What's New with Liver Transplants

Dr. David Bruno discusses the latest updates on liver transplants.
What's New with Liver Transplants
David Bruno, MD, FACS
Dr. Bruno oversees liver transplantation at VCU Health Hume-Lee Transplant Center. He specializes in liver and kidney transplantation, and leads all aspects of liver transplants, including deceased-donor transplantation and Hume-Lee’s reinvigorated living liver transplant program. 

Learn more about David Bruno, MD, FACS

Caitlin Whyte: Not all transplant centers are the same. The VCU Health Hume-Lee Transplant Center is a national leader in transplantation. Hume-Lee safely and effectively navigated the COVID-19 pandemic to continue liver transplants.

The center has recently performed two procedures amid COVID, both of which have only been performed a handful of times in centers in the U.S. Few centers are capable of performing these innovative transplants. Joining us to talk about those procedures and more is Dr. David Bruno, the surgical director of adult and pediatric liver transplant at the VCU Health Hume-Lee Transplant Center. This is Healthy with VCU Health. I'm Caitlin Whyte. Talking about liver transplant, can you talk about the great need is here? 

Dr. Bruno: Well, that’s what’s on every liver transplanters mind: How can we possibly help all these people on the waiting list and reduce that high wait list mortality that we have in the United States? It’s really the question that we’d been preoccupied with for 20 years now. There are a few strategies that we use here at Hume-Lee. First, our go to strategy — because the outcomes are so excellent — is living-donor liver transplantation. That means a friend or family member with a common blood type to yours, or a compatible blood type to you, will give a piece of their liver to you, if you need it. That doesn’t take a liver out of what we call our donor pool or our cadaveric donors that we use traditionally in America. So, those patients can be transplanted on schedules.

The other ways we’re looking at, trying to alleviate the organ shortage for liver transplant here at Hume-Lee, is using graphs (organs) that were traditionally thought of as disadvantaged. When we talk to our patients I always say to them, “Does it sound like a great idea if I call you up and I say, ‘well, this is a slightly disadvantaged liver, or this is a higher risk liver, or this is a liver that has a viral hepatitis.’ ” And I always say, “Does that sound good?” Invariably, my patients will say, “No, that sounds like a terrible idea.” But in reality, these livers that are slightly disadvantaged, I like to explain to them that they’re all used. You can’t get a new one, some are used a little harder, and some are used not so hard. There are organs that we were trained and we traditionally thought were not transplantable that, in fact, are transplantable. These are organs with a little more fat in them then what’s considered a pristine organ. These are organs with hepatitis C, which is a disease that up until 6 or 7 years ago was essentially incurable. What we do is we expand our donor pool by using these organs and our outcomes with them are excellent.

Host: And we'd love to hear more about those two procedures recently performed at the center. Let's start with the blood type incompatible liver transplant.

Dr. Bruno: In order to give a little background on that, I think those two cases would be unique, but in the midst of a global pandemic, it's a stunning achievement. And the reason why I would say that is at the beginning of the pandemic we all had to ask ourselves the question, especially in liver transplantation, about whether or not we were going to stop doing transplants, and our patients would suffer. Most of our patients have very, very little time. So, they're incredibly sick. The way that we measure how sick they are has a mortality factor that sometimes measured in weeks. So, we have to decide A, whether or not we were going to continue doing that and the ramifications of that, and B, how we were going to do it.

I think that was probably the biggest challenge of my career when we sat down. I think that what we came up with was really simple. These patients aren't going to be around when the global pandemic is over, and we don't know when the global pandemics going to be over. So, what we did was we tried to create an environment that protected our patients because they're somewhat immunosuppressed, but at the same time allowed them to still have this lifesaving therapy. The blood type incompatible liver transplant that we did, which was a living donor, this is a really quite a unique transplant in the United States. It's unusual for adult-to-adult blood type incompatible liver transplants. There are a lot of immunologic difficulties that you need to overcome to do that kind of transplant. So that situation really, our hand was forced.

That was kind of our shining moment. All of our other nurses, physicians, and providers really rallied around this patient. So the crux of that is it's a hugely immunosuppressive regimen that they have to undergo and to do it normally is dangerous — to do it in a pandemic is certainly a really, really difficult mountain to climb. You just really had to be flawless. And we were able to provide that here.

Host: And tell us also about the complex domino liver transplant.

Dr. Bruno: So, domino liver transplants are really a rare and unique event. That means that the patient who needs a transplant has a liver that is able to be transplanted. And that seems like a curious thing. You would think that if someone needed a liver transplant, that their liver itself wouldn't be useful to anyone else or would be cirrhotic or sick or scarred the way that it normally is. But patients who are able to be domino donors and recipients at the same time are patients who have various genetic defects that aren't focused in their liver. So, when we transplant them, we're trying to correct or have the liver that they're getting, provide the things that their old liver wasn't. Oftentimes, the liver in another person who doesn't have that genetic disorder will work just fine.

And that was the case with our domino transplant. So, we did a living donor and that living donor was given to our domino recipient. And we were able to take the domino liver and put it in someone who had a really unique disease, which is colorectal metastasis.

Host: Now I understand Hume Lee has undergone some programming changes recently. Tell us about how they separate your center from others?

Dr. Bruno: Traditionally, number of transplant programs in the United States for the past 20 or 30 years, have been transplanted patients with some really common conditions. One of them is alcoholic hepatitis. So, there's two ways that someone can have an alcoholic liver disease. One way is that they can have cirrhosis from kind of a lifetime of drinking, but sometimes they can have one episode of hepatitis where they don't have cirrhosis. So maybe a situation where someone binge drinking or some short-term drinking causes the liver to get really sick and swollen. And those patients, traditionally, when I was training, weren't allowed to get transplants because we use what's called a 6-month abstinence period for alcohol.

So, what we initially observed was that patients would come in with alcoholic hepatitis, and some of them, you would be able to prognosticate, fix, help get the addiction medicine specialist involved. So, they never had alcoholic hepatitis again, get alcohol treatment. And those patients did okay. But there was a subset of those patients who, no matter what medical treatment we tried on them, they wouldn't survive their hospitalization. So, we thought that we should look at these patients for transplant. And what we found over the past few years is that the recidivism rate, or their rate to going back to drinking, isn't any higher than the chronic cirrhotic who have 6 months of sobriety. And those are in really well selected patients. That's just not anyone who comes in with alcoholic hepatitis.

It's a really satisfying experience. These are usually young people who've, admittedly, made mistakes with alcohol, and unfortunately for them, are life-threatening mistakes. And it is through a really rigorous multi-disciplinary selection with addiction medicine specialists, alcohol counselors, social workers, our hepatologists, and our surgeons that we're able to figure out, at least allow some of these patients to have a second chance. Whereas 10 or 15 years ago, no one would have even looked at them. So, this is a really unique and different thing that we're doing here at Hume-Lee right now. The other group of people, it's really interesting to me, and that I think has really been traditionally thought of as not transplant patients, are patients with obesity and morbid obesity.

And it turns out that those patients aren't horrible transplant candidates actually, they're pretty good. And they actually do pretty well after transplant. So, as I was trained, if you had a BMI, which is how we measure body mass or obesity, of over 45 then you weren't considered a candidate for liver transplant. But it turns out that patients with BMI as well over 45, 50, actually, not only can they go through the transplant process, but after having a transplant, we could help them work on getting their weight down to a healthy level, it extends their life. So that is a really, alcoholic hepatitis, obesity are two really unique changes that we've had to the program in the past year.

Host: Just one more question wrapping up here. So once a patient goes through their surgery, they're on the other side. I mean, how do they transition back to so-called normal life?

Dr. Bruno: You know, I tell my patients all the time, after a few months, when everything is stabilized, that they really need to go back and live their life the way it was before they have their liver transplant.

And the only exception is that of course, that they can't drink anymore. And that's not just for our patients with alcohol, they're not all alcoholic cirrhotic, but our patients who aren't alcoholic cirrhotic, they can't drink anymore either because alcohol really harms that transplanted liver. I don't think there's an expiration date on these organs. I think these patients can live long, normal and healthy lives. It's not a temporary therapy. I don't put a liver in and think to myself it will last a year or last 5 years. I expect this to last their natural life. And if it's taken care of, it will. So, I don't think there are tons of limitations on what they could do. I've had patients who've gone skydiving. I've had patients who have climbed Kilimanjaro. I've had a patient who runs the Atlanta marathon every year and sends me a postcard afterwards. So, it's not a life limiting therapy. You don't turn into a liver transplant patient; you're just a person who had a liver transplant.

Host: Well, that was Dr. David Bruno. We really appreciate you joining us today. For additional information about liver transplantation at VCU Health, visit VCUhealth.org/transplant. This is Healthy with VCU Health. I'm Caitlin Whyte. Thanks for being with us.