WASHINGTON, DC — For individuals with both metabolic dysfunction-associated steatotic liver disease (MASLD) and obesity, bariatric surgery can prevent liver disease progression to the point where liver transplant is necessary and, in patients who do need transplant, can prevent liver disease from recurring. The key is determining which patients could benefit and the procedure type and timing.

Those considerations were the focus of a presentation by Julie K. Heimbach, professor of surgery and director of the William Von Liebig Center for Transplantation at the Mayo Clinic College of Medicine, Rochester, Minnesota, at The Liver Meeting 2025: American Association for the Study of Liver Diseases (AASLD).

“The most important risk for adverse outcomes for patients with MASLD is fibrosis, so ideally obesity can be treated before a patient develops fibrosis,” she said.

In patients with obesity, MASLD, and compensated cirrhosis, bariatric and endoscopic bariatric procedures can be considered as a possible strategy to reduce the inflammation and fibrosis that lead to metabolic dysfunction-associated steatohepatitis (MASH) and eventually to the need for a liver transplant, Heimbach told Medscape Medical News.

“Ideally, the endoscopic bariatric procedure can result in weight loss and then reduced steatosis in the liver, and prevent progression to fibrosis and cirrhosis,” she said.

Heimbach cited a 2020 study in which bariatric surgery was associated with long-term resolution of MASH without worsening fibrosis. In the study population of 64 adults, 70% had improved fibrosis and 84% had resolved MASH 5 years after the procedure. However, the stage of the liver disease is important when considering surgical intervention for patients with obesity and MASH, Heimbach said.

A meta-analysis from 2022 showed that bariatric surgery was safe and effective for patients with obesity with compensated cirrhosis, with a mortality rate of 0.9%. By comparison, mortality in patients with decompensated cirrhosis who underwent bariatric surgery was 18.2%.

Improving Posttransplant Outcomes

The need for liver transplant is inevitable when patients develop decompensated cirrhosis, Heimbach said. In patients with obesity who undergo transplant, liver disease can recur if obesity isn’t addressed, worsening their long-term outcomes, she said.

So if a patient has both end-stage liver disease and severe obesity (class III), it is important to consider strategies to treat both conditions, in order to manage liver failure while safely reducing weight, Heimbach said.

Obesity can be addressed simultaneously with liver transplant by combining transplant with a sleeve gastrectomy procedure. It could also be addressed after liver transplantation through medication or endobariatric surgery, Heimbach said. Endobariatric procedures such as endoscopic sleeve gastrectomy are minimally invasive and often performed on an outpatient basis, but they may not be sufficient for patients with severe obesity, she added.

A recent multicenter study published in the Journal of Hepatology showed that patients who underwent combined liver transplant and sleeve gastrectomy demonstrated reduced recurrence of MASLD after the liver transplant, as well as sustained weight loss and resolution of diabetes and high blood pressure compared with patients who underwent liver transplant alone.

However, research is needed to determine the optimal timing of bariatric or endobariatric procedures — before, during, or after liver transplant — in these patients, Heimbach said.

Additional Considerations

Data have shown that, in patients with liver disease, an elevated BMI is associated with a higher risk for hepatic decompensation and that lowering BMI may decrease the risk for decompensation and improve transplant outcomes, Kathleen E. Corey, MD, MPH, MMSc, told Medscape Medical News.

Patients with advanced liver disease are at risk for a host of other complications, such as frailty, malnutrition, and sarcopenia, a progressive loss of skeletal muscle mass, function and strength, said Corey, an associate professor of medicine at Harvard Medical School, Boston, and director of the MGH Fatty Liver Program at Massachusetts General Hospital, Boston.

“Weight-loss methods, whether with pharmacotherapy or surgery, have to be mindful to avoid inducing these complications,” Corey said. “Bariatric and endobariatric procedures result in consistent weight loss, reducing pre- and post-liver transplant complications and may reduce the risk of recurrent or de novo MASLD,” she added.

Procedures such as endoscopic sleeve gastrectomy may prevent the need for transplant in patients with less-severe liver disease, said Corey. “As was referenced in this presentation, a high proportion of patients with liver disease can experience fibrosis regression preventing the need for future liver transplantation,” she said.

However, monitoring and determining a safe rate of weight loss is essential with any weight-loss method, as is monitoring the impact of weight loss on sarcopenia, frailty, and the risk for malnutrition; therefore, tailored programs for individuals with advanced fibrosis are needed for successful weight loss, Corey said.

Heimbach had no financial conflicts to disclose. Corey disclosed consulting for Novo Nordisk.