The liver is one of the most vital and complicated organs in the body, involved in over 200 vital functions including manufacturing and synthesizing a wide range of hormones, clotting factors, cholesterol, and other proteins. The liver is my area of specialty, and it’s my life’s work to try to help people who are dealing with liver damage. That’s why I want to take a moment to share with you the uglier—although not hopeless—side of liver disease.

Liver damage may be in the form of cirrhosis, which is when healthy, functioning liver tissues are replaced by non-functioning scar tissue and the liver loses its ability to effectively do its job. In the very early stages of scarring, there is the potential to reverse some of the damage because the liver is capable of regenerating itself. But when it is subjected to a vicious cycle of damage-regeneration-damage-regeneration, it begins to develop irreversible scar tissue. Once cirrhosis is more advanced, very little can be done to save the liver short of a transplant and, without a transplant, death is imminent.

Since it is such a complex organ, efforts to create an artificial liver have thus far failed. That complicates already difficult prospects for transplantation; the need is far greater than the supply. According to UNOS, the organization that oversees transplants, there are 113,886 people waiting for an organ transplant (all organs, not just livers). As of January 2019, according to the U.S. Department of Health & Human Services Organ Procurement and Transplantation Network nearly 14,000 people were on waiting list for a liver transplant. However, due to organ shortages, more than 1,400 people waiting for a liver transplant die each year.

Only about half of cirrhosis cases are caused by alcohol consumption. The other half are caused by fatty liver, hepatitis B or C, or genetic abnormalities. In fact, cirrhosis caused by NAFLD (nonalcoholic fatty liver disease) is the number-one disease leading to liver transplant. NAFLD is more common in obese people, but as many as 7 percent of normal-weight people also have it. High-calorie diets with excess saturated fats, refined carbohydrates, and high-fructose and sugar-sweetened foods and beverages have been associated with NAFLD. NAFL (no “D” for “disease”) occurs when there is fat in the liver, but there is no inflammation or scarring. NASH (nonalcoholic steatohepatitis) is more aggressive and is more likely to develop fibrosis, cirrhosis, and liver cancer. NASH occurs in around 15 to 20 percent of patients who have NAFLD.

As the disease progresses, portal hypertension can develop. That can lead to fluid buildup in the abdomen, a potentially life-threatening condition known as ascites. Hepatic encephalopathy can also occur; this is a state of confusion caused by the buildup of toxins that affect the central nervous system. And then there is the risk of hemorrhage, or bleeding from varicose veins that develop in the esophagus and the stomach, a condition known as esophageal or gastric varices. Once portal hypertension develops, it’s time to be evaluated for a liver transplant. But in the current organ allocation system, only the very sickest individuals receive transplants.

The reality is that approximately 30 percent of my patients who are on the waiting list for liver transplants die because they become too sick for a transplant. That adheres to the national average, according to the Organ Procurement and Transplantation Network, which reports that between 2011 and 2014 just over 67 percent of patients waiting for a new liver actually received a transplant. It’s simply heartbreaking.

The problem with these diseases is that patients don’t feel sick or have symptoms, so they put off turning their lifestyle around. That’s where I take an aggressive stance. It is absolutely essential to eat healthy and exercise if you’re going to turn around liver disease. For the last 25 years, I have worked to intervene earlier in the disease process. I want to minimize the amount of time I spend standing outside the ICU waiting-room door as I console family members who wish they could turn back the clock.

Yes, liver disease is ugly. It is an agonizing, slow, painful death. And it’s painful for everyone involved—the patient, family, friends, and health care providers.

But there is hope. When we’re able to intervene earlier, we don’t just say “eat healthier and exercise.” Instead, we guide patients through a detailed assessment that looks at eating patterns, snacking, family structure, barriers to exercise, barriers to eating right, and more. In that way, we’re doing everything we can to help people turn back the clock on a very ugly disease.