Robert Rahimi, MD, a Transplant Hepatologist at Baylor Scott and White in Dallas talks about using Hep C infected livers to save lives for those on the organ wait list.
Interview conducted by Ivanhoe Broadcast News in September 2019.
Let’s talk a little bit about Kimberly first, and then we’ll talk a little bit more broadly about the whole concept. What did you see with her when she became your patient?
RAHIMI: Kimberly was very sick initially. Based on her blood type she was in this gray zone where she really was not too sick to get a liver transplant. However she needed one because she’s had the complications of liver disease. Her mother actually underwent hepatitis C therapy. With the new advent of antivirals hepatitis C treatment, patients take daily pills anywhere from eight to 12 weeks. We can cure ninety seven to ninety nine percent of patients. The risks are if a patient has hepatitis C, we would potentially give you the liver that is infected but the post-transplant treatment offers a high cure rate. She was a little hesitant, obviously, because her mother went through it back in the day when the injections which were very difficult. Interferon treatment was almost like chemotherapy. Now you take a pill daily for about eight to 12 weeks and we have a ninety-seven to ninety-nine percent cure rate.
She said that she got called six times and that turned out to be a false alarm. Is that right?
RAHIMI: That’s correct. So with that, when the surgeons go procure the organ, obviously, they have to make sure the liver is healthy or in good shape. If the organ is not in good shape, we take a biopsy or look at the surface of the liver. We might not be able to use those organs. So it has to be a match for the patient.
That would be a blood type and a size?
RAHIMI: Blood type size and also how much damage has been done to that liver.
OK Hepatitis C has become a very big deal. And with baby boomers there seems to be a heavy concentration of it, which is becoming mainstream knowledge these days. Can you understand why somebody would not want to get an infected liver?
RAHIMI: Oh yes. The reason why someone would not want an infected liver is because back in the day when you were diagnosed with hepatitis C, it was almost like a death sentence. A majority of cases would progress to cirrhosis. And the cure rates were very low. Less than about a third of the patients could be cured with the older generation medicine.
Now the oral antiviral medicine is very easy to treat these patients. So there was some hesitancy, but the public doesn’t know that we can actually cure a virus with a pill. Most viruses, same like with flu, there’s no cure. You can take some medicine. It decreases the symptom. But this is actually a cure. So a lot of the patients – they actually have no symptoms. They’re asymptomatic. And that’s a big deal. That’s why they didn’t know they had hepatitis C.
With the opioid epidemic, which is increased in the last decade, we’ve seen the advent of hepatitis C increase. In the past when an organ becomes available that has hepatitis C, we couldn’t give it to anyone. In the past we could only give it to the patients infected with hepatitis C.
So what Baylor University Medical Center thought about was those organs we weren’t able to use. So why should we discard them? We came up with an informed consent and we educated our patients. We told them this is your option. Just like in Kimberly’s case. A patient can accept an organ that is hepatitis C positive and now there is a treatment with a ninety-seven to ninety-nine percent cure rate. And she got the call and she took the organ. And she’s cured.
That’s amazing. What would typically happen to infected organs in the past?
RAHIMI: So infected organs in the past could only be used in patients that had hepatitis C. They already had hepatitis C and it goes through the bloodstream. And let’s say an organ came available that had hepatitis C. We could only give it to those patients that were already infected. Now with the advent of antiviral therapies, the treatment cures many, many patients. It’s almost like it’s limiting hepatitis C from the baby boomers, those that are asymptomatic. They don’t know that they have hepatitis C. So the new organs that become available because of the opioid epidemic and it’s found to be hepatitis C, we would actually discard them unless we could give the organ to a patient who already had hepatitis C. But nowadays with informed consent we can use these.
You used to throw them away.
RAHIMI: Yes, we would either throw them away, discard them, or if someone had hepatitis C already.
This is a huge medical breakthrough, right?
RAHIMI: It is. And the reason is because you’re saving lives. At the end of the day, we all want to help our patients and we want to save lives.
What do you think of all this?
RAHIMI: It’s amazing. It’s been a game changer. And the hope would be we could eradicate hepatitis C.
We were talking about the concept of being able to kill a virus or cure a virus. Talk about that.
RAHIMI: So viruses in general are very difficult to cure. You could suppress viruses. You can actually take care of their symptoms with medicines. But because the virus doesn’t integrate, it depends if it’s an RNA virus or a DNA virus. Hepatitis C specifically is an RNA virus. Humans are made up of DNA. So because of that they would also mutate. Viruses are smart. They adapt to the surrounding and they have different assembly proteins that actually make it difficult to target. However these specific antiviral medicines target the proteins that form the virus. So if you can’t form the virus you don’t have the virus. And because of that, that is where they stopped replication of the virus. And it becomes very important.
- Is that part of what cures them?
RAHIMI: That’s exactly what cures them. Because they can’t form the virus or they won’t be able to replicate. The virus won’t be able to double triple quadruple in the blood. And so when you stop the machine factory then everything is halted. And that’s the cure.
What do they do? They die or they get flushed out of the system?
RAHIMI: They basically die. So let’s say you had just one virus. Let’s say you were able to knock down all the viruses. We’re talking virus particles are in the millions in your blood for hepatitis C. But if you got down to one or two. If you haven’t stopped the machinery to build the virus, they would double, triple, quadruple and over time it would come back. But if you stop and get rid of all the viruses, it’s like there’s nothing in your blood system. You are cured.
Sounds like everything worked like a charm in her case. Is that right?
RAHIMI: It did. Everything went smoothly once she accepted. And the important thing of all this is we have to have informed consent. The patients need to know this is a risk. There is still a 1 to 3 percent chance you cannot be cured from this, although there are backup medicines in case the cure rate is in that 1 to 3 percent failure. There are some other medicines that they can take afterwards to cure. So, you know, with Kimberly’s case, there was a little hesitancy only because she had her mother back went through it and it was very difficult back in the day.
What about living with hepatitis C? I have a couple of friends who have it and it’s been a problem but maybe now that they’re exposed to this new medicine, maybe it’s not such a problem.
RAHIMI: That’s exactly right. So anyone with hepatitis C in general, they’re asymptomatic. In the 1970s when drug use was more prevalent and we didn’t know about hepatitis C until 1992. If patients had drug use, if they had tattoos or blood transfusions before 1992, they might contract hepatitis C yet not about it. It takes about 20 to 30 years to progress to cirrhosis. So anyone born between 1945 and 1965, the CDC recommends to get checked once with a simple blood test to determine if you unknowingly have hepatitis C. I would urge anyone that had high risk behaviors which happens to be any drugs, I.V., intravenous, things like opioids or snorting cocaine, blood transfusions before 1992 if they’ve been incarcerated or had tattoos. These are what we call the high risk group. They should just get checked with a simple lab test to make sure if they have hepatitis c. It’s very simple. Hepatitis C can be cured.
What about sexual contact?
RAHIMI: It can pass sexually. However it’s less than 4 percent overall. In general in a monogamous relationship it’s actually 1 percent. So if someone does not have a HIV or hepatitis B and does not engage in anal sex in general, you pass it off less than 1 percent. So we don’t really think of sexual as a big deal. We actually tell patients in a monogamous relationship with not having any other immunocompromised system that it’s OK to have unprotected sex.
You mentioned the cocaine. I guess I was under the impression that it had to be sort of intravenous drugs. But no, huh?
RAHIMI: That’s actually the interesting part. The hepatitis virus actually stays on the surface of when people do cocaine through the nasal passages. When they have their mucus from their nasal passages, it stays on the table. So even if you clean it, the virus can stay up to one to two weeks.
No, I think that’s fascinating. Because a lot more people did cocaine.
RAHIMI: Exactly. And in general even if they clean up that area and they disinfected, the virus can still stay alive.
And where does the virus come from?
What is the future of people who have fatty liver disease and other things that could cause serious problems with their liver? I guess all that is on the rise too?
RAHIMI: Fatty liver disease by 2025 will be the number one cause of liver transplant. And the reason is because the majority of people in the United States, especially Texas, are overweight and obese. And there’s something called the metabolic syndrome where fat deposits in the liver. And when that happens it can lead to chronic scarring and cirrhosis.
Right. And between the hepatitis C which we’re curing and the fatty liver is going to become more the big problem than even hep C. Is that right?
RAHIMI: That’s the assumption, yes, that fatty liver over time will develop more quickly and actually the curve when you look at it compared to hepatitis C – it’s going up almost in a straight line. And because a lot of people are not aware, they don’t know that oh when I eat too much if you’re overweight or obese that can damage your liver. Sure, there’s risk for stroke, heart attack, cholesterol problems. But they never actually believe that it could affect their liver. And this is one of the major things that in the future targeting hopefully with medicines. Obviously diet and exercise is the key. You can actually reverse the scarring of the liver with fatty liver disease.
- And what about alcohol?
RAHIMI: So alcohol in moderation is OK. But as a liver doctor, we can’t encourage it. Alcohol is still on the rise. However, it’s not as prevalent as fatty liver disease. The interesting thing is alcohol and nonalcoholic fatty liver disease or NAFLD act and look similar clinically, on ultrasound and almost on liver biopsy. So it uses the same pathway. There is a gene that has been associated with these two specific entities.
It’s fascinating. What do you see as the future? I mean you’re going to be in business for the rest of your career, for sure. But these breakthroughs are really significant.
RAHIMI: It is. I think the non-alcoholic fatty liver disease – specifically having fat in the liver – in the next decade or so, that will lead to the number one cause of liver transplantation. I think the future breakthrough would be any individual or company that can figure out how to reverse that process because the majority of the time it’s diet and exercise. Most of us, as we get older we have different priorities. We might make excuses to not exercise, diet, but this is the pathway that’s happening. Now if you look back even back in the 1970s, 80s, everyone was relatively thin. Now with the great food in Texas and other parts of the country, I think as Americans, we consume a lot more and we actually work out a lot less.
Yeah. And that obesity and all that’s contributed to heart disease, diabetes – it’s killing us.
RAHIMI: That’s actually is the mainstay of fatty liver disease. If you think about this metabolic syndrome that I discussed earlier, it includes usually diabetes, high cholesterol and high blood pressure. And all of that in general comes out when you are overweight or obese. And if you can reverse that process, which, again, the basic foundation of all that is diet and exercise. But a lot of people have two jobs, three jobs. They don’t have time to work out. Sometimes it’s very difficult when you’re on the run. You’re eating fast food. So it becomes very challenging. If that process can be reversed, it might potentially fix a lot of diseases.
Right. This whole putting an infected organ into somebody whose body was already sick with that organ – it just doesn’t make that much sense. But as you explain it as we understand it, it is a rather outstanding breakthrough and in many ways miraculous.
RAHIMI: It is, and the reason why we looked into this specifically, Baylor University Medical Center and other places around the country, is because on average about 15000 people need a liver transplant and about 5000 can get one. So because of the discrepancy and the organ shortage, we would be disastrous to discard these livers that are infected. We have to come up with another way, not just at Baylor, but also different parts of the country. We can actually cure hepatitis C now. So let’s use those organs because so many people need them, but a lot of people can’t get transplants. The other interesting thing about Baylor is that we do live donor liver transplants. And the reason that is important is because most places need a specialized team for that. The liver can heal in six weeks, so if you take half a liver from a live person and put it into someone that needs a whole liver, take out their old disease liver, both livers will grow back in six weeks.
It’s amazing. In fact we did that story a couple of years ago.
RAHIMI: You did? Okay. Good.
Let me just ask you a little bit about the donor. Kimberly doesn’t know the donor. She hasn’t been in contact. Was the donor aware that his or her diseased liver was going to go to her?
RAHIMI: The donor is not aware because at the time of donation usually unfortunately someone has to die. And during that process if they are a donor they don’t know where their organs are going to. However the family can actually request, and there is a process that we have here at Baylor, that depending on how the donor family is and the recipient, they can actually connect. We’ve had so many patients that have connected and become very good friends. That’s a separate process that our team is excellent at taking care of that. Sometimes a donor, they don’t know they have the disease. So when they unfortunately pass away, they don’t know they were infected with hepatitis C. And at the time of organ procurement when the surgeons goes in and takes a look at a liver it is required by law that they test the organ for pretty much everything. They test the donor for any viruses. And there is something called high risk donation, and we are required to inform any recipients, like Kimberly, that this is a high risk organ. Sometimes it can be hepatitis C in the blood, but when we do further testing, it was a false positive. That’s something that we also mentioned to the patients.
And how many lives is this going to save?
RAHIMI: We at our program have done about 13 in the last about six months. So if you think about those 13 patients – those are 13 potential patients that would have not been here today. This is just Baylor University Medical Center- one center. This is now adapting all across the United States and the world. Over time, it’s going to save thousands of lives.
And that feels good.
RAHIMI: It feels great. And it’s not only the liver we’re talking about. This is also now being implemented in kidneys, hearts and lungs. And so the reason that becomes very important is because back in the day if anyone was a donor for, let’s say, a heart or someone needed a heart transplant, someone needed a kidney transplant, they were on dialysis, or they needed a lung transplant, if the patient had hepatitis C or the donor organ had hepatitis C, they could not use it. But now with the advent of the antiviral therapy, you can, across all different organs, transplant patients with the donor organ with hepatitis C and actually cure them still at a high level, over 97 percent. However, the patients need to be informed. That’s probably a very important part to know that they are taking a high risk. But we can cure it, and we can use all those other organs. So now if you include all those other organs we’re talking tens of thousands of lives over time.
That’s amazing. To what degree was Baylor at the forefront of all this?
RAHIMI: Baylor University Medical Center in Dallas is doing a lot of research. And we collaborate across the country with many big universities. And we when we go to our meetings we talk about these things and we say look, there’s an organ shortage. We need to do something. Now we can cure it. Why don’t we together as a group think about having a protocol in place using those diseased organs that have hepatitis C and actually cure them afterwards? And a lot of big universities got together including Baylor and said look let’s try it. And up to now we’ve had great success.
Excellent. Thank you so much.
END OF INTERVIEW
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