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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.
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?
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.
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.
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, days post-transplant. Pretty neat. And that's a fantastic story. I'm familiar with that story, as well. 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 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. 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. 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 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. And that's because there are about 17, people waiting for a transplant.
And there are about 7, organs per year. So there's a big mismatch in need and availability of organs. 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. 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 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.
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