Gudur, A.R.; Geng, C.X.; Kshatri, S.; Martin, D.; Haug, R.; Radlinski, M.; Lei, Y.; Buerlein, R.C.; Strand, D.S.; Sauer, B.G.; et al. Comparison of endoscopic sleeve gastroplasty versus surgical sleeve gastrectomy: A Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database analysis. Gastrointest. Endosc. 2022, 97, 11–21.e4. [Google Scholar] [CrossRef]
  40. Dayyeh, B.K.A.; Edmundowicz, S.; Thompson, C.C. Clinical Practice Update: Expert review on endoscopic bariatric therapies. Gastroenterology 2017, 152, 716–729. [Google Scholar] [CrossRef]
  41. Beaudreuil, S.; Iglicki, F.; Ledoux, S.; Elias, M.; Obada, E.N.; Hebibi, H.; Durand, E.; Charpentier, B.; Coffin, B.; Durrbach, A. Efficacy and safety of intra-gastric balloon placement in dialyzed patients awaiting kidney transplantation. Obes. Surg. 2018, 29, 713–720. [Google Scholar] [CrossRef]
  42. Patel, N.J.; Gómez, V.; Steidley, D.E.; Roust, L.; Moreno, J.C.L.; Abraham, N.S.; Pannala, R. Successful use of intragastric balloon therapy as a bridge to heart transplantation. Obes. Surg. 2020, 30, 3610–3614. [Google Scholar] [CrossRef] [PubMed]
  43. Choudhary, N.S.; Puri, R.; Saraf, N.; Saigal, S.; Kumar, N.; Rai, R.; Rastogi, A.; Goja, S.; Bhangui, P.; Ramchandra, S.K.; et al. Intragastric balloon as a novel modality for weight loss in patients with cirrhosis and morbid obesity awaiting liver transplantation. Indian J. Gastroenterol. 2016, 35, 113–116. [Google Scholar] [CrossRef] [PubMed]
  44. Watt, K.D.; Heimbach, J.K.; Rizk, M.; Jaruvongvanich, P.; Sanchez, W.; Port, J.; Venkatesh, S.K.; Bamlet, H.; Tiedtke, K.; Malhi, H.; et al. Efficacy and safety of endoscopic balloon placement for weight loss in patients with cirrhosis awaiting liver transplantation. Liver Transplant. 2021, 27, 1239–1247. [Google Scholar] [CrossRef] [PubMed]
  45. Jirapinyo, P.; McCarty, T.R.; Dolan, R.D.; Shah, R.; Thompson, C.C. Effect of endoscopic bariatric and metabolic therapies on nonalcoholic fatty liver disease: A systematic review and meta-analysis. Clin. Gastroenterol. Hepatol. 2021, 20, 511–524.e1. [Google Scholar] [CrossRef] [PubMed]
  46. Matteo, M.V.; Bove, V.; Pontecorvi, V.; De Siena, M.; Taibi, C.; Costamagna, G.; Boškoski, I. Endoscopic Sleeve Gastroplasty as a Therapeutic Chance for Obese Patients not Eligible for Organ Transplantation. Obes. Surg. 2022, 32, 2460–2462. [Google Scholar] [CrossRef]
  47. Hashmi, M.F.; Benjamin, O.; Lappin, S.L. End-Stage Renal Disease. In StatPearls [Internet]; StatPearls Publishing: Treasure Island, FL, USA, 2025. Available online: https://www.ncbi.nlm.nih.gov/books/NBK499861/ (accessed on 4 June 2025).
  48. Kopple, J.D. Obesity and chronic kidney disease. J. Ren. Nutr. 2010, 20, S29–S30. [Google Scholar] [CrossRef]
  49. Pané, A.; Claro, M.; Molina-Andujar, A.; Olbeyra, R.; Romano-Andrioni, B.; Boswell, L.; Montagud-Marrahi, E.; Jiménez, A.; Ibarzabal, A.; Viaplana, J.; et al. Bariatric Surgery Outcomes in Patients with Chronic Kidney Disease. J. Clin. Med. 2023, 12, 6095. [Google Scholar] [CrossRef]
  50. Wakam, G.K.; Sheetz, K.H.; Gerhardinger, L.; Montgomery, J.R.; Waits, S.A. Population-based trends in obesity and kidney transplantation among patients with end-stage kidney disease. Transplant. Direct. 2021, 7, e787. [Google Scholar] [CrossRef]
  51. Bellizzi, V.; Annunziata, G.; Albanese, A.; D’Alessandro, C.; Garofalo, C.; Foletto, M.; Barrea, L.; Cupisti, A.; Zoccali, C.; De Nicola, L. Approaches to patients with obesity and CKD: Focus on nutrition and surgery. Clin. Kidney J. 2024, 17 (Suppl. S2), 51–64. [Google Scholar] [CrossRef]
  52. Park, J.; Ahmadi, S.; Streja, E.; Molnar, M.Z.; Flegal, K.M.; Gillen, D.; Kovesdy, C.P.; Kalantar-Zadeh, K. Obesity Paradox in End-Stage Kidney Disease Patients. Prog. Cardiovasc. Dis. 2013, 56, 415–425. [Google Scholar] [CrossRef]
  53. Port, F.K.; Ashby, V.B.; Dhingra, R.K.; Roys, E.C.; Wolfe, R.A. Dialysis Dose and Body Mass Index Are Strongly Associated with Survival in Hemodialysis Patients. J. Am. Soc. Nephrol. 2002, 13, 1061–1066. [Google Scholar] [CrossRef] [PubMed]
  54. Gill, J.; Lan, J.; Dong, J.; Rose, C.; Hendren, E.; Johnston, O.; Gill, J. The survival benefit of kidney transplantation in obese patients. Am. J. Transplant. 2013, 13, 2083–2090. [Google Scholar] [CrossRef]
  55. Hoogeveen, E.K.; Aalten, J.; Rothman, K.J.; Roodnat, J.I.; Mallat, M.J.K.; Borm, G.; Weimar, W.; Hoitsma, A.J.; De Fijter, J.W. Effect of obesity on the outcome of kidney Transplantation: A 20-Year Follow-Up. Transplantation 2011, 91, 869–874. [Google Scholar] [CrossRef]
  56. Siedlecki, A.; Irish, W.; Brennan, D. Delayed graft function in the kidney transplant. Am. J. Transplant. 2011, 11, 2279–2296. [Google Scholar] [CrossRef] [PubMed]
  57. Yemini, R.; Rahamimov, R.; Nesher, E.; Anteby, R.; Ghinea, R.; Hod, T.; Mor, E. The Impact of Obesity and Associated Comorbidities on the Outcomes after Renal Transplantation with a Living Donor vs. Deceased Donor Grafts. J. Clin. Med. 2022, 11, 3069. [Google Scholar] [CrossRef] [PubMed]
  58. Cohen, J.B.; Lim, M.A.; Tewksbury, C.M.; Torres-Landa, S.; Trofe-Clark, J.; Abt, P.L.; Williams, N.N.; Dumon, K.R.; Goral, S. Bariatric surgery before and after kidney transplantation: Long-term weight loss and allograft outcomes. Surg. Obes. Relat. Dis. 2019, 15, 935–941. [Google Scholar] [CrossRef]
  59. Dick, A.a.S.; Spitzer, A.L.; Seifert, C.F.; Deckert, A.; Carithers, R.L.; Reyes, J.D.; Perkins, J.D. Liver transplantation at the extremes of the body mass index. Liver Transplant. 2009, 15, 968–977. [Google Scholar] [CrossRef]
  60. Johansen, K.L. Obesity and body composition for transplant Wait-List Candidacy—Challenging or maintaining the BMI limits? J. Ren. Nutr. 2013, 23, 207–209. [Google Scholar] [CrossRef]
  61. Scheuermann, U.; Babel, J.; Pietsch, U.; Weimann, A.; Lyros, O.; Semmling, K.; Hau, H.; Seehofer, D.; Rademacher, S.; Sucher, R. Recipient obesity as a risk factor in kidney transplantation. BMC Nephrol. 2022, 23, 37. [Google Scholar] [CrossRef]
  62. Gillespie, H.; O’Neill, S.; Curtis, R.M.K.; Callaghan, C.; Courtney, A.E. When There is No Guidance From the Guidelines: Renal Transplantation in Recipients With Class III Obesity. Transpl. Int. 2023, 36, 11428. [Google Scholar] [CrossRef]
  63. Lim, W.H.; Wong, G.; Pilmore, H.L.; McDonald, S.P.; Chadban, S.J. Long-term outcomes of kidney transplantation in people with type 2 diabetes: A population cohort study. Lancet Diabetes Endocrinol. 2016, 5, 26–33. [Google Scholar] [CrossRef]
  64. Jacobs, M.L.; Dhaliwal, K.; Harriman, D.I.; Rogers, J.; Stratta, R.J.; Farney, A.C.; Orlando, G.; Reeves-Daniel, A.; Jay, C. Comparable kidney transplant outcomes in selected patients with a body mass index ≥ 40: A personalized medicine approach to recipient selection. Clin. Transplant. 2023, 37, e14903. [Google Scholar] [CrossRef] [PubMed]
  65. Lentine, K.L.; Xiao, H.; Brennan, D.C.; Schnitzler, M.A.; Villines, T.C.; Abbott, K.C.; Axelrod, D.; Snyder, J.J.; Hauptman, P.J. The impact of kidney transplantation on heart failure risk varies with candidate body mass index. Am. Heart J. 2009, 158, 972–982. [Google Scholar] [CrossRef]
  66. Oniscu, G.C.; Abramowicz, D.; Bolignano, D.; Gandolfini, I.; Hellemans, R.; Maggiore, U.; Nistor, I.; O’Neill, S.; Sever, M.S.; Koobasi, M.; et al. Management of obesity in kidney transplant candidates and recipients: A clinical practice guideline by the DESCARTES Working Group of ERA. Nephrol. Dial. Transplant. 2021, 37 (Suppl. S1), i1–i15. [Google Scholar] [CrossRef]
  67. Khajeh, E.; Aminizadeh, E.; Moghadam, A.D.; Sabetkish, N.; Dezfouli, S.A.; Morath, C.; Zeier, M.; Nickel, F.; Billeter, A.T.; Müller-Stich, B.P.; et al. Bariatric surgery in patients with obesity and end-stage renal disease. Surg. Obes. Relat. Dis. 2023, 19, 858–871. [Google Scholar] [CrossRef]
  68. Yemini, R.; Nesher, E.; Carmeli, I.; Winkler, J.; Rahamimov, R.; Mor, E.; Keidar, A. Bariatric surgery is efficacious and improves access to transplantation for morbidly obese renal transplant candidates. Obes. Surg. 2019, 29, 2373–2380. [Google Scholar] [CrossRef] [PubMed]
  69. Golomb, I.; Winkler, J.; Ben-Yakov, A.; Benitez, C.; Keidar, A. Laparoscopic sleeve gastrectomy as a weight reduction strategy in obese patients after kidney transplantation. Am. J. Transplant. 2014, 14, 2384–2390. [Google Scholar] [CrossRef] [PubMed]
  70. Ku, E.; McCulloch, C.E.; Roll, G.R.; Posselt, A.; Grimes, B.A.; Johansen, K.L. Bariatric surgery prior to transplantation and risk of early hospital re-admission, graft failure, or death following kidney transplantation. Am. J. Transplant. 2021, 21, 3750–3757. [Google Scholar] [CrossRef]
  71. Mousapour, P.; Ling, J.; Zimbudzi, E. Comparison of Kidney Transplantation Outcomes Between Patients with and Without Pre-transplantation Bariatric Surgery: A Systematic Review. Obes. Surg. 2022, 32, 4066–4081. [Google Scholar] [CrossRef]
  72. Outmani, L.; Kimenai, H.J.a.N.; Roodnat, J.I.; Leeman, M.; Biter, U.L.; Klaassen, R.A.; IJzermans, J.N.M.; Minnee, R.C. Clinical outcome of kidney transplantation after bariatric surgery: A single-center, retrospective cohort study. Clin. Transplant. 2020, 35, e14208. [Google Scholar] [CrossRef]
  73. Rinella, M.E.; Sookoian, S. From NAFLD to MASLD: Updated naming and diagnosis criteria for fatty liver disease. J. Lipid Res. 2023, 65, 100485. [Google Scholar] [CrossRef] [PubMed]
  74. Polyzos, S.A.; Kountouras, J.; Mantzoros, C.S. Obesity and nonalcoholic fatty liver disease: From pathophysiology to therapeutics. Metabolism 2018, 92, 82–97. [Google Scholar] [CrossRef]
  75. Terrault, N.A.; Francoz, C.; Berenguer, M.; Charlton, M.; Heimbach, J. Liver Transplantation 2023: Status Report, current and future challenges. Clin. Gastroenterol. Hepatol. 2023, 21, 2150–2166. [Google Scholar] [CrossRef] [PubMed]
  76. Machado, M.V. MASLD treatment—A shift in the paradigm is imminent. Front. Med. 2023, 10, 1316284. [Google Scholar] [CrossRef]
  77. Kwong, A.J.; Kim, W.R.; Lake, J.R.; Schladt, D.P.; Schnellinger, E.M.; Gauntt, K.; McDermott, M.; Weiss, S.; Handarova, D.K.; Snyder, J.J.; et al. OPTN/SRTR 2022 Annual Data Report: Liver. Am. J. Transplant. 2024, 24, S176–S265. [Google Scholar] [CrossRef]
  78. Jacobs, M.L.; Byrne, M.; Cai, X.; Gao, S.; Martens, J.; Ruffolo, L.I.; Cupertino, A.P.; Pineda-Solis, K. Outcomes of Living Donor Liver Transplant in Elevated Body Mass Index over a Decade in the United States. J. Liver Transplant. 2025, 18, 100274. [Google Scholar] [CrossRef]
  79. Agopian, V.G.; Kaldas, F.M.; Hong, J.C.; Whittaker, M.; Holt, C.; Rana, A.; Zarrinpar, A.; Petrowsky, H.; Farmer, D.; Yersiz, H.; et al. Liver transplantation for nonalcoholic steatohepatitis. Ann. Surg. 2012, 256, 624–633. [Google Scholar] [CrossRef] [PubMed]
  80. Spengler, E.K.; O’Leary, J.G.; Te, H.S.; Rogal, S.; Pillai, A.A.; Al-Osaimi, A.; Desai, A.; Fleming, J.N.; Ganger, D.; Seetharam, A.; et al. Liver transplantation in the obese cirrhotic patient. Transplantation 2017, 101, 2288–2296. [Google Scholar] [CrossRef]
  81. Suraweera, D.; Saab, E.G.; Choi, G.; Saab, S. Bariatric Surgery and Liver Transplantation. Gastroenterol. Hepatol. 2017, 13, 170–175. [Google Scholar] [CrossRef]
  82. Sharpton, S.R.; Terrault, N.A.; Tavakol, M.M.; Posselt, A.M. Sleeve gastrectomy prior to liver transplantation is superior to medical weight loss in reducing posttransplant metabolic complications. Am. J. Transplant. 2021, 21, 3324–3332. [Google Scholar] [CrossRef]
  83. Lin, M.Y.; Tavakol, M.M.; Sarin, A.; Amirkiai, S.M.; Rogers, S.J.; Carter, J.T.; Posselt, A.M. Laparoscopic sleeve gastrectomy is safe and efficacious for pretransplant candidates. Surg. Obes. Relat. Dis. 2013, 9, 653–658. [Google Scholar] [CrossRef] [PubMed]
  84. Chierici, A.; Alromayan, M.; De Fatico, S.; Drai, C.; Vinci, D.; Anty, R.; Schiavo, L.; Iannelli, A. Is bariatric surgery safer before, during, or after liver transplantation? A systematic review and meta-analysis. J. Liver Transplant. 2023, 9, 100139. [Google Scholar] [CrossRef]
  85. Zamora-Valdes, D.; Watt, K.D.; Kellogg, T.A.; Poterucha, J.J.; Di Cecco, S.R.; Francisco-Ziller, N.M.; Taner, T.; Rosen, C.B.; Heimbach, J.K. Long-term outcomes of patients undergoing simultaneous liver transplantation and sleeve gastrectomy. Hepatology 2018, 68, 485–495. [Google Scholar] [CrossRef]
  86. Lee, Y.; Tian, C.; Lovrics, O.; Soon, M.S.; Doumouras, A.G.; Anvari, M.; Hong, D. Bariatric surgery before, during, and after liver transplantation: A systematic review and meta-analysis. Surg. Obes. Relat. Dis. 2020, 16, 1336–1347. [Google Scholar] [CrossRef]
  87. Lopez-Lopez, V.; Ruiz-Manzanera, J.J.; Eshmuminov, D.; Lehmann, K.; Schneider, M.; Von Der Groeben, M.; De Angulo, D.R.; Gajownik, U.; Pons, J.A.; Sánchez-Bueno, F.; et al. Are we ready for bariatric surgery in a liver transplant program? A Meta-Analysis. Obes. Surg. 2020, 31, 1214–1222. [Google Scholar] [CrossRef]
  88. Papageorge, C.M.; Bolognese, A.C.; Odorico, J.S. Expanding access to pancreas transplantation for type 2 diabetes mellitus. Curr. Opin. Organ. Transplant. 2021, 26, 390–396. [Google Scholar] [CrossRef] [PubMed]
  89. Kandaswamy, R.; Stock, P.G.; Miller, J.M.; Booker, S.E.; White, J.; Israni, A.K.; Snyder, J.J. OPTN/SRTR 2022 Annual Data Report: Pancreas. Am. J. Transplant. 2024, 24, S119–S175. [Google Scholar] [CrossRef] [PubMed]
  90. Aswath, G.S.; Foris, L.A.; Ashwath, A.K.; Patel, K. Diabetic Gastroparesis. In StatPearls [Internet]; StatPearls Publishing: Treasure Island, FL, USA, 2025. Available online: https://www.ncbi.nlm.nih.gov/books/NBK430794/ (accessed on 4 June 2025).
  91. Owen, R.V.; Thompson, E.R.; Tingle, S.J.; Ibrahim, I.K.; Manas, D.M.; White, S.A.; Wilson, C.H. Too Fat for Transplant? The Impact of Recipient BMI on Pancreas Transplant Outcomes. Transplantation 2021, 105, 905–915. [Google Scholar] [CrossRef] [PubMed]
  92. Hanish, S.I.; Petersen, R.P.; Collins, B.H.; Tuttle-Newhall, J.; Marroquin, C.E.; Kuo, P.C.; Butterly, D.W.; Smith, S.R.; Desai, D.M. Obesity predicts increased overall complications following pancreas transplantation. Transpl. Proc. 2005, 37, 3564–3566. [Google Scholar] [CrossRef] [PubMed]
  93. Bédat, B.; Niclauss, N.; Jannot, A.; Andres, A.; Toso, C.; Morel, P.; Berney, T. Impact of recipient body mass Index on Short-Term and Long-Term survival of pancreatic grafts. Transplantation 2014, 99, 94–99. [Google Scholar] [CrossRef]
  94. Laurence, J.M.; Marquez, M.A.; Bazerbachi, F.; Seal, J.B.; Selzner, M.; Norgate, A.; McGilvray, I.D.; Schiff, J.; Cattral, M.S. Optimizing pancreas transplantation outcomes in obese recipients. Transplantation 2015, 99, 1282–1287. [Google Scholar] [CrossRef]
  95. Matar, A.J.; Wright, M.; Megaly, M.; Dryden, M.; Ramanathan, K.; Humphreville, V.; Mathews, D.V.; Sarumi, H.; Kopacz, K.; Leslie, D.; et al. Bariatric surgery prior to pancreas transplantation: A retrospective matched case-control study. Surg. Obes. Relat. Dis. 2024, 21, 489–496. [Google Scholar] [CrossRef]
  96. Kenchaiah, S.; Evans, J.C.; Levy, D.; Wilson, P.W.; Benjamin, E.J.; Larson, M.G.; Kannel, W.B.; Vasan, R.S. Obesity and the risk of heart failure. N. Engl. J. Med. 2002, 347, 305–313. [Google Scholar] [CrossRef]
  97. Kilic, A.; Conte, J.V.; Shah, A.S.; Yuh, D.D. Orthotopic heart transplantation in patients with metabolic risk factors. Ann. Thorac. Surg. 2012, 93, 718–724. [Google Scholar] [CrossRef]
  98. Kim, I.; Youn, J.; Lee, S.; Chang, W.; Kim, D.S.; Singer-Englar, T.; Chang, D.; Kransdorf, E.; Kittleson, M.; Patel, J.; et al. The impact of pre-heart transplant body mass index on long-term clinical outcomes according to the age distribution. J. Card. Fail. 2024, 30, 227. [Google Scholar] [CrossRef]
  99. Nagendran, J.; Moore, M.D.; Norris, C.M.; Khani-Hanjani, A.; Graham, M.M.; Freed, D.H.; Nagendran, J. The varying effects of obesity and morbid obesity on outcomes following cardiac transplantation. Int. J. Obes. 2016, 40, 721–724. [Google Scholar] [CrossRef] [PubMed]
  100. Liu, Y.; Padilla, F.; Graviss, E.; Nguyen, D.; Gnanashanmugam, S.; Suarez, E. Heart transplant outcomes in obese patients BMI 35–39.9. J. Heart Lung Transplant. 2020, 39, S225–S226. [Google Scholar] [CrossRef]
  101. Colvin, M.M.; Smith, J.M.; Ahn, Y.S.; Handarova, D.K.; Martinez, A.C.; Lindblad, K.A.; Israni, A.K.; Snyder, J.J. OPTN/SRTR 2022 Annual Data Report: Heart. Am. J. Transplant. 2024, 24, S305–S393. [Google Scholar] [CrossRef] [PubMed]
  102. Persson, C.E.; Björck, L.; Lagergren, J.; Lappas, G.; Giang, K.W.; Rosengren, A. Risk of heart failure in obese patients with and without bariatric surgery in Sweden—A Registry-Based Study. J. Card. Fail. 2017, 23, 530–537. [Google Scholar] [CrossRef]
  103. Aleassa, E.M.; Khorgami, Z.; Kindel, T.L.; Tu, C.; Tang, W.W.; Schauer, P.R.; Brethauer, S.A.; Aminian, A. Impact of bariatric surgery on heart failure mortality. Surg. Obes. Relat. Dis. 2019, 15, 1189–1196. [Google Scholar] [CrossRef]
  104. Esparham, A.; Mehri, A.; Hadian, H.; Taheri, M.; Moghadam, H.A.; Kalantari, A.; Fogli, M.J.; Khorgami, Z. The Effect of Bariatric Surgery on Patients with Heart Failure: A Systematic Review and Meta-analysis. Obes. Surg. 2023, 33, 4125–4136. [Google Scholar] [CrossRef]
  105. Lim, C.; Fisher, O.M.; Falkenback, D.; Boyd, D.; Hayward, C.S.; Keogh, A.; Samaras, K.; MacDonald, P.; Lord, R.V. Bariatric Surgery Provides a “Bridge to Transplant” for Morbidly Obese Patients with Advanced Heart Failure and May Obviate the Need for Transplantation. Obes. Surg. 2015, 26, 486–493. [Google Scholar] [CrossRef]
  106. McElderry, B.; Alvarez, P.; Hanna, M.; Chaudhury, P.; Bhat, P.; Starling, R.C.; Desai, M.; Mentias, A. Outcomes of bariatric surgery in patients with left ventricular assist device. J. Heart Lung Transplant. 2022, 41, 914–918. [Google Scholar] [CrossRef]
  107. Lee, Y.; Anvari, S.; Soon, M.S.; Tian, C.; Wong, J.A.; Hong, D.; Anvari, M.; Doumouras, A.G. Bariatric surgery as a bridge to heart transplantation in morbidly obese patients. Cardiol. Rev. 2020, 30, 1–7. [Google Scholar] [CrossRef] [PubMed]
  108. Yang, T.W.W.; Johari, Y.; Burton, P.R.; Earnest, A.; Shaw, K.; Hare, J.L.; Brown, W.A. Bariatric Surgery in Patients with Severe Heart Failure. Obes. Surg. 2020, 30, 2863–2869. [Google Scholar] [CrossRef] [PubMed]
  109. Challapalli, J.; Maynes, E.J.; O’Malley, T.J.; Cross, D.E.; Weber, M.P.; Choi, J.H.; Aggarwal, R.; Boyle, A.J.; Whellan, D.J.; Entwistle, J.W.; et al. Sleeve Gastrectomy in Patients with Continuous-Flow Left Ventricular Assist Devices: A Systematic Review and Meta-Analysis. Obes. Surg. 2020, 30, 4437–4445. [Google Scholar] [CrossRef]
  110. Sekine, A.; Wasamoto, S.; Hagiwara, E.; Yamakawa, H.; Ikeda, S.; Okabayashi, H.; Oda, T.; Okuda, R.; Kitamura, H.; Baba, T.; et al. Beneficial impact of weight loss on respiratory function in interstitial lung disease patients with obesity. Respir. Investig. 2020, 59, 247–251. [Google Scholar] [CrossRef]
  111. Dixon, A.E.; Peters, U. The effect of obesity on lung function. Expert Rev. Respir. Med. 2018, 12, 755–767. [Google Scholar] [CrossRef] [PubMed]
  112. Lo Mauro, A.; Tringali, G.; Codecasa, F.; Abbruzzese, L.; Sartorio, A.; Aliverti, A. Pulmonary and chest wall function in obese adults. Sci. Rep. 2023, 13, 17753. [Google Scholar] [CrossRef] [PubMed]
  113. Fernandez, R.; Safaeinili, N.; Kurihara, C.; Odell, D.D.; Jain, M.; DeCamp, M.M.; Budinger, G.R.S.; Bharat, A. Association of body mass index with lung transplantation survival in the United States following implementation of the lung allocation score. J. Thorac. Cardiovasc. Surg. 2018, 155, 1871–1879.e3. [Google Scholar] [CrossRef]
  114. Valapour, M.; Lehr, C.J.; Schladt, D.P.; Smith, J.M.; Swanner, K.; Weibel, C.J.; Weiss, S.; Snyder, J.J. OPTN/SRTR 2022 Annual Data Report: Lung. Am. J. Transplant. 2024, 24, S394–S456. [Google Scholar] [CrossRef]
  115. Lederer, D.J.; Kawut, S.M.; Wickersham, N.; Winterbottom, C.; Bhorade, S.; Palmer, S.M.; Lee, J.; Diamond, J.M.; Wille, K.M.; Weinacker, A.; et al. Obesity and primary graft dysfunction after lung transplantation: The Lung Transplant Outcomes Group Obesity Study. Am. J. Respir. Crit. Care Med. 2011, 184, 1055–1061. [Google Scholar] [CrossRef]
  116. Lederer, D.J.; Wilt, J.S.; D’Ovidio, F.; Bacchetta, M.D.; Shah, L.; Ravichandran, S.; Lenoir, J.; Klein, B.; Sonett, J.R.; Arcasoy, S.M. Obesity and underweight are associated with an increased risk of death after lung transplantation. Am. J. Respir. Crit. Care Med. 2009, 180, 887–895. [Google Scholar] [CrossRef]
  117. Jomphe, V.; Mailhot, G.; Damphousse, V.; Tahir, M.R.; Receveur, O.; Poirier, C.; Ferraro, P. The Impact of Waiting List BMI Changes on the Short-term Outcomes of Lung Transplantation. Transplantation 2018, 102, 318–325. [Google Scholar] [CrossRef]
  118. Leard, L.E.; Holm, A.M.; Valapour, M.; Glanville, A.R.; Attawar, S.; Aversa, M.; Campos, S.V.; Christon, L.M.; Cypel, M.; Dellgren, G.; et al. Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation. J. Heart Lung Transplant. 2021, 40, 1349–1379. [Google Scholar] [CrossRef] [PubMed]
  119. Moussaoui, I.E.; De Pauw, V.; Navez, J.; Closset, J. Roux-En-Y gastric bypass after lung transplantation: Case report and literature review. Surg. Obes. Relat. Dis. 2020, 17, 239–241. [Google Scholar] [CrossRef] [PubMed]
  120. Pokala, B.; Pagkratis, S.; Mcbride, C. Role of bariatric surgery and lung transplant eligibility in the setting of Pulmonary Hypertension(PHTN) and Systemic Sclerosis (SS). Surg. Obes. Relat. Dis. 2017, 13, S85. [Google Scholar] [CrossRef]
  121. Hussain, M.; Yazji, J.; Garg, P.; Wadiwala, I.; Alamouti-Fard, E.; Alomari, M.; Jacob, S.; Edwards, M.; Pham, S. (626) Bariatric Surgery is Safe and Effective in Thoracic Organ Transplant Recipients. J. Heart Lung Transplant. 2023, 42, S280–S281. [Google Scholar] [CrossRef]
  122. Ardila-Gatas, J.; Sharma, G.; Hanipah, Z.N.; Tu, C.; Brethauer, S.A.; Aminian, A.; Tolle, L.; Schauer, P.R. Bariatric surgery in patients with interstitial lung disease. Surg. Endosc. 2018, 33, 1952–1958. [Google Scholar] [CrossRef]
Table 1. Summary of the literature for bariatric surgery in relation to solid organ transplant type.
Table 1. Summary of the literature for bariatric surgery in relation to solid organ transplant type.
OrganRecommended BMIPerioperative ConsiderationsPreferred MBSNotes
KidneyBMI > 40 kg/m2Dehydration worsening, renal failureSleeveObesity paradox with no survival benefits in BMI > 40 kg/m2
LiverBMI 35–40 kg/m2Risk of hepatic decompensation. MBS after liver transplant with longer operative times and complications with associated adhesionsSimultaneous liver transplant and sleeveMBS is effective if MELD < 15 and no decompensated cirrhosis; sleeve preferred
PancreasBMI > 30 kg/m2Careful glycemic control with change in dietSleeveLimited data, but may decrease transplant rejection.
HeartBMI > 35 kg/m2Adjustment to heart failure medications. High risk of mortalityNo preferenceMBS improves listing eligibility; often combined with LVAD bridging.
LungBMI > 30 kg/m2 (BMI > 35 for high volume centers)Higher risk of pulmonary complications with prolonged mechanical ventilationGastric bypassHigher risk of aspiration pneumonia with sleeve gastrectomy
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Hui, D.; Judd, A.C.; Moneme, C.; Passerini, H.; Silpe, S.; Podboy, A.; Pelletier, S.J.; Hallowell, P.T.; Shin, T.H. Synergistic Integration of Multimodal Metabolic and Bariatric Interventions Transforming Transplant Care. J. Clin. Med. 2025, 14, 5669. https://doi.org/10.3390/jcm14165669

AMA Style

Hui D, Judd AC, Moneme C, Passerini H, Silpe S, Podboy A, Pelletier SJ, Hallowell PT, Shin TH. Synergistic Integration of Multimodal Metabolic and Bariatric Interventions Transforming Transplant Care. Journal of Clinical Medicine. 2025; 14(16):5669. https://doi.org/10.3390/jcm14165669

Chicago/Turabian Style

Hui, Donovan, Alex C. Judd, Chioma Moneme, Heather Passerini, Stephanie Silpe, Alexander Podboy, Shawn J. Pelletier, Peter T. Hallowell, and Thomas H. Shin. 2025. "Synergistic Integration of Multimodal Metabolic and Bariatric Interventions Transforming Transplant Care" Journal of Clinical Medicine 14, no. 16: 5669. https://doi.org/10.3390/jcm14165669

APA Style

Hui, D., Judd, A. C., Moneme, C., Passerini, H., Silpe, S., Podboy, A., Pelletier, S. J., Hallowell, P. T., & Shin, T. H. (2025). Synergistic Integration of Multimodal Metabolic and Bariatric Interventions Transforming Transplant Care. Journal of Clinical Medicine, 14(16), 5669. https://doi.org/10.3390/jcm14165669

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop