[MUSIC PLAYING] Hello, and welcome to the University of Chicago Medicine At the Forefront Live. There are many diseases and conditions that can impact your liver. Some liver diseases can be inherited. Some are caused by alcohol abuse. And others have different reasons for happening.
The liver is a large organ that is on the right side of your body, under your rib cage. It does a lot of work for the body and is very important in metabolism. Today, we will have two experts on liver disease and liver transplant joining us on the program.
Remember, we will take your questions live during the program. So start typing in the comment section. And we'll get to as many as possible. We also want to remind our viewers that this program is not designed to take the place of an actual visit with your physician.
Joining us today is Dr. Michael Charlton and Dr. Talia Baker. Welcome to the program. And we'll get right to the questions. Let's start off with, what's the most common reason that people might need a liver transplant?
The three most common reasons are alcoholic liver disease, and the patients that are selected for alcoholic liver disease are very carefully screened for having a very low probability of having the same problem following liver transplantation. And those outcomes are excellent. The second is fatty liver disease. So somebody watching today or tuned in today, if your body mass index is above 30, if you carry excess weight, there are 80 million people with fatty liver disease.
That's now the second most common reason to need a liver transplant. It's a silent condition. The great majority of people have no symptoms to go along with it. So if you meet these criteria-- say, type 2 diabetes, hypertension, lipid trouble, BMI above 30, ask your doctor if you should be concerned about your liver health.
And the third is hepatitis C. That used to be the most common indication for decades. And now we have effective therapies. We can cure almost everyone. If you're born between 1945 and 1965, make sure you've had your hepatitis C screening.
So Dr. Baker, talk to us about liver transplant and what happens during that process. This is a very complex surgery, obviously.
It's a very complex surgery. But the whole process actually starts way before the surgical procedure. So as a multidisciplinary team with our hepatology colleagues, we evaluate people who need a liver transplant, who have scarring of their liver, an indication for liver transplantation.
We very carefully risk stratify those patients to determine that the outcomes of a liver transplant will cause them to have a lifetime of healthy living. So we work on patients in a multidisciplinary fashion. We have them stratified for risk and try to abrogate that risk as much as we possibly can. And then when an organ becomes available, whether from a deceased organ donor or a living donor, we go forward with a surgical procedure, which is a big operation.
But patients do exceptionally well with the procedure. Postoperatively, they're generally in the hospital for five to seven days, barring any other type of complications. And then after the operation, we take care of them very closely. But our hope is that by about a month after surgery, they return to their normal quality of life. So a liver transplant is a life-changing operation, which hopefully gives your entire life hopes back.
Now, when we started the program off, in my little intro, we saw a graphic. And it showed where the liver was located-- large organ. And I gave a very brief overview as to what the liver does. But can you tell us a little bit more about why the liver's so important to you? And what would people look for if they think they've got an issue?
I can make a start. So the most important thing the liver does is it handles all the blood that returns from the intestines. so from our food pipes all the way down to our large intestine, all of that blood makes its way back into the liver. So it handles all of our nutrients. It's important, as you mentioned, in many aspects of metabolism. It makes proteins, including many of the proteins that are involved in blood coagulation and normal clotting. Talia, any other thoughts?
So there can also be complications from your liver disease which can cause you to need a liver transplant, as well. So probably the most common complication of end-stage liver disease, where the liver is actually still functioning quite well, despite its scarring, is liver cancer. So we have a very dedicated program here at University of Chicago looking at ways to optimally treat liver cancer.
For many people who come to us with liver cancer and liver disease, some of them will have surgical options, where we can actually take out the tumor. But most of them need to be treated in a way that can get them to a liver transplant and to a surgical cure for their disease. So liver cancer used to be a terminal condition. But it has changed in the last decade dramatically. And we're able to actually offer surgical cure for patients who present to us with liver-only disease.
Now, when you start having issues with your liver, I think, probably, most people think of jaundice. That's just one symptom. Talk to us a little bit about what's happening there, first of all. And what are some other symptoms that, maybe, people should be aware of?
I think the most important-- it's a great question. And the most important part of any answer to that is that most people with liver disease have no symptoms. You can have even the most advanced liver disease, with cirrhosis, and still have no symptoms. When you do have symptoms, the things that people will notice may be swelling of the belly as fluid collects.
As this blood is trying to return through a scarred-up liver, it has trouble doing that, the same way that water has trouble flowing through a beaver dam on a river. The water builds up behind it. Blood builds up behind the liver. And it can collect in the belly.
That same high pressure in those veins going into the liver can lead to varicose veins in the food pipe or esophagus. These can bleed. And you can have vomiting of blood or blood in your stool. Jaundice, you mentioned already. And then, of course, abdominal pain is a relatively unusual symptom. But that can absolutely happen, particularly if you have a liver cancer or an infection in your belly.
And finally, the liver is very important for clearing important metabolites, like ammonia. And if the liver's not healthy, it struggles to clear these ammonia levels. For example, it can build up and lead to changes in mental status. So you can become sleepy, a reversal of sleep patterns. So you don't sleep at night, you're sleepy during the daytime, and just general lethargy.
Interesting. Now, that one I didn't know. So that's very interesting. So we do take questions from our viewers. And I do want encourage people to type your questions in the comment section. We already do have one. And our first question that we've received from a viewer is concerning fatty liver disease. And they want to know, how important is diet in treating fatty liver disease?
Diet is critical. No one has been able to recreate fibrosing or fatty liver disease that scars the liver up without nutritional variation. And the most important component of this nutrition is cholesterol content. So that would be things that are in red meat. Fast food is terrible. It's got the combination of high cholesterol content and high carbohydrate content also.
And some things are protective. So we have these great Chicago life coffee mugs here. Coffee is actually great for the liver. The scientific evidence for that is overwhelming. So three cups, eight ounces, drip-filtered coffee a day.
We have-- we'll get out the paper towels for you here in a second. I'm sorry we put water in that. Talk just a little bit about what is, exactly, fatty liver disease. Because I think that's one thing we-- I probably asked the questions in the wrong order, to be honest with you. But let's talk about what is fatty liver disease first. And then we can talk a little bit more.
So a healthy liver should have less than 5% fat content. So if a liver weighed, say, 1,000 grams, it shouldn't have more than, say, 50 grams of fat in it. And it can be measured through noninvasive techniques.
If you have enough carbohydrate, just having more carbohydrate than is healthy for you, can start to accumulate fat in the liver, which we call steatosis. This is often referred to as non-alcoholic fatty liver disease. Sometimes, that's associated with inflammation, or steatohepatitis, and sometimes with fibrosis, as well.
Although to really grade and stage the severity of fatty liver disease requires a liver biopsy, you can figure most of what you need to know out without a liver biopsy. And this requires some very sophisticated techniques that we have here at University of Chicago, including something called vibration controlled transelastography and MR elastography. A small minority of our patients end up needing a liver biopsy, thanks to these advances in noninvasive techniques.
And we had a big situation in the news recently with the triple transplants-- two of those. And those involved both liver transplants as well, so incredibly complex procedure. And it was interesting to see all of the work that went into that, particularly the multidisciplinary aspect and the teamwork that went into that. I know both of you were heavily involved in that. Can you talk just a little bit about the process and what that was like, being part of that being?
It was an amazing privilege to be a part of that. I think the most wonderful part of the procedure was how smoothly it ran, how it was just a seamless effort to go from putting in a heart transplant, to putting in a liver graft, to putting in a kidney graft. I think, without us working together as a fully integrated team, and without the seamless integration of all of the different components of the team, the success of those operations would never have been as dramatic as they were.
Both patients are doing amazingly well now, over a month after transplant. We just saw them in our outpatient clinic together. And I really would emphasize that the success of the procedure was really based on how well the entire team-- the heart transplant team, including all the coordinators, the anesthesiologists, the profusionists, the liver transplant team, including the hepatologists as surgeons, but very importantly, the procurement coordinators and the nurses in the operating room, and then the kidney transplant team as well-- everybody worked together in, really, a seamless orchestrated fashion to have a phenomenal outcome for all of those patients.
You two are very popular. We're getting a lot of questions from viewers that are coming in right now. And usually, whenever we write we write up a bunch of questions in advance, that's when we get a ton of questions from viewers. That's what's happening. So let's try to get to as many of those as possible.
And the ones we can't get to, first of all, I will apologize. But we'll do our best to answer those after the program. So take heart in that. And this is a-- I'm going to let you pronounce this. So this is a question from one of our viewers.
Is hepatic encephalopathy reversed after a liver transplantation?
Almost always. So I'm going to-- nothing in medicine is ever 100%. And sometimes, the ammonia levels can stay elevated. Sometimes, some of the connections that enable blood to divert around the liver can persist. That's very unusual, though.
Liver transplantation is a nearly complete cure for encephalopathy. And the great majority of people have no residual effects of hepatic encephalopathy following liver transplantation. No ongoing medication is needed.
Can you tell us what that condition is?
Hepatic encephalopathy?
Yes.
So that's when ammonia levels-- mostly ammonia levels. It's more complicated than just ammonia. But mostly, ammonia levels increase, because the liver is not able to clear them. Muscle is also important for clearing ammonia from the blood. So as you lose muscle mass, which people do as they become ill, particularly with liver disease, you can have even worse effects of encephalopathy. But it's that slowness of thinking, drowsiness, and reversal of sleep.
And we have another question, possibly from the same viewer, that wants to know if there are meds available for that condition.
There a great meds. So we've had a medicine called Lactulose, which is a sweet-tasting, sort of orangey syrup that's not absorbed. This is very effective. But it has side effects of bloating, loose stools. And within not very many years ago, we had another medicine called Rifaximin. This is a nonabsorbable antibiotic, almost without symptoms. But it is really quite expensive.
So we start with Lactulose. And if people are not tolerating Lactulose, or if actually this is not working on its own, we'll often add this medicine called Rifaximin, which is one pill twice a day, very easy to take.
Dr. Baker, what are some of the risks that happen with a liver transplant? What should people be aware of?
So a liver transplant is a large operation. It's a physiological stress on the body, which, really, is not comparable to almost anything else we do. We actually take out the liver graft and put in a new graft in the same place. It's really, honestly, just fancy palming. There are risks associated with a liver transplant, which include both surgical technical problems, as well as medical problems after the liver transplant.
So probably the most significant risk after a liver transplant, or any organ transplantation overall, is rejection. The ability to control that rejection and treat the ability of the body to reject the organ has changed dramatically in the last decade, and most significantly over the last two decades. So the medicines that we use now are significantly less toxic, for example, to the kidneys, and even can help us abrogate the risk of recurrence of tumor after liver transplantation.
So one of the arts of liver transplant is figuring out the immunosuppression. And the most important thing that anybody who is going into a liver transplant, or considering whether they need a liver transplant, to know is that every day after the procedure for the rest of their very long, healthy life, they will have to take medications to stop the rejection.
Another question from a viewer. What's the prognosis for PBC? And does the average patient with PBC live a long life?
So PBC stands for Primary Biliary Cholangitis. This is a disorder where your own immune system attacks your bile ducts as if they were foreign, almost a rejection of your own bile ducts. This is the disease which has the best long-term outcomes following liver transplantation. Because we have more effective therapies than we used to for PBC, we're seeing less and less patients, thankfully, need liver transplantation for PBC. But when they do need it, the outcomes are consistently the best among patients undergoing this procedure.
Interesting. What about, what are the most commonly seen liver diseases that lead to cirrhosis, and how could we prevent those from happening? And that's, again, a question from a viewer.
So the most common two indications for liver transplantation are alcoholic liver disease and non-alcoholic fatty liver disease, this liver disease associated with being overweight and having complications of being overweight, such as diabetes, dyslipidemia, hypertension. The most common liver diseases, though, are by far non-alcoholic fatty liver disease, this fat accumulation in the liver related to nutrition.
80 million people in the United States, nearly 160 million between the United States and Western Europe, over a billion people worldwide-- a tiny fraction are aware of the liver disease. Luckily, the great majority don't progress to the point where they need liver transplantation. But again, if I can get one message across today in this, it's to make sure that you've discussed some assessment if your liver health with your primary care provider if you meet those criteria, with extra weight, any of those complications, diabetes, dyslipidemia, et cetera.
OK, now, my favorite comment or question-- I guess it's more of a comment that's come in so far on Facebook. This is very nice. Brad Goodman. You know who he is.
Ah, of course.
He says, Dr. Charlton, Dr. Baker, thanks for saving my life, 534 days post-transplant. Pretty neat. And that's a fantastic story. I'm familiar with that story, as well.
Yeah. Brad really exemplifies sort of the pioneering that we get from our patients, too. So we have the lowest wait list mortality in the country here. And part of that is by trying to use imaginative approaches to find a great donor organ for our recipients. And Brad's been on the news, so there's no violation of privacy, here, so--
Yeah, yeah. I'm glad you said that.
So Brad was one of the early recipients to accept an organ that other centers had turned down. I think he was more than 200 down on the list when he accepted the organ. And this is something which I think is a hallmark of our program, which is finding organs that make sense for a particular recipient.
And can you tell us a little bit about that? Again, he's been on the news. She's signed the releases. So we're safe here. But can you tell us a little bit about his situation? Because it was fascinating, the organ that you transplanted. What happened there?
Yeah, so Brad had been very sick with a type of liver disease that isn't well reflected in the score that gets you a priority on the wait list for liver transplantation. Brad has shown pictures of him when he was at his sickest. And we met and talked about this possibility of having an organ from a donor who had hepatitis C.
Because hepatitis C used to be a scourge, treatments weren't very good. They were difficult, weren't very effective. That had changed so we could cure almost 100% with one pill, once a day, for 8 to 12 weeks. So we approached Brad that many donors who were stepping forward with their families, and maybe they'd sign the driving license to register as a donor, people with hep C were having organs that were just discarded. There were organs that were discarded. So Brad agreed to be a pioneer and accept one of those organs for himself and did exceptionally well.
That's a fantastic story. And I want to tell our viewers, because this is very important to me. And I know it's certainly incredibly important to the two of you. We do keep our patients-- their information-- we protect that. We don't allow that out. This is a special case, because Brad has allowed that.
And he's told his story, because he's got a fantastic story. And he's just a great guy. And it's very inspiring. So that's why we're sharing this. We wouldn't do that otherwise.
No, no. And I--
I think one of the pieces of Brad's story, also, which is so important, and this is not individual to Brad, is that I think one of the real opportunities that we have had as we've started this, we've kind of built this program at University of Chicago, is to really offer personalized, individual attention to each of our patients. We're a smaller program who's really striving to be novel and innovative about how we are treating our patients, get grafts for our patients, and take care of them perioperatively, both before the transplant and after.
I think it can't be emphasized enough that we have the lowest wait list mortality, because we really try to see each patient as an individual, rather than an overall patient. So in this case, we had a patient who we call Mel Disadvantage. Dr. Charlton just alluded to the score that you get for an organ.
And the government has told us that we have to save most of the organs for the sickest first, which is absolutely the right thing to do. But there are many patients on liver transplant wait lists around the world, and some patients who actually don't even know that they need a liver transplant, who are very sick from their liver disease, but unfortunately don't have that number which gets them an organ.
So we were able to find for this patient, who had a very low MELD score, but was very sick, an organ which turned his life around, brought him back to his children, brought him back to his normal quality of life. And that's something that we really try to do for each of our patients on our waiting list.
That's just a fascinating insight, too, as to how the transplantation-- the wait list process works. And I think that's very interesting for our viewers to know. Question for you from one of our viewers. In a perfect world, how long does it take to have surgery after a live donor match is found and vetted?
Go ahead, Talia.
So the answer to that question is very vague, because there's no absolute number past that. We in the living donor community feel very strongly that anybody who comes forward to be a donor deserves what's called a cooling-off period after they are approved for a donation. So most patients who come forward for donation are actually ruled out for donation-- usually, most frequently, because of anatomic issues.
But if a patient is found to be a good match for whomever they decide to donate to, whether it's a family member, a friend, a loved one, or even an anonymous person who they have somehow found a connection with, we give them a two-week cooling-off period, just to be able to sit with the idea that they will actually go forward with this. Living donation is a very difficult prospect. It's something that we feel very passionately about. We feel it's the right thing to do.
But you're taking a perfectly healthy person and putting them at risk for, at worst, death. So we know that we have to do everything we can to protect the safety of that donor coming forward. It's an incredible gift that they're offering. And we kind of have implemented, in the living donor community, a two-week cooling-off period after they know that they are a donor, before going forward.
So it's a very artificial number. There's no absolute number. It doesn't have to be done at that two-week point. But I think it's important to remember that we, as a living donor community, really are most concerned with the donor's safety and making sure that the outcomes are as great as they possibly can be.
Now, you both have talked about wait list mortality. That's very interesting. And it's something that, I think, most people probably never consider. But it's very important.
It is.
Talk to us a little bit about why that number is so good here. What goes into that?
So firstly, nationally, for every 100 patients that are placed on a wait list for liver transplantation, about one in five don't survive to the liver transplant. It's very important to look at outcomes following liver transplantation. It's equally important to look at outcomes before liver transplantation.
So the national number is just shy of 20%, or one in five people who don't survive. And that's because there are about 17,000 people waiting for a transplant. And there are about 7,000 organs per year. So there's a big mismatch in need and availability of organs.
The number here at the University of Chicago is 6%. We lose 6, compared to that 19, 20% national average. And what goes into that is this multidisciplinary approach. And it's more than just a phrase. We have a team that rounds every day that includes surgeons, nonsurgeon physicians, nutritionists, social workers, pharmacists.
And we have an outpatient clinic where patients don't really even need an appointment. If you're not feeling well with a fever, shortness of breath, whatever it is, you can call up. We will see you that day, as soon as-- pretty much as soon as you arrive.
Hospital, as well-- our patients are prioritized for admission. We try and spend as little time for our patients in the ER as possible, sometimes coming direct to the hospital, as well. The journey from being not very well to being in a near-death state for liver disease can be very short and fast. So for that reason, we get to the patient's bedside as quickly as possible, make a rapid assessment, and when necessary, get things like antibiotics on board, et cetera. But I think it's that responsiveness and a multidisciplinary approach that really pays in dividends.
And I also think we come back to what we were just talking about, which is that we really are committed to transplanting people at a lower MELD. So although they may not have the MELD which would indicate that they immediately need a transplant, as Dr. Charlton said, you can get sick extraordinarily quickly. So we take people who are sick from their liver disease and try to find organs for them that are appropriate and will give them an excellent outcome in ways which other centers may not consider. So I think our devotion to using hepatitis C positive organs and hepatitis C negative recipients has really changed the way that we can offer organs for patients who need them.
That's true.
So is cirrhosis of the liver always caused by alcohol abuse?
No, certainly not. There are big, multitomed textbooks of causes of liver disease. Alcohol, as I mentioned earlier, is the most common reason for liver transplant. But that's still a minority of people undergoing liver transplant have alcoholic liver disease.
If you look at alcohol as a cause of liver disease, it's much smaller than is people with nutritional or fatty liver disease, as non-alcoholic fatty liver disease. Then there are so many things where your own body can attack your immune system, primary sclerosing cholangitis. There are the viral causes, hepatitis B, hepatitis C, more than we could come close to having time for today.
So that's something which patients with liver disease are often stigmatized by-- they feel like everyone feels that there must be some contribution from alcohol. That's true for a minority. And even with people with alcohol use as the cause of their liver disease, the people who are undergoing liver transplantation really have gone to great lengths to treat this alcohol use disorder, to make it as unlikely as possible the drinking will be a problem going forward.
And when we're talking about cirrhosis, correct me if I'm wrong, please. That's primarily scarring of the liver, right?
That's exactly what is. It's scarring of the liver, fibrosis or scarring of the liver.
So it can happen with a lot of different-- a lot of different things can cause it.
Anything that causes inflammation can lead to scarring of the liver. That's absolutely correct.
Right. So is there an age limit for transplant patients or being a candidate?
You know, I think the record-- they have put, like, a Guinness Book of Records for transplants. It actually exists. It's called Terasaki's-- I forget the rest of the name of the book. But it's Clinical Transplantation, I think, is the rest of it.
And at the back of it, they have these records for age, this kind of thing. And it's, I think, 88 years old, was the oldest. I've never had a patient that I've cared for that's been transplanted at the age of 88. But in the low 70s is not that unusual.
We don't have a number in our heads. What we have is the health of a patient. So I've seen people who are in their 40s who were too sick. And we've certainly seen patients who were in their 70s who are healthy enough to undergo the rigors of transplantation successfully.
Now, Dr. Baker, you touched on this earlier. I'd like for you to expand a little bit more, the difference with the University of Chicago Transplantation Institute. What makes this such a special place?
I think that we have really committed to innovative and novel approaches to liver transplantation. We see each patient individually. We try to make sure that each-- we are considering each patient as an individual and with personalized approaches to their liver disease. I think it's incredibly important that we are able, as a community, to take care of them in a multidisciplinary fashion as they present to us and become part of our team, up to the time of transplant, and then continue that continuity of care all the way through to the rest of their lives.
So I think that's something which is a smaller program, which is really offering innovative approaches to finding organs, to taking care of them, to indications for transplantation. We're able to offer something that is really remarkable and we're very proud to be part of.
That's great. So can transplants be offered to patients who are obese?
Certainly can. So this is something which programs are going to have to figure out. We've taken a proactive approach to this. Every center has patients that carry more weight than is healthy. And you can either set just a limit that if you're above a certain weight or BMI, then we won't be able to provide transplant services.
That's not our approach. We have a multidisciplinary metabolic liver clinic which includes nutritionists, endocrinologists. And we try hard to get patients to a healthy weight where transplantation is possible before transplantation. We also offer intraoperative weight loss procedures to help weight to stay at a healthy level following the transplant. So it's a series of services, and therapies, and treatments that we have before transplantation, during, and in the after-transplantation period.
So I would say, no, there is no number that I would give for body mass index. It really depends on the anatomy and whether someone like Dr. Baker is able to safely do the procedure.
Great. Another question coming in from a viewer. And before I read this one to you, I want to, again, let people know that this is-- we're not trying to take place of an actual visit with your physician. This is just some general information. But this is an interesting question. So we'll fire it at you two guys and see what you think.
I just got moved from Pete's to the adult list and have been waiting for four years. My dad's a donor and my blood type. My family's thinking of doing the living donor situation. Do you think that's a good idea? Because I'm 19 and have been diagnosed for eight years now.
Well, congratulations on graduating from pediatric to adult care. It can be difficult things, so that you're used to one set of providers. And there are usually a different set of providers. So there are challenges that go along with it.
Blood type, you have to be a compatible blood type, not necessarily the same blood type. So blood type O can donate to any blood type, for example. So I don't know enough details about your particular situation to have any important insight for whether this is a good idea for you. And I think it was your father, if I heard correctly. Now, Talia, any other thoughts or considerations, like weight and health of the donor?
I think exactly that. I think it's important to remember that the health of the donor is our primary concern. And that's obviously the health of you and your outcomes. But if you have a compatible donor, and it's something that you'd like to consider, that's certainly a possibility. It's hard to make an overall assessment without knowing the specific situation. But living donation, and the potential for living donation, should always be considered as part of your treatment algorithm.
Certainly something to talk to your physician about.
Yes. We encourage that.
Great. Well, that was fantastic. That 30 minutes went quickly, didn't it?
It really did.
That's all the time we have for At the Forefront Live. I want to thank our guests for being on the program. I also want to thank you for watching and submitting your questions. If you want to know about our liver transplant program, you can please visit our website. That's at uchicagomedicine.org/liver-transplant. You can also call 888-824-0200. It's right there on the bottom of the screen. So you can read it probably better than I again.
We have an At the Forefront Live scheduled for Monday. It's about bariatric surgery. Please make sure you join us Monday, January 28 at 12:30 to learn all about bariatric surgery and how it can change your life. And finally, make sure to check our Facebook page often to see the schedule for At the Forefront Live. There's lots of other great information there, as well. Thanks for watching. We hope you have a great week.
