Will I get back my original disease after liver transplantation?

Liver transplantation is the only viable treatment option for end stage liver disease. This treatment allows patients to live a new life with some restrictions. But the question that lingers on everyone's mind is whether the disease that caused the liver failure, will come back in the new liver.

This is the question we have attempted to answer in this blog post.

Of course, self harm induced by return to drinking will damage your new liver. This is not the focus at present. Rather we look at diseases that will make a come back despite precautions taken by the patient.

Hepatitis B

Today, there are highly effective and well tolerated medications available to control hepatitis B virus (HBV) replication prior to transplant. Most of the patients are referred to us with very good control of virus levels prior to transplantation. The medications that controlled the virus, need to be continued after transplantation long-term. In addition, patients transplanted for HBV cirrhosis will get injections of antibodies against the hepatitis B virus at regular intervals, during the first year, after liver transplantation. The combination of these measures is highly effective and can prevent HBV recurrence in the graft in almost all cases. The patient and the family must understand that the cost of transplant will increase when hepatitis B immunoglobulin has to be used.

Hepatitis C

In India, the pick up rate for Hepatitis C seems to be low. As a transplant surgeon, I am concerned about the possible increase in HCV due to non detection. We have some excellent drugs that have come up recently and are very effective in the eradication of Hepatitis C. 

However, if end stage liver disease has already occured and transplant is indicated, it may not be possible always to clear the virus prior to transplant. During transplantation for hepatitis C virus (HCV) related liver disease, the graft is always re-infected by HCV. There is no way to prevent this HCV re-infection, and recurrent hepatitis C in the graft occurs universally. 

In general, we predict that HCV infection after liver transplantation runs a more aggressive course than in the non-transplant setting. Thus, close to one-third of patients develop graft cirrhosis within 5 years after transplantation.  Current antiviral therapy for hepatitis C is less effective after transplantation, has numerous side effects and can trigger acute and chronic rejection of the graft. 

If the infection recurs in the graft, the transplant team will monitor this and start appropriate treatment. This may mean that you undergo appropriate blood tests and sometimes liver biopsy at regular intervals.

Non-Alcoholic Steatohepatitis

Fatty liver can recur in the graft after transplantation. This is the case in at least a fifth of patients. Good control of the risk factors for NASH, including diabetes and body weight, are important preventative measures. 

Beyond control of risk factors, there is no drug therapy available that is of proven efficacy and safety. It is rare, but not impossible, that recurrent NASH leads again to end-stage liver disease in the graft.

Autoimmune Liver Diseases

Autoimmune liver disease such as autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) may recur in the graft in up to one third of patients. Recurrent AIH, PBS and PSC are easily controlled by medications. 

It is rare that recurrent autoimmune liver diseases lead again to end-stage liver disease in the graft.

Inherited Liver diseases

Hemochromatosis (excess iron deposition)is not cured with liver transplantation and excess iron may reaccumulate with time in the new liver. 

It is advisable to regularly monitor total body iron stores with determination of serum ferritin and to re-start phlebotomies as required to keep them within normal limits.

The defect leading to excess copper accumulation is cured with liver transplantation and Wilson’s disease does not recur in the graft after transplantation. Damage caused by excess copper accumulation in other organs such as the brain is not reversible with transplantation.

The new liver does not carry the gene defect causing Alpha-1-Antitrypsin Deficiency and this disease will not recur in the graft. However, damage to other organs such as the lungs, is not cured by liver transplantation.

So a transplant recipient must be aware of the risks that the original disease may come back in the graft and take appropriate measures to minimize the effect of such recurrent disease.