Obesity Associated with Greater Morbidity in Cirrhotic Patients with Variceal Bleeding

Ebrahim Mirakhor, MD

The risks for liver decompensation and mortality in cirrhosis are increased by obesity—particularly class III obesity. To further clarify the impact of obesity on outcomes related to variceal bleeding among cirrhotic patients who are otherwise compensated, investigators presented data at the 2018 American Association for the Study of Liver Diseases (AASLD) Liver Meeting, November 9-13, 2018, in San Francisco, California.

“A number of prior studies have demonstrated the negative impact of obesity on chronic liver disease, including risk for decompensation, infection, and acute on chronic liver failure,” investigator Ebrahim Mirakhor, MD, told MD Magazine®. “We wanted to assess if obesity had a negative impact on variceal bleeding.”

Using Nationwide Inpatient Sample data that spanned from 2009 to 2013, investigators identified patients with cirrhosis, variceal bleeding, and obesity by using validated diagnostic coding algorithms.

Patients were identified as nonobese, obese class I-II (BMI 30-39.9), and obese class III (BMI ≥ 40) following the exclusion of patients with ascites, hepatic encephalopathy, and post-transplantation. The Deyo modification of the Charlson index was used to adjust for nonhepatic comorbidities.

Inpatient mortality, length of hospital stay, occurrence of bacterial infection, and transjugular intrahepatic portosystemic shunt (TIPS) placement were included in the study outcomes. Risk factors for inpatient mortality and TIPS placement were assessed with logistic regression.

Of the 16,654 patient records identified with variceal bleeding, 15,531 (93.3%) were nonobese, 669 (4%) had obesity class I-II, and 454 (2.7%) were obesity class III. The percentage of patients receiving TIPS during their hospitalization was greater among the patients with class III obesity (7.5%), compared with patients who were identified as class I-II (5.3%) or nonobese patients (3.8%) (P<.001).

A significantly longer length of hospital stay (6.1 days) was experienced by class III obese patients relative to nonobese (4.8 days) or class I-II obese patients (4.7 days) (P=.012). Compared with non-obese individuals (9.6), bacterial infections were more prevalent in both class I-II (11.4%) and class III obese patients (13.9%) (P = .004).

Among all 3 patient groups, inpatient mortality was similar; inpatient mortality was not associated with class I-II nor class III obesity.

“Though we did not see a significant difference in mortality, we did find that obese patients needed TIPS more often, suffered from more bacterial infections, and also had longer lengths of hospital stay” added Mirakhor. “The primary implication is that this study further underscores the importance of weight management in cirrhotic patients, to prevent obesity-related complications.”

Adjusting for age, gender, ethnicity and Charlson index, multivariable logistic regression analysis revealed an association between class III obesity and a greater likelihood of receiving TIPS procedure (OR=2.05, 95% CI 1.42-2.95).

“Obesity, particularly class III obesity, is associated with greater morbidity in the setting of variceal bleeding including development of infection and need for TIPS procedure,” study authors concluded.

The findings are important for risk stratification and underscore the importance of weight management in this population.

“We would like to start by validating this data by prospectively collecting patient information,” Mirakhor said, looking forward. “If we can validate these findings prospectively, then further studies should be initiated to improve weight loss among obese patients with cirrhosis.”