All About Liver Transplants
Like with other organs, the need for liver donations outweighs the supply of available donors. Cristiano Quintini, MD, Program Director and Surgical Director of Cleveland Clinic's Liver Transplantation Program joins Butts & Guts to discuss the importance of this surgery, common questions and misconceptions, and innovations taking place with living donor liver transplants.
All About Liver Transplants
Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.
Hi again everybody, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio, and today we're going to continue a little bit talking about transplants. And we're going to talk specifically about liver transplants, and I'm so pleased to welcome Dr. Cristiano Quintini, who is our program director and the surgical director of Cleveland Clinic's Liver Transplantation Program. Dr. Quintini, thanks so much for coming onto Butts & Guts.
Dr. Cristiano Quintini: Hi Scott, thanks for having me. It's a pleasure to be here today.
Dr. Scott Steele: So for all of our listeners out there, just to set the stage, why don't you tell us a little bit about your background? And I just would like to remind the listeners that we've had a couple of transplant ones out there from Dr. O'Neill Vaidya and Dr. Charlie Miller for more information about transplants and organ donation. But again, Dr. Quintini, where are you from? Where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?
Dr. Cristiano Quintini: Well, as my name indicates, probably the readers already know I'm from Italy. I did my medical school in Italy, did part of my residency there, and then I decided to move to the United States, in the University of Miami, particularly, for my transplant training. I got trained in basically doing all organs transplants, including intestine, kidneys, pancreas, and liver is really what has caught my passion more than anything else. And since 2007, I joined the Cleveland Clinic after my fellowship in Miami, and I've been here since then. The past three years, I've become the director of the Liver Transplant Program, which was a great honor. And it's a pleasure to have colleagues that have worked with us all throughout these 15 years, and the fortune to have great mentors at the Clinic and in Miami.
Dr. Scott Steele: Well, we are so glad to have you here. And so let's just start very basic. What are some diseases or indications, specifically regarding liver transplants, that would be required for a patient?
Dr. Cristiano Quintini: I think for the listeners, it's important to know that are two main reasons why a patient needs a liver transplant. There are acute reasons, meaning the patient emergently develops liver failure. It is somebody who has a completely normal life and all of a sudden is sick in the ICU, dying in the hospital with acute liver failure. And this can be the consequences of a viral infection, of mushroom poisoning, of a Tylenol overdose. We're seeing some of these more and more. And basically the liver fails acutely, immediately. In three, four, five days, all the functions of a body stop, and the patient is basically in extremely acute bad conditions, and a liver transplant is the only way to save these patients.
These are not the most common indication for liver transplant. About 2, 3% of the patients that do need a liver transplant for acute reasons. And then the majority of the patients do have liver disease that develop over the course of 10, 15, 20, 30 years, at times. And the most common causes of chronic liver failures are viral hepatitis, particularly hepatitis B and, most importantly, hepatitis C. Hepatitis C is now a curable disease, but five, ten years ago, it wasn't, and a lot of patients are still presenting with diseases related to that.
Alcohol is another common indication for liver transplant, alcoholic cirrhosis, obviously long-standing drinking. And then one indication that is more and more prominent is a NASH cirrhosis, which is a very fancy word for people that develop liver failure from a fatty liver disease, that is, obesity, diabetes, hypertension, all those conditions that cause the liver to accumulate fat and eventually fail. There are then some rare causes like autoimmune disease, and one emerging indication in the field of liver transplantation is cancer. We're transplanting more and more patients with cancer that are not resectable, cancer that cannot be removed from the liver, because they either are too extensive or the liver is damaged. And this is a field that is growing rapidly, and one that is also very successful.
Dr. Scott Steele: So when you talk about this, about roughly how many liver transplants are needed per year in the US, and are there enough donors out there, and what efforts are we making to increase the donors if there are not enough?
Dr. Cristiano Quintini: This is a very important question. Definitely the short answer is no, there are not enough donors for all the patients that are in need. About 20% of the patients that do develop liver failure will end up dying without having had the chance of a life-saving transplant. And I suspect the numbers is even higher if we take into consideration all the patients that die even before getting to a hospital or to a place where transplant is an option. So just to give you a magnitude of the problem, roughly 8,000 to 10,000 patients every year receive a liver transplant in the United States. About 12,000 to 15,000 patients are listed for liver transplants, and again, I suspect that many more would need a transplant if that was something that we could provide to everybody, and with a mortality rate of 15, 20% on the waiting list.
Dr. Scott Steele: So what are the different types of liver transplants, and do you have to transplant the entire liver?
Dr. Cristiano Quintini: That's another very good question. I think for the most part, people think that liver transportation is something that can be done from what we define cadaveric donors, so from people that have died of a brain hemorrhage or a car accident. And that's not necessarily the case. We are using more and more a type of transplant that is called the living donor liver transplantation, which is basically a healthy living person that is donating part of their liver to a person in need.
This is possible because the liver is an amazing organ. It's able to regenerate itself at a speed that is still really, really impressive to me, even after all these years. You can spend part of a liver to somebody and after four to six weeks, these liver has doubled in size. And so that allows us to take about 40, 50, even 60% or 70% of somebody's liver and transplant it to somebody sick, and both donor liver and recipient liver will regenerate very quickly, providing full function within a week or two after the transplant or after the operation.
Unfortunately, though, I have to say, this is still not the most common type of transplant. These are a great transplant because if we had infinite donors, we could provide a life-saving procedure to any patient you need. But as of now, it's only used 5, 6% of the time, at least in the United States, where a cadaveric transplant still is the most prevalent activity.
Dr. Scott Steele: So I have had the unique experience, unlike most of our listeners, of operating with you, Cristiano. And you're an incredibly gifted technical surgeon, and it's always a highlight of my day, but can you talk our listeners through the process? Very high level. You don't have to go into graphic detail, but what is it like? What do you do? A lot of people are like, "What does a liver transplant mean? What are you actually doing?"
Dr. Cristiano Quintini: Thank you, Scott. It's always fun doing surgeries together. Well, the procedure has been perfected about 30, 40 years ago, and I think with very small variations on the team. In fact, actually we do innovate quite frequently. I think we've reached a very good level of proficiency from a technical standpoint, but the biggest progress has been made in the way we care for these patients in the pre-transplant and post-transplant phase of the disease.
Now, these are big surgeries, about eight to ten hours' operation, where the patient loses at times five, six times or ten times the amount of blood that that is circulating in their own body. The first phase of the surgery is always very, very intense, at times bloody, because as a consequence of the liver disease, these patients have a very, very pronounced ability to bleed, and therefore the first phase, which is when we remove the old liver, is always very intensive and very bloody.
But then there is the implantation phase, which is when we bring in the new liver, and that's just a beautiful operation because everything stops, everything is more quiet, and we have the ability to do very fine work with the suturing on all these vessels from the donor into the recipient body. And then the most amazing part is when we release all the clamps that prevent the blood from flowing into the new liver, and then we'll release those clamps and the liver things happen, and it's almost like a new life taking place in front of our eyes. So it's just a beautiful thing to watch. And these patients do really come in in extremely ill conditions. And then you see them walking away from the hospital with a basically near-normal life, even two weeks after transplant.
Dr. Scott Steele: So we're going to transition to a segment of the program we like to call Truth or Myth. So Truth or Myth: it typically takes only weeks between getting on the waiting list to having surgery.
Dr. Cristiano Quintini: So this is difficult to generalize. Typically, the way organs are allocated to a recipient on the waiting list are by disease severity. So if there is a patient critically ill, extremely sick, the work-up can take even a few days, even two, three, four days, and then the patient is placed on the list, and if he's very sick and there is an organ available, then that procedure takes priority over patients that are less sick. It doesn't matter how long he or she has been on the waiting list. Now, if a patient has a much more subtle disease and slowly gets sicker, the work-up takes about a couple of weeks to get all the intense testing that we needed to do, and then the wait list time is variable, and it depends on how sick the patient is. So it's very difficult to actually give very exact numbers.
Dr. Scott Steele: Truth or Myth: recovery time from liver transplantation can take months.
Dr. Cristiano Quintini: I will say myth, with the caveat that, again, if somebody is in good conditions at the time of transplant, the average time spent in the hospital after a transplant is about 10, 12 days. And the patient walks away from the hospital with his own feet and is able to go back to his normal life and his normal work even a month and a half after liver transplant. However, there are those patients that are seeking the ICU with a number of life support, and those patients do require a long time to recall, because they're most of the time also malnourished and they have infections, and any rehab is critical for those patients, and yes, it can take a few months.
Dr. Scott Steele: Truth or Myth: donors need to be related to the patient to achieve successful surgery.
Dr. Cristiano Quintini: That's another myth. The only thing that has to be present... At least in the United States. That's not even true in some Asian countries where there's really a critical need for organs, but the only thing that needs to be present is blood type compatibility between the donor and the recipient. It doesn't have to be a family member. It can be a friend or a member of the community, and the good will of a stranger can make news happen. We have witnessed that, and it's a beautiful act of generosity. But yes, blood type, and then also the donor obviously has to be a healthy person, and we typically don't accept donors that are 60 years or older because it's still an operation for them, and we just want to make sure that that is done in the safest possible way.
Dr. Scott Steele: So a couple of different things about factors right now in terms of predicting outcomes. So first, what factors can impact qualifications, you mentioned this very briefly, to get yourself on the transplant list, or for somebody to put you on the transplant list? And then second, are there any specific factors that you would say this is a little bit better in terms of patients who go through in terms of overall success of the operation?
Dr. Cristiano Quintini: Absolutely. This has been extensively studied. So I tell all my patients getting a liver transplant is like running two marathons back to back. So your heart has to be perfectly fit, or reasonably fit. Your lungs have to be great. You have to have great psychosocial support at home. We don't like to transplant people with active infection. And there are a number of other things that we look, but basically also the nutritional status is critically important. You can imagine that if somebody arrives at the transplant with good muscles and good functional state, that person is going to recover much faster than somebody that has been debilitated by his disease and bedridden for a month. So factors are overall functional state of the person at the time of transplant, and particularly nutrition and the presence of infections. These are the three most important aspects for success.
Dr. Scott Steele: So looking ahead to the future, I know this is an ever-changing world and ever-evolving field. What's on the horizon in terms of research to liver transplantation that will ultimately result in better outcomes, both quality of life for donors as well as for the recipients?
Dr. Cristiano Quintini: This is one of the reasons why a lot of transplants is because the field is constantly changing. We always have the ability to introduce life-changing innovations. Just to give you a few example, we are pioneering at the clinic a new device to preserve organs. So we built our own device to maintain tissues and organs alive during the preservation time. So we've put a lot of effort, and I think this effort is paying great dividends. We have one of the busiest practices in the world now, and we've been able to transplant more patients as a result of this new technology that we are introducing.
Regenerative medicine, you brought in, and thank you for that, Dr. Amy Lightner, who was a world leader in regenerative medicine. There is a huge potential between regenerative medicine and transplant where we can actually use cells that have the ability to repair directly into the organs and make them better. There are studies that are looking at ways to prevent a patient from being on immunosuppressive treatment for their life. So there are ways to make them accept the organ better.
We discussed and briefly touched upon the field of transplant oncology. So now we can use transplant as a way to treat cancers that have been untreatable until now. And lastly, the field of living donor. Well, we're pushing more and more the limits to transplant more patients with a living donor, and therefore preventing death on the waiting list and making also these operations safer on the donor. So these are the very exciting things that we're currently working at the Cleveland.
Dr. Scott Steele: So we always like to get to know our guests a little bit better, so we're going to end up here with some quick-hitters. So first of all, what is your favorite food?
Dr. Cristiano Quintini: Definitely Italian.
Dr. Scott Steele: You got something specific within that grouping there?
Dr. Cristiano Quintini: Oh, well, so definitely I love Italian pizza, which is very different from American pizza. I know this sounds a little bit weird, but it is something that I always look forward to when I go back home, to have a very good pizza. For the listeners that have a pizza in Italy, they will probably understand why. And also as a good Italian, I love my mom's pasta. So every time I can, I either go back home or I get her here, and that's always something that we enjoy having together.
Dr. Scott Steele: And just hearing you say that, I don't normally plug shows, but I can say having watched extensively Stanley Tucci's Exploring Italy, that it makes me hungry when you talk about it. So what is your favorite sport?
Dr. Cristiano Quintini: My favorite sport? I think my favorite sport... I love water polo. I used to play water polo. I enjoy watching a good soccer game with friends. That, I would say, is my favorite sport.
Dr. Scott Steele: What is the last non-medical book that you read?
Dr. Cristiano Quintini: Ooh, that's a tricky question. I loved The Alchemist by Paulo Coelho. It's a book that I've read in the past, but I recently read it again, and it's just one of my favorites.
Dr. Scott Steele: Yeah. I would agree with you there. It's a nice, easy read, but it's a very, very sweet book. It's got a lot of take-home points. And then finally, what is it about Northeast Ohio, specifically here in Cleveland, that you like?
Dr. Cristiano Quintini: It's a place where there's a lot of good people, and it's a place that is perfect for families. I have three little children, and we just love the ability to connect with people and be surrounded by really, really generous people and lots of friends, and so that's what we value the most.
Dr. Scott Steele: That's fantastic stuff. So why don't you give us a final take-home message to our listeners regarding liver transplant?
Dr. Cristiano Quintini: Well, the final take-home is very simple. Liver transplantation is an exceptionally successful treatment option with a 90-93% chance of survival for patients that have basically no chance of surviving a disease. So it's something that is very effective. I think a few things that are important for the listeners. If you know somebody that is in need of a liver transplant, then please send them to large institutions, because that's where the multidisciplinary care happens at its best, and that's something that's very important for the success of liver transplantation. And also, always encourage people to look more into the living donor option, because a lot of people don't know that this is an option when somebody is dying from liver failure, and some days very important because it can be lifesaving.
Dr. Scott Steele: So for more information on Cleveland Clinic's Liver Transplant Program, please visit clevelandclinic.org/livertx. That's clevelandclinic.org/livertx. You can also call the program at 216.444.1976. That's 216.444.1976.
And again, you've heard me say it once; you've heard me say it a thousand times. Please remember it's important for you and your family to continue to receive medical care. Get your regular checkups and screenings and rest assured here at Cleveland Clinic, we're taking all the necessary precautions to sterilize our facilities and to protect our patients and caregivers. Dr. Quintini, thanks so much for joining us on Butts & Guts.
Dr. Cristiano Quintini: My pleasure, Scott. Thank you.
Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.