BACKGROUND: Over 85% of U.S. centers adhere to practice guidelines that consider morbid obesity to be a contraindication to liver transplantation (LT). The relationship of morbid obesity with LT outcomes and survival benefit in the current era is unknown. METHODS: We investigated the association of BMI with waitlist and post-LT outcomes, and survival benefit, using the United Network for Organ Sharing registry. We categorized BMI 18.5-29.9 kg/m as normal/overweight, 30-34.9 obese, 35-39.9 severely obese, and ≥40 morbidly obese, and evaluated waitlist outcomes using competing risk regression and post-LT outcomes and survival benefit using Cox regression. RESULTS: 3.9% of 80,221 waitlisted and 3.5% of 38,177 transplanted patients were morbidly obese. Waitlist mortality was higher for morbidly obese than normal/overweight patients (subdistribution hazard ratio 1.16, 95% confidence interval [CI]:1.08-1.26), but post-LT mortality and graft failure were comparable (hazard ratio [HR] 1.01, 95% CI:0.86-1.19; and HR 1.15, 95% CI:0.95-1.40). Morbidly obese patients also benefited more from LT (88% mortality reduction versus 80% for normal/overweight). Morbid obesity predicted higher post-LT mortality before 2007 (HR 1.18, 95% CI:1.04-1.34), but not afterward (HR 0.98, 95% CI:0.81-1.18). CONCLUSIONS: Morbid obesity is associated with higher mortality on the LT waitlist, but no longer predicts inferior outcomes after LT. Morbidly obese patients should be considered potential candidates for LT.
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