Please could you tell us a little bit about recurrent hepatitis?
We are very interested in hepatitis C as it is the most common indication for liver transplant in the Western world. The difficulty is that recurrence happens in the majority of patients within the first 2 to 7 years after transplant, and occasionally sooner.
It is a common reason for recurrent cirrhosis after transplant. Indeed hepatitis C survival is not as good as some other liver diseases because of recurrence, so it is a very serious outcome.
Please could you tell us a little bit about liver transplantation, when it is needed, and what life is like post-transplantation?
The simple answer is that a liver transplant is needed when your chances of surviving without one are reduced.
Because it is a big operation, there is a risk of complications due to the transplant itself. But when there is a clear benefit to the patient to go through the surgery, then it is needed.
It tends to be needed when the liver is functioning at very low levels and as a consequence patients develop complications of liver disease such as fluid in the abdomen, or problems relating to the inability of the liver to detoxify the blood, or bleeding due to the high pressure related to the liver disease. These are the typical reasons to think about a liver transplant.
Most importantly for the patient, quality of life is dramatically improved after the transplant. This is because having a healthy functioning liver is vital to a lot of daily normal functions.
However, patients have to be on medications for the rest of their lives, and this has to be taken into account. They also have to have fairly close follow-ups to make sure that the liver is functioning well.
Your recent research suggests that post-liver transplant patients who smoke are at risk of recurrent hepatitis. How did this research originate?
Recurrent hepatitis C is almost universal if you wait long enough after a liver transplant, thus it is not something that is surprising. What is surprising is how quickly it recurs in smokers. That was the cause for concern.
The question that we were actually asking was how does smoking affect all transplant health? So it wasn’t just recurrent hepatitis C. We were looking for:
- long term survival, i.e. the overall mortality
- we were looking to see if there were technical problems at the time of the surgery, such as clotting of the arteries that lead to the liver
- whether we lose the function of the liver early due to smoking
Similar things have been looked at before in other research, but we thought we would also look at long-term complications, such as recurrence of hepatitis. So this was something that was a little bit different to the literature that is already out there, because we looked at what happens several years after transplant.
Do you know the reason for the rapid recurrence of hepatitis in these patients?
The study was designed to look at any association of smoking with bad outcomes, so we were not looking to explain the mechanism. It would be pure speculation, as the data were not really intended to analyse that question.
The potential things that we think about relate to the oxygenation of the blood and also potentially some influence on the immune system. So, if I were speculating that is what I would say, but I caution into reading too much into data because that was not really the intention of the study.
Are smokers who have not had a liver-transplant at any higher risk of hepatitis C?
That is an interesting question. There are data from many different diseases suggesting that smoking can increase the amount of liver damage from various different types of liver disease. But there are a lot of other reasons why hepatitis C may have a better or worse outcome, for example there are different therapies available; it also depends on when you present, and what other things are going on with your health. Ultimately, it is very hard to measure the extent of smoking alone.
The interesting thing in this model is that you have a liver that is brand new and you can follow it from the time of transplant, so you have a good idea of when it recurs.
How does the time spent smoking affect the risk of recurrent hepatitis? And are current smokers more at risk than previous smokers who have now quit?
Again the limitation of the data constrains what I can say on this. We had found no difference between whether you are a current smoker or a previous smoker. But, one of the difficulties in doing a study like this is that the data is very much dependent on the reporting of the patient. For example, the data depend on whether a patient remembers or admits to smoking.
It is not something that we were able to quantify objectively with nicotine levels for example.
The bottom line is that any smoking should be discouraged. Presumably it may be worse if you smoke larger amounts, but the study wasn’t designed to show that.
Are there any ways that post-liver transplant patients, who are also smokers, can reduce their risk of recurrent hepatitis?
The short answer is to stop smoking, but there are several other factors that we look at, such as:
- keeping a healthy weight
- keeping a healthy activity level
- close follow-up of the state of the liver with a trained transplant professional
- minimising consumption of alcohol
Generally it is just living a healthy life.
Is whether a patient smokes taken into consideration when deciding on the patient’s place on the waiting list for organ transplant? Will this research change that?
There are some differences of opinion over whether smoking should influence whether someone is eligible for a liver transplant. There are some programmes that have questioned whether smoking cessation should be mandatory before transplant.
We generally don’t exclude people because they smoke. We counsel them to stop smoking. One of the things our program has done since the beginning is to actually evaluate lung function. We do refer patients with worse lung function to a specialist early in the course of their evaluation.
I think it is important to note that the overall mortality rates are no higher. So I would really caution against excluding smokers because the data support quite the opposite: that survival is quite good.
Having said that, I think there are many benefits to stopping smoking and reduced risk of recurrent hepatitis is only one of them. Certainly, the position on the list, i.e. how the organs are allocated, has nothing to do with what happened before being put on the list.
The priority is purely determined by how sick the patient’s liver is.
Do you have plans for further research into this area?
We will be looking at other outcomes relating to lung dysfunction.
Where can readers find more information about this?
They can read the original press release: https://www.news-medical.net/news/20120712/Smokers-at-risk-for-recurrent-hepatitis-post-liver-transplantation.aspx
I’d also direct people to information from any liver foundation, wherever in the world they may be.
About Dr Peter Ghali
Dr Ghali obtained his Medical Degree from McGill University in 1998, followed by residency in Internal Medicine and Gastroenterology. He completed an advanced fellowship in hepatology and liver transplantation at the Mayo Clinic, Rochester, MN and an MSc in Epidemiology and Biostatistics.
He joined the Department of Medicine at McGill in 2005, where he is currently an Associate Professor in the Division of Gastroenterology and Hepatology. He is the Program Director for Hepatology and Liver Transplantation and the Site Director for the Royal Victoria Hospital Division of Gastroenterology and Hepatology at the McGill University Health Centre (MUHC) in Montreal. His research interests and areas of publication are post-transplantation outcomes, Hepatitis C, and fatty liver disease.
Early smoking causes structural and functional heart damage