The growing pandemic of obesity is also increasing the prevalence of end‐stage liver disease (ESLD). The incidence of obese patients among liver transplant recipients has raised from 20% between 1988 and 1996 to 33% between 2001 and 2011. Liver transplantation (LT) also poses challenges in obese patients because of the increased risk of comorbidities and difficulties associated with perioperative and postoperative care. Plethora of evidence has revealed that obesity can cause nonalcoholic steatohepatitis, resulting in ESLD, hepatocellular carcinoma, and death, and several harmful effects on preexisting chronic liver disease caused by hepatitis C, hepatitis B, or alcohol‐related liver disease. It has been established with the help of various studies that obesity is correlated with significant morbidity and mortality among patients with ESLD.  Besides increased risk of mortality, obesity can also be considered as an independent risk factor for liver decompensation and infection in cirrhosis, as well as acute‐on‐chronic liver failure (ACLF). 

Acute liver decompensation is typified by acute development of one or more major complications of liver disease such as ascites, hepatic encephalopathy, gastrointestinal hemorrhage, bacterial infection), and can be further complicated by organ failures and high short‐term mortality in a syndrome referred to as ACLF. It is recognized as a state of excessive systemic inflammation and immune dysregulation. Assessment of molecular profiles in patients with ACLF shows significant increase in levels of circulating proinflammatory cytokines and chemokines. Human adipocytes pf an obese individual express several proinflammatory cytokines/chemokines that trigger inflammation and activate CD4+ T cells independent of macrophages. These inflammatory cells then, further infiltrate the adipose tissue to release more cytokines, including tumor necrosis factor‐α, interleukin (IL)‐1, IL‐6, adiponectin, and resistin, which act on immune cells to increase local and generalized inflammation. Thus, obese patients, owing to greater reservoir of inflammatory cytokines, increases the risk for acute decompensation and ACLF.

Source: Ahn JC, Sundaram V. Obesity and Liver Decompensation. Clin Liver Dis (Hoboken). 2019;14(1):12-15. Published 2019 Aug 2.