Part of our PBC Day 2021 bite-sized video series for PBC TV.
Hello my name is james newberger i’m a liver physician in birmingham and chairman of the medical advisory board of the ppc foundation what i’m going to talk about now is life after transplantation for pbc it’s an overview there’s an awful lot of detail that because of time and so on that i’m not going to discuss but i hope it gives you a flavor of what to expect
The huge benefits from transplantation as well as some of the consequences now the first liver transplant successfully done in the world was done by starsville in 1963 and the first successful liver transplant in the uk was done by sirai khan in 68. in the early days and i remember that well transplantation was a highly risky procedure with a very high mortality
Now because of a huge number of improvements it’s become virtually a routine procedure with very successful outcomes and we’re seeing people now who are alive 15 20 30 and even 40 years after transplantation there are over 900 liver transplants done in the uk each year numbers vary and of course because of covid last year’s numbers were down slightly and we’ve
Got well over 7 000 liver transplant recipients alive in the uk at the present time i’d finally make a point there’s still a shortage of organ donors so do please encourage your family and your friends to make their wishes known that they do wish to become organ donors if they die in an appropriate way and i would stress that by being an organ donor it actually
Helps the family with the bereavement process so not only does the organ donation help the recipients but also the family moving on to the next slide um now it’s important to say that life after transplantation is very good but it’s not normal the quality of life is very good we have people for example going up mount everest successfully becoming summiters and
Coming down again but it is not as good as normal healthy controls survival after transplant may also be reduced compared with healthy age and sex match population although actually this is not true for patients with pbc since we think that their survival is similar to an age match population so pbc is a very good indication for transplantation now one of the
Problems with transplants is that for the huge majority of patients immunosuppression is needed and it’s life long a small proportion do become tolerant of their graft and can stop immunosuppression but this has to be done very carefully because otherwise rejection and graft loss can occur there are an increasing number of immunosuppressive drugs that are being
Used they’re classed into various groups which you can see there most patients in the uk are managed on tacrolimus program advocate a portal it’s got various names often with either steroids such as breadness alone and class drugs or antimetabolites which is isotheraprine and mycophenolate we’re seeing a small but increasing number of new agents being evaluated so
There’s a significant armamentarium of drugs all with their own benefits and all with our own side effects now the purpose of immunosuppression is to protect the graft from rejection but immunosuppression itself has adverse consequences there’s a general am impact which is increased risk of some infections increased risk of some cancers and increased risk of heart
Disease and then there are the drug specific side effects which may include bone marrow depression renal impairment high blood pressure bone disease diabetes and particularly for sort of women of child bearing age some of the drugs such as mycophenolate and ceromas are territogenic and therefore should be avoided in women who might or wish to become pregnant so
As always you have to balance the risks and benefits of any treatment and different agents have a different profile of side effects therefore the choice and dose of immunosuppression must be carefully monitored and adjusted to individual needs for example with techrolimus i have some patients who are taking one milligram every third day and others who are taking 15
Milligrams a day so huge variation which has to be tailored to the individual some drugs such as particular tachromos and cyclosporine are monitored by blood tests it’s important you don’t stop immunosuppression without advice it’s important too that you are aware that some drugs and other factors such as grapefruit juice can affect drug levels so some medications
Will increase the metabolism of drugs and so lead to rejection others will decrease the metabolism and so lead to toxicity so when you’re taking other medicines always check with your gp the pharmacist or another health professional whether they interfere with the immunosuppression drugs this is also important to remember that some drugs such as tacrolimus are
Manufactured by a number of different companies sometimes they are interchangeable but not always so again check with your pharmacist or another healthcare professional to make sure that you’re not switching brands inappropriately follow-up after transplant should be lifelong why do you need to be followed up well you need to check on your well-being any medical
Problems you need to look for risk factors for complications smoking excess alcohol use and and and and um uh other factors weight gain is particularly a problem after transplant for a number of reasons we need to check your blood pressure we need to do blood tests which include a full blood count liver and kidney function sugar lipids and so on and check on
Your graft function how well your liver is doing and it’s important to remember that as with other liver tests or liver tests in other situations the liver tests do not perfectly reflect the graft function so you can have normal liver tests and inflammation in the liver and conversely you can have abnormal liver tests and the graft is perfect other factors you
Have to remember some infections are more common after transplant so treat early if you have worries call your doctor or your transplant unit and say if you’re having antibiotics particularly be careful of drug interactions for vaccinations you should avoid live or attenuated vaccines and the gp pharmacist or others should know which ones to avoid i would
Stress that those vaccines such as flu and covid vaccines which are safe for people with transplants they may be slightly less effective than not in the non-immunosuppressed person but the advice is very clear you should certainly take the vaccines when offered a recent study from the british transplantation society showed that those transplant recipients who
Were fully vaccinated few developed covid and none died whether those who declined vaccination there was a much higher risk of covet infection and a significant death so please do take the vaccines when offered it’s important to remember that immunosuppression will increase the risk of some cancers not all cancers skin is a particular one and therefore you should
Avoid unnecessary risk such as smoking or uv exposure so wrap up carefully use sunscreen in the sun not all cancers are increased so for example breast cancer is not increased after liver transplant so you should have the same breast screening as you would normally have there is no need to increase it but you and your clinician should be aware that some cancers
Are increased and take any skin lamp any change seriously as i say the quality of life is normally very good there are very few restrictions on activities as i said earlier we have patients who led by jacques iran have gone up mount everest who’ve gone skydiving fishing underwater and so on um pregnancy is possible and we now have many children born to mothers
After liver transplantation but there’s one caution as i mentioned some drugs such as mycophenolate the cyrolimus are damaging to the fetus and say should be avoided in those who wish to become pregnant after transplantation for pbc the itching rapidly resolves however the lethargy or brain fog or whatever you want to call it however it affects you improves only
Slightly and we do see that this persists after transplantation it’s important to remember that other conditions associated with pbc for example thyroid disease sick syndrome and so on do not improve after transplantation and they may develop for the first time after transplantation to always be aware that if you’re feeling tired after transplant it could be for
Example an underactive thyroid finally recurrent pvc unlike pbc in the native liver in the first liver if you will it can only be diagnosed with confidence by liver biopsy the anti-mitochondrial antibodies persist after transplantation whether or not you develop recurrence and so artists will guide and the liver test may be normal in those with evidence of pvc
Recurrence and many other causes of abnormal liver tests so to be sure the only way is to do a liver biopsy with increasing time after transplant the risk of developing recurrent pbc increases so roughly 50 to 60 percent of people transplanted for pvc after five years have evidence of recurrent disease but unlike other recurrent diseases it’s rarely a cause
Of graft loss and shouldn’t be a major cause for concern and recent evidence suggests that the impact of the current disease can be greatly reduced by the use of erthodoxicolic acid from the time of transplant and also by the use of cyclosporine rather than techrolimus although the latter is not always done because tachrolimus has other benefits as well so in
Summary then pbc is an excellent indication for transplantation and outcomes amongst the best for all indications for the huge majority of patients immunosuppression is required long term and the choice and dose of immunosuppression has to be monitored and adjusted and this means of course that you need to be followed up and followed up by people who are expert
In that condition look who’s looking after liver transplant patients as people are 5 10 15 years out blood tests every three or even six months are usually adequate so it shouldn’t impact on your work social life and so on even though suppression is associated with risks they can be mitigated in part by treatment of high blood pressure treatment of diabetes
Use of statins and so on but you have to be aware of these risks and act appropriately pbc does recur in the majority of transplant recipients but is usually not of significance from the clinical point of view and we do believe that erso from the time of transplant reduces the impact of disease so i hope that’s given you a useful guide as to what to expect after
Transplantation as i say i’ve been involved with transplants for 40 years or more and seen the terrific improvements that have come clearly the goal is to find a cure for pvc so we no longer need to transplant patients but for those who are either having intractable symptoms or end stage disease it remains a very good option this allows many people to lead a
Near normal life thank you for your attention you
Transcribed from video
PBC and Life after transplantation | Prof James Neuberger By PBC Foundation
