1. 實習生 : 中山醫 李佳靜 指導老師 : 陳燕慈 營養師 The Relationship of BMI and Lung Transplant Recipients 1

2. Lung transplant BMI risk of mortality 2

3. Literature(1) Influence of Nutritional Status in Lung Transplant Recipients 3

4. Introduction Serum albumin serum prealbumin Body Mass Index predict malnutrition and mortality among hospitalized patients predict malnutrition and mortality among hospitalized patients Purpose: post transplantation survival rates Purpose: post transplantation survival rates 4

5. Methods BMI Serum albumin Serum prealbumin BMI Group 1<18.5 Group 218.5~24.9 Group 325~27.5 Group 4>27.5 5

6. Result 6

7. Obese patients (BMI>27.5 )  risk of mortality Low levels of prealbumin ( level <18 gr/dL)  risk of mortality Low levels of albumin  No association about mortality 7

8. Conclusion BMI>27.5 Low pretransplant prealbumin levels Low pretransplant prealbumin levels mortality 8

9. Literature(2) Obesity and Underweight Are Associated with an Increased Risk of Death after Lung Transplantation 9

10. Introduction Obesity (BMI >30 kg/m 2 ) is considered a relative contraindication.  Little is known about underweight(BMI <18.5 kg/m 2 ) Underweight → higher risk of death after lung transplantation  1- or 5-year mortality was unknown 10

11. Purpose We hypothesized that underweight and obesity would be associated with an increased risk of death after transplantation after adjustment for potential confounders. Obesity v.s underweight risk of death pretransplant after lung transplantation 11

12. Methods Participants : IncludedExclude 1.Recipient age >18 years 2.single or bilateral lung transplant procedure 3.cystic fibrosis(CF), chronic obstructive pulmonary disease (COPD), diffuse parenchymal lung disease(DPLD). 1.Donor age < 12 years 2.Recipient or donor height 198cm 3.BMI 40 kg/m 2 4.Unknown height or weight 5.Use mechanical ventilation 12

13. Methods BMI : BMI <18.5Underweight 18.5~24.9Normal weight 25~29.9Overweight >30Obese 13

14. Methods The lung allocation score (LAS) was calculated using data obtained at the time of transplantation. The primary outcome was recipient survival, calculated as the number of days from the date of transplantation to the date of death. They estimated odds ratios for early death (at 1 yr) and late death (at 5 yr conditional on 1-yr survival) 14

15. Result Median age =54 years 3,671 single- 2,307 double- Median LAS =32.8 15

16. Result Medium survival time =4.8 years 16

17. Result 17

18. Discussion - Obesity Higher risk of death due to respiratory failure among obese recipients. A risk of death : obese > overweight obese recipients 1 year after LTs odds of death 40% 18

19. Discussion- Underweight Underweight was associated with a higher risk of death after transplantation. The greater risk of infection in underweight transplant recipients. early mortality late mortality older population younger recipients CF COPD risk of death 19

20. Discussion- Clinical Implication At the extremes of BMI may be at particularly high risk of early or late death after transplantation. Promote long survival corticosteroid withdrawal and avoidance Nutritional counseling dietary modification bariatric surgery pulmonary rehabilitation corticosteroid withdrawal and avoidance Nutritional counseling dietary modification bariatric surgery pulmonary rehabilitation 20

21. Conclusion Primary care providers and pulmonologists should promote a healthy weight for patients with lung disease long before transplantation is considered. Obesity underweight Risk of death 12% of deaths in the first year 21

22. Literature(3) The impact of recipient body mass index on survival after lung transplantation 22

23. Background Few studies have examined recipient weight and outcomes after Lung transplant (LTx). The United Network for Organ Sharing(UNOS) database provides an opportunity to examine outcomes related to body mass index (BMI) in a large cohort of LTx patients. 23

24. Methods Data source: The UNOS data set was retrospectively reviewed for 11,411 adult primary LTx patients (1998 to 2008) 24

25. Methods BMI : BMI <18.5Underweight 18.5~24.9Normal weight 25~29.9Overweight >30Obese 25

26. Methods The primary end point : all-cause mortality. Secondary outcomes : rejection episodes in the first year and short-term mortality were also examined. 26

27. Result Figure 1 Number of lung transplants performed during the study period, stratified by body mass index categories 27

28. Result Figure 2 Kaplan-Meier estimates of survival for lung transplant recipients stratified by body mass index categories. 28

29. Result 29

30. Discussion The increase in mortality risk was 15% for obese patients and 14% for underweight patients. The absolute decrease in 5-year survival was 3.0% for overweight recipients, 6.1% for obese recipients and 2.7% for underweight recipients. 30

31. Discussion The increase in mortality for overweight and obese recipients was present as early as 30 days after LTx and persisted though all follow-up times examined. This argues strongly that the negative effect of overweight or obese BMI manifests early after LTx. 31

32. Conclusion Underweight, overweight, and obese recipients have decreased survival compared with normal weight recipients. For overweight and obese recipients, this survival difference is demonstrable as early as 30 days after LTx. Underweight recipients do not manifest survival differences until 1 year after LTx. 32

33. Summary Obesity Overweight Underweight Suggest BMI of lung transplant : normal BMI : 18.5~24.9 survival risk of mortality 33

34. 34