The Liver Lowdown with Dr. James Burton

0:16 I watch while you were sleeping don't got no wall keep you you got someone else's dreams wake wake up call you get out the sun is creeping all right welcome everybody to this episode of transplant talks I'm Rachel Davis uh living liver donor psychiatrist and Mentor for the American transplant foundation and I'm with my uh co-host Anastasia Henry who's executive director of the American transplant foundation and today we are talking with uh Dr James Burton he is a professor of medicine at the University of Colorado anuts uh the section head of hepatology or he's a liver doctor and he's the medical director of liver trans so welcome Dr Burton thank you nice to be here today and I will turn it over to Anastasia to get us started off today I've been waiting for this day and for this episode for a long time my cousin who was my best childhood friend he died from liver failure before he turned 35 so this is extremely personal this is extremely challenging subject and also that something that that I'm so passionate about because liver is the only organ in our body that can regenerate we have an epidemic of liver disease we'll talk about it and we are so excited that we were able to get Dr Burton he's one of the leading hepatologist he's amazing he's

1:47 passionate about Liver Health so let's jump in let's jump in thank you so much Dr Burton for being here my pleasure great time this is a great topic and one that I think it benefit many people and something I enjoy talking about yes and for all our listeners and for all our YouTube viewers so listen up because you're going to learn some incredible information that potentially can change your life and the health of your liever let's start with the notion of liver epidemic the first time I heard about liver epidemic specifically in the state of Colorado was earlier this year can you explain what it means epidemic liver disease epidemic is it local to specific States or is it nationwide issue well I think this uh when you refer to like an epidemic of Liver Health I mean uh there's multiple things that that refers to I think the one thing that stands out for us in our Liver Center is uh the the very widespread and increasing use of alcohol in America uh this has uh was something that was going up before the pandemic uh I think the pandemic lit it on on fire um I think we were fortunate enough to start developing some uh processes and evaluation of people with severe alcohol associated liver disease uh but those rates were increasing before the pandemic and then you know as we all sat around in our pajamas uh uh doing Zoom

3:17 calls for the first time and having happy hour at two o'clock in the afternoon I think this is when things really started going up but you know alcohol is not the only problem in America right now and there's other problems uh associated with a term called metabolic dysfunction associated steatotic liver disease that's a fancy way of saying fat inflammation in your liver related to metabolic derangements like obesity and diabetes this too is a problem in America and it's something that's been going up you're seeing this in younger and younger people uh and the consequences of this is uh all these conditions can uh lead to sorosis uh and require transplant if you think about your patients 10 years ago what was the average age when people actually had a liver failure versus now that's a good question actually I I used to see older people coming to me when I say old my talking about my own age in their 50s who uh were diagnosed with therosis a lot of these problems had not really been developed they might be uh people who had long-standing diabetes obesity never told they had any problems with their liver until they decomp compensated with complications of jaundice or uh AES fluid in the abdomen or uh it might have been you know older men with who were long-standing drinkers of alcohol uh who came in with their wives and said they've been drinking alcohol for all their lives and had developed therosis I think in the last

4:48 10 years we've started seeing younger and younger people with these problems um particularly with alcohol I mean I am today seeing patients who are in the early 20s who need liver transplants and finding out that they've been drinking alcohol since you know they were 13 or 12 years old um that is very is a big change and uh I think the uh other change I'm seeing is younger and younger people who have abnormal liver test who have diabetes and obesity at an earlier age and I'm looking at these people now in their 30s and I'm saying hey I used to see you in your in your 50s you know but now we're seeing them earlier we now have some things we can uh we can you know address some of these problems with uh but certainly the age has shifted to younger uh younger people and for alcohol a big shift has been women I'm seeing more and more women uh who are developing alcohol associated liver disease than I had 10 years ago um so it's both a change in younger people and uh more females so how much alcohol is too much well that's a good question I think whenever I see a patient and I'm talking about about alcohol you just can't ask how many drinks do you have uh you have to quantify what a drink is and I remember seeing this woman in the hospital once and it was this big mystery of what her liver disease was though if you looked at her Labs it was like classic for alcohol associated liver disease and everyone kept asking her what do you drink she goes I drink

6:19 one glass of wine and uh she uh was from Burma and there was a language barrier and everything and I went in to see her because they no one could figure it out and I asked her I said well what how big is your glass and she picked up a glass like this big and it held an entire bottle of wine and she was drinking that every day no one ever asked her how much wine are you drinking it was just saying one glass so I mean I have patients who have glasses that will fit an entire bottle in it so you need to be you need to ask what what you're drinking when you say I I always go through finding out how do you buy your alcohol do you buy it with a handle do you buy it in pints do you buy it uh in packs um quantify what they're drinking and then I ask you know if you drink beer do you drink craft beer do you drink you know Bud Lights I mean those are those are very different uh amounts of alcohol um people uh you know if you're drinking bottles of wine do you drink a whole bottle yourself you split it with your spouse I mean this gets you an idea of how much you drink you know if you're pouring mixed drinks are you just kind of like this or are you actually measuring shots so once you can identify perhaps how much people are drinking then then i' start telling saying to uh you know men and women you know one drink is moderate drinking for a woman uh two drinks would be moderate drinking for a man I often find that people uh underestimate how much they're drinking and most of the time I can actually double it so I think once I identify how

7:50 much alcohol people are drinking then you can start to engage the patient into you know well that's actually quite a bit you know especially for small woman you know one thing that's not been known over years is Al bypass surgery for obesity can put you at more at risk for having alcohol associated liver disease wow with the same amount of alcohol so these people might not necessarily have an alcohol use disorder but they're doing the same things they were doing all before but they're not realizing that the impact of that alcohol can have on them so many takeaways just from this one answer so first of all like it's probably if you have any concerns about your alcohol usage it's a good idea to get a simple app um and just track your numbers right track your what are you drinking how much right and then when you are talking to your doctor they've heard it all they've heard they've you've heard it all right if you say I drink a bottle of wine and you think you're like the only person like you're like yeah right like i' I've heard it all right when nobody's going to surprise you so just being honest so you're not going into circle into circles right just being honest and saying this is where I am right now I would like to do better but this is what's happening I think that's number one and then number two so there there was a very specific example of a woman who was drinking a bottle of wine a day a night and she did develop liver failure so as I Was preparing for this episode a very good friend of mine told me that her primary care

9:20 practitioner they told her and her husband that if they drink two glasses of wine per night every day of the week perfectly fine uh well I would say for a woman that would be moderate to severe drinking for the man it would be moderate drinking it might be okay I think as we've learned about alcohol this whole thing about the French paradox and there must be benefits of drinking red wine actually I think there's really no data that drinking alcohol at all cause has any benefit at what at all I mean not only is it have complications with liver disease it has complications of cancer it has complications of raising your blood pressure extra calories obesity I mean I I mean I wish I could tell you that drinking alcohol is going to save all your problems but there's really no benefit of alcohol in my opinion now that doesn't mean you one should live a life of sobriety if you don't want to I mean I enjoy having craft beers and uh uh a nice glass of whiskey from time to time but I mean I don't think that it's am it's about how you utilize it in your in your life and how does it impact your life not only from your health standpoint but how does it affect your relationships with other people um and your work and and those kind of things as well so it's not like alcohol is just a health benefit it can have all kinds of ranges of problem and we can't forget the psychiatric problems of course absolutely absolutely and a lot of times

10:51 I see people who start drinking alcohol when I kind of go back and go when did this happen they say well I used to help me sleep at night you know and yeah it will help you sleep but that sleep you're getting is not good sleep and a lot of times people turn to their depression or their anxiety by drinking alcohol and you know that first drink or two it probably you know helps kind of relax you and stuff but then with that third or fourth you're probably causing more harm and you know what there's lots of good treatments for anxiety and depression out there that one shouldn't have to turn to alcohol right do we know why some people end up with curosis and others don't or is it that everybody who drink a certain amount would end up with therosis well thank God not everyone who drinks heavily ends up with liver disease because I would be in a world of hurt you know I I I've seen that about 10% of heavy drinkers will develop liver disease and um there's Pro there's obviously there's issues related to genetics I think there's co-actors with other liver disease so you may have there's a term this whole term of metabolic dysfunction Associated scat hepatitis or that can be there's now a term called met Al so metabolic problems with too much alcohol um I think um you know there's probably I you know people always tell me well I don't I don't drink hard alcohol you know your liver doesn't care how it looks uh it's a twocc carbon chain that gets to your liver and a lot of the times it's not

12:23 the the alcohol going to the liver and causing damage a lot of where the injury starts is in the gut in the intestine it causes inflammation and that inflammation all the blood from your gut goes rushing to your liver so that inflammation that Cascade of events that leads to fat and disregulation and Metabolism problems in the liver occurs and that's very unique in each certain individual um and so I don't you know most people can you know I see people who drink tons and I'm afraid sometimes amazed they don't have liver disease and then I had people come to my clinic and go well God brother drinks twice as much as me how come he's not sitting here in front of me it's very variable and I don't think you can just measure the amount of alcohol and know that you're going to develop liver disease so when we're drinking that one glass of prco basically what's happening there's inflammation that is happening as we you know having that one drink so it's yeah I mean the the when you drink alcohol and you break it down and as asah alahh which causes you to have the feeling of being hung over the next morning that's not NE necessarily causing the damage it's the ongoing inflammation at the level of the gut that causes inflammatory cyto kindes and mediators of inflammation to go to the liver there's disregulation of fat you know what's very interesting about alcohol Associated uh liver disease and non-alcohol associated liver disease underneath a microscope they look the same they both have fat in the liver with Associated inflammation and

13:56 honestly sometimes I'm shown a biopsy and I can't tell the difference between someone having too many donuts or too many Budweisers they can look the same so these it's interesting in that the two biggest causes of of liver disease in America alcohol and metabolic Associated dysfunction of uh fatty liver disease those are the two leading causes in America and they look the same on Imaging they look the same on uh on a biopsy so if if listeners are listening to this and maybe getting a little bit worried what what should they do if they're concerned about their drinking well I I mean I I see patients sent to me from their for abnormal liver test from their primary care doctors often times and the question isn't is this alcohol the question I'm posed is why are their liver enzymes elevated and I can tell sometimes walking into the room that it's due to alcohol there's very characteristic findings about the the way the pattern is there's very characteristic findings of on the Imaging you can see other lab testing that can suggest it so you know in terms of I think just a asking people I mean if you get to me and for me to tell you you're drinking too much these people have been doing this with their primary care or maybe they've even thought about it themselves so again I don't think it's as much as just to ask people how much do you drink I have three drinks check and move on to the next thing you should ask okay three drinks you're a

15:27 woman how are these drinks you know and find out that it's six drinks so I think I think we all probably need to you know stop and pause and and and look at how much we drink I mean if you think about it in back in the olden days you could only drink wine and whiskey you know and there were bad beers and now we live in a in a especially in Colorado here we've got a huge craft beer industry a huge craft Distillery business they sell seltzers now with alcohol in them that are fortified with vitamins and we're told that this is somehow healthy for you so I mean you the amount of access to alcohol is overwhelming it's kind of become kind of you know kind of expected I mean it's advertised on TV you can't go to a sports game without lots of alcohol so I think it's something you know it's you know tobacco kind of shifted and you started putting warning s signs on it and saying this is bad and we outli outlawed tobacco and restaurants and on airplanes we don't do that with alcohol we serve alcohol in airplanes we serve Al called all these events and so I think that I mean that when the baseball started being faster there was criticism we won't be able to drink as much beer at the baseball game so I think there is a a big problem in America that we we drink too much we have too much access to it and and you guys are at least raising this question for people to start looking at how much they drink yes and I think you know someone as someone who grew up in Eastern Europe and definitely alcohol it was your number one uh prescription

16:57 medication right depressants everything however there was not a culture at least back in the days when I lived there there was not a culture of this everyday consumption of alcohol so if there was a big party everybody would go you know go crazy but nowadays with all the wine clubs it's like I'll just have one two glasses of wine every single day can you talk to us how can you affect the health of your liver if you simply don't drink every day maybe if it's just one or two glasses but let's say you only drink 3 days a week will you make a difference for your liver well I I can't say that it's GNA make you worse I it's got to be helpful I mean I guess if you're having I mean there's The Chronic daily use of alcohol but also binge drinking is equally as bad I mean for for a man that would be five drinks for a woman four drinks and I mean even if you binge drink once a week that probably has the same impact as having moderate drinking on a daily basis and in terms of defining what an alcohol use disorder is you know bins drinking four or five times a month would be considered abnormal so um I mean I think drinking less is got is is go is the benefit how you go about doing that is going to be good but I I think if you just put all your drinks from the week and put them on the weekend not sure that's going to necessarily help you

18:29 and my suggestion was instead of like let's say if you have these two glasses one glass per day if you simply keep the same amount absolutely no bit drinking but let's say you give your liver a thoughtful rest three to four days a week yeah well I mean uh I I think there's a lot of things related to alcohol that people don't realize you know causes problems you know you know so I see people who are having a hard time losing weight and yet they're drinking two glasses of wine a night and I'm like well gosh you could cut that out and you're getting rid of calories I mean the Improvement not only in blood glucose control um your sleep uh high blood pressure I mean people start to feel better when they stop drinking I think that's something you notice even after uh several weeks and you know we were talking earlier about you know the benefit of you know taking a month off of alcohol you know January is coming up people notoriously want to quit drinking in January I think a lot of the benefits of stopping alcohol for a month is looking back and seeing how well you feel and I think a lot of people don't realize the impacts alcohol has on your overall health um and sometimes just taking that dry you know that month of dry January to really feel like oh my God I feel so much refreshed I'm saving money um aspect of my life I have more energy I have more exactly I can think better mhm and we actually this January for the

20:02 first time ever we will be doing Li refresh challenge four weeks we're going to start January 10 and I encourage everyone to sign up it's a free initiative it you will learn so much about your Li Health and we will try to reset our lever and learn healthy new habits together so go to americant transplant foundation.org to sign up that will be a really fun initiative to do together some other questions they have so some patients ask what about liver detoxes what can we buy something from Amazon that plants plant-based fixs and this and that some people do cleanses right with machines what what are your thoughts on all that uh I see well I see people every week who have some uh liver toxicity or a drug induced liver injury which I often contribute to some herbal supplement or some cleanse or something where a patient is taking it because they're under the impression it's going to help them um so a lot of those things are not regulated uh some of them may have what might be considered benign things but you don't know what else is in there uh you know the liver was designed to do this work it's doing I mean you have more liver than you need first of all as evidenced by the fact that you can take 60% of it out and give it to someone else or throw it in a bucket if there's

21:32 a tumor in there so your liver is very resilient I think this idea that your liver needs to be detoxified or cleansed is really not based in any fact a reality and that a lot of the things that you could do to live a healthier life for your liver is to eat better avoid alcohol you know get your blood glucose under control you lose weight the Fat's going to go away I mean the a lot of these things are things that are going to help you more than uh something you buy on Amazon and a in a cleanse that's I think it's a gimmick to be honest with you it's a quick way of thinking I'm doing something but I think if you really want to have good lever Health you really got to focus on your entire health and your whole body are there any supplements that are particularly harmful or notorious for leading to liver damage uh well I mean there's there's been talks it with ashanda which a lot of people swear by and when you bring it up they feel like they that's no way I can stop doing that um you know cumin uh has you know big concentrated capsules of that I've seen patients come in with liver toxicity um I've seen red rice yeast uh toxicity in people thinking that's going to be good for them I mean there's so many things out there that I think are in packages that claim things and um you know a lot of times you I can look these

23:04 up on you know the NIH has a good uh website on uh drug toxicity as well as herbal toxicity and sometimes you can find the drug that particularly uh that the person's taking and sometimes it isn't been reported but I mean whenever I see someone with an unexplained liver injury and I find they're taking supplements you know I have to tell the patient I they could be in this basket of pills you're taking here I have no idea and I don't even know what's in all these things often times if I can convince the patient to get off everything their liver tests get better and then they and then a few months later I get their Labs back and they're back abnormal again and the patient's gone back to taking them it really probably requires taking them all off and then going back each one and seeing which one has it I mean there's some that you know I'm not talking about vitamins here I'm not talking about I'm talking about herbal supplements things that you know you don't know these things are not regulated by the FDA what's in them may be true what's extra in there is probably what the problems are is there such thing as taking too many vitamins uh well there I mean you can get uh liver toxicity from taking too much vitamin A so I mean there is well described uh toxicity from vitamins I mean honestly I think if someone is taking vitamins um they're probably just having expensive urine because your body if it

24:37 doesn't need it it's just going to get rid of it and people who really need vitamins I think are people who have chronic uh gastrointestinal diseases where there may be impacting or there may be impairment of absorption of vitamins uh or you might have a SE I can think of some severe liver diseases where you might have a problem absorbing fat soluble vitamins but for healthy people eating a well-balanced diet I mean our bread in America is fortified with thymen and folate and thing I mean as long as you're eating a well-balanced diet I don't think we most people need vitamins um no do take does taking a vol multivitamin hurt you no does it hurt your pocketbook maybe uh that may be up to a person to decide what they want to do but I don't think we most people who are healthy don't need to take vitamins supplementation now what if someone has had a liver transplant are they more at risk for effects from certain vitamins or are more likely to need certain vitamins I would say as long as their liver transplants working well uh the goal of a liver transplant is to make you back to normal and most of my patients who have had liver transplants I would consider as normal as you and me and uh the only difference is they take an immunosuppressant medicine that most patients don't take and then there's Tylenol so what about Tylenol I think a lot of people don't realize how much Tylenol is too much uh that's a good question um when I see patients in my

26:07 clinic most people have severe liver disease most patients I am seeing in my clinic have uh endstage liver disease and need liver transplant and they ask me what medicine they can take for pain and surprisingly I tell them they should take aetam menen or Tylenol um acetamin and Tylenol have taken in doses of 2,000 milligrams a day even someone that who has the worst liver function at the top of the transplant list can tolerate that um what's bad for people with with with therosis and severe liver disease are taking non-steroidal anti-inflammatories these can cause ulcers in the stomach these people have a lot of congestion of blood around the stomach so a little bleeding turns into a lot of bleeding and most importantly in severe liver disease uh those drugs can precipitate uh uh kidney failure so um uh I think it's very well known that people are told oh you can't take a camenen because you have liver disease um I usually counsel my patients that they can do it because they've often been told they haven't and if you look on the bottle of cedam Menin it says please consult your doctor I think in America the one thing that's a problem with acetaminophen and uh and Tylenol is that you can go to Costco and buy 500 tablets in a bottle uh though in uh in the United Kingdom they put it in blister caplets uh and they've actually shown a reduction in acute liver failure from acetaminophen uh and it's probably because people just get tired of popping the pills uh when they doing having a

27:38 suicide attempt but in America you can go to Costco and easily buy two bottles of five 500 milligrams uh and without any ease take it so I think uh in America the problem is one of too much ease uh and you got to keep in mind there's a lot of other medicines with acetaminophen in them cold medicine so you need to look on the back of any medicines you're taking to see what's in them cold allergy medicines might have a cedam Menin in them um and then you know the fact that you can the tablets are not 250 milligrams but 500 you can get up to 2,000 milligrams pretty quickly well I do we want to talk about leaving lever donation because that is such an exciting and not wellknown area so of often I'm talking to someone they're like you can donate a part of your liever and you're going to be okay I was like yeah talk to Rachel Rachel Davis well as you as you know as you mentioned earlier it's the only organ except for maybe your skin if you consider that an organ that can regenerate um and uh yes it is very it's remarkable uh that someone uh can you can take someone's uh diseased liver out completely and replace it with 50 60% of a normal liver and within a month uh both of the liver and the recipient and then the donor have uh reach gone back to their normal volume one thing about liver uh um living donor liver

29:09 transplant the liver it doesn't regenerate like a salamander's tail so if you donate the right lobe it doesn't just grow back the if the donor's left with the left lobe the left lobe gets bigger and the recipient receives the right lobe the recipient's liver will grow back but yeah um it's something uh we do here at the University of Colorado uh um and um there are a number of places across the country that have the expertise in doing this I mean the outcomes with living donation are equivalent to having a cavic transplant um I think uh in my line of work I see lots of people who are sick and would benefit from a liver transplant but uh they're just not sick enough to get high on the transplant list I tell people when I see anyone who needs a liver transplant uh who doesn't is not so sick that they need a full liver or are already at the top of the transplant list I did I do discuss living donor liver transplantation it's like getting out of line I mean if you're on the transplant list it's like being in a long line you know maybe at a barbecue waiting for hamburgers to be thrown on your plate living donation is like coming to the barbecue with your own steaks I mean you don't have to wait in line it's a scheduled procedure um I've seen patients who need to improve their Nutri nutition so we have a goal date of you're going to improve your nutrition to get a transplant on a Tuesday in in December type thing so it takes away a lot of the when will I get transplanted the unknown um it's an

30:40 incredible I mean I'm not I don't want to minimize the uh risk to a donor it's a major operation that a donor is going to undergo especially if it's a right lobe uh trans uh transplant or donation um though I have seen the benefits of it and we've all seen the benefits of it uh and uh it's something that you know I think if I know a lot of patients have a lot of I don't want to put my loved ones through that you know I sometimes turn it around and say well how's your loved one going to feel if you die on the transplant list waiting for that thing and why get so sick that you're in the hospital or in the ICU on dialysis to get your liver transplant you know I there's so many times in my career where I've seen a patient who has the very beginning stages of you know requiring a transplant and and they're saying well I guess I'm going to have to get sicker in order to get better and I'm like well why don't we just do this now why don't you take a month off of work you can have a liver transplant you're not going to lose out on your health put yourself at risk you're your recovery is going to be faster so there's a lot of a lot of benefits of this option unfortunately it's not you know available for everyone uh but you know it's one of those things if you know if you don't ask people no one's going to do it I I had a police officer and I he had a disease of his bod duct and and he felt like you know he didn't have anyone to donate him I said you're a police officer do do your do your fellow police officers know you need a

32:11 liver transplant he goes well I don't I'm pretty private person and stuff and I go I can understand being private but I guarantee it if you go and tell your your crew of firefighters or police officers or other former military people that you need a liver transplant and he did on the following week he did and four people wanted to come forward to donate so you'd be surprised I always tell people you know I have family members who want to be the advocate for the patient and they maybe they aren't candidates to be donor but they could be a donor Champion for that recipient and getting the word out getting it out on social media mentioning you know my brother my sister my Aunt my father needs a liver transplant hey blame it on me go back to your community go to to your church and say Dr Burton says I need this you know if it makes you feel better but it's a it can make a huge difference in people's lives yeah and I think what what a lot of people don't think about well when you're the one who's sick it's hard to think about it but a lot of us in fact the majority of the population feel better when we do things to help people right for those of us who aren't sociopaths and I will say personally you know it donating the right L with my liver is one of the coolest things I've gotten to do in life and it was an honor and a privilege and I was you know I'm happy I was and still am healthy enough to do it and I think speaking with other live living donors people feel the same way like it's a really cool exciting thing to do and it's nice to be able to help someone um

33:42 I've never I've never met anyone who did it who regretted it right right same I am I do have a question that I'm curious about though I think for some liver diseases um they're viewed through a lens lens of judgment or the idea that someone did this to themselves so for example with alcohol related liver disease um or metabolic liver disease do you use um let's say alcohol related liver disease do you use living donors for alcohol rated liver disease and um is there controversy about that um do people who are non-directed living donors have concern about this I mean well that's a good question I mean when I see a patient who has alcohol associated liver disease one could argue metabolic associated liver disease could you know have a role in there uh I mean historically decades ago there were people with hepatitis C who got Hepatitis C through intervenous drug use so I I mean as a physician taking care of people with liver disease my role is to take care of the person's liver disease and if I think that a living donor would be good for them that's between my me and and that recipient now when I see a donor to evaluate a donor I do ask them especially if they're coming forward to donate specifically to someone if they know why they have liver disease um I do like to hear that they know that it's due to alcohol and I do

35:14 ask them you know how would it impact you if you know the recipient went back to drinking because you know alcohol um alcohol use disorders are are are diseases that are character Iz by relapse and you know the biggest predictor of long-term sobriety is maybe being sober for five years so I think I you know the fact that someone might have a slip can happen so I when I talk to a donor I always kind of go through how would that make you feel and everything and surprisingly I think the type of pre people that come forward to be donors are doing it for the right reason they aren't being judgmental and they're there to give them a chance at Living altruistic people donors that we have this is something we've been doing at the University of Colorado more and more since 2016 or 17 we um if someone comes forward and and doesn't know someone and wants to donate I bring it up and say well you know liver disease from alcohol is a common cause I mean is that something you're against I've never met like an altruistic person who's already Don half of them have already donated a kidney who says oh no no it must not go to a person who drinks alcohol um I mean a lot of times uh I I can't say that most of the times um that is an issue I mean obviously if someone comes forward being altruistic you know we do want to make sure that you know we're not going to I guess my point about some if we're

36:45 offering uh someone a liver transplant from an altruistic living donor we we feel that that person is going to do well with that organ much like everyone on the transplant list I mean we wouldn't put someone on the list if we didn't think they were ready to have a transplant and make good use of that that gift so uh but it's a question that comes up and I we often bring it up the hard thing is if someone says oh I was told the recipient has like you know hemocromatosis and you're like that's not what they have you know that that doesn't feel quite right but that rarely comes up so this is one of the very popular questions that we are being asked so if somebody has a lib failure due to alcoholic um abuse and they feel like they're not worthy they will never get a transplant from a disease donor from a living donor this is simply not true and the medical team will work with you and they will make sure like if if this is a person who says I've been drinking all my life and I'll continue to drink all my life well you know that's probably not the best candidate for transplant like that's not going to happen but if the medical team is certain that this person is on the path of sobriety and committed to sobriety and there are resources that available do you provide support for your patients to make sure that they still sober stay sober after the surgery well I tell people look we're not doing a brain transplant we're doing a liver transplant and you have an

38:17 alcohol use disorder okay it has caused you to go into liver failure and if we just fix your liver and don't address the alcohol use disorder we are IGN ignoring the major component that caused your problem and a lot of times people I I mean I only a few times in my hisory in my career has someone said I plan to go back to drinking after a liver transplant most people say I'm never drinking again well granted that's what everyone tells me but you know data would show 20 or 30% of people will have a relapse and go back to at least some component of drinking maybe not harmful drinking so I always approach it as look we need to give you the tools to understand why you drank to understand you know what the circumstances were around why this happened to you and it's not just me making this decision it's a multidisiplinary group we have everyone who has an alcohol use disorder sees a transplant psychologist they see transplant social work they see a hepatologist and we in most cases will have the patient engage in alcohol treat going before a transplant to and it's not like just because someone is six months sober and has done the treatment oh everything's going to be fine I mean there's some people who have done alcohol treatment are six months sober and I think they're high risk to going back to drinking because they've done it all their life so I don't know why this would be any

39:48 different um I think what has changed is that we have now seeing younger and younger people who have had shorter and shorter periods of heavy alcohol use who are presenting with severe alcohol Associated hepatitis where they're going to die in the next month or so without a liver transplant and they don't even have time to engage or approach their disease much less comprehend every aspect of their disease so I think it's that has been a change for our program and I think a lot of programs in developing what I might call a high-risk uh uh pathway or a limited sobriety pathway where maybe people haven't fully done the work they need to do but they show good prognostic indicators they've got social support they've got Insight they they recognize the use alcohol in them they don't have comorbid psychiatric diseases personality disorders you know it's not like they failed alcohol treatment several times including inpatient stays and things like that so they've got some good favorable factors and we've you know we started a process of evaluating patients like that uh in in 2019 and I'm really glad we developed it because when the pandemic hit everything just got went nuts and uh and we were ready for that and uh you know the first 30 patients we put through that that pathway uh not one of them had a relapse with phosp tidal ethanol test which is a

41:19 test that can really assess for you know probably more you know at least moderate alcohol after a year after a transplant now I think when we relook at that data we said oh we may have been a little too strict in our criteria because we probably should have seen some people relapse and then you know we kind of maybe expanded a little bit and then saw some uh relapse but we've we've we've uh realized that we don't have a six-month sobriety rule there's nothing magic about six months I mean the reason sobriety should be entertained before transplant is you know your liver has the ability to regenerate as we're talking about and your liver can improve prove once you stop drinking I sometimes see people at a month that I think are going to die in the next several months and I start the process of evaluating transplant and then they come back in a month and they're dramatically better and so I think um I think sobriety the reason one should have sobriety is you might not need a transplant now someone gets to the point where it looks like they might need a transplant say they're sick enough that they would need a transplant but then they're sober they're able to get out of the hospital and they have what we call compensated therosis or you know they're able to function with their liver disease are they eventually going to probably need a transplant or could they possibly live the rest of their life like that I have I have many many patients who I have taken care of for now coming up on 20 years with alcohol related therosis who have well-defined therosis

42:50 their liver works completely fine the only caveat is that they're at risk for developing liver cancer so do need to have uh at least twice annual Imaging of their liver but having therosis doeses not mean I'm going to die without a liver transplant people need liver transplants if they have therosis with complications and those would be varices these dilated veins in the esophagus that can bleed aites fluid in the abdomen ayop goofy confusion from not being able to clear toxins or liver cancer those are reasons to have a transplant there's also you could you might be doing totally fine but there's a scoring system called the meld score and then and if it's you know it used to be 15 it's probably down closer to 11 where you will have benefit of having a liver transplant than keeping your current liver but the type of patient you're talking about that I take care of has a mild score of six or eight that's my mild score is six so it is not a death sentence and I I wish there were people who so many times I see people in my clinic who are coming to see me for a consult and they've spent the last month waiting to see me thinking I'm going to die any minute now and then I say well the good news is you're going to make it you know and and so just having therosis is not a death sentence and I have lots of patients with therosis the management of that is really making sure you get screening for cancer which uh in patients with alcohol associated liver disease hepatitis C even if it's been

44:22 cleared you know you're talking about rates of 2 to 4% a year of getting cancer you know I've got hundred of those patients uh being seen in my uh office every month I mean two or four of them are going to get cancer every month now you can't with liver cancer that often requires transplant because the definitive treatment of liver cancer is surgery and if you have curosis you can't often just whack off half your liver to take a tumor out so it often is an indication for a liver transplant I would like to ask you how can you test your liver health I just had a conversation with with the volunteer two days ago and he said oh I go to this acupuncturist and she does something and she tells me the precise health of all my organs let's address that and what can you actually do to find out how healthy is your liver well that sounds wonderful I I wish I had that test to be able to tell everyone well I mean I sometimes see people who have had Imaging of their liver that shows therosis and you look at their Labs you look at them and there's no way to know that they had therosis I mean it is true that most people with with with liver disease have overt evidence of it with abnormal liver test but there are there are uh you know with hepatitis C for example 10% of people with normal liver test people used to think oh you don't need any treatment or worry about this but 10% of people with hepatitis C would develop curosis there's a percentage of people out there with fatty liver disease with

45:53 obesity diabetes uh who probably are developed fibrosis with normal liver test so I don't I I mean in terms of uh you know are there true liver function test there are a few tests out there that can actually um assess you know the function of the liver they're not something you do probably for people who don't have any other suggestion or signs of that um I would have a hard time thinking that you could stick a needle someplace in the body and know everything about it but um I don't I must admit I don't have uh that experience or expertise but um I would say just because someone I mean there's people out there with fat in their liver who have normal liver tests who don't know it and it gets picked up incidentally well just having simple fat in your liver may not be a problem however if you have simple fat in your liver because you drink too much alcohol that's a potential problem if you have fat in your liver and you're obese and you have borderline diabetes that potentially could be a problem in the future so I think when you find these things it is it does lead to you know raising your threshold and and trying to you know modify the risk factors that might put you at risk for developing liver disease in the future and I will say I I do have people come to me and say that they're worried they drink too much can I check their liver enzymes and I often say sure yes

47:25 we can also your liver enzymes may be just fine and that doesn't mean you're not drinking too much um yeah absolutely I mean I sometimes see people who I see and knowing they have alcohol associated liver disease and then you know they go on a period of sobriety and then they see their liver test are normal and then they think oh I can go back to drinking so I mean I think the difference between an alcohol use disorder and having alcohol associated liver disease are two different things there are way more people out there drinking way too much alcohol putting themselves at risk you know climbing ladders driving intoxicated falling down the stairs you know not to mention you know their relationships with other people their spouses their family you know engage and impacts on their work that have nothing to do with the health of their liver um and and as we've said multiple times there's so many benefits of of limiting alcohol not just for you know Liver Health um and and having liver normal liver enzymes would be suggestive of it's not causing major problems for your liver today but it doesn't mean go out and drink more or don't address all the problems alcohol may have in your life and I think it's important to point out that alcohol use disorder does not discriminate right so I treat a lot of very high functioning patients including Physicians and um you know other

48:56 professionals who have alcohol use disorder and it it's also not a disorder of fault it's a you know it's a like you said you don't do a brain transplant it is a brain disorder and it it's a brain disorder that we have treatments for and you know I asked earlier what can people do if they're afraid they might be drinking too much and um one we'll put some resources in the description of the video here so that you can um kind of check things out on your own and also I would encourage encourage you to go to your primary care doctor or even your therapist and and just broach the topic and say hey I'm worried that I might be drinking too much and um most providers will not be judgmental they'll actually be thrilled that you brought it up and they're curious and that you're interested in in learning more and um we'll be able to support you in that if you don't feel comfortable going to uh Healthcare professional you can um just Google um alcohol support groups and you'll find all sorts of groups there's AA if you're not a big fan of AA there's uh different variations of peer support groups um as Anastasia mentioned there's apps you can just go into your app store and Google alcohol use or stop drinking or you know anything like that you'll find apps that can help you so you know I think we've talked about a lot of things today that might be kind of scary and might make people feel bad like they maybe they're doing something wrong and I guess what I really want to highlight is it's it's not wrong it's just something that can affect your health and there are things

50:27 you can do about it so it's important I think to be aware of the impact it can have I I couldn't agree more I think one thing I do see is patients who are preferred to me they've got liver disease and for some reason in their mind you know someone with an alcohol use disorder is someone drinking out of a paper bag and you know in the alley you know I've seen very successful you know companies business company owners and I've seen mothers taking care of three children who do an excellent job of taking care of their kids the problem is when the kids go to bed they're turning on Netflix and having forg and tonics you know but they get up and do the work the next day so I mean these are it's it's um yeah it is not uh I think there's a stigma sometimes associated with this uh that maybe prevents people from getting help I mean there's now you can do alcohol treatment completely online these days um and you know that's very helpful for us living in a rural environment where people can't get to some of these resources but there's a lot of different options as you mention I think for people to get the help they need and I think the first thing is just maybe doing an inward look and seeing how much you do you know there are some calculators online uh uh uh that can questionnaires uh I think audit is one where you can fill out 10 questions and it kind of puts you in a category of whether alcohol has it the CDC has a a check your drinking uh part of their

51:58 website that asks you questions and then tells you what the chances are you might have a problem with alcohol and I think those are some things to kind of consider and start with and also if you are drinking heavily more than several drinks a day you probably don't want to just stop because a lot of people will go through alcohol withdrawal so it's important you reach out for support in in um cutting back and eventually quitting and if you are on the weight list for a lever transplant or you interested in learning more learning more about leaving lever donation we have an incredible mentorship program at the American transplant foundation so make sure to check it out and maybe you can even get Rachel as your Mentor all right well thank you Dr Burton and Anastasia I think this has been a very interesting and useful discussion and um it's been a pleasure talking with you it's been my pleasure talking with you as well have a great day thank you up call W you get out the sun is creeping wake wake up call