Successful liver transplantation in a critically underweight patient: a case report

Introduction. Living-donor liver transplantation (LT) is a viable and effective treatment option for patients with end-stage liver disease. Cachexia is widely recognized in medical literature as a risk factor affecting patient sur vival after LT. However, there are relatively few reports on LT in adult patients with critically low body weight.

Materials and methods. The clinical case of successful LT in a critically underweight patient (BMI 12.9 kg/m²) is presented.

Results. The patient’s pre-transplant preparation included intensified enteral and parenteral nutrition, albumin and fresh frozen plasma transfusions, diuretic therapy, multivitamins, symptomatic treatment, and structured exercise. At the time of transplantation, the recipient’s MELD (Model for End-Stage Liver Disease) score was 22. In the postoperative period, the patient had multiple complications, reflected by a comprehensive complication index (Comprehensive Comprehensive) score of 99. Multicomponent rehabilitation was implemented. The patient was discharged 30 days after LT. During a 17-month follow-up, graft function remained satisfactory.

Conclusion. Our experience, supported by literature data, indicates that cachexia in liver transplant recipients is associated with a higher overall complication rate after LT. Patients with low body weight require careful pre-transplant preparation, including intensive nutritional support and exercise programs. Successful treatment of such patients is feasible only in a multidisciplinary hospital or a transplant center with extensive expertise in managing complex cases.

1. Salimov UR, Stoma IO, Fedoruk DA, Kovalev AA, Scherba AE, Rummo OO. Sarcopenia in chronic liver disease, can we predict complications? Transplantologiya. The Russian Journal of Transplantation. 2022; 14 (4): 408– 420. https://doi.org/10.23873/2074-0506-2022-14-4-408-420.

2. Pelletier SJ, Schaubel DE, Wei G, Englesbe MJ, Punch JD, Wolfe RA et al. Effect of body mass index on the survival benefit of liver transplantation. Liver Transpl. 2007; 13 (12): 1678–1683. https://doi.org/10.1002/lt.21183.

3. Salimov U, Kovalev A, Stoma I, Fedoruk A, Rummo O. Evaluation of Factors Affecting Long-Term Survival after Liver Transplantation. Surgery. Eastern Europe. 2023; 12 (3): 238–247. https://doi.org/10.34883/PI.2023.12.3.016.

4. Diaz-Nieto R, Lykoudis PM, Davidson BR. Recipient body mass index and infectious complications following liver transplantation. HPB (Oxford). 2019 Aug; 21 (8): 1032–1038. https://doi.org/10.1016/j.hpb.2019.01.002.

5. Van Son J, Stam SP, Gomes-Neto AW, Osté MCJ, Blokzijl H, van den Berg AP et al. Post-transplant obesity impacts long-term survival after liver transplantation. Metabolism. 2020 May; 106: 154204. https://doi.org/10.1016/j.metabol.2020.154204.

6. García-Fernández N, Cepeda-Franco C, Beltrán-Miranda P, García-Muñoz P, Álamo-Martínez JM, PadilloRuiz FJ, Gómez-Bravo MÁ. Body Mass Index as a Prognostic Factor in Liver Transplantation. Transplant Proc. 2020 Jun; 52 (5): 1493–1495. https://doi.org/10.1016/j.transproceed.2020.03.008.

7. Dick AA, Spitzer AL, Seifert CF, Deckert A, Carithers RL Jr, Reyes JD, Perkins JD. Liver transplantation at the extremes of the body mass index. Liver Transpl. 2009 Aug; 15 (8): 968–977. https://doi.org/10.1002/lt.21785.

8. Bambha KM, Dodge JL, Gralla J, Sprague D, Biggins SW. Low, rather than high, body mass index confers increased risk for post-liver transplant death and graft loss: Risk modulated by model for end-stage liver disease. Liver Transpl. 2015 Oct; 21 (10): 1286–1294. https://doi.org/10.1002/lt.24188.

9. Bari K, Sharma P. Impact of body mass index on posttransplant outcomes reexamined. Liver Transpl. 2015 Oct; 21 (10): 1238–1240. https://doi.org/10.1002/lt.24227.

10. Joliat GR, Kobayashi K, Hasegawa K, Thomson JE, Padbury R, Scott M et al. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022. World J Surg. 2023 Jan; 47 (1): 11–34. https://doi.org/10.1007/s00268-022-06732-5.

11. Lee DD, Li J, Wang G, Croome KP, Burns JM, Perry DK, Nguyen JH et al. Looking inward: The impact of operative time on graft survival after liver transplantation. Surgery. 2017 Oct; 162 (4): 937–949. https://doi.org/10.1016/j.surg.2017.05.010.

12. Semash К, Janbekov Т, Akbarov М, Usmonov А, Gaibullaev Т. Stages of preparation and examination of related liver donors and their perioperative management. Coloproc. 2023; 15 (1): 41–54. https://doi.org/10.56121/2181-4260-2023-1-41-54.

13. Semash K, Dzhanbekov T, Akbarov M, Mirolimov M, Usmonov A, Razzokov N et al. Implementation of Living Donor Liver Transplantation Program in the Republic of Uzbekistan – Report of First 40 cases. Clin Transplant Res. 2024 Jun 30; 38 (2): 116–127. https://doi.org/10.4285/ctr.24.0013.

14. Semash KO, Dzhanbekov TA, Gaybullaev TZ. Single center experience of intraoperative ligation of the splenic artery for prevention of splenic artery steal syndrome in patients after living donor liver transplant. Transplantologiya. The Russian Journal of Transplantation. 2024; 16 (2): 230–243. https://doi.org/10.23873/2074-0506-2024-16-2-230-243.

15. Semash KO, Dzhanbekov TA, Akbarov MM. Vascular complications after liver transplantation: contemporary approaches to detection and treatment. A literature review. Russian Journal of Transplantology and Artificial Organs. 2023; 25 (4): 46–72. (In Russ.). http://doi.org/10.15825/1995-1191-2023-4-46-72.

16. Orci LA, Majno PE, Berney T, Morel P, Mentha G, Toso C. The impact of wait list body mass index changes on the outcome after liver transplantation. Transpl Int. 2013 Feb; 26 (2): 170–176. https://doi.org/10.1111/tri.12017.

17. Lai Q, Melandro F, Nowak G, Nicolini D, Iesari S, Fasolo E et al. The role of the comprehensive complication index for the prediction of survival after liver transplantation. Updates Surg. 2021 Feb; 73 (1): 209–221. https://doi.org/10.1007/s13304-020-00878-4.

18. Niederman MS, Cilloniz C. Aspiration pneumonia. Rev Esp Quimioter. 2022 Apr; 35 Suppl 1 (Suppl 1): 73–77. https://doi.org/10.37201/req/s01.17.2022.