Outcomes of Liver Transplantation in Patients With Severe Obesity: The Impact of Performance Status

Background. This study aims to evaluate the impact of obesity on post–liver transplant outcomes stratified by low- and high-performance status. Methods. Patients undergoing liver transplantation between 2006 and 2023 were identified in the United Network for Organ Sharing data set. Patients with severe obesity body mass index ([BMI] ≥40 kg/m 2 ) and super obesity (BMI >50 kg/m 2 ) were compared with those with lower BMI on perioperative and long-term outcomes stratified by preoperative performance status. Results. Severe obesity has a significant negative impact on perioperative and long-term outcomes on the low-performance group (LPG). This effect was not observed in the high-performance group. Five-year survival in the high-performance group was 81.7%, compared with 77.9% in the LPG. The multivariable analysis revealed that severe obesity in the LPG increased early graft loss by 53%, and 30- and 90-d mortality by 57% and 50%, respectively ( P < 0.001). Severe obesity significantly impacted overall graft survival but did not affect long-term patient survival. When advanced age was combined with severe obesity in the LPG, our analysis showed a 2.3-fold increased risk of early graft loss ( P = 0.01) and 83%, 90-d perioperative mortality ( P < 0.001). Overall long-term graft and patient survival were decreased by 56% and 59%, respectively, in the LPG ( P < 0.001). Conclusions. Severe obesity in patients with a low-performance status before transplantation significantly increases the risk of poor perioperative and long-term outcomes. Interestingly, this effect is not seen in patients with high-performance scores. Additionally, the combination of severe obesity and advanced age in low-performance status patients may have a compounded negative effect on posttransplant survival.