Search for tag: "liver disease"

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today, "The Specialists" with Dr. Tom Miller is on The Scope.

Interviewer: Fatty liver disease affects more than 80 million Americans, and many of them don't even know they have it. Dr. Tom Miller, why does fatty liver disease concern you as a doctor?

Dr. Miller: Well, fatty liver disease is becoming the most common chronic liver disease in the industrialized Western world, and especially in the United States. And it used to be, we had viral hepatitis as a cause of liver disease and a major cause of transplantation, which it still is, but very shortly the major reason for liver transplantation due to liver failure is going to be fatty liver.

Interviewer: And not necessarily caused by alcohol. I always thought it was, you know, people that drank a lot tend to get fatty liver disease.

Dr. Miller: Well, they get liver disease. It's not necessarily fatty liver disease as you would think about it, and it was and still continues to be a cause of liver disease, but because of our lifestyle and the fact that 30% of the people living in the United States have obesity, fatty liver disease is now the most common cause of chronic liver disease.

Interviewer: Yeah, 80 million Americans, that's quite a . . . that's almost an epidemic, isn't it? Like, if 80 million Americans had any other sort of disease, we would be freaking out.

Dr. Miller: Right. I think the term might be just a little bit . . . The categorization of it is a little bit misleading because not everyone with fatty liver disease goes on to develop liver failure. In fact, a small percentage of those people end up with liver failure, but given the large number of people with fatty liver disease, a significant number of Americans will end up with end-stage liver disease.

Interviewer: And what exactly is going on? So I think the name implies that there's some fat, maybe excess fat deposits in the liver, but why is that bad?

Dr. Miller: Fat is a cause, a driver of inflammation, and we don't exactly know why, but when people gain weight, some of that weight is stored centrally and also stored between the cells in the liver. So if you look at a person's tissue from the liver, you will see if they have fatty liver, which is called non-alcoholic fatty liver. You'll see fat stores or globules in between the cells. For whatever reason, this causes inflammation, and inflammation predisposes to damage, fibrosis, and destruction of the active cells in the liver which help us cleanse our body of toxins.

Interviewer: And you're talking about scarring.

Dr. Miller: I'm talking about scarring.

Interviewer: That's why I used those words, yeah.

Dr. Miller: Fibrosis leads to scarring.

Interviewer: Yeah.

Dr. Miller: Now, again, most people with fatty liver don't end up with inflammation, and we don't exactly understand why some people have problems with inflammation related to their fatty liver versus those who don't. And not everyone who has inflammation in the liver goes on to develop cirrhosis.

Interviewer: But it's certainly a path you don't want to go down and find those things out.

Dr. Miller: No, definitely not, and it can be treated.

Interviewer: All right. So, when a patient comes into your office, can you look at them and tell if they have the bad kind of fatty liver disease that could lead to transplant or death?

Dr. Miller: I think the way that we think about it now, I believe the way we think about it now is if you're obese, that is you have a body mass index greater than 30, your chances are pretty high of having non-alcoholic fatty liver disease. So, basically, the same thing that we've talked about on these shows in the past, right diet, right weight, right exercise is your best treatment to prevent it. This is a problem with industrialized countries having too much food and the wrong kinds of food available.

Interviewer: Yeah. And once that scarring happens, there's no cure for it. It eventually will lead to liver failure.

Dr. Miller: Once you start down a path of scarring, your chances of ending up with end-stage liver disease and needing a transplant are pretty high. Not only that, you are predisposed, with that scarring, to liver cancer.

Interviewer: And if you start to lose some weight, I understand it doesn't take, necessarily, a lot of weight reduction to reduce the number of fat cells in the liver and kind of start backing that thing up if scarring hasn't occurred.

Dr. Miller: Right. I think one, again, wants to head for a normal BMI, which is between 18.5 and 25.

Interviewer: Okay.

Dr. Miller: And that's not easy. I mean, I tell you that that's the treatment, but attaining that treatment for everybody is difficult because we don't have a medication for weight loss that works, and basically it's a lifestyle adjustment, which is hard for people given the abundance of food.

Interviewer: And there are tests that you can do to determine, for sure, if there are.

Dr. Miller: There are. So we basically start looking at the issue of inflammation in people who we think might have fatty liver disease by looking at the enzymes that the liver produces on a blood test. If these are elevated, there are a number of causes, but eventually, if you can rule out sort of the medical, the drug-associated causes and other causes, that is if they're not drinking, you can think that this is probably related to a non-alcoholic fatty liver disease. And if you really want to know damage to the liver, you're going to have to do a liver biopsy. There's another test now that's non-invasive, but liver biopsy is still the gold standard.

Interviewer: And we haven't really hit on this, but it often doesn't have symptoms.

Dr. Miller: The vast majority of people with non-alcoholic fatty liver disease are not symptomatic.

Interviewer: Yeah.

Dr. Miller: And, in fact, you're only symptomatic towards the end . . .

Interviewer: When it's kind of too late.

Dr. Miller: . . . with this disease when you have fibrosis and scarring or liver cancer. So, again, we want to look at obesity and lifestyle as a response to prevent this.

Interviewer: So get that body mass index back into a reasonable area?

Dr. Miller: Well, it's the same thing we talk about for all of the things that we now kind of associate with the Western world diet, which is high blood pressure, heart disease, metabolic syndrome, type 2 diabetes. They're all in a basket, including this non-alcoholic fatty liver disease. And, again, the treatment is at our hand, but it's not easy to achieve.

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Dr. Campsen: There's a new treatment available for hepatitis C without the horrible side effects, and we are preventing the recurrence of hepatitis C and the need for retransplantation of the liver due to reinfection. I'm Dr. Jeffrey Campsen. I'm a liver transplant surgeon at the University of Utah, and that's next on The Scope.

Announcer: Medical news and research from the University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Campsen: I'm here with . . .

Dr. Gallegos-Orozco: Dr. Juan Gallegos-Orozco. I'm an Assistant Professor of Medicine at the University of Utah School of Medicine, and I'm part of the liver transplant team.

Dr. Campsen: Juan, thanks for joining us today. The study that we're talking about today is a study that we're involved with for our patients that are receiving liver transplant for hepatitis C. What's exciting about it was that it's never been available, especially in the state of Utah, and its available now to our patients as a trial. The way that the trial is set up is that these patients are listed for liver transplant because of their cirrhosis, but they also have a Hepatitis C infection. They also probably have had a cellular cancer on top of it. They are then treated with the antivirals that you described, and hopefully the hepatitis C virus is cleared down to an undetectable level. At time of transplant, they receive their liver transplant and are given an immunoglobulin called Civacir that then continues after transplant. Hopefully, in combination of the antivirals before transplant, the liver transplant, and then the immunoglobulin after transplant will keep them from ever having hepatitis C again.

Dr. Gallegos-Orozco: Yes. This strategy is very exciting because following the footsteps of the hepatitis B immunoglobulin, which are antibodies against hepatitis B and was a big step forward in transplanting patients with hepatitis B, which is another kind of viral infection that can also cause chronic hepatitis, cirrhosis, and liver cancer. In hepatitis C, we're following this strategy, and our goal is to prevent the reinfection of the new or healthy liver that's being transplanted. The way we achieve that, like you mentioned, is not only with treatment before the transplant, but also with this immunoglobulin or antibodies against hepatitis C in an effort to neutralize any residual virus and, hence, preventing the reinfection of the transplanted liver. We hope that this strategy, in combination with the antiviral therapies, will ultimately lead us to prevent infection of hepatitis C, which, as you know, is a big problem in transplantation.

Dr. Campsen: It's a huge problem. So if you get a liver transplant and then the Hepatitis C comes back, it's basically a brand new infection in the liver transplant. It can really blossom to the point to where those patients won't survive the year after the liver transplant because the virus is so aggressive in how it comes back, which is demoralizing and tragic to everybody involved.

Dr. Gallegos-Orozco: I agree.

Dr. Campsen: Let's talk about this study. We started this study this past year, and we enrolled our first patient in the study. Can you tell us a little bit about him?

Dr. Gallegos-Orozco: Yes. This gentleman that we enrolled was a patient with chronic hepatitis C. He had developed cirrhosis and complications of his cirrhosis, and one of those complications was liver cancer. The patient was listed for liver transplant, and we followed him very closely during his course. We treated his liver cancer successfully, but he still required a liver transplantation. We knew that he had hepatitis C. He had the genotype one, which is one of the most difficult genotypes of hepatitis C to treat, and we were fortunate enough that we were able to get him through treatment with these new antivirals that did not require any interference. Just the combination of two pills that he took everyday for several weeks were good enough to decrease the amount of virus in his blood to basically undetectable levels.
At that time, a liver became available, and he was transplanted successfully with this healthy liver. Because of his participation in the trial, he also received this hepatitis C immunoglobulin or antibodies against hepatitis C, and he's completed the first six weeks of this treatment after transplant. So far, there's been no evidence of recurrence of hepatitis C in his blood, and his liver graft is doing very well.

Dr. Campsen: How exciting is that? Basically, what we did was we cured the hepatitis C if you can use that word. It's a strong word, but that's what I believe. We also cured him of his liver cancer, which is something that you probably couldn't have done a year ago.

Dr. Gallegos-Orozco: Correct. I agree, and I think that's a very exciting time, not only in the treatment of the hepatitis C overall, but certainly in the treatment of hepatitis C in our liver transplant patients.

Dr. Campsen: As with any medical procedure, there are concerns as to the safety of the procedure. Liver transplant in and of itself is a high-risk procedure. At the University of Utah, we have excellent outcomes, and our patients have done very well. However, when you add other new medications on top, there's a concern. Specifically for the Civacir trial, the hepatitis C immunoglobulin trial that we're speaking about today, I feel that it is a very low-risk procedure. How do you feel about it?

Dr. Gallegos-Orozco: I agree. So far, the evidence of the side effects from this clinical trial that we're participating in have shown that this procedure is safe and very well tolerated. It basically requires the patients that are participating to receive this immunoglobulin after an IV infusion, and they do that for several times during their first few weeks after liver transplant. So far, they've tolerated the procedure well. It hasn't been associated with any significant adverse events, and we feel that it's similar to the hepatitis B immunoglobulin and other types of antibodies that are used in medicine that overall it's a safe procedure. Of course, in the setting of the clinical trial, we're very vigilant about side effects, and we monitor our patients very, very closely.

Dr. Campsen: We're one of the centers that are involved in this trial. I think there's about 20 centers across the United States that are involved in the trial, and they're seeing very similar results to ours. Which are one, the safety profile of the drugs seems to be excellent, and then, two, the efficacy, meaning does it actually work, also seems to be very good. There are different arms of the study, but the study arms where the patients are actually getting the drug that we're talking about, no one's had a recurrence of the virus, which, I think, is an excellent result.

Dr. Gallegos-Orozco: I agree, and definitely, that's what we're wishing for with this, hepatitis C antibodies to prevent reinfection of the liver. So far, that's what the trial has shown.

Dr. Campsen: But with any study, it's the long-term follow-up that really makes the difference. So today we're talking about the early success of this, how excited we are to do something that we've never been able to do before, but, again, we're going to monitor it at a university setting along with our other universities that are involved and see if it truly is a therapy that will be used long-term.

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Interviewer: You've been diagnosed with liver disease. How is that going to affect your diet? We'll talk about that next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: After you've been diagnosed with liver disease, dietary changes can make a difference. We're going to find out what you should be eating and what you should be avoiding right now, with Doctor Juan Gallegos. He's a liver expert at the University of Utah hospital. Tell us about diet and the importance of diet with liver disease.

Dr. Juan Gallegos: Thank you, Scot. It is very important because the liver receives most of the nutrition that you get through your mouth. It actually makes it into the blood from the small bowel and, then, that blood has to go and get through the liver. The liver cells, basically, detoxify your blood, and are very important in making proteins, making cholesterol, and it's basically like a chemical factory.

Interviewer: So, very important diet.

Dr. Juan Gallegos: Yes. Most of the time when I see patients in my clinic who have chronic liver disease, my main recommendation for them is, first, abstain from alcohol because we know alcohol has a direct toxic effect on the liver. So, if somebody already has liver disease, we strongly recommend that they abstain from alcohol so as not to damage the liver even further. In regards to any particular change in their diet, I do recommend that they try to eat healthy. Meaning, have adequate portions of fruits and vegetables, trying to limit their simple sugars, like a lot of flour, and bread, things of that nature. The other main thing, especially in patients that have very advanced liver disease, something we call cirrhosis, is to limit their salt intake because increased salt intake can lead to complications of liver disease or worsening of those complications, such as fluid build up in the abdomen, which we call ascites, or swelling of the legs and arms.

Interviewer: And why does that happen?

Dr. Juan Gallegos: Well, it happens because the liver is important in maintaining the amount of protein in our blood and, also, in maintaining the adequate amount of salt in our blood. So, when the liver isn't working well, there is an imbalance in those things that lead to people having low levels of protein in their blood, and that makes it easier for the water part of our blood to filter out, or go out of, the blood vessels and stay in the tissues and that causes ascites and swelling.

Interviewer: Is it the same thing with sugar, as well?

Dr. Juan Gallegos: It's a little bit different, but yes, the liver is very involved in sugar and metabolism. So people that have advanced liver disease can have sugar problems similar to diabetics.

Interviewer: So it sounds to me, essentially, the liver is just not doing its job the way it should be and you just have to be really careful because a normal functioning liver might be able to take the overload.

Dr. Juan Gallegos: Correct, that is true. It's just that the liver is so noble that it takes a lot of injury before it actually manifests itself as having problems. So, normally, people, when they get diagnosed, it tends to be later on in their disease course and that's where nutrition is so important.

Interviewer: All right. So we hear these things a lot. We hear nutrition is important. We hear that you should stop drinking because it can affect your liver. How important is it? It's like we hear it so often that I think a lot of people ignore it, so give us some context.

Dr. Juan Gallegos: Well, it is very important because we are what we eat, basically, and when you have a liver that's already damaged, or faulty, then, you don't want to increase the damage to that liver or make things worse and some of the symptoms that have to do with liver disease. The other important part is the alcohol issue. Even patients that have liver disease not related to alcohol, we know that the liver will be damaged by the alcohol intake, so that's why we recommend, in those cases, not to drink alcohol.
But, in those patients that have had injury to their liver because of significant alcohol intake, or now have what we call liver cirrhosis from alcohol, it is extremely important for them to stop their behavior and stop drinking alcohol because what is going to happen, if they continue to drink alcohol, is that their liver is going to get worse and their going to reach a point where their liver fails them and there's no way we can treat them anymore.

Interviewer: But one drink a day, that's not that big of a deal is it?

Dr. Juan Gallegos: Well, that's not big of a deal for a healthy person, that is true. In general, the recommendations are, for men, not to drink more than three or four drinks per day, and in women, as they are more sensitive to the effects of alcohol, the recommendation is not more than two drinks per day, but that's only for healthy people. In patients that have already liver disease, our recommendation is that there's really no minimal safe amount of alcohol and, hence, we tend to be more strict and say "No alcohol for you."

Interviewer: So when it comes to diet and alcohol, when you have liver disease, it makes a huge difference?

Dr. Juan Gallegos: It does. It makes a big difference. Of course, the other important part of it is making sure that you are being taken care of by the adequate medical provider and that you follow the recommendations, not only from a diet standpoint, but also if you're already on medications, to make sure that you follow those as well.

Interviewer: Like the difference of living and dying, living a great life and living a mediocre life; I mean how important are these things that we're talking about.

Dr. Juan Gallegos: It can be, especially in those patients with alcoholic liver disease. Continued use of alcohol will definitely result in, not only a very bad life quality, but, also, a shortened life and those people look forward to, basically, being in the hospital and dying in a very short period of time. And patients that have their types of liver disease, it might not be as dramatic, but, certainly, anything we can do to prolong their life and improve their quality of life, I think, is very important.

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