Benjamin Samstein, MD, Surgical Director, Living Donor
In this issue: Liver Transplant Program
1 Laparoscopic Living Donor
Liver Surgery Minimally Invasive Live
2 Advances in Liver Preservation
Result in Improved Outcomes Over the past six months, the CLDT has introduced
laparoscopy to all living donor surgeries performed
3 Chronic Hepatitis B Update at NewYork-Presbyterian Hospital (NYPH).
4 Hypertension Management Post- Laparoscopy promises to significantly shorten After introduction of the laparoscopic
recovery in comparison to the standard approach for all NYPH living donor hepa-
procedure for living donor hepatectomy, tectomies during the summer of 2009, the
which involves an incision extending from Center for Liver Disease and Transplanta-
5 Management of Bone Disease the breast bone to the navel. If the tion (CLDT) surgeons have performed 13
Pre- and Post-Liver Transplant laparoscopic approach catches on and laparoscopic living donor surgeries, includ-
becomes a standard procedure, it could ing three that were fully laparoscopic. For
6 The Importance of a Caregiver potentially revolutionize living donor trans- adult-to-adult living donor liver transplan-
and a Community Physician for plantation by encouraging more donors, tation, laparoscopic techniques result in in-
increasing the availability of organs, and cisions half the size of the standard incision
the Success of a Liver Transplant
improving outcomes. for open hepatectomy and avoid the mus-
cle division required for the standard pro-
7 New Faculty and Staff Despite the facts that recipient outcomes
cedure. For adult-to-pediatric living donor
for living donor liver transplant have
liver transplantation, the donor receives five
Visit “OR Live” to view a improved during the past five years, and
small incisions, the largest of which is three
that living donor grafts are often superior
CLDT Webinar about inches long. In these procedures, division of
to deceased donor grafts, living donor
Hepatocellular Carcinoma: the donor liver is achieved with the same
transplantation volume has not increased
www.orlive.com/nyp/videos/ techniques as in the standard procedure,
dramatically across the United States. This
hepatocellular-carcinoma1 and the proportion of liver removed is the
is because the standard adult organ donor
same. Implantation of the liver into the re-
surgical procedure requires a long recovery
cipient is performed using standard tech-
The Center for Liver Disease and has been characterized by a significant
and Transplantation at level of morbidity. In addition, long recovery
time for a parent donating a portion of their We have been encouraged by results to date.
NewYork-Presbyterian Hospital liver to their child impedes their ability to care Recovery from laparoscopic donation appears
Columbia office: 212-305-0914 for the child, and has potential for a debili- to be significantly faster than for standard
tating effect on the family. donor surgery, enabling donors to get back to
Weill Cornell office: 646-962-4129
Referrals: 212-305-0914 Continued on page 6
Physician on call: 212-305-0914
Fellow on call: 212-305-5880
enter pager #89666
We are available 24 hours
a day, 7 days a week.
Traditional incision for right Minimally invasive right or left Fully laparoscopic left lateral
hepatectomy hepatectomy incision hepatectomy
James V. Guarrera, MD, FACS, Surgical Director, Adult Liver Transplantation*
Emerging From the “Ice Age” of Liver Preservation
Preserving organs on ice prior to transplantation, an approach known as
cold storage or CS, has been standard practice in liver transplant for 20 years.
Now there is new evidence that the preservation technique donors has shrunk — and that’s obviously a good thing. But there
hypothermic machine perfusion (HMP) may offer improved is no denying the stark fact that the median age of the average
transplant outcomes. The first-ever study comparing the impact liver donor is higher today, which means that the quality of avail-
of CS and HMP was carried out at NewYork-Presbyterian able organs is reduced.
Hospital/Columbia University Medical Center (NYPH/Columbia).
The HMP technique dates back to the 1960s, when it was
We found in this study that HMP has advantages over CS in
introduced for kidney preservation. It was soon dropped in favor
preserving donor livers — and that it most likely constitutes an
of cold storage, a method that was deemed simpler. But in the
advance over the traditional method. By improving preservation
1990s, HMP made a comeback in kidney transplantation, coin-
and reducing preservation-related injury, we may be able to
ciding with greater reliance on “imperfect” kidneys from older
expand the availability of organs for transplantation to more
donors with more comorbidities.
patients who need them.
When we began our research, investigators
Cold storage involves flushing out the liver
in the NYPH/Columbia-based HMP study
with a preservation solution and storing the
strongly suspected that HMP could be
organ in a cooler of ice. This reduces the
adapted to the liver transplantation setting,
metabolic rate, which is a fairly effective way
particularly because the liver is inherently
to keep a liver healthy en route to trans-
more vulnerable to injury than the kidney.
plant surgery. Machine perfusion, on the
We began using a pump produced by
other hand, provides a continuous flow of
Medtronic originally designed for use in car-
oxygen and key nutrients to the liver while
diopulmonary bypass, combined with a
diluting and removing toxins and waste
preservation solution called Vasosol.
products. It appears from our preclinical
work and kidney transplant experience We have now received FDA approval to
that machine perfusion promotes better conduct a phase II study focusing specifi-
function and less preservation-associated cally on the effects of HMP in livers from
damage after transplant. Our study com- extended-criteria donors, a group that
pared 20 transplant patients who received makes up a growing propor tion of the
HMP-preserved livers with 20 patients with total number of donors today. Organs
CS-preserved livers, finding that the first from these older, sicker donors are the
group experienced shorter hospital stays ones most likely to benefit from machine
and fewer long-term complications. The HMP group also had perfusion. This trial is also supported by the HRSA Division of
lower levels of the blood markers indicating liver injury that may Transplantation grant.
have occurred during the preservation interval. Establishing the benefits of HMP over CS will depend on the
The findings are reported in the February issue of the American results of larger clinical studies, but it is equally important to
Journal of Transplantation.* The study was supported by a grant clarify the way the two techniques play out at a cellular and
from the Health Resources and Services Administration (HRSA), molecular level. Molecular and mechanistic studies also are
Division of Transplantation. underway at NYPH/Columbia.
Expanding Availability of Livers for Transplant Through these studies, our team aims to show that even imper-
fect livers can be maintained in peak condition via HMP during
Improving organ preservation is especially important in light of
the critical period when they are in transit from donor to
major changes in the transplantation landscape during the past
recipient.This is the kind of “quality improvement” that will trans-
two decades and could broaden the availability of donor organs.
late into long-term benefits for patients. z
In the early days of liver transplantation, high-quality organs were * Dr. Guarrera is Principal Investigator of the Liver Machine Preservation Trial.
plentiful for two reasons: First, liver transplantation had not yet Findings of the trial were published in the American Journal of Transplantation
become widespread, so demand was relatively low; and second, in February 2010:
there was a greater supply of livers from young trauma victims. Guarrera JV, Henry SD, Samstein B, Odeh-Ramadan R, Kinkhabwala M, Gold-
Thanks to a significant drop in violent crime and to public safety stein MJ, Ratner LE, Renz JF, Leeb HT, Brown, Jr., RS, and Emond JC. Hypother-
measures such as mandatory seat belt use, the pool of young mic Machine Preservation in Human Liver Transplantation: The First Clinical
Series. American Journal of Transplantation, 2010; 10 (2): 372-381.
2 CLDT Liver News ~ Spring 2010
Damaris C. Carriero, CNP, MHA, Hepatology Nurse
Review of Chronic Hepatitis B: First in a series of
articles about hepatitis B
An estimated 350 million individuals are chronically infected with
hepatitis B virus (HBV) worldwide.
Persons with chronic HBV (CHB) are at greater risk for hepatocel- terized by periodic reactivation with a pattern of fluctuating HBV
lular carcinoma (HCC) than uninfected individuals, and the relative DNA and ALT levels, and active inflammation. Patients with
risk of HCC has wide variability in both case-control and cohort HBeAg-negative disease have HBV variants with nucleotide substi-
studies.1 Results from a large population-based prospective cohort tutions in the precore and/or the basal core promoter regions that
study of untreated individuals with CHB — The Risk Evaluation of express no or low levels of HBeAg. Furthermore, they have low
Viral Load Elevation and Associated Liver Disease/Cancer-In HBV rates of prolonged spontaneous disease remission and have active
(REVEAL-HBV) study —demonstrate the need for prolonged sup- liver disease with a high risk of fibrosis progression, decompensated
pression of HBV replication to prevent CHB-related liver disease. cirrhosis and HCC. The ‘resolution’ phase is characterized by anti-
Data show a strong association between progression to cirrhosis HB surface (HBs)Ag loss, undetectable serum HBV DNA, although
and viral replication.2 The cumulative inci- low-level HBV replication may persist with
dence of cirrhosis increased with the HBV I have chosen to present our detectable HBV DNA in the liver, and de-
DNA level and ranged from 4.5 to 36.2% for tectable anti-HB core (HBc) anti-bodies with
patients with serum HBV DNA of less than
review of hepatitis B in or without HBsAg. HBsAg loss is associated
300 copies/ml and greater than 106 parts to deliver the best with reduced risk of cirrhosis and HCC, al-
copies/ml, respectively. Additionally, elevated comprehension of the disease, though immunosuppression may lead to
viral DNA was shown to be an independent sequelae, and implications for HBV reactivation.4,5 Hepatitis B virus has a
risk factor for the development of HCC. community as well as global high rate of replication,6 and unlike most
Corresponding cumulative rates of HCC health policies.This article DNA viruses, replicates via reverse transcrip-
were 1.3 and 14.9% for patients with serum is an excerpt from the tion and is distantly related to the retro-
HBV DNA less than 300 and greater than viruses. The HBV replication process is
106 copies/ml, respectively.3 This association
recently published chapter mediated by the viral polymerase. Rapid viral
underscores the importance of durable “Hepatitis B therapies and turnover and the distinctively error-prone
HBV DNA suppression with concomitant antiviral resistance detection retroviral life cycle lead to the development
histological improvement as a primary and management” in Expert of HBV polymerase mutants.Virus mutations
objective to prevent cirrhosis, decompen- Review of Gastroenterology also cause the emergence of quasispecies
sation, HCC, and death. and Hepatology.* that evolve during the course of infection sec-
ondary to host selective pressure.7 Overlap-
ping HBV genes, the poor replication accuracy
The natural course of CHB is an actively changing process, and viral, of HBV polymerase and the reverse transcription strategy of HBV
host and external factors determine disease progression. CHB lead to genetic variations that affect infectivity, vaccine efficacy, patho-
presents as either hepatitis Be antigen (HBeAg)-positive (‘wild genesis, the response to antiviral therapy, and transmission.7,8 z
type’) or HBeAg-negative disease. ‘Wild type’ CHB represents an 1 Nguyen VT, Law MG, Dore G J Hepatitis B-related hepatocellular carci-
early phase of chronic infection, while HBeAg-negative disease rep- noma: epidemiological characteristics and disease burden. J Viral Hepatol 16,
resents a later phase and is associated with naturally occurring HBV 453–463 (2009).
variants. The natural history of CHB is divided into five phases. The 2 Iloeje UH,Yang HI, Su J, et al. Predicting cirrhosis based on the level of circu-
‘immune-tolerant’ phase is characterized by HBeAg positivity, high lating hepatitis B viral load. Gastroenterology 130, 678–686 (2006).
serum HBV DNA levels, normal or minimally elevated alanine 3 Chen CJ, Iloeje UH,Yang HI. Long-term outcomes in hepatitis B: the REVEAL-
transaminase (ALT) levels, and mild inflammation, with absent or HBV study. Clin Liver Dis 11, 797–816 (2007).
limited fibrosis. High levels of viremia make these patients highly 4 European Association for the Study of the Liver. EASL Clinical Practice Guide-
lines: Management of chronic hepatitis B. J Hepatol 50, 227–242 (2009).
contagious.The ‘immune-reactive’ phase is characterized by HBeAg
positivity, lower serum HBV DNA levels, persistently or intermit- 5 Keeffe EB, Dieterich DT, Han S-H B, et al. Special Report. A treatment algo-
rithm for the management of chronic hepatitis B virus infection in the United
tently elevated ALT levels, moderate or severe active inflammation, States: 2008 update. Clin Gastroenterol Hepatol 6, 1315–1341 (2008).
and more rapid fibrosis progression. This phase may last several 6 Nowak MA, Bonhoeffer S, Hill AM, et al. Viral Dynamics in hepatitis B virus
weeks to several years.Very low or undetectable serum HBV DNA infection. Proc Natl Acad Sci USA 93(9), 4398–4402 (1996).
levels, normal ALT levels, and minimal fibrosis characterize the ‘inac- 7 Park SG, Kim Y, Park E, et al. Fidelity of hepatitis B virus polymerase. Eur J
tive HBV’ or ‘HBsAg carrier’ state. This state may follow serocon- Biochem 270(14), 2929–2936 (2003).
version from HBeAg to anti-HBe antibody and, due to immunologic 8 Zoulim F, Locarnini S. Hepatits B virus resistance to nucleos(t)ide analogues.
control of infection, confers very low risk of cirrhosis or HCC. Gastroeneterology 137(5), 1593-1608. (2009).
‘HBeAg-negative CHB’ may follow seroconversion from HBeAg to *Holness G, Carriero DC, Dieterich DT.“Hepatitis B therapies and antiviral re-
anti-HBe antibodies during the immune-reactive phase. It is charac- sistance detection and management.” In Expert Rev Gastroenterol Hepatol.
Ariana Rose, MSN, CFNP, CCTC, Clinical Coordinator/Nurse Practitioner
Cardiovascular Management Post-Liver Transplant
As long-term survival after liver transplantation (LT) increases and outcomes
continue to improve, metabolic complications have become more prevalent.
When compared with age- and gender- Renal impairment after liver transplant is Cholestyramine, a resin and bile acid se-
matched controls, liver allograft recipients associated with CNI-dependent hyperten- questrant used to treat dyslipidemia, may
have a higher risk for cardiovascular and sion that results from hemodynamic and decrease absorption of CNI, and doses
cerebrovascular events, and death.1 Early histological abnormalities. Anti-hypertensive should be separated by at least two hours.
recognition and treatment of comorbid agents may improve CNI-associated renal Hypertensive LT patients who are managed
conditions, specifically hypertension, dia- impairment. Management of CNI-induced with CCB must be closely monitored when
betes, renal impairment, and hyperlipidemia nephrotoxicity may require dose reduction statin therapy is initiated, because drug-drug
are essential to healthy survival. of immunosuppression, which is guided by interactions may increase serum concentra-
graft function, drug levels, and optimal tion of the statin and risk for toxicity.
Hyper tension is a silent killer, often
treatment of hypertension.
requiring decades before its implications The management of metabolic complica-
for morbidity and mortality are fully real- The criteria for diagnosis and management tions in the LT patient should be a joint col-
ized. The negative impact of cardiovascu- of diabetes in the nontransplant population laboration between the transplant team
lar disease on LT recipients is brought to are applicable to LT patients. Risk factors and primary care physician. We welcome
light by recent data that indicate it is a for diabetes mellitus after transplantation involvement by community physicians in
significant cause of late mortality, second include older age, Black race or Hispanic the effort toward improving long-term out-
only to malignancy.2 ethnicity, obesity, hepatitis C infection, comes in this patient population. z
corticosteroids (standard of care therapy
Data from previous studies show that the 1 Mells G, Neuberger J. Long-Term Care of the
post-transplantation) and CNI, specifically
incidences of hypertension, hyperlipidemia, Liver Allograft Recipient. Seminars in Liver Disease
tacrolimus, a more diabetogenic agent than
and diabetes post-transplant are as high as 2009;29:102-119.
cycloSPORINE.5 Therapeutic management
85%, 66%, and 60%, respectively. Prevalence 2 Bostom AD, Brown RS, Cosio FG, Culver K,
for most patients requires daily insulin.
rates of cardiovascular events range from
Patients with persistent hyperglycemia Curtis JJ, Danovitch GM, et al. Prevention of post-
9.4% at 5 years to 25% at 10 years post-
despite withdrawal of glucocor ticoids transplant cardiovascular disease-repor t and
may remain on insulin or change to oral recommendations of an adhoc group. Am J Trans-
Currently, there are no specific guidelines antidiabetic agent(s). plantation 2002;2:491-500.
for the treatment of cardiovascular com- 3 Heller JC, Prochazka, AV, Everson GT, Forma LM.
Treatment recommendations for dyslipi-
plications in LT recipients.3 JNC 7 guide- Long-Term Management After Liver Transplanta-
demia are set forth in The Third Report of
lines (2003) define blood pressure of tion: Primary Care Physician Versus Hepatologist.
the Expert Panel on Detection, Evaluation,
140/90 in the general population and Liver Transplantation 2009;15:1330-1335.
and Treatment of High Blood Cholesterol
130/80 in persons with DM or chronic
in Adults (Adult Treatment Panel III, or ATP 4 Chobanian AV, Bakris GL, Black HR, et al. The
kidney disease (CKD) as thresholds for
III) from the National Cholesterol Educa- Seventh Report of the Joint National Commit-
tion Program (NCEP). tee on the Detection, Evaluation, and Treat-
Studies of patients with hyper tension ment of High Blood Pressure: the JNC 7
Reversible risk factors for dyslipidemia after
have shown the benefits of therapeutic repor t. JAMA 2003;289:2560-2572. [Erratum,
liver transplant include obesity and im-
lifestyle changes in the nontransplant JAMA 2003;290:197.]
munosuppression. Glucocorticoids are as-
population. Calcium channel blockers
sociated with increased total cholesterol 5 Hjelmesaeth J, Har tmann A, Kofsad J, et al.
(CCB), beta blockers, and angiotensin-
(TC) and LDL cholesterol (LDL-C), de- Glucose intolerance after renal transplantation
converting enzyme inhibitors (ACEI) are
creased HDL cholesterol and increased depends on prednisolone dose and recipient
efficacious in the LT patient. However,
triglycerides.6 CycloSPORINE is associated age. Transplantation 1997;64:979-983.
comorbid conditions such as diabetes,
with increased LDL-C and TC, and sirolimus
hyperlipidemia, and CKD; history of MI 6 Sholter DE, Armstrong PW. Adverse effects of
is strongly associated with hypercholes-
or heart failure; and drugs that undergo corticosteroids on the cardiovascular system. Can
terolemia.There is no evidence to date that
CYP metabolism are important consid- J Cardiology 2000;16:505-511.
tacrolimus has this lipogenic effect.7
erations for appropriate management.
7 Deleuze S, Garrigue V, Delmas S, et al. New
Choice of pharmacotherapeutic agent(s) CycloSPORINE and tacrolimus, as well
onset dyslipidemia after renal transplantation: is
should be guided by side effect profile as fibrates and most statins, undergo CYP
there a difference between tacrolimus and
and potential drug-drug interactions. metabolism. Statins and fibrates should not
cyclosporine? Transplant Proc 2006;38:2311-2313.
be combined in patients receiving CNI.
4 CLDT Liver News ~ Spring 2010
Lance L. Stein, MD, Hepatology Fellow
Management of Bone Disease Pre- and Post-Transplant
Diseases of the bone associated with chronic liver disease (termed hepatic
osteodystrophy) are common both pre- and post-liver transplantation.
Hepatic osteodystrophy encompasses osteoporosis and less months, then rises again to pre-transplant levels within 2 years. As
commonly, osteomalacia from poor bone mineralization due to a result, fracture rate is high within the first 2 years with reported
vitamin D deficiency. Historically, osteomalacia has been reported rates of 15-27%. Pre-transplant vertebral fracture is more predic-
in a high percentage of individuals with primary biliary cirrhosis, tive of post-transplant fracture than BMD but a reduced BMD
but today is rarely seen in adult patients with chronic liver disease post-transplant correlates with post-transplant fracture risk.
(LD).This shift is possibly due to earlier diagnosis, recognition, and Cumulative steroid exposure in the first few months after
improved nutritional management. It was reported that 96% of transplant increases the fracture risk. Over the last decade, the
patients awaiting liver transplantation have low 25-hydroxy trend towards reducing prolonged steroid use post-transplant has
vitamin D levels in the absence of osteomalacia, suggesting that led to fewer fractures.6 The role of calcineurin inhibitors (ie.
osteomalacia in this patient population is uncommon.1 Osteoporo- tacrolimus or cyclosporine) and fracture risk remains controversial.
sis is more common in patients with LD and it is important that
There are no published guidelines regarding screening for BMD
clinicians understand surveillance and treatment of osteoporosis.
with DEXA in patients with chronic LD. This is due to the diffi-
Osteoporosis is reported to have up to twice the prevalence culty of predicting an individual’s risk for osteoporosis.3 There is
in patients with LD, compared to age-matched controls.2 It is a clear consensus that patients who have had previous osteo-
unclear whether cirrhosis and cholestasis are independent risk porotic fractures, those taking prolonged corticosteroids (>5mg
factors for osteoporosis, as studies have not been adequately daily for > 3 months), patients with cholestatic LD and elevated
powered to study this relationship.3 However, commonly identi- bilirubin, and all patients being assessed for liver transplantation
fied risk factors coexist in this population and include an age > be screened. At Columbia, we perform DEXA scans every 1-2
40, poor nutrition, excess alcohol intake, hypogonadism, and years on the above patient populations, post-menopausal
previous corticosteroid use. women, and all patients post-transplant.
Bone mineral density (BMD) as measured by DEXA is currently The treatment is based on trials of postmenopausal osteoporosis
the best predictor of fracture risk, which increases 2-fold for each which revealed reduced fracture risks.This has not definitively been
standard deviation below the mean of normal controls (T-score). translated into LD patients. All patients need to be encouraged to
Osteoporosis is defined by a BMD on DEXA of less than 2.5 stan- perform weight-bearing exercises and avoid alcohol and tobacco
dard deviations (or T-score of -2.5) below normal peak bone mass. use. In patients with osteopenia, we start supplementation with
Independent of BMD, an additional risk for fracture is a previous calcium 1000 mg and with vitamin D 800 IU daily. Patients with
history of vertebral fracture which further increases vertebral osteoporosis should be given a bisphosphonate (such as ale-
fracture risk by 10-fold and subsequent hip fracture risk increases dronate or risidronate). In cholestatic LD and post-transplant, stud-
2.3-fold.4 Often, underlying vertebral fractures present without ies have shown a benefit with bisphosphonates by increasing BMD.
symptoms and are not recognized in many patients. However, studies have been too small to show a benefit in reduc-
ing fracture risk. After starting therapy, DEXA should be repeated
Prevalence of osteoporosis depends on the severity of underly-
annually to assess response. Patients not responding to therapy
ing LD. Cirrhosis increases fracture risk 2-fold with a reported
may benefit from referral to an endocrinologist. z
prevalence of 12-55% depending on the population examined. In
addition, risk of osteoporosis increases with severity of LD, with 1 Crawford BA, Labio ED, Strasser SI, McCaughan GW. Vitamin D replace-
Child’s C patients having a lower BMD than Child’s A.5 In PSC, ment for cirrhosis-related bone disease. Nature clinical practice
prevalence of osteoporosis varies from 8-32% and risk of fracture
2 Diamond T, Stiel D, Lunzer M, Wilkinson M, Roche J, Posen S. Osteoporo-
has been linked to advanced age, duration of coexisting inflam- sis and skeletal fractures in chronic liver disease. Gut 1990;31(1):82-7.
matory bowel disease, and more advanced biliary disease. Urso-
3 Collier J. Bone disorders in chronic liver disease. Hepatology (Baltimore,
diol use has not been shown to improve BMD. In PBC, recent Md 2007;46(4):1271-8.
studies have shown a 4-fold risk of osteoporosis and a 2-fold in-
4 Sambrook P, Cooper C. Osteoporosis. Lancet 2006;367(9527):2010-8.
creased fracture risk. Patients with end-stage PBC who undergo
5 Monegal A, Navasa M, Guanabens N, et al. Osteoporosis and bone min-
transplantation have an even higher prevalence of osteoporosis eral metabolism disorders in cirrhotic patients referred for orthotopic liver
and fracture risk.3 transplantation. Calcified tissue international 1997;60(2):148-54.
Understanding of changes in BMD post-transplant, both early and 6 Guichelaar MM, Schmoll J, Malinchoc M, Hay JE. Fractures and avascular
late (after 2 years), is important to prevent vertebral and hip frac- necrosis before and after orthotopic liver transplantation: long-term follow-
up and predictive factors. Hepatology (Baltimore, Md 2007;46(4):1198-207.
tures. Following liver transplant, the BMD falls for the first few
Maura Hagan, LMSW
The Importance of a Caregiver and a Community
Physician for the Success of a Liver Transplant
“No man is an island.” – John Donne
Studies have shown that the support from tions and in being the patient’s voice dur- The Role of the Primary Care Physician
a caregiver is one of the most important ing this time, allowing the patient to focus A primary care physician is an integral
factors in predicting the success of a trans- on his or her recovery. par t of the caregiving team, and the
plant. Patients with a caregiver are more impor tance of a patient establishing
The Caregiver Role at Home
likely to be medically compliant, thus reduc- a relationship with one cannot be
A caregiver familiar with transplant and med-
ing the risk of medication errors, complica- overemphasized. Medical decisions are
ications will need to be at home with the pa-
tions, and re-hospitalizations. Adherence to commonly made by the transplant team
tient for a minimum of three weeks. While
the medical regimen both before and after for the specific purpose of achieving the
the patient is still recovering in the hospital,
transplantation is of critical importance and best results for the patient. The trans-
the caregiver will need to learn the patient’s
is more easily accomplished when the pa- plant team, however, cannot replace a
complicated medication regimen, which nor-
tient has a person or persons dedicated to primar y care physician. If a transplant
mally includes 10-14 new medications. The
taking care of them. candidate does not have a primary care
patient will not be allowed to leave the hos-
physician, it is best to put this relation-
The Caregiver Role Pre-Transplant pital before an adequate care plan has been
ship in place during the transplant eval-
Pre-transplant, helping the patient means established at home and the caregiver feels
accompanying them to the psychosocial confident with managing the medication reg-
evaluation and various other medical imen. By the time the patient is home, the While it is understandable that liver re-
appointments. A caregiver will also need to caregiver must be familiar with the various cipients develop an emotional connec-
accompany the patient to the educational side effects of the medications and monitor tion with those who have cared for them
workshops. Should the patient’s condition these in the home environment. through their transplant, it is unrealistic not
deteriorate pre-transplant, a caregiver may to have a transition to medical decisions
The caregiver must assist with additional
need to increase their level of support by being made by the primary care physician
tasks the liver transplant patient cannot ac-
helping the patient manage medications, regarding common ailments, such as colds,
complish on their own. The caregiver will
assisting them in getting to their appoint- gout, stomach upsets, skin problems, etc. A
need to monitor the surgical incision for
ments, and helping with activities of daily skilled primary care physician will be able
signs and symptoms of infection. The care-
living and household chores. to make the determination if a particular
giver will need to monitor vital signs and
problem falls under the transplant um-
The Caregiver Role Post-Transplant may need to learn to check the patient’s
brella and will not hesitate to inform the
Post-transplant, the caregiver continues to blood sugar, administer insulin, administer IV
patient/caregiver that they should contact
play a vital role in the care of the patient. Ini- antibiotics, or learn wound care, including
the transplant team.
tially after transplant, the patient will need dressing changes or how to manage a
emotional support in the hospital as they wound vac in the home environment. The In summary, a successful caregiving team
move from the ICU to the step-down unit patient will need transportation and will should include a dedicated caregiver and
to the floor bed. The caregiver can be in- need to be accompanied to and from their a primary care physician. z
strumental in helping smooth these transi- post-transplant follow-up appointments.
Minimally Invasive Live Donor Hepatectomy ~ Continued from Page 1
life more quickly. In most cases, donors have been able to Medical Center. Today more than half of kidney transplants
return to work in a matter of weeks rather than months. involve a living donor, and nearly all of these donor kidneys
are retrieved laparoscopically.
The new surgical advance represents the latest chapter in
a history of innovations in living organ donation by New York- Laparoscopic living donor liver retrieval for pediatric transplant
Presbyterian/Columbia surgeons. Dr. Jean Emond, Chief of was developed by Dr. Daniel Cherqui, Professor of Surgery at
Transplantation at NYPH/Columbia, was a key member of the Hospital Henri Mondor/University of Paris XII, who re-
the team that performed the first pediatric living donor liver ported the first case in 2002. Dr. Cherqui trained under Dr.
transplantation in North America in 1989 while at the Uni- Emond in the late 1980s. With a reputation as one of the most
versity of Chicago Medical Center. Dr. Lloyd Ratner, Director experienced laparoscopic liver surgeons in the world, Dr.
of Renal and Pancreatic Transplantation at NYPH/Columbia, Cherqui has been a valuable resource to our center in making
performed the nation's first adult-to-adult laparoscopic living laparoscopic living donation available in New York. z
donor kidney transplant in 1995 while at Johns Hopkins
6 CLDT ~ Liver News
Announcing New CLDT Faculty and Staff
Megan Sykes, MD Sonja Olsen, MD Cynthia Sterling-Fox, Judith Gang, BSN, MS, FNP Teresa Lukose, PharmD
BSN, MSN, FNP
Megan Sykes, MD the same species (allografts) and from University Medical Center (NYPH/Colum-
Professor of Medicine and Microbiology other species (xenografts). This work has bia) for a gastroenterology and hepatology
& Immunology and Surgical Sciences resulted in the first successful trials of inten- fellowship. Dr. Olsen then returned to
(in Surgery), Columbia University tional allograft tolerance induction in hu- NYPH/Weill Cornell where she was
College of Physicians and Surgeons mans. At Harvard, Dr. Sykes’ laboratory named Chief Medical Resident, and was
Director, Columbia Center for worked toward the development of clini- charged with training NYPH/Weill Cornell
Translational Immunology, cally feasible, non-toxic methods of re-edu- medical housestaff and overseeing the res-
Columbia University College of cating the T cell, B cell and NK cell idency program. During 2008-2009, Dr.
components of the immune system to ac- Olsen was awarded an American Associ-
Physicians and Surgeons
cept allografts and xenografts without re- ation for the Study of Liver Diseases
Director of Research,Transplant Initiative, quiring long-term immunosuppressive (AASLD) training grant based on her fel-
NewYork-Presbyterian Hospital therapy. Her work has also extended into lowship work in hepatitis B and joined the
Megan Sykes, MD, joined Columbia Univer- the area of xenogeneic thymic transplanta- team at the CLDT NYPH/Columbia cam-
sity in April, 2010. She comes to us from tion as an approach to tolerance induction, pus to study transplant hepatology for
Massachusetts General Hospital/Harvard and into the mechanisms by which non- one year. “I feel very fortunate to be part
Medical School, where she was the Harold myeloablative induction of mixed of such a wonderful team and enjoy both
and Ellen Danser Professor of Surgery and chimerism reverses the autoimmunity of campuses with my outpatient office at
Professor of Medicine (Immunology) and type 1 diabetes. Cornell and my time at Columbia on the
Associate Director of the Transplantation inpatient service,” she says. “I am delighted
She is the Immediate Past President of the
Biology Research Center. to be caring for patients in partnership
International Xenotransplantation Associa-
with dedicated and skilled clinicians Leah
Dr. Sykes’ research career, during which she tion and is Vice President of The Transplan-
Buco, NP, and James Spellman, NP, at the
has published 365 papers and book chap- tation Society. She has recently been
Weill Cornell campus of the CDLT.” Dr.
ters, has been in the areas of hematopoi- elected to membership in the Institute of
Olsen’s clinical specialties are liver can-
etic cell transplantation, achievement of Medicine. z
cer, non-alcoholic fatty liver disease, and
graft-versus-leukemia effects without
viral hepatitis. z
GVHD, organ allograft tolerance induction,
Sonja Olsen, MD
Assistant Professor of Medicine
Her current research focuses on utilizing Cynthia Sterling-Fox, BSN,
Born in Brooklyn, Dr. Olsen attended MSN, FNP
bone marrow transplantation as im-
Stuyvesant High School in New York City Clinical Coordinator
munotherapy to achieve graft-versus-tumor
and graduated from Williams College in
effects while avoiding graft-versus-host dis- Cynthia completed her graduate training at
1997 with a BA in biology and economics.
ease, the common complication of such the Columbia University School of Nurs-
A graduate of Dartmouth Medical School,
transplants. Her laboratory studies in this ing, where she earned an MSN (cum laude)
she returned to New York for her residency
area have led to novel approaches that as a family nurse practitioner. She holds a
and completed her internal medicine train-
have been evaluated in clinical trials. An- BSN degree from SUNY Health Science
ing at NewYork-Presbyterian Hospital/Weill
other major area of her current research Center (Downstate Medical Center).
Cornell Medical Center (NYPH/Weill Cor-
focuses on utilization of bone marrow
nell). Her interest in hepatology led her to Early in her career, Cynthia worked as a
transplantation for the induction of trans-
NewYork-Presbyterian Hospital/Columbia registered nurse in the medical surgical
plantation tolerance, both to organs from
Continued on page 6
Announcing New CLDT Faculty and Staff ~ Continued from Page 7
unit and emergency room of a major worked as a floor nurse, a liver transplant co- ture for the multidisciplinary transplant re-
New York hospital for five years, and as ordinator, and a hepatobiliary/HCC coordi- search center of the NYPH solid organ
an emergency room NP for six years. She nator. She also served as the primary liaison transplant programs.
discovered her true career passion in between Mt. Sinai’s hepatobiliary/surgical on-
Before coming to the CLDT, Theresa
transplantation nursing in 2002, when she cology and liver transplant services, where
spent five years as a clinical pharmacy
joined the NYPH/Columbia Center for her objective was to streamline the referral
manager specializing in lung and hear t
Advanced Cardiac Care, caring for pre- and evaluation processes of patients with
transplantation, working with the Colum-
and post-cardiac transplant patients. HCC and expedite their transplant listing.
bia and Cornell transplant teams at
At the CLDT, Cynthia works collabora-
A graduate of Yeshiva University, in New York NewYork-Presbyterian Hospital. During
tively with hepatologist Dr. Eva Sotil, City, where she received a BA in Jewish His- that time, she guided the inpatient trans-
to provide care for pre and post liver tory, Judy completed her nursing training in plant team in medicationmanagement of
transplant patients. 2007 at Pace University's Lienhard School the post-transplant patient, instructed
Cynthia’s other interests include clinical re- of Nursing. At the CLDT, Judy works collab- transplant recipients about medications,
search and teaching. She has provided re- oratively with NP Ariana Rose and Dr. Scott developed policies and protocols related
search support to many studies at Columbia Fink to provide care for pre- and post-trans- to transplant, and par ticipated in trans-
University Medical Center, including in the plant liver transplant patients. z plant related research. She also served as
areas of immunosuppression and molecular Director of NYP’s PGY2 Solid Organ
expression testing in transplant patients. She Theresa Lukose, PharmD Transplantation Pharmacy Residency and
is an adjunct assistant professor of nursing at Director, Clinical Transplant Research taught pharmacy residents and students.
CUNY Medgar Evers College. z
Theresa joined the CLDT and the Theresa graduated from Albany College of
NewYork-Presbyterian Hospital Transplant Pharmacy in 2002 and completed a PGY-1
Judith Gang, BSN, MS, FNP pharmacy residency at NYPH/Columbia in
Initiative in September, 2009. She oversees
Transplant Coordinator 2003 and a PGY-2 Specialty Residency in
the ongoing clinical trial activities of
Judy Gang, who has a special interest in he- the center and identifies and applies for fed- Solid Organ Transplantation at Duke Univer-
patocellular carcinoma research and treat- eral and foundation grants. She also sity Hospital in Durham, North Carolina in
ment, comes to the CLDT from Mount Sinai oversees transplant protocol development 2004. It was during her liver transplant rota-
Medical Center’s Racanati/ Miller Transplan- and execution, and manages the CLDT tion as a PGY-1 Resident at Columbia that
tation Institute, where she worked from research staff. One of Theresa’s main initia- Theresa discovered her interest and passion
2000 through 2009. At Mt. Sinai, Judy tives is facilitating a centralized support struc- for transplant pharmacy. z
622 West 168th Street, 14-Center
New York, NY 10032-3784