Comprehensive Approach to Transplantation
MCW, as part of an academic medical center, is able to combine groundbreaking research, advanced surgical techniques and innovative education to achieve exceptional outcomes
Most organ transplants begin with an element of sadness because the family of the donor had to lose a loved one to make the process possible. But transplants often end with immense joy when the family of the recipient realizes a spouse, parent, sibling or child was the beneficiary of this ultimate gift of life.
Physicians, scientists, students and staff at MCW and its clinical and research partners traverse the broad spectrum of transplant-related issues and emotions on almost a daily basis across the institution's missions of patient care, research and education.
For example, the Solid Organ Transplant Center, a collaboration among MCW, Children's Hospital of Wisconsin (Children's), Froedtert Hospital and BloodCenter of Wisconsin, recently has become a nationally recognized program focused on growing the number of those joyful family moments. This is being accomplished through innovative surgical techniques, novel treatment protocols and research that increase the number of organs considered "transplantable," as well as improved outcomes for patients who need a liver, kidney, pancreas, lung or heart transplant. In fact, MCW's transplant teams are highly skilled in every type of single- as well as multi-organ transplantation.
MCW's Transplantation Program brings together the expertise of a broad range of patient care providers including Dr. Johnny Hong, Dr. Motaz Selim, Dr. David Cronin and Kelly Kristbaum, NP.
"The recent reorganization and collaborative effort among our four institutions has led to excellent clinical outcomes after transplant, and better access for those people in need of a transplant," says Johnny C. Hong, MD, Mark B. Adams Chair of Surgery, associate professor of surgery (transplant surgery), chief of transplant surgery, and director of the solid organ transplantation service line. "We also are building a body of research that has the potential to make transplant a possibility for more patients with irreversible organ failure, with the primary goal of reducing the number of patient deaths while on the transplant waiting list."
Over the past decades, MCW's Transplantation Program has given more than 5,400 children and adults a new chance at life, with survival rates for transplant procedures meeting or exceeding the national averages reported through resources such as the United Network for Organ Sharing. This is doubly impressive, Dr. Hong notes, because, as an academic medical center, "while our program takes care of the community's sickest people, our outcomes remain excellent."
The program optimizes the use of donor organs by offering all possible graft options, increasing the access for a timely life-saving transplant. The majority of transplantable organs still come from deceased donors and in the traditional manner of transplanting, with the full liver organ removed. But additionally, the program offers the in-situ split liver transplant – in which a liver from a deceased donor is divided into two functional grafts, allowing two patients to receive the gift of life from one deceased donor. MCW's transplant teams also are nationally known for live donor kidney and liver transplants. Live donor transplant provides the advantage of not relying on the availability of the deceased donor organ pool – allowing for the ability to receive the transplant before further progression of the patient's medical condition. This enables the transplant teams to transplant livers and kidneys from both live and deceased donors into either adults or children.
Successful adult-to-child live liver transplant
One such adult-to-child live liver transplant was undertaken in October 2014, when Chelsie Peterson, 26, donated part of her liver to her then six-year-old nephew, Tayten Krueger. Dr. Hong led the teams which cared for Chelsie at Froedtert Hospital and Tayten at Children's. Both are doing well more than 16 months following the surgery.
In fact, both are doing better than they could have hoped for. Tayten, who was born with biliary disease, needed to have a feeding tube implanted in his stomach at 11 months, was sick often before the transplant, and wasn't growing much or gaining weight. As a result, he was unable to participate in sports and was too short for many of the rides at amusement parks. Post-surgery, things have changed.
Last summer, Tayten participated in a T-ball league for the first time, and in January, he and his family went to Disney World. He had grown enough since the surgery to be allowed on the majority of the rides he could not go on beforehand.
Live liver transplant recipient Tayten Krueger (center) is flanked by his donor (and aunt) Chelsie Peterson (left) and his mother, Katie Krueger (right).
"Tayten has grown more in the year since surgery than he did in the two or three previous years," said his mother, Katie Krueger. "The feeding tube is gone, his appetite is increasing and he is thriving. For the first time in his life, he registers on the growth charts for children his age."
The program, which can claim many transplant firsts for Wisconsin, is one a few in the country to offer "incompatible blood type kidney transplantation" through an affiliation with BloodCenter of Wisconsin.
The Transplantation Program offers strong multidisciplinary care for the adult and pediatric patient, both before and after transplant. This is critical because patients with end-stage disease that requires transplant often have underlying conditions (e.g., malnutrition, diabetes, lipid disorders or hypertension) and are more prone to complications. Through the breadth of specialties and resources available, MCW providers can adeptly offer care that encompasses all patient needs.
MCW's research optimizing transplant outcomes
Unfortunately, approximately two-thirds of those in need of an organ transplant will not get one – but MCW faculty members are conducting research to optimize the use of donor organs to increase the number of transplantable organs and improve the outcomes for those who receive them.
Dr. Hong is investigating ways to resuscitate donor organs that were previously not transplantable because of damage caused by ischemia (when blood flow to an organ is restricted) and reperfusion injury (vascular injury that occurs when blood flow is returned to an organ). He also is conducting research into a new drug to minimize the risk of organ rejection.
Michael Mitchell, MD, professor of pediatric cardiothoracic surgery, and a team of MCW/Children's investigators are developing a rapid, non-invasive blood test to monitor rejection in children and adults with heart transplants. The test precisely quantifies the amount of donor-specific cell-free DNA in the recipient's blood – which increases during organ rejection – and offers the promise of earlier detection and treatment to reverse the rejection process. Dr. Mitchell and his wife, Aoy Tomita-Mitchell, PhD, recently launched TAI (Transplant And Immunology) Diagnostics, Inc. to commercialize a transplant monitoring test which meets FDA regulatory requirements. Elizabeth Jacobs, MD, is developing diagnostics to detect ischemia early enough to prevent or minimize complications following lung transplant.
First heart transplant in Wisconsin
First adult liver transplant
First adult pancreas after kidney transplant in eastern Wisconsin
First adult lung transplant in eastern Wisconsin
First laparoscopic kidney live donor nephrectomy
First pediatric living donor liver transplant
First incompatible blood type kidney transplant
First pediatric combined heart and liver transplant
First in-situ split liver transplants
To ensure potential live liver donors make a decision they are comfortable with, the program mandates that the potential live donor undergo a stringent medical and psychosocial evaluation and informed consent process. Additionally, MCW appoints faculty members to serve as independent live living donor advocates. The advocate assesses the potential donor to make sure she/he is a good candidate from a social and personal standpoint, and clearly articulates the health, life and insurance risks. Post surgery, the advocate also meets with the donor to ensure she/he doesn't feel ignored.
MCW's educational endeavors focus on transplantation
A critical mission of an academic medical center is education, and MCW has developed programs to educate medical students, residents and fellows about transplant surgery.
Dr. José Franco (MD '90, GME '95) is among several MCW faculty members who teach medical students about organ failure and transplantation.
MCW recently received accreditation of its abdominal organ transplant surgery fellowship for the first time, and Dr. Hong shares that his goal is to expand the fellowship to include intestinal transplants.
MCW's medical school curriculum provides many opportunities for students to be educated about organ failure and transplantation during the first two years of medical school training. This includes learning about normal organ functions, the consequences of organ failure leading to the need for solid organ transplant, and potential complications of transplantation. Students are taught about long-term management of transplant patients, including the management of organ rejection and opportunistic infections, and also about the ethical principles and social aspects of transplantation in pediatric and adult patients. The curriculum also provides an opportunity for students to learn more about transplant during the M3 surgical clerkship and an M4 elective rotation.
MCW hosts an annual solid organ transplantation symposium and recently signed academic affiliation agreements with two leading international institutions to expand the opportunities for residents and fellows to share techniques: the University of Zurich provides leading-edge treatment for patients suffering from diseases of the liver and bile duct, and Seoul National University Hospital is renowned for doing live donor liver transplants – something undertaken less frequently in the US.
Beyond exemplary clinical care, research and training, MCW and its partners work tirelessly to reach out to and educate the public about the importance of organ donation and transplantation. In fact, the Transplantation Program received Gold Level recognition from the US Department of Health and Human Services in 2013 for its community outreach efforts, and Children's was recently awarded a Bronze Medal from the HRSA (Health Resources and Services Administration) Workplace Partnership for Life Organization for its efforts to encourage organ, eye and tissue donations.
Collectively, these efforts in the area of solid organ transplant are leading to more joyful family moments, like the one experienced by Chelsie and Tayten.
"Five minutes after I met Dr. Hong, I trusted him and his team with my son. They tried to make it as perfect and stress-free as possible, and we couldn't have asked for anything more."
– Katie Krueger, mother of transplant patient Tayten Krueger
Chelsie adds, "They were very responsive before, during and after the surgery, were amazing advocates, and made me feel like a priority. I never had any doubts about Dr. Hong and his team, and would recommend him to anyone."
40 Years of Improving Survival
MCW also is a leader in blood and marrow transplantation and research, due in part to its Center for International Blood and Marrow Transplant Research (CIBMTR) – a research collaboration between MCW and the National Marrow Donor Program©/Be the Match©. The CIBMTR has been collecting hematopoietic cell transplantation (HCT) outcomes data worldwide for more than 40 years from approximately 400 transplant centers (and 425,000 transplant patients), in an effort to improve survival, treatment and quality of life for those facing life-threatening illnesses. (HCT cells come from bone marrow, peripheral blood or umbilical cord blood and are typically transplanted to treat patients with cancer. In contrast to solid organ transplants, all HCT donors are healthy individuals and the donation procedure does not involve major surgery.)
MCW researchers have built an extensive body of research around blood and marrow transplantation, including research related to graft vs. host disease, the major complication associated with bone marrow transplants. Mary Horowitz, MD '80, GME '89, MS '91, (pictured right), the Robert A. Uihlein, Jr. Chair in Hematologic Research, professor of medicine and chief of hematology and oncology at MCW, is chief scientific director of the CIBMTR.
– Anthony Braza
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