‘Silent killer’ liver disease on rise and what can we do about it | Interview

Call them silent killers because they don’t often show warning signs until they reach an advanced stage. The incidence of liver diseases, unfortunately, is on the rise across the world. The good news, amid the growing concerns about failing livers, is that the hepatology stream of medical science, a comparatively younger specialisation, has been bringing out advanced modalities of treatment, including transplants with a high success rate.

Dr Abhishek Yadav, director – Comprehensive Liver Care (Surgery), VPS Lakeshore Hospital, Kochi has performed over 1,500 liver transplant surgeries over 15 years, with a success rate of more than 90 per cent. A medical professional known for his compassionate nature, Dr Yadav speaks about the rising challenges of liver diseases and the solutions available. He also busts some common myths about liver diseases and liver transplants.

There is often a tendency to connect liver diseases with alcohol consumption. This perception seems to be prevalent in Kerala, a state with an apparently higher rate of liquor consumption. How much fact is there in this perception?

Liver disease incidences are increasing all over the world. It’s just that more and more cases are diagnosed in Kerala because people are more aware of health care here. The state also has better health infrastructure. Awareness and facilities help people here detect liver diseases at an early stage.

Liver disease is a silent killer. It will not give you symptoms unless you are at a very advanced stage of liver failure. I have worked in at least five states and I have seen that alcoholic liver disease cases in Kerala are the same as in any other state.

The number of liver transplants is rising in Kerala. What can be considered the main reasons for this?

There are many reasons. Awareness is more here. People are diagnosed with liver problems and referred for transplants early. Kerala is a very close-knit community so people interact a lot among themselves and share information regarding advanced treatments with each other. The second factor is the expertise available here. It is because of this that people from other states also come here for treatment and transplants. The third reason is that the cost of a transplant is lesser here. The cost of a transplant is 30-40 per cent cheaper in Kerala compared to other big cities around. In Kochi alone, last year around 350 liver transplants were performed. This is not happening in Chennai or Bengaluru.

Is liver cirrhosis or chronic liver damage related to one’s age? Which age group is at more risk of liver diseases?

Liver cirrhosis can happen in any age group. Generally, there are two peaks for liver diseases. Either it happens in the first five years or it happens after 50. Children born with some congenital problems may have liver disease. Cirrhosis caused by hepatitis, alcohol use or lifestyle problems usually happens after 50.

Food and lifestyle seem to play an important role in liver health. As a medical practitioner in Kerala, have you observed a pattern in Kerala’s diet and lifestyle which need to be corrected?

Consumption of carbohydrate is much higher here because rice is the staple food. Consumption of red meat is also higher while fibre-rich and green vegetables as well as fruits get little space in one’s platter. It would be better to have one salad with every meal and one fruit every day. When it comes to the lifestyle I don’t think people are lazy. More people are into exercise and physical activity here compared to other parts of the country.

Can parents' lifestyles contribute to liver disease among children?

Lifestyle diseases are basically multi-factorial, genes being one of the factors. Genetic problems need not be only from parents. It could be about the whole family. Genetic cases can be detected early based on their severity.

How successful are liver transplants in kids?

The success of a transplant surgery depends on a lot of factors. The most common factor is where they have transplants. The expertise of the doctors is important. A paediatric transplant is technically very challenging. In India, only 25-30 hospitals are doing it. Generally, the success rate is more than 90 per cent in a good and experienced centre.

After the transplant, people have to be on immunosuppressant medicines. Now a lot of research is coming that in children after four-five years this medication can be stopped. Out of the children we performed transplants on, immunosuppressants were stopped after five years. Kids can lead a normal life after a transplant. The first child in India to have a paediatric transplant is a doctor now. He is from Andhra and he had surgery at Apollo, Delhi in 1991.

How normal will be life after liver transplant surgery for a patient?

People try to avoid transplants as late as possible. Of course, it’s complicated, but in medicine, everything that we do has an element of risk in it. As doctors, we analyse the risk and benefit factors and take a decision based on the calculations. Once liver disease is so severe in a patient, the risk of the disease is much more than the risk of a transplant. During the transplant, there could be a risk of 5 to 10 per cent, but if you don’t do a transplant then there is 100 per cent risk.

After a transplant one doesn’t need any major lifestyle modification. For the first 3-5 months the patient needs to be a little cautious because immunosuppressants are administered which pose a high risk of infections. After that, they have to take the necessary medicines but can go to work, sports and all. Women can have children. Unlike other organ transplants, one big advantage of the liver is the risk of rejection is much lower especially compared to kidney transplants. The liver is more immune tolerant. The body’s immunity can tolerate the liver much better. Incidence of rejection is lower.

What happens in case of rejection?

There are good medicines available. Sometimes people might require one more transplant but that’s quite rare. The amount of immunosuppression used after liver transplant is also much lower. Most of the complications after transplants arise because of the side effects of immunosuppressants. In liver transplant the amount of immunosuppressants used is low; so are its side effects.

How safe is a donor’s life? Are they at risk of liver disease or any infection later?

If a donor develops hepatitis or fatty liver later they are at normal risk, but from donation, no long-term risk arises. Many studies have proved that. The liver is the only organ in our body which can regenerate. If you cut the liver it grows back to its normal size. In a transplant, 60-70 per cent of the liver of a donor is removed. That grows back in two-three weeks.

You have been performing transplants for years. Have you observed any pattern in donors’ behaviour?

I have observed that donors get a sense of well-being. They get a feeling that they have made a difference in someone’s life. Family bonds become stronger in cases where the patient and donor come from the same family. A couple of months back, I had a patient who required a transplant. His wife was ready to donate but not suitable. It was inevitable to conduct the surgery within 2-3 months. Then his brother came forward. He was two years elder than the patient. He was obese and had fatty liver. He was a chronic smoker also. However, he was so motivated that from day one he quit smoking and went on a crash diet. He lost 10 kg in 2 weeks and made himself suitable for organ donation. We see this kind of story every day.

The number of people coming to Kerala for liver transplants from abroad and other states of India is also increasing. What is the reason for this?

People from abroad come for all kinds of treatments because of the good infrastructure and expertise available here. We see a lot of patients coming here from the former Soviet nations and also from Africa of late.

The incidence of liver cancer is also increasing. What’s the reason and is transplant a solution for such cases?

Liver cancer is increasing because other liver diseases are increasing. Liver cancer is not an isolated disease like other types of cancer. The scope of transplant is high among liver cancer patients, but even among medical professionals, the information is not available. I don’t mean to say that transplant is the only solution. There are many treatment options. But if one is eligible for a liver transplant then it’s one of the best options available.

You have come across a number of unique situations and challenges in your career. Could you share one of such incidents?

Three years ago, we had to perform a transplant on a small baby who was only 6 months old. The main blood vessel which gives blood to the liver is called the portal vein. The child’s portal vein was not fully developed yet. During the surgery, we had to keep it open to ensure that the new liver gets enough blood supply. For that, we required a stent but there was no manufacturer making stents for portal veins of such a small size. This left us in a fix. Then it struck us that the carotid artery which goes through the neck of an adult is of the size of the portal vein of the child. So we used the stent manufactured for the carotid artery of the adult for the portal vein of the child and the surgery was successful.