Wednesday, April 1, 2015

Can we avoid liver transplant for cirrhosis?

Liver is an amazing organ with tremendous power to regenerate. The prevalent belief is that liver cirrhosis is progressive and leads to decline in synthetic functions with time. However experience in managing patients with cirrhosis proves otherwise! Not all types of diseases are progressive. For a liver disease to be progressive the rate of regeneration must be overcome by the rate of destruction, in other words there has to be an ongoing liver cell death and resultant scarring.  Most cases of alcoholic cirrhosis tend to be stable once the insult is stopped and power of regeneration can restore volume and function.  Similarly in the case of virus induced cirrhosis, the balance can tilt in favour of regeneration if the viral suppression can be sustained.  Regeneration of the liver is dependent on external  factors as well as gene triggers and most likely these two are interlinked. Factors such as steroids, insulin and thyroid hormones may play the role of modulators of regeneration. a combination of external factors and internal milieu of the cell may block the intra-cellular pathways like HIPPO pathway which plays an inhibitory role on regeneration and modelling.  Clinically I have seen patients with cirrhosis, high bilurubin, low albumin and deranged prothrombin time, actually improve their synthetic function by administration of Branched chain aminoacids, low dose steroids and administration of B-complex vitamins in high doses. It seems that if the right milieu can be created, there is scope of regeneration.

More studies are needed to adopt preventive strategies in cirrhotics so that many patients can regain their lost function and essentially avoid or postpone the need for a liver transplant.  After all liver transplant carries one of the highest morbidity and mortality figures among all surgical procedures.  It is only fair to give the benefit of supportive therapy to patients with cirrhosis to enable them to live with their own livers as long as possible.

Cirrhosis = scarring and liver shrinkage
Internal milieu = chemical environment within the cell
Prothrombin time = test to evaluate prothrombin synthesis by the liver

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