Transplant hepatologist AnnMarie Liapakis, MD, cares for patients with end-stage liver disease, optimizing their health to prepare them for surgery and life after transplant. While she finds great joy in this work, she also sees more than her share of disappointment. In liver transplantation, there is a huge and growing gap between supply and demand. Each year some 11,000 Americans are added to the liver transplant waitlist — but only about 7,000 receive a transplant.
“By the time we see patients, they’re already quite ill,” says Liapakis, associate professor of medicine (digestive diseases) in the Department of Internal Medicine at Yale School of Medicine, and of surgery (transplant); and medical director, Living Donor Liver Transplantation at the Yale New Haven Transplantation Center at Yale New Haven Hospital. “In our region, one in five people die on the transplant waitlist. So as transplant physicians, I believe we have to find ways to increase our patients’ chances of actually getting an organ.”
Liapakis has made it her mission to raise awareness about the importance of organ donation from both deceased and living donors. In recognition of her advocacy, she recently was honored as a “Transplant Superhero” by Donate Life Connecticut, an organization dedicated to increasing the donor registry. She is quick to deflect credit. “I’m not a superhero,” she demurs. “The real superheroes are the deceased donors, the living donors, their families, and our entire transplant team.”
With living donor transplantation, the patient receives part of a liver from a living donor. Because the liver has the ability to regenerate, the donor’s remaining liver will grow back almost to its normal size. The transplanted portion of the liver will also regenerate and restore normal liver function.
While many countries have moved more toward living donor liver transplants, the focus in the U.S. has traditionally been on deceased donor transplants. Slowly that is changing, and the number of living donor transplants is increasing here. Liapakis recently participated in an American Society of Transplantation consensus conference dedicated to identifying barriers to expansion of living donor liver transplantation in the U.S. and strategies to safely overcome them. “Living donor transplants involve not one, but two patients,” says Liapakis. “This requires an extra layer of expertise, which our team has. What sets the Yale New Haven Transplantation Center apart from others is our deep experience in living donor transplant.”
Liapakis joined Yale’s liver transplant program in 2012. Born, raised, and educated in New York, she is the first physician in her family, though her father, formerly a New York City detective, served as a corpsman in the Vietnam War. As a high school student, a part-time job in a large cardiovascular surgery practice opened her eyes to helping others.
Transplant hepatology drew her in because of its team-based approach. “Liver disease affects many organ systems, so transplant is really a multidisciplinary field,” she notes. “Our six transplant surgeons are amazing, and their skills are top-notch. But it takes the involvement of our entire team to prepare patients before, during, and after surgery.” In addition to the surgeons, the transplant team includes eight primary transplant hepatologists, others in the division who are transplant-trained, dietitians, social workers, a skilled nursing staff, a psychologist and psychiatrist, a fellowship-trained addiction specialist, and a specialty anesthesia team, as well as consulting cardiologists and infectious disease specialists. The world-renowned hepatologists at Yale School of Medicine and the VA CT Healthcare System provide expertise across the spectrum of liver disease.
Educating patients and families about liver disease begins at the first visit. They also learn the hard reality of the waitlist. Placement on the list is designated by severity of illness. A numerical score, called MELD, is assigned based on laboratory values. “We follow some patients with lower MELD scores for years, some of whose score does not sufficiently represent their severity of illness,” she comments. “The course of liver disease is not predictable and is marked by acute events—like a roller coaster—so sometimes people deteriorate very quickly. That’s why we educate patients on trying to seek earlier transplantation through living donation. Shortening the wait will lead to a much better outcome.”
The most common cause of liver disease in the U.S. at present is non-alcoholic fatty liver disease, which is related to the obesity epidemic and impacts around 25% of the population.
AnnMarie Liapakis, MD
A donor does not have to be a family member; it can be a friend, an acquaintance, or a total stranger. Increasingly, potential donors come forward because they’ve learned of a patient’s need through social media or news outlets. “We are also seeing a rise in non-directed donors, who are willing to be considered as a donor for any eligible waitlist candidate,” says Liapakis. The transplant team is evaluating other ways to increase organ access, including use of hepatitis C deceased donor grafts and donation after cardiac death.
Liapakis works hard to inform the general public about the importance of organ donation. As a co-chair of Donate Life Connecticut, she contributed to many public awareness initiatives. One of the most successful was a collaboration with the New Haven public school system.
“We developed a curriculum to educate middle and high school students about end-stage organ disease, preventive medicine, donation and transplantation,” she says. “We want them to know what steps they can take to stay healthy. We also outlined the facts and myths about transplant. One myth we try to dispel is that liver disease is self-inflicted and solely addiction-based. While personal lifestyle choices may be a factor as in any chronic disease, causes of liver disease are multifactorial and can even be genetic or environmental.” The most common cause of liver disease in the U.S. at present is non-alcoholic fatty liver disease, which is related to the obesity epidemic and impacts around 25% of the population.
She added, “This vision for increasing organ accessibility is shared by all my Yale colleagues. They are leading innovation in transplant and liver disease management. I consider it a privilege to be on this team, and be part of the miracle of transplantation.”
Since forming one of the nation’s first sections of hepatology and then gastroenterology over 50 years ago, Yale’s Section of Digestive Diseases has had an enduring impact on research and clinical care in gastrointestinal and liver disorders. To learn more about their work, visit Digestive Diseases.