Caitlin Whyte (Host): Welcome to the Flourish Podcast by PRISMA Health, where we share expert advice on health and healing. I'm your host, Caitlin Whyte. Today, we are joined by Dr. Derek DuBay, a PRISMA health transplant surgeon to explore the intricacies of liver transplants. We'll discuss their necessity, the challenges involved in obtaining one and the comprehensive journey of liver transplant recipients from surgery preparation to post-transplant recovery. Now, Doctor, my first question to start off our conversation is why would a liver transplant be needed?

Derek DuBay, MD: Yeah, so there's a variety of indications for liver transplant in the United States. By far, the most common reason is for liver failure or what we call end-stage liver disease. About 60% of transplants in the US are performed for liver failure. This would be when your liver is working suboptimally and you develop manifestations such as fluid in your abdomen, ascites, hepatic encephalopathy where your body doesn't clear the toxins out of the blood, bleeding, jaundice, where you turn yellow, things like that.

So again, 60% of transplants in the US are performed for liver failure, the most common reason. Liver cancer accounts for about 25% of transplants that are performed in the US and the number one risk factor for developing liver cancer is underlying cirrhosis. About 5% of liver transplants in the US are performed for acute liver failure.

This oftentimes is due to specific medications most commonly Tylenol, but certainly many other medications can cause that. But there are also some autoimmune and other etiologies that can cause acute liver failure, and sometimes we just don't know why the liver fails. And then about 10% of transplants are done for everything else, which collectively are a whole host of diagnoses, but, account for just a small portion of the number of transplants that are performed.

Host: So with all of these reasons for transplant, just how difficult is it to get a liver transplant?

Derek DuBay, MD: Yes. So in the US in the year 2025, we're predicted to do over 11,000 transplants. There's still, you know, mortality in the, on the wait list is substantial and, you know, ranges in most centers, up to 20% of patients are waitlisted. Don't get a transplant. So it, it is challenging. One of the things I love the most about liver transplant in the United States is that it's a sickest first allocation system.

The patients who have the, you know, highest liver sickness score, what we call MELD score get the next liver. One of the things I hate the most about liver transplant is that it's the sickest first system. So you've gotta be pretty ill before you make your way to the top of the list. And, you know, sometimes we talk about getting a liver being similar to playing a game of Russian roulette. You gotta get sick enough to get to the top of the list, but not too sick to where you die. So it, it certainly can be a, a challenge for it right there. But you know, if only if 20% of the wait lists are passing, that means 80% of the people are, you know, getting to the finish line and getting liver transplants.

But there are many challenges to get put on a transplant wait list. You gotta be medically suitable for transplant. So acceptable, you know, cardiac function, lung function, so on, got appropriate surgical risk for transplant. But more than that, there's a lot of psychosocial aspects that can be a, a challenge to get put on the transplant wait list and including you need adequate social support, family caregiver support.

Your underlying psychiatric issues have to be under control. And any addiction issues adequately treated.

Host: Now, what is it like to prepare for your liver transplant before surgery?

Derek DuBay, MD: Yeah, so the number one reason we perform transplant in the United States in the year 2025 is for alcoholic liver disease. That's a huge issue, right? Most people suffer from significant addiction issues, commonly underlying psychiatric disorders. So, certainly the substance abuse has to stop and the underlying psychiatric disorders treated.

A lot of times these patients have alienated their, their family and close friends and need to, you know, re-bridge some of those relationships to set themselves up for success following a transplant. The number two reason we do transplant in the US is for metabolic associated liver disease.

So this commonly is what is called in the lay press of metabolic syndrome. So metabolic syndrome typically is some constellation of diabetes or pre-diabetes,obesity, particularly truncal obesity, having a, a, a large waist line associated with you know, high blood pressure and or, high blood cholesterol level and that syndrome associated with inactivity, whatnot.

So the metabolic syndrome, of course, that's associated with elevated risk of cardiovascular death, heart attacks and strokes. It's also associated with developing fatty liver disease, of which a proportion will go on to develop liver failure. So again, it's our number two indication for liver transplant.

In that setting, patient's diabetes have to be under adequate control. The BMI, or your weight needs to be in an acceptable level. So there, there are a few things that are related to the underlying etiology of their liver disease, but beyond that, I would say it's important for patients to try to improve their functional status if it's compromised.

And I should mention that the Hallmark of developing liver failure is muscle wasting. So we lose significant muscle to the disease. It's very similar to people who develop advanced cancer. They lose a lot of weight. Patients who develop advanced liver disease look very similar to people with advanced cancer.

And a lot of times they become more frail and lose their functional status. So we encourage people to try to, you know, exercise and, and to try to improve their functional status to, to improve their perioperative outcomes. And then, and then finally, just making sure you got adequate social support. For the first month following the transplant, you, you, you need a, you need an adequate number of people that can come by and, and care for you and be with you and that's becoming more of a challenge amongst our patients that we see.

Host: And what is the transplant procedure like Doctor?

Derek DuBay, MD: Obviously my, my perspective is a bit biased because I only know it from a surgeon perspective, but I have many patients that have talked to me about their perspective and they frequently tell me that they experience both excitement and fear. Excitement that they're getting a transplant, and also fear that they're getting a transplant.

From my perspective, there's tons of logistics associated with getting the organ offer, accepting the offer, procurement of the DC stone or transport of the organ to our center. Coordinating a time to start the case, coordination of the different teams involved, anesthesia team, our dedicated OR team, the blood bank, so on and so forth.

There's a lot of logistics that are associated with it. And that's the frustrating part about it. The awesome part is once we get started, the liver transplant itself takes about four to six hours. Almost all patients get some blood products during the case. It's pretty amazing to watch the liver, the start quickly.

And you know, the patients recover. Some hallmarks of liver failure that we see just physiologically reverse very quickly. And, and it's, you know, it's quite gratifying to see those immediate changes.

Host: Well, how long does that recovery take after receiving a transplant?

Derek DuBay, MD: The initial recovery following the transplant is in the ICU. The median hospitalization following a liver transplant in the US is between nine and 10 days. It does take a good, you know, six weeks before people really feel like they're back on their feet and probably three months before they feel like they're completely recovered.

I mentioned before that, you know, one of the hallmarks of liver failure is muscle wasting. So your body converts to a state of what we call catabolism or muscle breakdown. And it takes a good three months before your body, you know, flips from that state and becomes what we call anabolic or putting muscle down.

So the recovery is pretty lengthy following the transplant.

Host: Now, doctor, would you say you're able to live a normal life after receiving a transplanted liver?

Derek DuBay, MD: For sure. That's, that's the goal. We don't transplant people to put them in a bubble and keep in the hospital for the rest of their life. We want them to be normal, healthy, productive citizens and do the things that they want to do in life. You know, there's a few things in medicine that we do that will prolong your life as much as performing a liver transplant in the setting of liver failure.

Long term, liver transplant requires the least amount of immunosuppressive medications compared to like kidney transplant or heart transplant or lung transplant. It's very, very low amounts of immunosuppression and it's got the longest graft survival. So most organs you transplant unfortunately only make it about a decade.

Your liver will engraft and, and if it does, it'll last the rest of your life,if you take care of it for it there. So it's pretty amazing. Can you go back to the, your previous lifestyle though? I, I would argue that a lot of times people who need a liver transplant, it's a previous lifestyle that, contributed to or completely caused their liver failure.

So it's important that lifestyle modifications are made following liver transplant to try to not repeat the cycle.

Host: That is a very good point. And leads me right into my next question. Are there permanent changes that you need to make to stay as healthy as possible after a liver transplant?

Derek DuBay, MD: The biggest challenges are to avoid or modify the risk factors that cause the liver failure in the first place. And this largely applies to alcohol cessation, excellent diabetes control, acceptable physical fitness, compliance with post-transplant care and so forth.

 Those I think, would come naturally to a lot of people. But for the folks that you know, that have developed the liver failure, sometimes those can be particularly challenges.

Host: And my final question, can you receive a liver transplant from a living donor?

Derek DuBay, MD: Yeah. In the US, 6% of liver transplants are from living donors. Last year there was zero performed in South Carolina. It's pretty amazing. If you look at people that go to centers to get a living donor, the wait list mortality essentially goes down to zero because they get transplanted.

So it's fantastic. It, there's an incredible survival advantage to having a living donor and getting transplanted with a living donor. Unfortunately, the postoperative complications are higher in living donor liver transplant than they are in deceased donor transplant, mainly related to bile duct complications.

But there's a, there's an enormous survival advantage to getting a living donor transplant. People that do have living donors and they go living donor transplant,they oftentimes get transplanted at a much lower MELD score or liver sickness score.

So they, they frequently have a shorter hospitalization and a quicker recovery because they don't get to the point where they're knocking on death's door before they get transplanted. So there's collectively, there's enormous benefits to doing living donor liver transplant, but there are greater complications, surgical complications following a living donor transplant compared to a whole graft deceased donor transplant.

We intend to start a living donor liver transplant program in the future at, at PRISMA, just not in our first year.

Host: Thank you for joining us on this insightful journey through the liver transplant process. We hope today's discussion provides clarity and hope for those navigating or considering this life-saving procedure.

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