Nutritional issues in patients with obesity and cirrhosis

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metabolic syndrome 10 endocrinologydiseases
obesity 113 endocrinologydiseases
osteoporosis 1 endocrinologydiseases
cholecalciferol 1 endocrinologydiseasesdrugs
hypoglycemia 1 endocrinologydiseases

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cholecalciferol 31156 is low[[70]]. Interestingly, in a small study of NAFLD patients, daily supplementation with 2000 IU cholecalciferol for 6 mo did not correct hypovitaminosis D in the majority of patients with NASH compared to those with
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hypoglycemia 61540 thrombosis may further complicate the access to LT. The risk of dumping syndrome and hyperinsulinemic hypoglycemia may be further concerns of the RYGP.In conclusion, with all of the potential that bariatric surgery
metabolic syndrome 1454 iannelli.a@chu-nice.frPublication date (ppub): 8/2018Publication date (epub): 8/2018AbstractObesity and metabolic syndrome are considered as responsible for a condition known as the non-alcoholic fatty liver disease that goes
metabolic syndrome 3754 and hypertension. Non-alcoholic fatty liver disease (NAFLD) represents the hepatic manifestation of metabolic syndrome and is intimately related to the chronic intrahepatic inflammation that, in turn, is linked to adiposity
metabolic syndrome 14155 compared to a control group. Individuals with sarcopenia had more body fat mass, more components of the metabolic syndrome , and higher levels of low-grade systemic inflammation compared with those of people with normal muscle
metabolic syndrome 21203 recipients with at least 12 mo of follow-up. Post-transplant sarcopenic obesity was present in 88%, and metabolic syndrome was present in 52% of recipients with no significant difference among liver failure etiologies. Patients
metabolic syndrome 21421 Patients with sarcopenic obesity had a significantly higher BMI and significantly higher prevalence of metabolic syndrome when compared to patients without sarcopenic obesity[[36]]. Thus, the weight gain frequently observed
metabolic syndrome 24905 addition, an independent association was also observed between VDD and insulin resistance[[55],[56]], the metabolic syndrome as a whole[[57]], and type 2 diabetes or prediabetes, after adjusting for multiple confounders including
metabolic syndrome 49508 condition of stress such as that after a major surgical procedure[[144]]. Furthermore, the presence of metabolic syndrome , which is associated with obesity but not obesity alone, is significantly associated with an increased
metabolic syndrome 53200 optimize the nutritional status and the choice of procedure in relation to the presence or absence of metabolic syndrome . The presence of adhesions linked to transplantation is not a formal contraindication to the laparoscopic
metabolic syndrome 57052 the etiology of liver disease (namely NASH vs viral infections and alcohol abuse), the presence of metabolic syndrome , and NASH recurrence on the graft in cases of patients that have already been transplanted are key factors
metabolic syndrome 59791 drug absorption[[155]]. Although short and medium-term results of SG on weight loss and control of metabolic syndrome indicate equivalent efficacy between the SG and the RYGP[[159]], long-term results of SG are still too
obesity 76 Title: World Journal of GastroenterologyNutritional issues in patients with obesity and cirrhosisLuigi SchiavoDepartment of Translational Medical Science, University of Campania “Luigi
obesity 1259 University Hospital of Nice, F-06202, Nice, France; Inserm, U1065, Team 8 “Hepatic complications of obesity ”, Nice F-06204, FranceUniversity of Nice Sophia-Antipolis, Nice F-06107, France. iannelli.a@chu-nice.frPublication
obesity 1687 accumulation of triglycerides to hepatic inflammation and may progress to cirrhosis. Patients with obesity also have an increased risk of primary liver malignancies and increased body mass index is a predictor
obesity 1847 malignancies and increased body mass index is a predictor of decompensation of liver cirrhosis. Sarcopenic obesity confers a risk of physical impairment and disability that is significantly higher than the risk induced
obesity 2092 alone as it has been shown to be an independent risk factor for chronic liver disease in patients with obesity and a prognostic negative marker for the evolution of liver cirrhosis and the results of liver transplantation.
obesity 2236 the evolution of liver cirrhosis and the results of liver transplantation. Cirrhotic patients with obesity are at high risk for depletion of various fat-soluble, water-soluble vitamins and trace elements and
obesity 2582 according to recent recommendations. Bariatric surgery is sporadically used in patients with morbid obesity and cirrhosis also in the setting of liver transplantation. The risk of sarcopenia, micronutrient status,
obesity 2749 The risk of sarcopenia, micronutrient status, and the recommended supplementation in patients with obesity and cirrhosis are discussed in this review. Furthermore, the indications and contraindications of bariatric
obesity 2923 indications and contraindications of bariatric surgery-induced weight loss in the cirrhotic patient with obesity are discussed.Core tip: Obesity is a frequent cause of chronic liver disease that can progress to cirrhosis.
obesity 3064 is a frequent cause of chronic liver disease that can progress to cirrhosis. Cirrhotic patients with obesity frequently have alterations in specific aspects of nutritional status, such as poor protein intake and
obesity 3354 be carefully monitored. Bariatric surgery may be an option in the management of patients with morbid obesity and cirrhosis also in the setting of liver transplantation but scientific evidence is still scarce.INTRODUCTIONLiver
obesity 3493 setting of liver transplantation but scientific evidence is still scarce.INTRODUCTIONLiver cirrhosis and obesity : Definitions and epidemiologyObesity is associated with many adverse consequences for health and is
obesity 5287 pro-oxidant effects on several tissues. Few data exist regarding the epidemiological and clinical impact of obesity in patients with pre-existent liver disease, however, obesity is considered an independent risk factor
obesity 5349 epidemiological and clinical impact of obesity in patients with pre-existent liver disease, however, obesity is considered an independent risk factor for the presence of severe fibrosis, fibrosis progression,
obesity 5530 fibrosis, fibrosis progression, and cirrhosis[[7],[8]]. Several population-based studies have identified obesity as an independent risk factor for alcohol-induced liver damage. Indeed, ethanol influences the adipose
obesity 5830 of the proinflammatory state. However, it is still unclear whether the hepatotoxic consequences of obesity and ethanol ingestion are additive or synergistic. The DIONYSOS study clearly showed a synergistic effect
obesity 6250 was increased to 46% in subjects with a daily intake of > 60 g of alcohol and to 76% in patients with obesity compared to lean controls who only revealed hepatic steatosis in 16% of cases. Moreover, in individuals
obesity 6367 to lean controls who only revealed hepatic steatosis in 16% of cases. Moreover, in individuals with obesity drinking > 60 g of alcohol per day, steatosis was found at an even higher level of 95% and the relative
obesity 6540 even higher level of 95% and the relative risk of cirrhosis increased more than six-fold in women with obesity and alcohol consumption (> 150 g/wk) vs normal weight and drinking < 70 g/wk women. Ekstedt et al[[10]]
obesity 6881 et al[[11]] analyzed more than 1 million middle-aged women in the UK and reported that in women with obesity who drank > 150 g of alcohol/week, the relative risk of cirrhosis increased more than six fold.Figure
obesity 7401 virus (HCV)-related liver disease and severe liver fibrosis or compensated cirrhosis, up to 43% had obesity , and 32% were overweight. Each quartile increase in BMI is associated with a 14% increase in the risk
obesity 7649 (worsening of liver fibrosis or decompensation of cirrhosis over 3.5 years of follow-up)[[12]]. Among obesity -related variables, the severity of insulin resistance and the histological grade of steatosis appeared
obesity 8452 developed in 14% of patients with normal weight, in 31% of overweight patients, and in 43% of patients with obesity . Obesity also negatively impacts portal hypertension. Indeed, when comparing the results after a 1-year
obesity 8708 hypertension was reduced only in patients who were of normal weight or overweight, whereas patients with obesity showed a significant increase.Even in patients with end-stage liver disease and, therefore, awaiting
obesity 8845 increase.Even in patients with end-stage liver disease and, therefore, awaiting liver transplantation (LT), obesity could worsen the prognosis. Recent data suggest that in these patients, obesity increases substantially
obesity 8925 transplantation (LT), obesity could worsen the prognosis. Recent data suggest that in these patients, obesity increases substantially (HR = 13.1), independently and significantly (P = 0.016) the risk of portal
obesity 9183 transplantation technically more difficult and increase the risk of portal thrombosis recurrence. Indeed, obesity is considered as a risk factor for venous thromboembolism as well as thrombosis of the hepatic artery[[16]].
obesity 9378 hepatic artery[[16]]. The proinflammatory, prothrombotic, and hypofibrinolytic milieu patients with obesity may be responsible for the local thrombophilia that favors portal vein thrombosis. Concerning perioperative
obesity 9715 complications, and biliary complications requiring intervention have been shown to be higher in recipients with obesity [[17]]. Despite the increased technical operative challenges and medical complexities associated with
obesity 9840 the increased technical operative challenges and medical complexities associated with recipients with obesity , morbid obesity in itself should not be an absolute contraindication to LT as these patients have reasonable
obesity 9856 technical operative challenges and medical complexities associated with recipients with obesity, morbid obesity in itself should not be an absolute contraindication to LT as these patients have reasonable long-term
obesity 10016 to LT as these patients have reasonable long-term outcomes. Although the complex interplay between obesity and cirrhosis is far from elucidated, undoubtedly alcohol, viral hepatitis, and obesity appear to be
obesity 10104 interplay between obesity and cirrhosis is far from elucidated, undoubtedly alcohol, viral hepatitis, and obesity appear to be a dangerous combination. General impact of obesity on liver pathophysiology are summarized
obesity 10168 undoubtedly alcohol, viral hepatitis, and obesity appear to be a dangerous combination. General impact of obesity on liver pathophysiology are summarized in Table 1.Table 1Impact of obesity on liver pathophysiologyPathologiesObesityHepatic
obesity 10244 combination. General impact of obesity on liver pathophysiology are summarized in Table 1.Table 1Impact of obesity on liver pathophysiologyPathologiesObesityHepatic steatosis[[9]]Increased1Cirrhosis[[11]]Increased1Hepatoxicity[[9]]Increased1Liver
obesity 11521 diabetes[[18]]. Recent evidence suggests that low muscle mass and function may have a similar negative impact in obesity despite the potential difficulties in identifying and defining muscle changes within the obese phenotype[[19]].
obesity 11700 changes within the obese phenotype[[19]]. Whatever the definition, the coexistence of sarcopenia and obesity in the same patient, now indicated as “sarcopenic obesity”, confers a risk of physical impairment
obesity 11760 definition, the coexistence of sarcopenia and obesity in the same patient, now indicated as “sarcopenic obesity ”, confers a risk of physical impairment and disability that is significantly higher than the risk
obesity 12221 bioimpedance analysis (BIA) or anthropometric measurements[[18]]. In this section, the role of sarcopenic obesity as a prognostic factor in patients with liver chronic disease will be briefly elucidated. The problem
obesity 12519 played by sarcopenia as an independent risk factor for the occurrence of liver diseases in patients with obesity will be discussed and, second, the significance of sarcopenia as a negative prognostic marker for disease
obesity 12672 significance of sarcopenia as a negative prognostic marker for disease progression and death in patients with obesity and advanced liver disease will be addressed.Sarcopenia as an independent risk factor for chronic liver
obesity 12809 will be addressed.Sarcopenia as an independent risk factor for chronic liver disease in patients with obesity As already mentioned above, NAFLD is today the most common liver disorder in Western countries and it
obesity 13003 countries and it is becoming the leading cause of chronic liver disease and cirrhosis[[22]]. Visceral obesity and related metabolic disorders, insulin resistance, in particular, are considered the most relevant
obesity 13376 negatively affected also by the coexistence of sarcopenia in the clinical picture, with sarcopenic obesity being both an independent risk factor for NAFLD and a marker for its progression to the more advanced
obesity 14997 associated with significant liver fibrosis in subjects with NAFLD, and this association was independent of obesity and insulin resistance[[25]].The independent and additive role of reduced skeletal muscle mass and increased
obesity 15528 in extrapolating these data to the Caucasian population, the association of sarcopenia with visceral obesity and insulin resistance is now considered an important risk factor for NAFLD, which further accelerates
obesity 15769 advanced life-threatening stages.Sarcopenia as a prognostic negative marker in the cirrhotic patient with obesity As shown in Figure 2, cirrhotic patients with obesity frequently have a combined loss of skeletal muscle
obesity 15822 negative marker in the cirrhotic patient with obesityAs shown in Figure 2, cirrhotic patients with obesity frequently have a combined loss of skeletal muscle and gain of adipose tissue, culminating in the condition
obesity 15961 of skeletal muscle and gain of adipose tissue, culminating in the condition known as “sarcopenic obesity .” Sarcopenia in cirrhotic patients has been associated with increased mortality, sepsis complications,
obesity 16241 length of hospital stay after LT[[27]]. The prognostic impact of the coexistence of sarcopenia and obesity in patients with chronic liver disease has been analyzed recently in a few studies. Montano-Loza et
obesity 16413 recently in a few studies. Montano-Loza et al[[28]] evaluated the frequencies of sarcopenia and sarcopenic obesity in a cohort of 457 cirrhotic patients evaluated for LT, aiming to establish the impact of these muscular
obesity 16641 on the prognosis of cirrhotic patients. In this sample, sarcopenia was present in 43% and sarcopenic obesity in 20% of patients. Both patients with sarcopenia and with sarcopenic obesity had worse median survival
obesity 16719 in 43% and sarcopenic obesity in 20% of patients. Both patients with sarcopenia and with sarcopenic obesity had worse median survival than patients without muscular abnormalities[[28]]. Hara et al[[29]] evaluated
obesity 16991 and visceral fat accumulation in 161 patients with cirrhosis. Patients with sarcopenia or sarcopenic obesity both had a poor prognosis, and this difference was pronounced in the subset of patients classified as
obesity 17211 class A. However, the group with the worst prognosis was represented by patients having sarcopenic obesity [[29]]. This latter observation seems to confirm that the coexistence of visceral obesity and sarcopenia
obesity 17300 sarcopenic obesity[[29]]. This latter observation seems to confirm that the coexistence of visceral obesity and sarcopenia could be considered the worst clinical situation for a patient with cirrhosis. Muscle
obesity 17787 poor outcomes[[28]].Figure 2Sarcopenia as a prognostic negative marker in the cirrhotic patient with obesity . Cirrhotic patients with obesity frequently have a combined loss of skeletal muscle and gain of adipose
obesity 17820 2Sarcopenia as a prognostic negative marker in the cirrhotic patient with obesity. Cirrhotic patients with obesity frequently have a combined loss of skeletal muscle and gain of adipose tissue, culminating in the condition
obesity 17959 of skeletal muscle and gain of adipose tissue, culminating in the condition known as “sarcopenic obesity ”. Sarcopenia in cirrhotic patients has been associated with increased mortality, sepsis complications,
obesity 18234 length of hospital stay after liver transplantation.The prognostic negative role of sarcopenia and obesity could have an impact also in LT. Sarcopenia and sarcopenic obesity are seen in a significant number
obesity 18301 negative role of sarcopenia and obesity could have an impact also in LT. Sarcopenia and sarcopenic obesity are seen in a significant number of patients with cirrhosis undergoing liver transplant evaluation,
obesity 18609 associated with short-term survival after living donor LT[[31]]. The question of whether the coexistence of obesity and sarcopenia could impose additional risk after LT over that imposed by sarcopenia alone is still
obesity 19828 however mostly confined to patients who were overweight and does not address specifically the impact of obesity itself[[32]]. On the other hand, obesity presents important medical and surgical challenges during and
obesity 19869 overweight and does not address specifically the impact of obesity itself[[32]]. On the other hand, obesity presents important medical and surgical challenges during and after a liver transplant. Specifically,
obesity 19979 presents important medical and surgical challenges during and after a liver transplant. Specifically, obesity is associated with an increased incidence of wound infections, wound dehiscence, biliary complications,
obesity 20130 of wound infections, wound dehiscence, biliary complications, and overall infection[[33]].Sarcopenic obesity could represent an important clinical problem also for long-term survival after LT. Sarcopenia tends
obesity 20670 the pre-transplant chronic disease state[[34]]. This double phenomenon paves the way to sarcopenic obesity . Schütz et al[[35]] analyzed body composition in patients after liver and kidney transplantation and
obesity 20980 graft function, many long-term liver or kidney transplant survivors exhibit a phenotype of sarcopenic obesity with increased fat but low muscle mass[[35]]. Choudhary et al[[36]] evaluated 82 living donor liver
obesity 21171 living donor liver transplant recipients with at least 12 mo of follow-up. Post-transplant sarcopenic obesity was present in 88%, and metabolic syndrome was present in 52% of recipients with no significant difference
obesity 21343 recipients with no significant difference among liver failure etiologies. Patients with sarcopenic obesity had a significantly higher BMI and significantly higher prevalence of metabolic syndrome when compared
obesity 21485 significantly higher prevalence of metabolic syndrome when compared to patients without sarcopenic obesity [[36]]. Thus, the weight gain frequently observed after LT could contribute to the creation of a novel
obesity 21629 frequently observed after LT could contribute to the creation of a novel group of patients with sarcopenic obesity and associated metabolic derangements.MICRONUTRIENT STATUS AND RECOMMENDED SUPPLEMENTATION IN PATIENTS
obesity 22807 discussed below, beginning with vitamin D deficiency, which is almost universal and also related with obesity .Vitamin D deficiency (VDD, < 50 nmol/L; < 20 ng/mL) is a worldwide pandemic, reported in more than half
obesity 24417 found to be an independent risk factor for mortality[[43],[45]]. With the increasing prevalence of obesity and NAFLD-related cirrhosis, attention should be paid to the cirrhotic patient with obesity. An association
obesity 24509 prevalence of obesity and NAFLD-related cirrhosis, attention should be paid to the cirrhotic patient with obesity . An association between VDD and obesity has also been suggested. Since vitamin D is a lipophilic molecule
obesity 24549 cirrhosis, attention should be paid to the cirrhotic patient with obesity. An association between VDD and obesity has also been suggested. Since vitamin D is a lipophilic molecule it is selectively deposited in subcutaneous
obesity 26433 NASH[[69]].To summarize, a few possible mechanisms could explain VDD among cirrhotic patients with obesity : (1) NAFLD as the undelaying cause of cirrhosis; (2) Sedentary lifestyle or long standing chronic illness
obesity 27472 daytime (10:00 AM-15:00 PM) on a daily basis[[40]]. However, after exposing healthy individuals with obesity (BMI > 30 kg/m2) and matched lean control subjects (BMI < 25 kg/m2) to whole-body ultraviolet radiation,
obesity 27603 matched lean control subjects (BMI < 25 kg/m2) to whole-body ultraviolet radiation, the subjects with obesity showed a 57% lower increase in circulating concentrations of vitamin D3, 24 h after irradiation[[53]].
obesity 30147 guidelines or clear recommendations regarding vitamin D supplementation for cirrhotic patients with obesity . One authoritative paper[[49]] recommended vitamin D status assessment in all patients with chronic
obesity 31686 and fibrosis[[83]], and prevents hepatic stellate cell activation[[84]]. Relevantly for patients with obesity and liver disease, high-dose (800 IU/d) long-term (24 mo) vitamin E treatment among nondiabetic NASH
obesity 42834 degree of liver function compensation[[120]], without a specific reference for cirrhotic patients with obesity , which may still be malnourished. However, weight loss should be encouraged in patients with obesity
obesity 42935 obesity, which may still be malnourished. However, weight loss should be encouraged in patients with obesity and well-compensated cirrhosis, nevertheless, over-restriction will result in endogenous muscle breakdown.
obesity 43225 monitoring alongside increased physical activity and caloric intake of 25-35 kcal/(kg•d) in patients with obesity (30-40 kg/m2) and not less than 20-25 kcal/(kg•d) in patients with morbid obesity (> 40 kg/m2). The
obesity 43309 in patients with obesity (30-40 kg/m2) and not less than 20-25 kcal/(kg•d) in patients with morbid obesity (> 40 kg/m2). The recommended dietary pattern is for small, frequent meals evenly distributed throughout
obesity 44293 g/(kg•d).Currently, the recommended daily protein intake is 1.2-1.5 g/(kg•d)[[120]]. For cirrhotic patients with obesity , a moderately hypocaloric diet must include an adequate amount of proteins [1.2-1.5 g/(kg•d)] in order
obesity 46405 regarding nutritional effects[[133]]. General nutritional recommendations in the cirrhotic patients with obesity are summarized in Table 2.Table 2Nutritional recommendations for cirrhotic patients with obesityNutrientRecommendation1Daily
obesity 46502 with obesity are summarized in Table 2.Table 2Nutritional recommendations for cirrhotic patients with obesity NutrientRecommendation1Daily energy intake[[117]]25-35 kcal/(kg•d) in patients with BMI 30-40 kg/m2
obesity 47260 proteins are rich in branched-chain amino acids (BCAA)[[117],[127],[128]]. 3Cirrhotic patients with obesity are at high risk for depletion of various fat-soluble, water-soluble vitamins and trace elements and
obesity 47618 AND CONTRAINDICATIONSIn recent years, parallel to the rapid and sharp increase in the prevalence of obesity [[134]], bariatric surgery has reached a rapid and deep penetration, as it is the only therapeutic means
obesity 47794 as it is the only therapeutic means leading to long-term weight loss with consequent improvement of obesity -related comorbidities and patients’ quality of life[[135]]. NAFLD has become an extremely frequent
obesity 47940 quality of life[[135]]. NAFLD has become an extremely frequent condition in recent years due to the obesity epidemic[[136]]. While NAFLD includes a spectrum of histologic features ranging from simple liver steatosis
obesity 48589 probability of clinical decompensation of liver cirrhosis is significantly increased in the presence of obesity compared to overweight and lean subjects[[140]].As a consequence, LT surgeons are faced more and more
obesity 48745 subjects[[140]].As a consequence, LT surgeons are faced more and more frequently with candidates for LT with morbid obesity [[141]]. Traditionally obesity has been considered a main risk factor for postoperative morbidity and
obesity 48775 are faced more and more frequently with candidates for LT with morbid obesity[[141]]. Traditionally obesity has been considered a main risk factor for postoperative morbidity and mortality in the context of major
obesity 48943 morbidity and mortality in the context of major and complex surgical procedures[[142],[143]]. However, obesity is a heterogeneous disease including different conditions sharing a common denominator represented by
obesity 49140 represented by an increased BMI. Indeed, there is clear epidemiological evidence that the presence of obesity has a protective effect against postoperative mortality and morbidity in the range of BMI below 35 kg/m2.
obesity 49284 postoperative mortality and morbidity in the range of BMI below 35 kg/m2. This phenomenon, known as the obesity paradox, has been attributed to the increased reserve of energy due to obesity that may confer an advantage
obesity 49363 phenomenon, known as the obesity paradox, has been attributed to the increased reserve of energy due to obesity that may confer an advantage in a condition of stress such as that after a major surgical procedure[[144]].
obesity 49553 surgical procedure[[144]]. Furthermore, the presence of metabolic syndrome, which is associated with obesity but not obesity alone, is significantly associated with an increased risk of postoperative morbidity
obesity 49569 procedure[[144]]. Furthermore, the presence of metabolic syndrome, which is associated with obesity but not obesity alone, is significantly associated with an increased risk of postoperative morbidity and mortality after
obesity 49760 morbidity and mortality after major abdominal surgery. In spite of this, in many LT centers the presence of obesity , defined only on the basis of a BMI above 35 or 40 kg/m2, is considered as a contraindication to LT[[145]].
obesity 50146 presence of metabolic comorbidities may help to identify suitable candidates for LT among individuals with obesity without the need for massive weight loss[[146],[147]].Losing weight before LT remains an important goal
obesity 50339 an important goal but there is no consensus on how best to achieve it, especially in patients with obesity and cirrhosis. Many non-surgical methods can be used to allow patients to reach the desired BMI and
obesity 53386 formal contraindication to the laparoscopic approach nor is the use of immunosuppressive drugs[[151]].As obesity recurs often after LT, affecting the graft with NASH recurrence and patient survival with metabolic
obesity 60282 be dissected before gastric division. It is also more effective against metabolic complications of obesity that may be either present before or after LT[[161]]. Strong evidence in support of the preventive effect
obesity 61686 RYGP.In conclusion, with all of the potential that bariatric surgery has candidates to LT with morbid obesity , well-designed studies are still necessary to gain widespread acceptance from clinicians. Several points
obesity 62026 surgical procedure and its timing to maximize the efficiency of bariatric surgery in liver recipients with obesity . Only when this research is furthered to the point where the effectiveness of bariatric surgery is no
obesity 62218 bariatric surgery is no longer in doubt, the latter will be included in the care of liver recipients with obesity for mainstream use. In the meantime, the policy of a case-by-case discussion involving a multidisciplinary
obesity 62459 hepatologists and both LT and bariatric surgeons, seems to be justified.CONCLUSIONWith the recent epidemic of obesity , the coexistence of liver cirrhosis and obesity has become very frequent. The complex interplay between
obesity 62507 be justified.CONCLUSIONWith the recent epidemic of obesity, the coexistence of liver cirrhosis and obesity has become very frequent. The complex interplay between obesity and the liver especially in the setting
obesity 62571 coexistence of liver cirrhosis and obesity has become very frequent. The complex interplay between obesity and the liver especially in the setting of liver cirrhosis is a formidable challenge for current medicine
obesity 62741 a formidable challenge for current medicine that goes from the prevention of liver complications of obesity , screening for these complications in patients at risk to the management of patients with sarcopenia
osteoporosis 30727 disease (especially patients with cirrhosis or severe cholestasis) as a general preventive treatment for osteoporosis along with adequate nutrition monitoring[[81]]. The European Association for the Study of the Liver

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