Pre-transplant bariatric surgery is associated with increased fungal infection after liver transplant

Margaret R Jorgenson; Adam S Gracon; Bret Hanlon; Glen E Leverson; Sandesh Parajuli; Jeannina A Smith; David P Al-Adra

doi:10.1111/tid.13484

Pre-transplant bariatric surgery is associated with increased fungal infection after liver transplant

Transpl Infect Dis. 2021 Apr;23(2):e13484. doi: 10.1111/tid.13484. Epub 2020 Oct 15.

Authors

Margaret R Jorgenson¹, Adam S Gracon², Bret Hanlon², Glen E Leverson², Sandesh Parajuli³, Jeannina A Smith³, David P Al-Adra²

Affiliations

¹ Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA.
² Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA.
³ Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA.

PMID: 33012079
DOI: 10.1111/tid.13484

Abstract

Aim: The impact of pre-transplant (pre-TXP) bariatric surgery (BS) on outcomes after liver transplant (LTX) has not been completely elucidated. Roux-en Y gastric bypass (RYGB) is one of the most common BS procedures. The primary objective of this study was to identify the risk of infection in LTX recipients with pre-TXP RYGB.

Methods: Adult patients with LTX between 1/1/2001 and 9/30/2018 at our center were screened for pre-TXP RYGB; patients with gastrectomy via sleeve or banding were excluded. Patients with no history of BS pre- or post-transplant were placed in a comparator group, matched 2:1 via incidence density sampling on age epoch.

Results: There were 16 LTX recipients with pre-TXP RYGB matched to 32 controls. Median time from RYGB to transplant was 11.7 years. Mean weight loss was 66 ± 19 kg. There were significantly more women with pre-TXP RYGB than in the matched control (RYGB:68.8% vs control:25%, P = .009). Demographics were otherwise similar between groups. Pre-TXP RYGB did not significantly increase hospital or ICU length of stay (P = .5, P = .3) but was associated with a significantly increased rate of fungal infection at 1 year (RYGB:33.4% vs control:9.7%, P = .01), and a numerical trend to increased bacterial infection (RYGB:56.2% vs control:32.2%, P = .09).

Conclusion: Despite the substantial weight loss attributed to BS, patients with pre-TXP RYGB demonstrated increased rates of fungal infection after transplant and trended toward increased bacterial infection. While the anatomical complexity associated with LTX surgery after RYGB did not appear to significantly affect ICU or hospital length of stay, it may have contributed to overall infectious risk, and possibly to impaired survival. Additionally, bypass of the host natural barrier defenses of the stomach could also have contributed to infectious risk. Our findings highlight the complexity of this patient population. Future prospective studies are needed to investigate risk of infection after LTX in the setting of pre-Txp BS. Potential modification in fungal prophylaxis protocols to include pre-TXP RYGB may be warranted.

Keywords: bariatric surgery; infection; transplant outcomes.

MeSH terms

Bariatric Surgery*
Female
Humans
Liver Transplantation*
Male
Mycoses*
Obesity, Morbid
Prospective Studies
Retrospective Studies
Treatment Outcome