Transcription:
Cirrhosis

Melanie Cole (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care. Keeping you informed, so you can make informed healthcare choices for yourself and your whole family.

Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine. I'm Melanie Cole. Joining me today is Dr. Danielle Brandman. She's the Medical Director of the Center for Liver Disease and Transplantation at Weill Cornell Medicine, and she's here to tell us about cirrhosis from diagnoses to liver transplant.

Dr. Brandman, thank you so much for joining us today. I'd like you to just start by kind of telling us what is cirrhosis of the liver, how common is it. Tell us a little bit about this disease.

Dr Danielle Brandman: Well, thanks so much for having me. And to tell you a little bit about cirrhosis. Cirrhosis basically tells us how much scarring is there in the liver. And really any cause of chronic liver disease can ultimately result in cirrhosis after many years of damage. Cirrhosis really tells us that patients are at risk for complications such as liver failure and liver cancer, but you can also have cirrhosis and normal liver function.

Melanie Cole (Host): So, you said scarring and liver damage. Please tell us what causes it. I mean, we've heard about alcohol and that association. But we also have heard about non-alcoholic fatty liver disease. We've heard about all these different other liver diseases that don't involve alcohol, but I'm guessing that's probably top of the list. Can you tell us a little bit about what causes it? Who's at risk? Is it genetic? Tell us about that.

Dr Danielle Brandman: Yeah, absolutely. And I think when a lot of patients hear about cirrhosis, they assume alcohol, and they automatically say, "Well, I'm not a drinker." And for most people, that may actually be the case. So, alcohol-related liver disease is one of the leading causes of cirrhosis. But as you appropriately mentioned, non-alcoholic or metabolic dysfunction-associated fatty liver disease is one of the other leading causes of chronic liver disease and cirrhosis. But there's so many other causes of chronic liver disease, namely viral hepatitis like hepatitis B and C, autoimmune liver diseases like autoimmune hepatitis or primary biliary cholangitis, and several genetic liver diseases such as alpha-1 antitrypsin deficiency or Wilson Disease. And really, the point is any chronic liver disease that's causing inflammation and liver cell damage, as the liver tries to repair itself, that can ultimately lead to cirrhosis or scarring of the liver.

Melanie Cole (Host): I'm going to veer off for just a second because I'd like you to give us just a little physiology lesson, Dr. Brandman. I'm not sure everybody really understands what the role of the liver is in our body and how it's related to metabolic disease, as you said, and fat processing. Can you tell us what the liver does?

Dr Danielle Brandman: Yeah. So, the liver is a really fascinating organ and it's one of the many reasons why I went into this field. It's an organ that we're still learning a lot about, but we also know a lot about what it does. So, the liver has a whole host of functions. The liver makes several proteins that are involved in immune function, and other functions throughout the body. It's important in formation of blood clotting factors. It's also really important in processing medications and hormones and really cleans the blood. So when I hear about liver detoxes, I think, well, that's really not necessary because the liver is kind of the ultimate detoxification organ. It's also really involved in the metabolism of fats or lipids as well as blood sugar. So again, the liver just does so many different things, which is why when it fails, we see a lot of things go wrong throughout the body.

Melanie Cole (Host): And what are some of those things? How does it present itself when the liver is failing, whether it's scarring or getting disease? Tell us a little bit about some of the symptoms.

Dr Danielle Brandman: So, I think the first thing to mention is really when someone has cirrhosis without liver failure, they may have no symptoms at all. But when they develop signs of liver failure, I think the thing that people most commonly recognize is turning yellow or jaundice, and we can see yellowing of the skin and/or the eyes.

One of the other complications is fluid retention, and this can come in the form of fluid in the abdomen called ascites, fluid in the lungs and/or fluid accumulation in the legs. Now, I mentioned that the liver is a really important filter or cleaning the blood. So, one of the things that can happen when the liver is not cleaning the blood well is a problem called hepatic encephalopathy or more easily said as HE. And this is when ammonia and other toxins build up in the blood and they can accumulate in the brain and it can interfere with thinking. And you can sometimes see this as difficulty concentrating, difficulty sleeping, memory problems, things like that, and can be as severe as going into a coma.

Other problems that can occur are bleeding and one of the bleeding complications that we try to look out for and prevent is bleeding from varices. And varices are kind of like varicose veins that most commonly form in the esophagus and the stomach. And if they become really large, they can burst and cause life-threatening bleeding.

The final complication that I will mention is kidney problems. And the kidney problems can be related to a series of hormonal changes that occur related to blood flow that can be altered when someone has advanced cirrhosis.

Melanie Cole (Host): I'm always fascinated at how these organs are so interconnected, and the kidneys and the liver, and how it all works together for this amazing machine. Now, tell us a little bit about treatment. If you do see somebody with jaundice or they have varices or any of these things, how is it treated? Transplant's not the only or first option, right? Tell us a little bit about what you might try first.

Dr Danielle Brandman: So, you know, I will say we really need treatments that are available to actually reverse scarring in the liver, and we don't have those yet. But I'm very hopeful that, in my lifetime and in many of my patients' lifetimes, that we will get those medications.

Aside from that, we're really looking for things that can be reversible. The liver is a very resilient organ. And sometimes if you remove the thing that is injuring the liver in the first place, the liver can make a recovery. So to give an example, if a patient is a heavy user of alcohol, and if that's the primary or major contributing cause to their liver disease, if they stop drinking, some patients can have reversal of their liver injury. Similarly, if they have hepatitis C infection and if we cure them, some of those patients may have improvement in liver function. Though oftentimes if we're meeting these patients by the point that they have liver dysfunction, it can be very difficult to reverse.

So at that point, we're really trying to manage the complications of liver disease, such as treating and/or preventing bleeding from varices, putting patients on diuretics or water pills to try to eliminate the excess fluid that they may have accumulated, and prescribing medications that reduce the formation of ammonia and other toxins, and also removing the ammonia basically through having extra bowel movements with one of the medications that we do use.

The other thing to know is that if we see someone who has really severe liver disease, meaning that they were doing okay and then suddenly they're in the hospital and their liver function is much worse, we're looking for things like infection or blood clots in the abdomen that may contribute to the sudden worsening of liver dysfunction.

Melanie Cole (Host): You're such a great educator, Dr. Brandman. You explained this all so well and so clearly. Now, speak about transplant because that does become an option for treatment. Tell us at what point this is discussed. And is this controversial at all if it is related to alcohol? Speak about transplant, the process, and you can even mention living donation, which is absolutely amazing.

Dr Danielle Brandman: Yeah. So, liver transplantation is really an amazing process to be a part of because it's really one of the few times in medicine that we are essentially curing a chronic disease. And what is involved in liver transplant is basically removing the diseased liver and putting in a brand new liver. So, we start to think about liver transplantation really when patients have cirrhosis. I mention it very early when I'm meeting patients, even if they don't have evidence of liver dysfunction, because it can sometimes be unpredictable as to if or when they will develop signs of liver failure. So, I want my patients to be well educated and prepared for the fact that this may be in their future.

But in reality, we don't start to do the formal liver transplant evaluation until the patients have shown signs of complications of cirrhosis, such as one of the complications of liver failure that I mentioned, or development of liver cancer. One of the ways that we objectively assess someone's degree of liver dysfunction is by using a score called the MELD score, M-E-L-D. And that score currently is calculated using four blood tests. And it gives us an assessment of how severe the liver disease is. And it also allows us to prioritize patients on the liver transplant waiting list according to how sick they are. The score ranges from six to 40, where six is the healthiest and 40 is the sickest. And most transplant centers will think about doing transplant evaluations either when the MELD score is at least 15 or once the patient has developed one of the complications of the cirrhosis.

Now, I would say that piece of the transplant evaluation is really not controversial at all. And it's that cut point of 15, is really where we think the benefit from transplant is derived, where we think there's more of a benefit from transplanting someone versus not transplanting someone. I think where there's still, I would say, not necessarily controversy, but a lot of discussion and a lot less uniformity amongst programs," Is liver transplantation for alcohol-related liver disease?" In the not so old days, we used to use a cutoff of six months of abstinence from alcohol before a patient could be considered for liver transplantation. But what we recognized was that that six-month cut point was really very arbitrary.

And first, the French group, Franco-Belgian group over 10 years ago now, reported on their experience of doing liver transplant for patients very early in their recovery from alcohol use disorder. And several years after that, the practice was adopted in the United States. And I would say at many transplant centers these days, there is no longer this arbitrary cut point of six months of abstinence. It's really based on a variety of factors involving the patient's history of alcohol use disorder, their support network, their mental health. And this is through a detailed evaluation from our psychiatrists and social workers. And ultimately, these patients actually do really well after liver transplantation.

The other thing that you were asking about was living donor liver transplantation, and that is such an important component of liver transplant, because there are so many patients on the waiting list. There are about 11,000 on the waiting list as we speak and, unfortunately, each year about 2000 of the candidates are going to die or they will be removed from the waiting list due to being too sick for transplant each year.

So, living donor liver transplantation is an opportunity to offer our patients transplant before they reach that point where they are too sick for transplant. So whenever I have a patient on the waiting list, I always think about living donor liver transplant in parallel. And it's something that I bring up early and often because it's something that I really want them and their families to think about. And when we do find a donor, it's really such an amazing gift for the patient and their family.

Melanie Cole (Host): Wow. This is just such an important episode and discussion that we're having. As we wrap up, Dr. Brandman, what's next for these patients, for research? Anything that's exciting that you would like listeners to hear about cirrhosis of the liver and transplant, and your team at Weill Cornell Medicine?

Dr Danielle Brandman: Well, there's so much research that's ongoing at this point to treat a variety of chronic liver diseases, particularly non-alcoholic fatty liver disease. And I really do expect that we will have medications that reverse liver fibrosis in the next 10 to 20 years.

In terms of liver transplantation, the outcomes after transplant are really quite amazing, particularly if you compare it with how things started out many years ago. At this point, at five years post-transplant, 80% of patients will be alive. And this is not just alive, it's alive with a functioning liver and an excellent quality of life. So, it's really exciting that we're taking these patients from being incredibly sick and in the hospital and extending their lives and giving them so much more time with their families.

So, I'm really excited here at Cornell that we offer liver transplantation with excellent outcomes as well as living donor liver transplantation. We have an amazing team of surgeons where we can offer minimally invasive living donor surgery, which is really a great thing for both the donor and the recipient. So, I really look forward to continuing to provide this high level of care for our patients, so that they're having long, meaningful lives with their families.

Melanie Cole (Host): Wow. And they are lucky to have you, I can tell. I can hear it in your voice, how compassionate you are. What a great physician and a great interview. Thank you so much, Dr. Brandman, for joining us today.

And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review Back to Health on Apple Podcast, Spotify and Google Podcast. And for more health tips, go to weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast. I'm Melanie Cole.

Promo: Every parent wants what's best for their children. But in the age of the internet, it can be difficult to navigate what is actually fact-based or pure speculation. Cut through the noise with Kids Health Cast featuring Weill Cornell Medicine's expert physicians and researchers discussing a wide range of health topics, providing information on the latest medical science.

Finally, a podcast to help you make informed choices for your family's health and wellness. Subscribe wherever you listen to podcasts. Also, don't forget to rate us five stars.

Disclaimer: All information contained in this podcast is intended for informational and educational purposes. The information is not intended nor suited to be a replacement or substitute for professional medical treatment or for professional medical advice relative to a specific medical question or condition. We urge you to always seek the advice of your physician or medical professional with respect to your medical condition or questions.

Weill Cornell Medicine makes no warranty, guarantee or representation as to the accuracy or sufficiency of the information featured in this podcast. And any reliance on such information is done at your own risk.

Participants may have consulting, equity, board membership, or other relationships with pharmaceutical, biotech, or device companies unrelated to their role in this podcast. No payments have been made by any company to endorse any treatments, devices, or procedures. And Weill Cornell Medicine does not endorse, approve, or recommend any product, service, or entity mentioned in this podcast.

Opinions expressed in this podcast are those of the speaker and do not represent the perspectives of Weill Cornell Medicine as an institution.