Universal vaccination against Hepatitis B is critical in order to create immunity in the community from viral infections that attack the liver, K. Rajender Reddy, director of Hepatology, Hospital of the University of Pennsylvania, says.
The Hepatitis B virus vaccine has been proven to be very effective. It is the only other vaccine, apart from the Human Papilloma Virus vaccine, that has favourable impact on the incidence of liver cancer, decreasing it substantially, Dr. Reddy explains.
The burden of liver disease globally is enormous, and is primarily driven by viral Hepatitis B and C. Both cause liver diseases over a spectrum of severity, beginning from liver failure, cirrhosis, and liver cancer. From a public health point of view (since these viruses are transmitted through the faeco-oral route), Hepatitis A and E are known to occur in epidemic form in India. There are, of course, other causes of liver disease, but they do not have a great impact, Dr. Reddy said in a chat with The Hindu on Friday.
Dr. Reddy, and his colleague Abraham Shaked, director, PENN Transplant Institute, were at MIOT Hospital, on their way to Hyderabad to participate in the Digestive Diseases Week workshop/seminar. At MIOT, they held discussions with the teams led by George M. Chandy, director, MIOT Advanced Centre for Gastrointestinal and Liver Disease, and Rajan Ravichandran, director, MIOT Institute of Nephrology.
The good news, Dr. Reddy, explains is that there are effective treatments. But they can be expensive, and a challenge/burden on patients, governments and insurance companies. Ideally, therefore, prevention must be the focus.
While Hepatitis E and A can be avoided by maintaining good sanitary conditions, Hepatitis B and C are transmitted mostly through the sexual route or contaminated blood and blood products, similar to HIV infections. The best way out would be to take the same precautions during sex, as recommended for HIV prevention; making blood products safe; and following universal good practices in a health care setting, he adds.
Dr. Shaked, an expert on liver transplant procedures, responding to a question on the advisability of doing adult living donor transplants, says: “In many ways if we do living donors, it is because we do not have cadaveric donors. Let us not fool ourselves. While it makes no difference to the recipient, studies demonstrate that there is a chance of mortality and morbidity in donors.”
It is estimated, based on self-reporting, that the mortality among donors is one among every 250 cases. “This is 0.25 per cent, and it is significant, especially if you are healthy,” he adds.
“Unfortunately we do not have enough cadaveric donations to match the demand, even though our rate is one of the highest in the world,” Dr. Shaked says. His centre also tries to maximise utilisation of cadaveric organs, conducting split liver transplants from good cadaveric livers. The larger wedge of the liver will be used for an adult, while the smaller one will be used on a child.
What is important when conducting live liver transplants is the amount of education that is given to potential donors on the risks involved. In the U.S., there is a very rigid policy that will not allow the physician who is involved with the recipient to deal with the donor, because of conflict of interest, Dr. Reddy says. A separate team deals with the donor always, as the policy specifies he/she should be given an independent opportunity to decide without the compulsions of peer pressure and guilt. “In fact, if the donor does not want to donate, and is unwilling to tell others about this, we can even find a medical reason to cite for rejecting the donor,” Dr. Reddy explains.
Also joining the discussions were the office-bearers of the recently-launched Tamil Nadu branch of the Indian National Association for the Study of Liver — A.T. Mohan, gastroenterologist, and K. Narayanasamy, hepatologist.