Transplant: Liver Transplant
Guest: Dr. Prabhakar Baliga – Surgery
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing, today, Dr. Prabhakar Baliga who is Chief of Transplant Surgery.
Dr. Baliga, I know that two of the organ systems that you are involved in the transplant of are liver and kidney. Let’s start with liver transplant. Who is a typical candidate for a liver transplant?
Dr. Baliga: The vast majority of patients have cirrhosis. What we mean by cirrhosis is scarring of the liver which is irreversible. That is probably about 85 to 90 percent of patients. A much smaller number of patients develop acute liver failure which is no more dramatic than, for example, a Tylenol overdose which destroys a liver that is of normal architecture but the liver cells are completely destroyed. So, among the cirrhotic patients, currently the number one cause is hepatitis C virus which causes a severe scarring over time.
Dr. Linda Austin: What is the typical age of a patient who comes for transplant?
Dr. Baliga: The majority of patients are adults in their most productive years, in mid life, because hepatitis C, like I mentioned, is one of the important causes. It usually affects patients at an early age but it remains silent for a long period of time. So, usually in the mid 40s is when it strikes you. And once they develop liver failure, it is progressive and there are currently no medications which can reverse the condition. Once you have cirrhosis, short of a transplant, these patients have no options.
Dr. Linda Austin: Now, of course, with kidney failure, you can go on dialysis and that can be kind of way station, but nothing like that is available for liver. So, I would imagine, by the time these patients are coming for transplant, they must be pretty sick.
Dr. Baliga: That is true. We hope to get them early. We are constantly educating the public and I think, currently, most physicians are comfortable with liver transplantation. The program at MUSC has been functional since 1990, so physicians in the area know that earlier diagnosis is important because one of aspects that we have to deal with is organ shortage, so that patients can get a transplant in time.
Dr. Linda Austin: What is the typical wait time for a patient to get a liver for transplantation?
Dr. Baliga: There are two aspects to your question. One: There is a national allocating system. Livers are distributed based on severity of illness. So, it does not matter how long you have waited. The livers are distributed through a scoring system based on certain lab values, such as the level of your jaundice, how thin your blood is. That is measured by what we call PT/INR. The third barometer of use is your serum creatinine, a level of your kidney function. Those three numbers are placed into a formula and it is a national website, called UNOS (United Network for Organ Sharing), which gives you a score. So, the livers are distributed based on these lab values and patients with the highest score will get the transplant first.
The second part of the answer is that MUSC is probably the best kept secret in the country. We have one of the shortest waiting times in the country. And I would say, for the vast majority of patients, the waiting time is less than three months for a liver transplant.
Dr. Linda Austin: And for patients who are on the MUSC waiting, what percentage of them do, ultimately, get a liver in time to save their lives?
Dr. Baliga: I would say, currently, for the last couple of years, probably more than almost 90 percent of patients get a liver transplant in time.
Dr. Linda Austin: Boy. That is very exciting. When a liver is transplanted, is an entire liver required for one patient? Can you ever serve two patients with one liver?
Dr. Baliga: That is an excellent question. Usually that is done in children. We call it a two for one. So, if you have a child who needs a transplant and the child is only 10 kg, you can take a small piece and place that into a child then take the larger piece and place it into an adult.
On the other hand, there are occasions when we do living donor transplants for a condition which I mentioned earlier, acute live failure, where we have a very short period of time and if there is no cadaver organ available, we could then perform a living donor transplant. In this case, we can take half a liver from a healthy person and transplant into an adult. The liver is probably one of the few organs that grows back to full-size, and that happens very rapidly, within a few weeks. So, unlike other organs which take longer or do not have the capacity to regenerate or develop scar tissue, the liver grows back to normal architecture very rapidly.
Dr. Linda Austin: That really is fascinating. Now the surgery itself, how long does that take?
Dr. Baliga: A straightforward liver transplant takes between five and six hours. It is a long surgery and there is a lot of preparation in terms of monitoring lines to be placed by anesthesia. We have a special team, the liver transplant anesthesiologist, a liver transplant nurse. So we have a special team designated just for liver transplants, so it adds a couple of hours prior to surgery to get a patient ready in the operating room, to place all these monitoring lines.
Dr. Linda Austin: And then how long is the patient in the hospital, and how long until you would consider them to be fully recovered, let’s say, able to go back to work?
Dr. Baliga: The hospital stay is very dependent upon how sick the patient is. If you were not that sick, like I mentioned earlier, there is a scoring system, so we would, ideally, like to transplant patients with a score of less than 20. So, if you have a straightforward liver transplant with a score of less than 20, chances are that you will be in the hospital for less than a week, five to six days.
If you come in very sick, however, with a score of greater than 30 or 35 then you may have a much more prolonged ICU course and, therefore, a more prolonged hospital stay. So, the hospital stay, many times, is defined by how sick the patient is. The same is true in terms of how soon they can return to work.
Like I mentioned earlier, we are fortunate that we a short waiting time. The vast majority of our patients are able to return to work in about three to six months after their transplant. Most of them can return after three months.
Dr. Linda Austin: Now, you mentioned that you started doing this here, or we started doing this here, in the early 90s. So, then, what is our median survival rate? It is probably a little hard to calculate because that is a short period of time.
Dr. Baliga: The one-year survival rate runs close to 90 percent. So, again, you know, when you compare programs, you have to take into account the severity of patient illness. So, if your program is treating more severely ill patients, you cannot expect to have higher than a 90 percent success rate. But, our program, overall, for the last several years, has been running a survival rate of between 85 and 90 percent.
Dr. Linda Austin: And, I would imagine then, with our shorter waiting list, we have healthier patients which allows us to have an advantageous survival rate which, of course, is good news for the patients, I would assume.
Dr. Baliga: It is kind of hard because, you know, liver disease, in some ways, is unpredictable. Patients who are stable can sometimes decompensate rapidly. Our overall score, the score that we calculate, is called a MELD (Model for End-stage Liver Disease) score. It tends to be a little bit less than the national average but not by very much. Sometimes we have some very sick patients that show up at the door. So, from a survival rate and risk standpoint, we are very equal to national statistics.
Dr. Linda Austin: It is very exciting work that you are doing. Thanks so much for talking with us today.
Dr. Baliga: Thank you very much.
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