Minimally Invasive Live Donor Hepatectomy

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Minimally Invasive Live Donor Hepatectomy Powered By Docstoc
					                                                                                                                            Spring~ 2010

                                       Benjamin Samstein, MD, Surgical Director, Living Donor
  In this issue:                       Liver Transplant Program
1 Laparoscopic Living Donor
  Liver Surgery                        Minimally Invasive Live
                                       Donor Hepatectomy
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-
  Liver Transplant
                                       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                                                                     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-
Natural History
                                                                                                    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.
                                                                               2009 Dec;3(6):693-9.                                                                                                                                          3
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
liver transplant.1
                                               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-
pharmacologic intervention.4
                                               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                                                                                                                                     5
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
                                                                                                        uation process.
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
and xenotransplantation.
                                                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                                                                                                                                  7
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

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