Liver 101

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Liver 101

• Adrian M. Di Bisceglie M.D., FACP
• Medical Director, American Liver Foundation
• Chief of Hepatology, Saint Louis University

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The Liver has Multiple Functions

• It makes things
• Proteins (e.g albumin, blood clotting proteins)
• It excretes things
• Bilirubin
• Drugs
• It detoxifies things
• Drugs
• It helps with digestion
• Makes bile (bile acids)

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Right lobe
Left lobe
Bile ducts
Pancreas
Gallbladder
Duodenum
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Some Cool Things About the Liver

• The largest solid organ in the body (2 to 3 lbs)
• Gets 60 of its oxygen from a vein (?!)
• Can regenerate 30 of its mass within 1 to 2
  weeks
• Doesnt get old

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What Happens when the Liver Fails?

• Blood flow through the liver stalls (portal
  hypertension)
• Ascites (fluid in the abdomen)
• Varices (internal varicose veins)
• Hypersplenism (enlarhed spleen)
• The brain doesnt work (hepatic encephalopathy)
• It stops making things (synthetic dysfunction)
• Albumin
• Blood clotting protein
• Bilirubin (jaundice)

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Cirrhosis Portal hypertension Esophageal varices
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10 leading causes of death in the U.S.

• Heart disease 31
• Cancer 23
• Stroke 7
• Asthma and emphysema 5
• Accidents and adverse effects 4
• Pneumonia and influenza 4
• Diabetes 3
• Suicide 1
• Kidney diseases 1
• Chronic liver disease and cirrhosis 1

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Annual Deaths due to Liver DiseaseTotal 44,677

• Chronic liver disease and cirrhosis 25,192
• Primary liver cancer 5,682
• Viral hepatitis 4,796
• Chronic liver disease (other sequelae) 2,819
• Bile duct cancer 2,470
• Disorders of liver NOS 1,403
• Hepatitis NOS 693
• Hepatorenal syndrome 443
• Hepatic coma 435
• Fulminant liver disease 270
• Esophageal varices 205
• Portal hypertension 111
• Other disorders of liver 158

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Some Common Causes of Liver Disease

• Disease population affected
• Hepatitis A 31
• Nonalcoholic fatty liver 20
• Gallstone disease 8
• Alcohol abuse/dependence 7
• Hepatitis B 5
• Hepatitis C 2
• NASH 2

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Some Not So-Common Causes of Liver Disease

• Hemochromatosis 0.5
• Alpha-1-antitrypsin deficiency 0.06
• Primary biliary cirrhosis (PBC) 0.04
• Primary liver cancer 0.004
• Wilson disease 0.003
• Fulminant hepatic failure 2,000/yr
• Primary sclerosing cholangitis 450
  deaths/yr

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Preventable/Treatable Liver Diseases

• Hepatitis A
• Hepatitis B
• Fatty liver disease
• Alcohol abuse
• Gallstone disease
• Hepatitis C
• Hemochromatosis

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Transplanted Deceased Donor Organs 2002
Kidney
Pancreas
Liver
Heart
Lung
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Waiting List at Year End 1993-2002U.S.
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Deaths on the Waiting List2000, 2001, 2002
Total Unique Patient Deaths
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MELDModel for End-Stage Liver Disease

• Accurately estimates 3 month mortality in
  patients with cirrhosis
• Bilirubin, prothrombin time, creatinine
• Used for liver allocation from March 2002
• Range 6 to 40
• gt10 to be listed
• 10 to 15 dont do well with transplant
• gt30 dont do well with or without transplant
• 24 priority points for patients with liver
  cancer

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Exceptions to MELD

• Children (PELD)
• Status I - fulminant hepatic failure
• Additional priority points for
• Liver cancer
• Hepatopulmonary syndrome
• Special exemptions (regional review board)
• Living donor transplantation

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Some Cool Things About Liver Transplantation

• Donor and recipient matched only on blood group
  and body size
• Some patients can stop ALL their
  immunosuppression
• Cells from the transplanted liver can later be
  found all over the body of the recipient
  (chimerism)
• Living donor transplantation

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Treatment of Liver DiseaseSome Unmet Needs

• Complications of cirrhosis
• Liver fibrosis
• Portal hypertension
• Ascites
• Synthetic function
• Hepatitis C
• Treatment for all patients
• Vaccine
• PBC, PSC, autoimmune hepatitis