Challenges in obese liver transplant recipients

PURPOSE OF REVIEW: The global obesity epidemic has significantly altered the epidemiology of chronic liver disease and liver transplantation, with metabolic dysfunction-associated steatohepatitis emerging as a rapidly increasing indication for liver transplantation worldwide. Obesity in liver transplantation candidates is frequently accompanied by sarcopenia, frailty, cardiovascular disease, and metabolic comorbidities, creating complex perioperative and long-term management challenges. This review summarizes contemporary evidence regarding assessment, pretransplant preparation, perioperative management, and long-term outcomes of obese liver transplant recipients, while highlighting evolving therapeutic strategies and unresolved clinical questions. RECENT FINDINGS: Recent literature emphasizes that BMI alone inadequately characterizes obesity in cirrhosis, with body composition, sarcopenic obesity, visceral adiposity, and frailty emerging as important prognostic factors. Structured prehabilitation, lifestyle modification, incretin-based pharmacotherapy, and selective metabolic bariatric surgery have shown promising results in carefully selected patients. Although obesity increases perioperative complexity and postoperative complications, carefully selected obese recipients can achieve graft and patient survival comparable to nonobese recipients. SUMMARY: Obesity should not be considered a contraindication to liver transplantation. Individualized recipient assessment, coordinated perioperative optimization, and long-term metabolic surveillance are essential to improve outcomes. Future research should refine obesity assessment beyond BMI and clarify the optimal integration of pharmacologic and surgical weight-loss strategies in liver transplantation candidates before and after transplantation.