This question is primarily for those with a medical degree or other specialized knowledge.
My brother lives in Skokie, Il, 1000 miles from me, so I don’t have much contact with him. Somehow (no one knows how)he acquired hepatitis C which progressed to cirrhosis. He had a liver transplant last month since they found a compatible donor. His wife and my nephew have told me that he’s progressing, but they are hesitant on details. He’s in a rehab center. At first after the operation, which lasted 18 hours, he was totally physically and mentally incompetent. I’ve been told that he is now able to walk some, but he’s still not all there mentally and physically.
My question is why would the liver transplant affect his mind? Would it be the effects of the immunosuppressant agents? Would it have something to do with the lack of blood to his brain? They say he is progressing. Is total recovery to be expected? Any details anyone can furnish would be welcome.
When the liver isn’t working right (or when it’s absent!) it fails to deal with the ammonia and nitrogen resulting from incomplete metabolism. When this crap circulates in the blood, it deranges the brain.
Maybe after a transplant the new liver doesn’t really get going right away, takes some time to adjust to the new hookup.
The sick thing about liver transplants for Hep C patients is that they are now transplanting livers that are already infected with Hepatitis C. That’s right. They take out the bad one only to put in another bad one. The rationale for this is that the HCV-infected livers can’t be put into non-Hep patients and would otherwise go to waste. How long before someone gets slapped with malpractice for this?
I can’t answer your question, but I can relate from family experience. My brother-in-law had Hep C and required a transplant. He was able to get a partial transplant from his daughter. (Evidently, your liver has 2 lobes, and you can donate a lobe to a compatible recipient. Both lobes will grow back to the size of the original liver and function just as well.)
Anyway, he was pretty out of it for a few days after the surgery, but not to the degree that your brother is. He had a few complications over the last year since the surgery, mostly involving fevers and such. There are all sorts of complications from any type of organ transplant, but my brother-in-law seems to be pretty much recovered.
Besides Jomo’s post, there could be another possibility. A year ago my father had knee replacement surgery. He had the same mental and physical problems that you describe your brother having, and he had them for months. It turned out that my father had a stroke from a blood clot resulting from the surgery. I hope that’s not the case with your brother, but I’d certainly inquire about it if they haven’t already checked for that.
There’s a bunch of different reasons why someone may be “out of it” after major surgery.
First of all - with end-stage liver problems (which is where you need to be to get on the transplant lists) all kinds of toxins are building up in the blood and body, which can have a bad effect on your mental state.
Some people react to anesthesia with various altered states - my mother was outright delirious after both of her open-heart surgeries. Since the liver is the one of the major de-toxifying systems of the body I would expect anyone with liver troubles to be more prone to this sort of thing.
Also - 18 hours under the knife is a tremendous stress to any person, much less someone who has been ill for an extended period of time.
I guess what I’m saying is that the condition your brother is in isn’t necessarily permanent, due to something horrific (other than having a transplant - if you think about it, removing internal organs and replacing them is a bit, um, well if it hadn’t been done by trained medical people that sort of thing - slicing folks open - is usually considered attempted murder), or a sign of some terrible complication. It may simply be a reaction to everything he’s gone through and as he heals up his condition will improve.
Try finding a survivor support group on the Internet and ask them how typical that sort of reaction is.
What’s the problem? You’re about to die from liver failure due to Hep C. No clean livers are available, but another liver is available, that is still functioning, but has hep c. You already have Hep C! You can’t get it from the working (but infected) liver! If you got transplanted with a clean liver, you’d probably give it your hep c! It’s a crapshoot as to whether this liver will fail due to the virus, but hell, at this stage, all life’s a crapshoot! Malpractice? As long as informed consent is given (we’ve got a liver, it’s got hep c just like you, but it might work. You’ll die if we do nothing. You may die even if we do this) there’s no malpractice in the outlined procedure!
I’ll leave the more proficient answers to Qagdop and the other real MDs around (I’m only in med school), but here are a few guesses. Note that these answers are for “entertainment” purposes only as I am not a real medical authority.
Immunosuppressives or steroids can have mood altering side effects.
Encephalopathy from graft dysfunction – can be temporary post transplant or permanent from rejection, primary non-function, thrombosis, etc.
Immunosuppression has weakened his immune system and he may be fighting off an infection. Altered mental status goes hand in hand with sepsis.
No, unfortunately, Hep C courses thru the system. Removing the liver won’t remove it from the rest of the body. I fear I must admit I don’t know the exact rate of re-infection of a clean liver (transplanted into a hep c patient), but I do know its more than zero.
Edwino-good points. Now get back to studying! Don’t you have some scut to do?
Well, anyway, it will probably be another 20 or so more years before he has to worry again. Good news, though, my nephew said he really is progressing. Thanks every one for responding.
I have a related question and since this is my thread I figure I can pirate it. I read that about 16% of those who acquire HCV are able to ward it off. (I think that’s the percentage, but I’ve seen different ones. Anyhow, a small minority has an immune system that defeats the virus.) Is there any reason why some can and some cannot? Is there a genetic difference that accounts for that?
Moreover, why can’t every one’s immune system take care of HCV? Esp. when it courses through the blood. Related to that is why the body’s immune system cannot get to viruses that reside in the ganglia, such as herpes?
My numbers may be out of date, but the mantra we repeated in medical school for HCV (or maybe HBV) was :
Roughly 10% get chronic infections.
Of those, roughly 10% get cirrhosis.
Of those, roughly 10% get hepatocellular carcinoma.
So 0.1% of all diagnosed with HCV eventually go on to get HCC. This is very bad.
Like varicella zoster (chicken pox), HCV is most severe when it becomes a chronic infection. Our bodies aren’t so good at defeating chronic infections, and we carry a host of viruses around for the rest of our lives after we are infected once (EBV, CMV, VZV, etc.) There are even examples with bacteria and parasites (TB and malaria).
The basic problem is that a virus can hide in a cell and not reproduce. If it is not reproducing, it is not making much protein. Due to the nature of the immune system, unless virus protein is actively being made and degraded, the infected cell is indistinguishable.
I have heard no data on why the infection is chronic in some and acute (goes and then leaves) in others. It probably is partially genetic and partially environment and partially luck.
For HIV, quite a lot of work has been done on this. It turns out that even if you get HIV in your bloodstream, there is a quite low probability that the virus will enter a cell and be able to replicate itself (which is what is needed for a true “infection.”) This is usually due to luck – the virus load is quite small at infiltration, those need to enter the circulatory system, encounter the proper cell (I believe they infect macrophages first), bind to the cell, enter the cell, and then hijack the cell’s defense mechanism well enough to be able to replicate their DNA (which in itself is a dicey proposition with RNA->DNA reverse transcription which is how HIV does it.) I would imagine much of this is true with HCV as well, as the methods of transmission are similar.
I should mention to clarify the above post that many of these chronic viruses can become reactivated (herpes and chicken pox) and cause a new infection. The body rapidly deals with them, causing shingles and cold sores and the like. The original ganglion in these cases (which is by the spinal cord and contains the genome of the virus) remains untouched.
Other viruses, like HIV (and if IIRC HBV and HCV) slowly leak viruses into the bloodstream, maintaining a low blood level everlong. This causes reinfection in other cells. While the body does identify and kill cells which are leaking virus, it is often I guess below the alert levels to kill ALL of them.
Thanks!
About scut – my scut now is different (I’m doing MD/PhD and in grad school). Although I wouldn’t mind chasing down some films or a few blood draws from time to time, most of my time now is spent doing science. Scut for me is pouring plates or flipping stocks.
For a personal story of someone with Hep C who is battling it into remission, you can see Ayesha’s thread WooHoo ! Ayesha is undetectable !. In the thread are several links to Hepatitis support and information sites on the web, including the site she references in her sig, http://hepatitis-central.com/.
[QUOTE About scut – my scut now is different (I’m doing MD/PhD and in grad school). Although I wouldn’t mind chasing down some films or a few blood draws from time to time, most of my time now is spent doing science. Scut for me is pouring plates or flipping stocks.
**[/QUOTE]
Oh, a Mud-Phudder! Awesome, man! I thought about the medical scientist route, but decompensated after 4 years of being in the labs part time, and went pure clinical. Sometimes I regret it. Good luck!
My limited understanding of the human anatomy is that there is a pair of ganglia at each vertebral segment. You mention one. Does the virus genome reside in only one, any particular one, some of them, or all of them? Another question, Edwino: the herpes simplex type I activity is usually manifested by ulcers on the lips (sometimes near the eyes)but always on the face; type II is at the genitals. Type I is very common and I have it, and when it becomes active (during periods of stress, such as colds), I get cold sores. I had assumed that the virus genome lived in one of the facial nerves, since activation is always there. Since it is at a vertebral ganglion, why is the manifestation on the lips (or, in case of type II, in the genitals)?
Thanks in advance for your kind reply. I should mention that I find Curasore (active ingredient is ether) very effective, altho I know there is a prescription medicine, Zoviran or acyclovir (or something like that). My dentist once gave me a prescription for that, but I found it no more effective than Curasore, which is 5 times cheaper.
The body has billions of ganglia. A ganglion is formed wherever a number of nerve cells interact with each other to form a nexus, receiving and sending out nerve fibers there. The spinal ganglia are just larger, and more obvious than most others. Viruses (virii?) can reside in many different ganglia thruout the body. HSV I and II both tend to prefer mucous tissue to other types, although they can occur in and around the eyes and elsewhere. So they mostly stick to the mucous tissue of the lips, tongue, palate, glans and labia, and reside in the most conveniently located ganglia ennervating these areas. Type I is more common in the mouth, and type II in the genitals, but it doesn’t have to be that way. HSV can be spread to the genitals thru oral contact, so your spouse can give you genital lesions from their oral lesions, then accuse you of infidelity! I’ve seen this happen more than once. Then we have to match up the genotypes of the respective spouse’s viral lesions to demonstrate that they both are sharing the same virus.
**Thanks Billdo ! ** I just found this thread. First those who have said transplant isn’t a cure are right. It isn’t a cure but if you get a new healthy liver it can buy you some years. Hep C is a fairly slow acting disease.
As for using infected live on transplant paitents with Hep C, I have never heard of that, but hell I had never heard of HepC until I was diagnosed a few years ago either. But I will say this, Hep C has many sub-groups called geno-types. (examples - there is 1a, 1b, ect, 2a, 2b, ect 3a (that would be me) 3b, ect and so on) It is possible to be infected with more than one geno-type (cross-infected). This is not a good thing. Some geno-types respond better to treatment than other. 3a’s such as yours truly , respond pretty well to therapy.
barbitu8, You asked some good questions, maybe a GI doc could answer them. I have no idea why this is true, but it is. That is why there are test just for the anti-body and then other more sensitive test if you test positive they do to see if you have the anti-body to see if you have the active form of the disease. At this point there is no cure, but the results of the combo treatment look pretty good. Sadly not everyone can deal with the treatment. It can be pretty harsh on ones body.
I will add a bright note, I have not had a cold or the flu since starting combo. The anti-viral and interferon seem to keep them away or at least very mild.