So, there's just going to be a lot of pop culture references now, so the talk is pretty much over. So his debate was to be promoting the idea that we don't need, or that we do need to worry about Nash and its recurrence. And because I actually, again, feel that's probably more relevant, but the data just does not support it. I'm not sure which one of us is potentially lying. I had assumed that he was going to actually show some of this data, which is one of the only studies that really is out there on biopsy, protocol biopsy-based data. And it does show a little bit of concern for recurrent Nash and advanced fibrosis over time in patients at one year and at five year. But they're very, very tiny numbers, and we really can't read a lot into those numbers. So I do think we just need to have better data. Progression another study that does give us that concerning value for progression of fibrosis after transplant, and this is the University of Toronto group. They have some data to suggest that this fibrosis progression can be 2.5 years just to progress one stage, which is actually quite accelerated. It comes in the reference of allograft steatosis, but it was in fact excluding all Nash patients. So it's really not recurrent Nash that this would be applicable to. So it's really just patients in the hep C era, which is obviously not the current era that we can really read much into that data. So had he talked about that, this would have been a good rebuttal. So I leave it with a couple more office commentaries, and that's what she said. So the one thing I do want to make the plug for is let's just avoid this whole discussion. Let's promote weight loss. Let's promote the not gaining weight after transplant, and then we don't have to have these types of debates, and it's just ironic that this five-pound piece of blubber looks like a liver. So. Thank you. Thanks. So thanks, Kim and Abraham. So let's do a vote. How many of you think that we should actively prevent Nash and support Dr. Haneno? Just a show of hands. I believe the question was, does it matter? Should we actively prevent it? Of course we should actively prevent it. And how many support Dr. Watt? We should all support Dr. Watt. There we go. She gets very angry. All right. I'm going to open up the floor for discussion and questions. So please come up to the microphone. Yes. Susan Roloff, Portland, Oregon. This was a great session. And just in terms of the last two talks, when are we as a nation and maybe across the globe going to address obesity? We've heard about the cost. We've heard about the cardiovascular complications, diabetes, recurrence rates, re-transplant potential. And maybe we should look at it like alcohol in the transplant population, where we make a patient abstinent, goes to counseling, rehab, whatever it takes. Maybe we should be more dedicated to programs where we insist on them losing weight, not by bariatric surgery, because a lot of them can't have it pre-transplant. But actually actively participate in a weight loss program that they stick to, show adherence to their medications, and some of those other things that we do for the alcoholic patients. I think it's super challenging to try to... Obesity is not sort of a, I drank too much, I ate... I ate too much, sure, but there's a lot of other factors as well. And if anyone in the room, has anyone tried to lose weight? Anyone? No one? Yeah? I mean, it is hard. It is very hard. And you've got these patients that can't walk six minutes and go 300 meters, so they're not going to get on treadmills. They're not going to be able to exercise. It's pure calorie reduction. You're worrying about sarcopenia. You're worrying about protein intake. It's really hard. But they are the most highly motivated group, at least in our center, that have successfully lost weight when their feet are to the fire. The problem is, is after transplant, they gain it all back. So I completely agree with you. I think we need to work on the obesity in the whole general population. But that requires a lot of lifestyle, environment, society changes, which is, oh yeah, never going to happen. So I think we need to, you know, you're right. We absolutely need to work on that. But that's not a quick fix. It's not just a, let's give them an antiviral or an antibiotic or tell them to stop drinking. It's just more complicated. Do you have a counselor, though, or someone that works with these patients pre and post long term? Yeah. So we have a pre-transplant, very aggressive obesity program with very strict calorie restrictions and exercise. And we give them little pedometers. It's actually very, reasonably successful, more so than average for weight loss. We haven't had a formalized program post, but we are looking to start that. Thanks. And again, great talks all afternoon. Thank you. I monopolized that, I'm sorry. I was very intrigued by the way you present the bias against these patients. And actually, I'm absolutely sure that there is bias against patients with NASH. And I'm trying to understand why. By the end of the day, why would you agree that the outcome with hepatitis C was similar or even worse? And with alcoholic patients, it's similar or worse. Why do we have this kind of bias? The only answer that I have as a surgeon, that it's miserable to operate this patient in the middle of the night and to help a fellow taking a liver from someone who is 600 pounds. So why there is a bias against these patients? I think there's a societal bias. It's well known that there's a societal bias against obesity. That's a baseline start. But I do think a lot of the data from the 90s and the early 2000s where we looked, we community-wise looked at BMI and saw worse outcomes. And so the automatic easy thing to say was let's not transplant these people. Where we didn't correct for ascites and didn't correct for all the other issues that were actually going to end up with these worse outcomes. But do you think that this bias today compromised patient care? I think there's a lot of patients that are denied transplant that could be transplant candidates just based on either NASH or more likely it's their BMI that really turns the tide. And I don't know if people really reject for NASH, but I think people get rejected for BMI. There is any case that a high BMI patient ever sued a surgeon for not transplanting them? I don't know of that. I don't know. I would like to congratulate you for your initiative of creating a network to study objectively the problem. I think this kind of initiative will solve a little bit the issue of how big is the problem and how it is a matter of concern. I would like to add that probably getting more information on donor characteristics would help in complementing the picture. So there are many factors that can deal to fibrosis in the graft liver. And one of them is the genetic background of the donor as well. And probably this should be taken into account. And finally, I love the way you presented the data, so congratulations. Thank you. Yeah, we will be looking actually at donor factors. I don't think we're going to have the funding to help us with genetics as far as that goes. But I mean, we have looked at PNPLA3 and donor and recipient pairs, and so has the group from Austria, and didn't show that the donor had a big impact, but there are other genes that we absolutely definitely need to be looking at down the road. Thank you. Since it came up, you know, there are lots of papers that showed that BMI had comparable post-transplant outcomes, but I'm quite sure the data for waitlist mortality is really strong, right? So even if you are putting them on the waitlist, there's still I think a doubling of the waitlist mortality. Did you guys look at that at all? We haven't looked at it, but I have seen those papers as well, yeah. So the waitlist mortality is higher for the high BMI, like the super obese patient. They do die more so on the waitlist. Presumably they're getting passed over as the offers come in, waiting for whatever. I'm going to guess that that's a part of it, and I'm going to guess that they're probably more hospitalized, and you know, it's probably a multitude of things. It might go to Avi's point, which is that it's easy to come up with an excuse for a transplant you don't want to do. That's a possibility too. You don't need to find a donor that's 400 pounds to transplant into the 400-pound person. So there's something happening there that's not well studied. I don't think this problem's going to go away, so I do think that, you know, we do need to start looking into why the transplants maybe aren't happening or why people are being passed over and all the biases that are going into it. And I know I hear a lot about the, we're not treating the addiction, why are we just letting people eat and gain weight, and I think that's something we all need to start really taking heat of and, you know, prevent the weight gain, and then we don't have to worry about all these bad outcomes. And I think that's the single most important take-home message is let's just prevent the weight gain. All right. Well, on behalf of the committee, I'd like to thank the organizers, the speakers, and the audience for participating. This is clearly a problem that's going to be here for a while, and it's maybe harder to challenge than alcohol and Hep C, so.

Nash recurrence

transplant patients

obesity biases

weight management programs

transplant care