June 4, 2025 • 23 mins
Dr. Nikhil Kapila joins Dr. Michael Koren on this live MedEvidence! presentation. Dr. Kapila, a liver disease specialist, explains why we can't live without our liver. The doctors review what the liver does, what can cause damage to the liver, and what can go wrong when the liver suffers damage. They also discuss the importance of early testing, treatment options for some conditions, and the importance of clinical research in pushing liver health forward.
Be a part of advancing science by participating in clinical research.
Have a question for Dr. Koren? Email him at askDrKoren@MedEvidence.com
Listen on Spotify
Listen on Apple Podcasts
Watch on YouTube
Share with a friend. Rate, Review, and Subscribe to the MedEvidence! podcast to be notified when new episodes are released.
Follow us on Social Media:
Facebook
Instagram
X (Formerly Twitter)
LinkedIn
Want to learn more? Checkout our entire library of podcasts, videos, articles and presentations at www.MedEvidence.com
Music: Storyblocks - Corporate Inspired
Thank you for listening!
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Announcer (00:00):
Welcome to the MedEvidence! podcast.
This episode is a rebroadcastfrom a live MedEvidence!
presentation.
Dr. Michael Koren (00:06):
I'm really excited to welcome Dr Kapila to
our MedEvidence! program.
He's a rising star in thiscommunity, a brilliant,
brilliant physician whospecializes in liver disease,
and he's going to educate all ofus about liver disease,
including me.
And the first question I'mgoing to ask you is can you live
without the liver?
No, no, you cannot.
(00:26):
Okay, well, there you go.
So you've heard it from theexperts, so we're going to talk
about why your liver isimportant and why you should
take good care of it.
So this is the first timeyou're doing this program yeah,
first time.
And what we like to tell ourfolks is that, even though
they're enjoying some food,there's no such thing as a free
(00:50):
lunch.
That's right, all right.
So everybody's got to work here, okay, and everybody's got to
be involved.
So we like to start by doingsome audience participation
questions.
So here we go.
The first question which of thefollowing is not a function of
liver?
Is it A (00:58):
detoxifying harmful substances?
Is it B (01:02):
producing bile for digestion?
Is it C (01:06):
regretting that fourth alcoholic drink, so you don't
have to?
Is it D (01:11):
producing insulin or E
So what do you guys think?
All right, I heard one E, but Ithink most people said C, and
that is absolutely correct.
All right.
Next question what are the waysto push your liver towards
(01:32):
early retirement?
I'm sure that's what you dealwith.
Is people that have done that?
Yep, is it A (01:36):
avoiding hepatitis testing.
B (01:40):
heavy long-term alcohol consumption.
Is it C (01:44):
eating an excessive amount of kale.
Is it D (01:52):
ignoring signs of jaundice and fatigue?
Or is it E (01:58):
A, B and D?
This is a really smart audience.
It is.
Dr. Nikhil Kapila (02:00):
Absolutely or all of the above.
Dr. Michael Koren (02:10):
Right, well, there's an extra one there.
But they even knew it beforeeven seeing the last option.
So that's how you know theywere smart.
All right, so I think, withthat introduction, I give the
floor to you.
And why don't you explain to ushow the liver is an example of
form meeting function?
Dr. Nikhil Kapila (02:17):
yeah, I mean.
I mean the liver is well, Dr.
Koen, First of all, thank youguys for the invitation to speak
to you all.
I mean, it's a it's an honorand a privilege to be here and
to share some of my knowledge Ihave about the world of
hepatology.
You know, today it's going tobe a whirlwind tour about what
the liver is, what it does andwhy it's so important for you
know your everyday life.
So the liver serves manyfunctions.
(02:38):
It helps detoxify things thatyou eat.
It helps the metabolism of thedifferent medications that you
take.
It's intimately involved inproducing blood clotting factors
.
If your liver stops working,you cannot clot blood.
It is involved in themetabolism of various fats,
proteins, is involved in thestorage of sugar in the liver.
(03:00):
It's involved in the productionof bile, as well as excretion,
vitamins, mineral storage.
And it is very important inmaintaining a healthy immune
system.
If your liver doesn't work, youare immunocompromised.
Liver disease can present in avariety of different ways the
one that we think about, or theone that's a prototypical
presentation of somebody who'sjaundiced.
(03:20):
They look like a yellowhighlighter and that's when
jaundice happens.
Your skin becomes yellow, thewhites of your eyes become
yellow.
But there's othermanifestations as well.
Some people can develop fluidin the belly, which usually
happens much later on in thecourse of liver disease.
People can develop itchy skin,otherwise we call it pruritus.
They can develop bruising,usually because they lack those
(03:42):
important clotting factors.
They can have low bloodpressure.
They can have pain.
They can develop swelling inthe legs and the feet.
Some people can develop atremor, especially when they get
the confusion associated withliver disease.
Weakness, fatigue are othervery common symptoms of liver
disease and, as I mentioned,also confusion and loss of
orientation.
Dr. Michael Koren (04:01):
So just to be clear from my knowledge, does
liver disease make your t-shirtturn red, or is that just for
dramatic effect?
Dr. Nikhil Kapila (04:07):
I think that's for dramatic effect.
Okay, yes, absolutely, and it'sa rare case that the liver
actually causes pain.
Only very few conditionsactually cause.
Only very few liver conditionsactually cause abdominal pain.
That's an important clinicalpoint.
Dr. Michael Koren (04:20):
Excellent, so keep on telling us about all
these manifestations of liverdisease.
Dr. Nikhil Kapila (04:24):
So many of them, right?
There's so many different kindsof liver disease.
The thing that we think aboutprobably most commonly is
alcohol-associated liver disease, and while alcohol is one of
the leading causes of liverdisease, it's not the leading
cause.
Actually, this new conditioncalled MASLD or MASH, otherwise
known as metabolic dysfunction-associated steatotic liver
(04:46):
disease Very long, complex name,otherwise known as fatty liver
disease is very rapidly becomingthe number one cause of liver
disease, not only in the UnitedStates but around the world.
We also have conditions likeprimary biliary cholangitis.
We have autoimmune hepatitisand Wilson's disease, which are
much less common.
You can develop viral hepatitis,which is hepatitis A, b, C, D
(05:11):
and E, and then when peopledevelop chronic liver disease,
they can develop liver cancer,which is known as hepatocellular
carcinoma.
So hepatitis B, hepatitis B issomething that is not so common
in the United States, don't getme wrong.
It's here and it's around, verycommon though in East Asia.
It is caused by the hepatitis Bvirus, spreads usually through
infected blood or bodily fluids.
Many people won't experiencesymptoms until they develop
(05:33):
cirrhosis, until their diseasehas really progressed.
However, in the United States,we've also done a really good
job of preventing people fromgetting hepatitis B because we
have a robust vaccinationstrategy and most kids who go to
school, college et cetera havebeen vaccinated for hepatitis B.
Dr. Michael Koren (05:50):
Now you might get to this when you talk about
cirrhosis, but at one pointhepatitis infectious hepatitis
was the number one cause ofcirrhosis, but no longer the
case.
Dr. Nikhil Kapila (06:01):
That's correct, I mean that's hepatitis
C, which was definitely theleading cause of cirrhosis, and
we'll talk about that movingforward.
Dr. Michael Koren (06:08):
Here we go.
Dr. Nikhil Kapila (06:09):
Yes, so hep C .
Hep C was a killer.
At one point of time it wasactually one of the worst
viruses to get, because in manyways, the treatment strategies
for hepatitis C when I wascoming through training were
really not great.
You had interferon and you hadribavirin, which were two
medications that were reallypoorly tolerated and the cure
(06:30):
rate was like 30 or 40%.
But over the past five or 10years there's been a tremendous
amount of research in thehepatitis C world and they have
very effective antiviral agentsthat cure hepatitis C with an
almost 99% cure rate, which isjust remarkable.
There's no vaccines forhepatitis C, unlike hepatitis B.
However, because we now have anexcellent medication for the
(06:54):
treatment of hepatitis C, theUnited States there's a USPSTF,
which is a preventive servicestask force basically now
recommends that all adults overthe age of 18 get tested at
least once for hepatitis C.
So your primary care doctorshould be approaching you about
getting tested for hepatitis C,because it's something that is
now easy to treat.
Dr. Michael Koren (07:15):
Now we don't have a slide on hepatitis A.
Is that something we don't haveto worry about?
Dr. Nikhil Kapila (07:21):
It's a great question.
Hepatitis A is something thatcauses an acute viral illness.
People can become jaundiced,but hepatitis A does not cause
chronic disease.
Saying that most Americansshould be vaccinated for
hepatitis A because in certaincases, especially if you're
immunocompromised, hepatitis Acan lead to fulminant liver
failure.
It's not common, but it canhappen.
Dr. Michael Koren (07:42):
And, as I understand it, hepatitis A is
more likely to come from sort ofan oral route, whereas B and C
are more from a blood-basedroute.
Dr. Nikhil Kapila (07:51):
Correct, absolutely.
Somebody who goes, you know,eats out and eats at a seafood
restaurant, comes back five dayslater is jaundiced, having
fatigue chills you really thinkabout hepatitis A.
Or the person who went down toCosta Rica for vacation and
comes back jaundiced, that'swhen you really think about
hepatitis A, correct?
Dr. Michael Koren (08:06):
And another question.
Sorry to ask too many questionsat this point Do we need to
worry about hepatitis D?
Is that on the horizon?
Dr. Nikhil Kapila (08:13):
That's more obscure.
Hepatitis D is only seen inpeople who are co-infected or
super infected with hepatitis B,so I really wouldn't worry
about it right now.
Dr. Michael Koren (08:21):
One less thing to worry about, yes, okay,
so let's talk about alcohol.
Dr. Nikhil Kapila (08:31):
Yeah, so again, alcohol.
You know, we really do thinkthat alcohol is a toxin.
Alcohol is definitely poisonousfor the liver, there's no doubt
about it, and it's caused byexcessive alcohol drinking.
It can go through variousstages of alcoholic-related
liver disease.
People can just have, you know,bland, you know, elevation of
liver enzymes.
They can get significantinflammation called alcoholic
hepatitis, or you can developcirrhosis and many people won't
have symptoms.
(08:52):
You'll go to your primary caredoctor, get labs done and they
say, hey, your labs are elevatedand in many cases it's related
to alcohol-related liver disease.
Dr. Michael Koren (09:01):
It's now the real bad stuff.
Dr. Nikhil Kapila (09:03):
Absolutely so .
This is why we care so muchabout liver disease, because in
the early stages liver diseaseis preventable or treatable in
many ways.
Either you can cut out thingslike alcohol, you can modify
your risk factors, you can gettreated for viral hepatitis, and
our goal is to prevent thedevelopment of scar tissue,
because when a liver getsreplaced by scar tissue you
(09:24):
develop a condition calledcirrhosis and at that point it's
almost like the point of noreturn.
When you develop cirrhosis,your liver really can't heal
itself that well, and manypeople you know.
When they develop cirrhosis,that's when you start developing
the real nasty complications ofliver disease and the
complications are related tosomething called portal
hypertension and people canstart developing confusion
called hepatic encephalopathy.
(09:45):
They can start bleeding becauseof plump, distended blood
vessels that form in theesophagus, called esophageal
varices, and they can startgetting confused in a condition
called hepatic encephalopathyand they can get fluid in the
belly.
I may have mentioned that calledascites.
The thing is that once youdevelop cirrhosis and you really
can't really get treated sowell for your liver disease with
(10:05):
medications, oftentimes at thatpoint the only way to get
treated is with a livertransplant.
So this is the new kid on theblock.
In a way, it's a new kid on theblock.
That's really an old kid that'sjust been renamed block in a way
, it's a new kid in the block,that's really an old kid that's
just been renamed.
You know, M-A-S-L-D, otherwiseknown as MASLD, is what used to
(10:28):
be known as NAFLD or NASH, andit was called non-alcoholic
fatty liver disease, and nowthat term has been changed to
metabolic dysfunction associatedsteatotic liver disease.
A lot more words, a lot morecomplicated.
Maybe it makes us look a littlebit more fancy, I don't know.
But really, why they changedthe nomenclature was for two
reasons.
One, a nod to the metabolicsyndrome, that we know that the
metabolic syndrome is theleading cause of people to
(10:49):
develop this particularcondition, metabolic syndrome
meaning diabetes, high bloodpressure, obesity and high
cholesterol.
And also understanding thatvery few people do not drink at
all, and so therefore thedefinition of NAFLD, or the
previous term, said you cannotdrink any alcohol.
This condition now incorporateslow to moderate amounts of
(11:10):
alcohol consumption and gothrough various stages.
So you could see on thatschematic very nice, it shows a
healthy liver, and when thehealthy liver is insulted by the
metabolic syndrome, you couldstart developing fatty liver,
and over periods of time, whenyou have fat in the liver, it
leads to an inflammatoryresponse, you get inflammation,
and when the liver gets inflamed, you develop this condition
(11:32):
called MASH, a metabolicdysfunction associated with
steatohepatitis, and over aperiod of time, inflammation
progressive inflammation leadsto scarring and scarring leads
to cirrhosis.
So how do you diagnose a patientwith metabolic dysfunction
associated with steatotic liverdisease?
First of all, blood tests.
(11:53):
Your routine blood work thatyou get with your primary care
doctor may indicate that you maysee elevated transaminases,
your AST or your ALT.
You may see an elevatedbilirubin.
We also offer fibroscans.
Fibroscans have changed the waywe diagnose and we stage people
with liver disease.
A fibroscan is a fancyultrasound.
(12:14):
It's taken the place of a liverbiopsy, which used to have to
be done in many cases, and afibroscan is a basic ultrasound.
Goes on your right upperquadrant, where your liver is,
and it tells you how muchscarring and how much fat you
have in your liver.
We can use a basic ultrasoundas well to tell us if there's
some degree of fat in the liver.
We also can use an MRI and usetheir technology called MR
(12:35):
elastography to characterize howmuch scarring may be in a liver
.
And in rare cases you need todo a liver biopsy in order to
figure out exactly how much.
And in clinical studies wesometimes need to use liver
biopsy as well to help trulyelucidate how much scarring and
how much fat is in the liver.
Dr. Michael Koren (12:54):
Out of curiosity.
This is an audience question,spontaneous audience question.
How many people in the roomprior to today have heard of a
FibroScan?
Show of hands?
Okay, this may be a third.
How many people in the roomhave had a FibroScan personally?
Okay, it's probably the samepeople raising their hands twice
, which is okay, which is to beexpected.
(13:18):
As a matter of fact.
The reason I bring this up isbecause one of the things that
research brings to the communityis better access to this
technology, and so, if you aresomebody that is concerned and
has the risk factors, talk toone of our people and we may be
able to get you in for a freefibro scan as part of a
screening process for a possiblestudy.
No obligation whatsoever, butat least we'll get you some data
(13:39):
and get some information aboutwhether or not you could qualify
for one of the studies thatwe're doing to help people
prevent liver diseasemanifestations.
Dr. Nikhil Kapila (13:46):
And just to piggyback on that, you know I
mean that's an incredibleresource.
Fibro scans are not commonlyfound in the community and have
such easy access to one To beable to accurately and
objectively characterize thestate of your liver.
It's a remarkable asset to thecommunity.
Dr. Michael Koren (14:03):
Absolutely, so keep my going.
Sorry to interrupt.
Dr. Nikhil Kapila (14:06):
No, no problem at all.
So risk factors.
Again, it's a metabolicsyndrome.
It's got its name in the actualdisease state, and metabolic
syndrome consists of severaldifferent disease states, so
obesity being the first, themost powerful risk factor for
the development of fatty liverdisease.
The number two is diabetes.
Then you also have high bloodpressure and you have
(14:27):
hyperlipidemia either hightriglycerides, low HDL or high
LDL.
So all of these factorscontribute to the development of
fatty liver disease.
How do you reduce your risk?
So several different things, andit's been for many years and
for decades we've understoodthat the bedrock of the
(14:47):
management of fatty liverdisease has been lifestyle
interventions diet and exercise.
So weight loss about 10% ofyour weight going into it has
been shown.
A weight loss of about 10% ofyour current weight has been
shown to have dramaticimprovement in people with fatty
liver disease.
When you take a biopsy ofsomebody prior to weight loss
and you biopsy them afterthey've lost 10% of their body
(15:10):
weight, you see significantimprovement in both fat and
scarring on that biopsy slide.
Eating a healthy diet theMediterranean diet has been
tried and tested to bebeneficial in people with fatty
liver disease.
Exercising is great andavoiding alcohol.
But for years we've only talkedabout lifestyle interventions.
(15:35):
But now, thanks to the work thatENCORE does and thanks to the
work that has been done in theresearch field, we now have one
FDA-approved drug.
It's called Resmitron orResdifera.
It is the only currentlyFDA-approved drug.
It's called Resmitrom orRezdiffra.
It is the only currentlyFDA-approved drug for people who
have F2 to F3 scarring.
So when you get a FibroScan, aFibroScan will tell you how much
scarring you have, on a scaleof 0 to 4.
(15:56):
0 being no scarring, 4 beingyou've developed cirrhosis.
So if you're at that stage ofF2 to F3, you may qualify for
this medication and, amazingly,ENCORE was part of the clinical
trials to get Rizdiffra approved.
Dr. Michael Koren (16:10):
Yeah, and I'll tell you this is personally
very gratifying to me, notbecause I'm a liver person, I'm
a cardiologist but just to bepart of the process that takes
disease that had no solution andthen get people involved in the
community to find the solution,and then working with a company
to get the solution through theregulatory process and now
having a product in the marketis just so reassuring and
(16:34):
gratifying.
Dr. Nikhil Kapila (16:35):
So absolutely as a hepatologist who for years
has not had a valid or viableoption, I mean it's amazing, so
it's, I mean yes, it is on allfronts, absolutely.
But that's not the only drug,you know.
There's more drugs that arecoming down the pipeline and we
at ENCORE are evaluating otherdrugs that can be used to help
(16:58):
in patients with metabolicdysfunction associated steatotic
liver disease.
While there's different targetsof thyroid receptors within the
liver, there are othermedications now that have other
mechanisms of action that canalso help, or potentially help,
in fatty liver disease, and theycan work in a variety of
different ways by decreasing thefat in the liver, by lowering
your blood sugar, by loweringcholesterol and by increasing
(17:21):
insulin sensitivity, becausewhat we realize with fatty liver
disease is that there's a realcomponent of insulin resistance,
and so that's another mechanismto hit.
So hepatocellular carcinoma,HCC.
So the number one cause ofcancer in the liver is actually
metastatic disease, right, theliver.
Because of where it sits andits blood supply, it's very
(17:44):
vascular.
When somebody develops cancer,let's say in the colon or
elsewhere in the body,oftentimes you can get, or
sometimes you can get a livermet [metastatis], and so that's
the number one cancer the liver.
But if you talk about primaryliver cancer developing de novo
from the liver, the number oneliver cancer is hepatocellular
carcinoma, and in almost allcases.
(18:06):
It's very rare.
In most cases, hepatocellularcarcinoma is preceded by
cirrhosis.
So most people will havecirrhosis for years and then
develop HCC.
Because what do cancers like?
Cancer likes chaos.
And what is a fatty liver?
What is an inflamed liver?
What is cirrhosis?
It is a liver in chaos, and sothat's where cancer forms, and
(18:28):
oftentimes tumors don't causeany symptoms.
And here, right now actually asof now, and I'm the primary
investigator on this study isthat we're actually
investigating the use of a bloodtest to detect cancer at early
stages.
So in people who have cirrhosis, we're able to do a blood test,
and it's obviously in the earlystages of investigation right
(18:50):
now, but we're trying to see ifthat can help and detect cancer,
as opposed to requiring peopleto undergo regular imaging
studies.
Dr. Michael Koren (18:57):
Yeah, and that's super cool, and I guess
there are more and more diseasesthat are being diagnosed with
simple blood tests.
Dr. Nikhil Kapila (19:03):
Correct, so this is kind of part of that
trend, absolutely, absolutely, Imean, and you know it's in its
earliest stages and we're tryingto see whether this is
beneficial, whether it works,but absolutely, I mean, whatever
helps the patient get to adiagnosis is what we're trying
to do.
Dr. Michael Koren (19:18):
And is this study ongoing as we speak?
Dr. Nikhil Kapila (19:20):
Absolutely Correct.
Correct.
We're still recruiting forpatients in the study.
Dr. Michael Koren (19:24):
Maybe just a little bit of information.
These are people that have animaging test that get referred,
or how does that work?
Dr. Nikhil Kapila (19:29):
No, it's anybody who has got a diagnosis
of cirrhosis actually Whoeverhas a diagnosis of cirrhosis.
They get enrolled, they get ablood draw and at the same time
they get an ultrasound and thenwe follow them over the course
of one to two years.
So primary biliary cholangitiswe're entering the more obscure
world of liver disease now.
It used to be called primarybiliary cirrhosis.
The name changed in the pastabout five years or so.
(19:51):
It's a chronic autoimmunemediated liver disease that
affects the bile ducts, usuallyseen in women.
Symptoms are oftentimesdisregarded, the most common
symptom being fatigue, usuallyseen, as I said, in middle-aged
women who present with fatigue,itching, maybe jaundice, and
currently there's severaldifferent medications that we
(20:12):
have that we can use.
Ursodeoxycholic acid,obeticholic acid and a new class
of medication called PPARs haveall been shown to improve
outcomes in those patients andslow liver damage.
So do you qualify for acomplementary FibroScan?
We actually have some of ourstaff in the back and they'll be
(20:33):
able to talk to you about whatFibroScan is and whether or not
you qualify and can sign up forone even today.
But the people who qualify forit at our center on south side
are those who are overweight orobese, high cholesterol, high
triglycerides or who have type 2diabetes.
So lots of benefits, guys, inparticipating or partaking in
clinical trials.
(20:53):
One you're really helpingmedicine expand.
I mean, you're not only helpingyourself, you're helping people
in this room, you're helping agreater good by making medicine
progress and advance.
You receive a lot of attentionfrom not only physicians but
also from our study staff.
You receive a lot of additionalmonitoring and tests and you
(21:17):
truly are a medical hero.
There's no doubt about it.
So it's interesting that therestill remains some degree of
hesitation when it comes toclinical trials and in a survey
that was done of the generalpopulation, less than 50% were
actually interested in clinicaltrials.
But in those people whoactually enroll in a clinical
(21:39):
trial, they enjoy it and 97% ofpatients who were in one
clinical trial say, hey, we'llgo to another one.
And that just shows you thatthere's a lot of benefit that is
derived from a patient, eitherfrom a satisfaction perspective,
the extra care perspective, orhaving access to drugs that are
not yet on the market.
Dr. Michael Koren (21:58):
I find this to be an absolutely remarkable
statistic.
How many products can you thinkof that?
There's a tremendous skepticismbefore somebody tries it.
Then they try it once and theybecome sold for life?
Dr. Nikhil Kapila (22:11):
All the time.
Yeah, absolutely.
Dr. Michael Koren (22:13):
It's not a common product, that's like that
.
So to me this is reallyreinforcing in terms of what we
do on a day-to-day basis.
The other thing to your pointabout sharing information I had
a recent lecture tour in SaudiArabia.
I did that about two weeks ago.
I actually gave 14 lectures inthree cities in Saudi Arabia in
(22:33):
six days, so it was a bit of awhirlwind tour before Trump came
.
They were joking with me that Iwas getting everything ready
for Trump's visit.
Dr. Nikhil Kapila (22:40):
Sure, sure, sure.
Dr. Michael Koren (22:41):
But anyhow, what I found so remarkable was
we presented some data ofstudies that we did here in
Jacksonville and they absolutelywere spellbound on every detail
and so appreciative of the workthat we have done in this
community and that our patientshave done in this community to
help educate people in otherparts of the world.
Yeah, So there's also anelement of diplomacy in it,
(23:04):
almost that this is our goodwillambassador type of approach to
creating connectivity with otherpeople around the world, that
we share information about whatwe learn about people's health,
absolutely.
So to me that was really anexciting experience and it gets
to this point right hereAbsolutely,
Announcer (23:22):
Thanks for joining the MedEvidence! Podcast.
To learn more, head over toMedEvidence.
com or subscribe to our podcaston your favorite podcast
platform.
Welcome to the MedEvidence! podcast.
This episode is a rebroadcastfrom a live MedEvidence!
presentation.
Dr. Michael Koren (00:06):
I'm really excited to welcome Dr Kapila to
our MedEvidence! program.
He's a rising star in thiscommunity, a brilliant,
brilliant physician whospecializes in liver disease,
and he's going to educate all ofus about liver disease,
including me.
And the first question I'mgoing to ask you is can you live
without the liver?
No, no, you cannot.
(00:26):
Okay, well, there you go.
So you've heard it from theexperts, so we're going to talk
about why your liver isimportant and why you should
take good care of it.
So this is the first timeyou're doing this program yeah,
first time.
And what we like to tell ourfolks is that, even though
they're enjoying some food,there's no such thing as a free
(00:50):
lunch.
That's right, all right.
So everybody's got to work here, okay, and everybody's got to
be involved.
So we like to start by doingsome audience participation
questions.
So here we go.
The first question which of thefollowing is not a function of
liver?
Is it A (00:58):
detoxifying harmful substances?
Is it B (01:02):
producing bile for digestion?
Is it C (01:06):
regretting that fourth alcoholic drink, so you don't
have to?
Is it D (01:11):
producing insulin or E
So what do you guys think?
All right, I heard one E, but Ithink most people said C, and
that is absolutely correct.
All right.
Next question what are the waysto push your liver towards
(01:32):
early retirement?
I'm sure that's what you dealwith.
Is people that have done that?
Yep, is it A (01:36):
avoiding hepatitis testing.
B (01:40):
heavy long-term alcohol consumption.
Is it C (01:44):
eating an excessive amount of kale.
Is it D (01:52):
ignoring signs of jaundice and fatigue?
Or is it E (01:58):
A, B and D?
This is a really smart audience.
It is.
Dr. Nikhil Kapila (02:00):
Absolutely or all of the above.
Dr. Michael Koren (02:10):
Right, well, there's an extra one there.
But they even knew it beforeeven seeing the last option.
So that's how you know theywere smart.
All right, so I think, withthat introduction, I give the
floor to you.
And why don't you explain to ushow the liver is an example of
form meeting function?
Dr. Nikhil Kapila (02:17):
yeah, I mean.
I mean the liver is well, Dr.
Koen, First of all, thank youguys for the invitation to speak
to you all.
I mean, it's a it's an honorand a privilege to be here and
to share some of my knowledge Ihave about the world of
hepatology.
You know, today it's going tobe a whirlwind tour about what
the liver is, what it does andwhy it's so important for you
know your everyday life.
So the liver serves manyfunctions.
(02:38):
It helps detoxify things thatyou eat.
It helps the metabolism of thedifferent medications that you
take.
It's intimately involved inproducing blood clotting factors
.
If your liver stops working,you cannot clot blood.
It is involved in themetabolism of various fats,
proteins, is involved in thestorage of sugar in the liver.
(03:00):
It's involved in the productionof bile, as well as excretion,
vitamins, mineral storage.
And it is very important inmaintaining a healthy immune
system.
If your liver doesn't work, youare immunocompromised.
Liver disease can present in avariety of different ways the
one that we think about, or theone that's a prototypical
presentation of somebody who'sjaundiced.
(03:20):
They look like a yellowhighlighter and that's when
jaundice happens.
Your skin becomes yellow, thewhites of your eyes become
yellow.
But there's othermanifestations as well.
Some people can develop fluidin the belly, which usually
happens much later on in thecourse of liver disease.
People can develop itchy skin,otherwise we call it pruritus.
They can develop bruising,usually because they lack those
(03:42):
important clotting factors.
They can have low bloodpressure.
They can have pain.
They can develop swelling inthe legs and the feet.
Some people can develop atremor, especially when they get
the confusion associated withliver disease.
Weakness, fatigue are othervery common symptoms of liver
disease and, as I mentioned,also confusion and loss of
orientation.
Dr. Michael Koren (04:01):
So just to be clear from my knowledge, does
liver disease make your t-shirtturn red, or is that just for
dramatic effect?
Dr. Nikhil Kapila (04:07):
I think that's for dramatic effect.
Okay, yes, absolutely, and it'sa rare case that the liver
actually causes pain.
Only very few conditionsactually cause.
Only very few liver conditionsactually cause abdominal pain.
That's an important clinicalpoint.
Dr. Michael Koren (04:20):
Excellent, so keep on telling us about all
these manifestations of liverdisease.
Dr. Nikhil Kapila (04:24):
So many of them, right?
There's so many different kindsof liver disease.
The thing that we think aboutprobably most commonly is
alcohol-associated liver disease, and while alcohol is one of
the leading causes of liverdisease, it's not the leading
cause.
Actually, this new conditioncalled MASLD or MASH, otherwise
known as metabolic dysfunction-associated steatotic liver
(04:46):
disease Very long, complex name,otherwise known as fatty liver
disease is very rapidly becomingthe number one cause of liver
disease, not only in the UnitedStates but around the world.
We also have conditions likeprimary biliary cholangitis.
We have autoimmune hepatitisand Wilson's disease, which are
much less common.
You can develop viral hepatitis,which is hepatitis A, b, C, D
(05:11):
and E, and then when peopledevelop chronic liver disease,
they can develop liver cancer,which is known as hepatocellular
carcinoma.
So hepatitis B, hepatitis B issomething that is not so common
in the United States, don't getme wrong.
It's here and it's around, verycommon though in East Asia.
It is caused by the hepatitis Bvirus, spreads usually through
infected blood or bodily fluids.
Many people won't experiencesymptoms until they develop
(05:33):
cirrhosis, until their diseasehas really progressed.
However, in the United States,we've also done a really good
job of preventing people fromgetting hepatitis B because we
have a robust vaccinationstrategy and most kids who go to
school, college et cetera havebeen vaccinated for hepatitis B.
Dr. Michael Koren (05:50):
Now you might get to this when you talk about
cirrhosis, but at one pointhepatitis infectious hepatitis
was the number one cause ofcirrhosis, but no longer the
case.
Dr. Nikhil Kapila (06:01):
That's correct, I mean that's hepatitis
C, which was definitely theleading cause of cirrhosis, and
we'll talk about that movingforward.
Dr. Michael Koren (06:08):
Here we go.
Dr. Nikhil Kapila (06:09):
Yes, so hep C .
Hep C was a killer.
At one point of time it wasactually one of the worst
viruses to get, because in manyways, the treatment strategies
for hepatitis C when I wascoming through training were
really not great.
You had interferon and you hadribavirin, which were two
medications that were reallypoorly tolerated and the cure
(06:30):
rate was like 30 or 40%.
But over the past five or 10years there's been a tremendous
amount of research in thehepatitis C world and they have
very effective antiviral agentsthat cure hepatitis C with an
almost 99% cure rate, which isjust remarkable.
There's no vaccines forhepatitis C, unlike hepatitis B.
However, because we now have anexcellent medication for the
(06:54):
treatment of hepatitis C, theUnited States there's a USPSTF,
which is a preventive servicestask force basically now
recommends that all adults overthe age of 18 get tested at
least once for hepatitis C.
So your primary care doctorshould be approaching you about
getting tested for hepatitis C,because it's something that is
now easy to treat.
Dr. Michael Koren (07:15):
Now we don't have a slide on hepatitis A.
Is that something we don't haveto worry about?
Dr. Nikhil Kapila (07:21):
It's a great question.
Hepatitis A is something thatcauses an acute viral illness.
People can become jaundiced,but hepatitis A does not cause
chronic disease.
Saying that most Americansshould be vaccinated for
hepatitis A because in certaincases, especially if you're
immunocompromised, hepatitis Acan lead to fulminant liver
failure.
It's not common, but it canhappen.
Dr. Michael Koren (07:42):
And, as I understand it, hepatitis A is
more likely to come from sort ofan oral route, whereas B and C
are more from a blood-basedroute.
Dr. Nikhil Kapila (07:51):
Correct, absolutely.
Somebody who goes, you know,eats out and eats at a seafood
restaurant, comes back five dayslater is jaundiced, having
fatigue chills you really thinkabout hepatitis A.
Or the person who went down toCosta Rica for vacation and
comes back jaundiced, that'swhen you really think about
hepatitis A, correct?
Dr. Michael Koren (08:06):
And another question.
Sorry to ask too many questionsat this point Do we need to
worry about hepatitis D?
Is that on the horizon?
Dr. Nikhil Kapila (08:13):
That's more obscure.
Hepatitis D is only seen inpeople who are co-infected or
super infected with hepatitis B,so I really wouldn't worry
about it right now.
Dr. Michael Koren (08:21):
One less thing to worry about, yes, okay,
so let's talk about alcohol.
Dr. Nikhil Kapila (08:31):
Yeah, so again, alcohol.
You know, we really do thinkthat alcohol is a toxin.
Alcohol is definitely poisonousfor the liver, there's no doubt
about it, and it's caused byexcessive alcohol drinking.
It can go through variousstages of alcoholic-related
liver disease.
People can just have, you know,bland, you know, elevation of
liver enzymes.
They can get significantinflammation called alcoholic
hepatitis, or you can developcirrhosis and many people won't
have symptoms.
(08:52):
You'll go to your primary caredoctor, get labs done and they
say, hey, your labs are elevatedand in many cases it's related
to alcohol-related liver disease.
Dr. Michael Koren (09:01):
It's now the real bad stuff.
Dr. Nikhil Kapila (09:03):
Absolutely so .
This is why we care so muchabout liver disease, because in
the early stages liver diseaseis preventable or treatable in
many ways.
Either you can cut out thingslike alcohol, you can modify
your risk factors, you can gettreated for viral hepatitis, and
our goal is to prevent thedevelopment of scar tissue,
because when a liver getsreplaced by scar tissue you
(09:24):
develop a condition calledcirrhosis and at that point it's
almost like the point of noreturn.
When you develop cirrhosis,your liver really can't heal
itself that well, and manypeople you know.
When they develop cirrhosis,that's when you start developing
the real nasty complications ofliver disease and the
complications are related tosomething called portal
hypertension and people canstart developing confusion
called hepatic encephalopathy.
(09:45):
They can start bleeding becauseof plump, distended blood
vessels that form in theesophagus, called esophageal
varices, and they can startgetting confused in a condition
called hepatic encephalopathyand they can get fluid in the
belly.
I may have mentioned that calledascites.
The thing is that once youdevelop cirrhosis and you really
can't really get treated sowell for your liver disease with
(10:05):
medications, oftentimes at thatpoint the only way to get
treated is with a livertransplant.
So this is the new kid on theblock.
In a way, it's a new kid on theblock.
That's really an old kid that'sjust been renamed block in a way
, it's a new kid in the block,that's really an old kid that's
just been renamed.
You know, M-A-S-L-D, otherwiseknown as MASLD, is what used to
(10:28):
be known as NAFLD or NASH, andit was called non-alcoholic
fatty liver disease, and nowthat term has been changed to
metabolic dysfunction associatedsteatotic liver disease.
A lot more words, a lot morecomplicated.
Maybe it makes us look a littlebit more fancy, I don't know.
But really, why they changedthe nomenclature was for two
reasons.
One, a nod to the metabolicsyndrome, that we know that the
metabolic syndrome is theleading cause of people to
(10:49):
develop this particularcondition, metabolic syndrome
meaning diabetes, high bloodpressure, obesity and high
cholesterol.
And also understanding thatvery few people do not drink at
all, and so therefore thedefinition of NAFLD, or the
previous term, said you cannotdrink any alcohol.
This condition now incorporateslow to moderate amounts of
(11:10):
alcohol consumption and gothrough various stages.
So you could see on thatschematic very nice, it shows a
healthy liver, and when thehealthy liver is insulted by the
metabolic syndrome, you couldstart developing fatty liver,
and over periods of time, whenyou have fat in the liver, it
leads to an inflammatoryresponse, you get inflammation,
and when the liver gets inflamed, you develop this condition
(11:32):
called MASH, a metabolicdysfunction associated with
steatohepatitis, and over aperiod of time, inflammation
progressive inflammation leadsto scarring and scarring leads
to cirrhosis.
So how do you diagnose a patientwith metabolic dysfunction
associated with steatotic liverdisease?
First of all, blood tests.
(11:53):
Your routine blood work thatyou get with your primary care
doctor may indicate that you maysee elevated transaminases,
your AST or your ALT.
You may see an elevatedbilirubin.
We also offer fibroscans.
Fibroscans have changed the waywe diagnose and we stage people
with liver disease.
A fibroscan is a fancyultrasound.
(12:14):
It's taken the place of a liverbiopsy, which used to have to
be done in many cases, and afibroscan is a basic ultrasound.
Goes on your right upperquadrant, where your liver is,
and it tells you how muchscarring and how much fat you
have in your liver.
We can use a basic ultrasoundas well to tell us if there's
some degree of fat in the liver.
We also can use an MRI and usetheir technology called MR
(12:35):
elastography to characterize howmuch scarring may be in a liver
.
And in rare cases you need todo a liver biopsy in order to
figure out exactly how much.
And in clinical studies wesometimes need to use liver
biopsy as well to help trulyelucidate how much scarring and
how much fat is in the liver.
Dr. Michael Koren (12:54):
Out of curiosity.
This is an audience question,spontaneous audience question.
How many people in the roomprior to today have heard of a
FibroScan?
Show of hands?
Okay, this may be a third.
How many people in the roomhave had a FibroScan personally?
Okay, it's probably the samepeople raising their hands twice
, which is okay, which is to beexpected.
(13:18):
As a matter of fact.
The reason I bring this up isbecause one of the things that
research brings to the communityis better access to this
technology, and so, if you aresomebody that is concerned and
has the risk factors, talk toone of our people and we may be
able to get you in for a freefibro scan as part of a
screening process for a possiblestudy.
No obligation whatsoever, butat least we'll get you some data
(13:39):
and get some information aboutwhether or not you could qualify
for one of the studies thatwe're doing to help people
prevent liver diseasemanifestations.
Dr. Nikhil Kapila (13:46):
And just to piggyback on that, you know I
mean that's an incredibleresource.
Fibro scans are not commonlyfound in the community and have
such easy access to one To beable to accurately and
objectively characterize thestate of your liver.
It's a remarkable asset to thecommunity.
Dr. Michael Koren (14:03):
Absolutely, so keep my going.
Sorry to interrupt.
Dr. Nikhil Kapila (14:06):
No, no problem at all.
So risk factors.
Again, it's a metabolicsyndrome.
It's got its name in the actualdisease state, and metabolic
syndrome consists of severaldifferent disease states, so
obesity being the first, themost powerful risk factor for
the development of fatty liverdisease.
The number two is diabetes.
Then you also have high bloodpressure and you have
(14:27):
hyperlipidemia either hightriglycerides, low HDL or high
LDL.
So all of these factorscontribute to the development of
fatty liver disease.
How do you reduce your risk?
So several different things, andit's been for many years and
for decades we've understoodthat the bedrock of the
(14:47):
management of fatty liverdisease has been lifestyle
interventions diet and exercise.
So weight loss about 10% ofyour weight going into it has
been shown.
A weight loss of about 10% ofyour current weight has been
shown to have dramaticimprovement in people with fatty
liver disease.
When you take a biopsy ofsomebody prior to weight loss
and you biopsy them afterthey've lost 10% of their body
(15:10):
weight, you see significantimprovement in both fat and
scarring on that biopsy slide.
Eating a healthy diet theMediterranean diet has been
tried and tested to bebeneficial in people with fatty
liver disease.
Exercising is great andavoiding alcohol.
But for years we've only talkedabout lifestyle interventions.
(15:35):
But now, thanks to the work thatENCORE does and thanks to the
work that has been done in theresearch field, we now have one
FDA-approved drug.
It's called Resmitron orResdifera.
It is the only currentlyFDA-approved drug.
It's called Resmitrom orRezdiffra.
It is the only currentlyFDA-approved drug for people who
have F2 to F3 scarring.
So when you get a FibroScan, aFibroScan will tell you how much
scarring you have, on a scaleof 0 to 4.
(15:56):
0 being no scarring, 4 beingyou've developed cirrhosis.
So if you're at that stage ofF2 to F3, you may qualify for
this medication and, amazingly,ENCORE was part of the clinical
trials to get Rizdiffra approved.
Dr. Michael Koren (16:10):
Yeah, and I'll tell you this is personally
very gratifying to me, notbecause I'm a liver person, I'm
a cardiologist but just to bepart of the process that takes
disease that had no solution andthen get people involved in the
community to find the solution,and then working with a company
to get the solution through theregulatory process and now
having a product in the marketis just so reassuring and
(16:34):
gratifying.
Dr. Nikhil Kapila (16:35):
So absolutely as a hepatologist who for years
has not had a valid or viableoption, I mean it's amazing, so
it's, I mean yes, it is on allfronts, absolutely.
But that's not the only drug,you know.
There's more drugs that arecoming down the pipeline and we
at ENCORE are evaluating otherdrugs that can be used to help
(16:58):
in patients with metabolicdysfunction associated steatotic
liver disease.
While there's different targetsof thyroid receptors within the
liver, there are othermedications now that have other
mechanisms of action that canalso help, or potentially help,
in fatty liver disease, and theycan work in a variety of
different ways by decreasing thefat in the liver, by lowering
your blood sugar, by loweringcholesterol and by increasing
(17:21):
insulin sensitivity, becausewhat we realize with fatty liver
disease is that there's a realcomponent of insulin resistance,
and so that's another mechanismto hit.
So hepatocellular carcinoma,HCC.
So the number one cause ofcancer in the liver is actually
metastatic disease, right, theliver.
Because of where it sits andits blood supply, it's very
(17:44):
vascular.
When somebody develops cancer,let's say in the colon or
elsewhere in the body,oftentimes you can get, or
sometimes you can get a livermet [metastatis], and so that's
the number one cancer the liver.
But if you talk about primaryliver cancer developing de novo
from the liver, the number oneliver cancer is hepatocellular
carcinoma, and in almost allcases.
(18:06):
It's very rare.
In most cases, hepatocellularcarcinoma is preceded by
cirrhosis.
So most people will havecirrhosis for years and then
develop HCC.
Because what do cancers like?
Cancer likes chaos.
And what is a fatty liver?
What is an inflamed liver?
What is cirrhosis?
It is a liver in chaos, and sothat's where cancer forms, and
(18:28):
oftentimes tumors don't causeany symptoms.
And here, right now actually asof now, and I'm the primary
investigator on this study isthat we're actually
investigating the use of a bloodtest to detect cancer at early
stages.
So in people who have cirrhosis, we're able to do a blood test,
and it's obviously in the earlystages of investigation right
(18:50):
now, but we're trying to see ifthat can help and detect cancer,
as opposed to requiring peopleto undergo regular imaging
studies.
Dr. Michael Koren (18:57):
Yeah, and that's super cool, and I guess
there are more and more diseasesthat are being diagnosed with
simple blood tests.
Dr. Nikhil Kapila (19:03):
Correct, so this is kind of part of that
trend, absolutely, absolutely, Imean, and you know it's in its
earliest stages and we're tryingto see whether this is
beneficial, whether it works,but absolutely, I mean, whatever
helps the patient get to adiagnosis is what we're trying
to do.
Dr. Michael Koren (19:18):
And is this study ongoing as we speak?
Dr. Nikhil Kapila (19:20):
Absolutely Correct.
Correct.
We're still recruiting forpatients in the study.
Dr. Michael Koren (19:24):
Maybe just a little bit of information.
These are people that have animaging test that get referred,
or how does that work?
Dr. Nikhil Kapila (19:29):
No, it's anybody who has got a diagnosis
of cirrhosis actually Whoeverhas a diagnosis of cirrhosis.
They get enrolled, they get ablood draw and at the same time
they get an ultrasound and thenwe follow them over the course
of one to two years.
So primary biliary cholangitiswe're entering the more obscure
world of liver disease now.
It used to be called primarybiliary cirrhosis.
The name changed in the pastabout five years or so.
(19:51):
It's a chronic autoimmunemediated liver disease that
affects the bile ducts, usuallyseen in women.
Symptoms are oftentimesdisregarded, the most common
symptom being fatigue, usuallyseen, as I said, in middle-aged
women who present with fatigue,itching, maybe jaundice, and
currently there's severaldifferent medications that we
(20:12):
have that we can use.
Ursodeoxycholic acid,obeticholic acid and a new class
of medication called PPARs haveall been shown to improve
outcomes in those patients andslow liver damage.
So do you qualify for acomplementary FibroScan?
We actually have some of ourstaff in the back and they'll be
(20:33):
able to talk to you about whatFibroScan is and whether or not
you qualify and can sign up forone even today.
But the people who qualify forit at our center on south side
are those who are overweight orobese, high cholesterol, high
triglycerides or who have type 2diabetes.
So lots of benefits, guys, inparticipating or partaking in
clinical trials.
(20:53):
One you're really helpingmedicine expand.
I mean, you're not only helpingyourself, you're helping people
in this room, you're helping agreater good by making medicine
progress and advance.
You receive a lot of attentionfrom not only physicians but
also from our study staff.
You receive a lot of additionalmonitoring and tests and you
(21:17):
truly are a medical hero.
There's no doubt about it.
So it's interesting that therestill remains some degree of
hesitation when it comes toclinical trials and in a survey
that was done of the generalpopulation, less than 50% were
actually interested in clinicaltrials.
But in those people whoactually enroll in a clinical
(21:39):
trial, they enjoy it and 97% ofpatients who were in one
clinical trial say, hey, we'llgo to another one.
And that just shows you thatthere's a lot of benefit that is
derived from a patient, eitherfrom a satisfaction perspective,
the extra care perspective, orhaving access to drugs that are
not yet on the market.
Dr. Michael Koren (21:58):
I find this to be an absolutely remarkable
statistic.
How many products can you thinkof that?
There's a tremendous skepticismbefore somebody tries it.
Then they try it once and theybecome sold for life?
Dr. Nikhil Kapila (22:11):
All the time.
Yeah, absolutely.
Dr. Michael Koren (22:13):
It's not a common product, that's like that
.
So to me this is reallyreinforcing in terms of what we
do on a day-to-day basis.
The other thing to your pointabout sharing information I had
a recent lecture tour in SaudiArabia.
I did that about two weeks ago.
I actually gave 14 lectures inthree cities in Saudi Arabia in
(22:33):
six days, so it was a bit of awhirlwind tour before Trump came
.
They were joking with me that Iwas getting everything ready
for Trump's visit.
Dr. Nikhil Kapila (22:40):
Sure, sure, sure.
Dr. Michael Koren (22:41):
But anyhow, what I found so remarkable was
we presented some data ofstudies that we did here in
Jacksonville and they absolutelywere spellbound on every detail
and so appreciative of the workthat we have done in this
community and that our patientshave done in this community to
help educate people in otherparts of the world.
Yeah, So there's also anelement of diplomacy in it,
(23:04):
almost that this is our goodwillambassador type of approach to
creating connectivity with otherpeople around the world, that
we share information about whatwe learn about people's health,
absolutely.
So to me that was really anexciting experience and it gets
to this point right hereAbsolutely,
Announcer (23:22):
Thanks for joining the MedEvidence! Podcast.
To learn more, head over toMedEvidence.
com or subscribe to our podcaston your favorite podcast
platform.
Popular Podcasts
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.
24/7 News: The Latest
The latest news in 4 minutes updated every hour, every day.
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.