Liver Review - Issue 3 - Fall 2000
- New Data Examines Living-Donor Liver Transplants
- New Immunosuppressives Improve Transplant Options
- New Physician Brings Women's Issues to Forefront
- California Pacific's Transplant Outcomes in the Top Among Transplant Centers Nationwide
- Herbal Remedies and Liver Disease
- New Telemedicine Program Expands Community Outreach
- State-of-the-Art Liver Unit in Development for Transplant Patients
New Data Examines Living-Donor Liver Transplants Top of Page
In response to a growing number of patients who are considering living-donor liver transplantation to shorten their wait for a liver, the American Society of Transplant Surgeons (ASTS) recently announced the development of a nationwide registry to track living-donor liver transplant outcomes. "The goal of the registry is to help potential donors assess their risk and learn of possible side effects related to the living-donor procedure," explains Robert Osorio, MD, surgical director of liver transplant at California Pacific Medical Center.
Survey Findings Show Mixed Results
Preliminary data from the registry was recently presented by John Renz, MD, PhD, during Transplant Grand Rounds at California Pacific. In reviewing 208 living donor liver transplants performed at 30 medical institutions, Dr. Renz found a 30% incidence of complications among living-donor liver recipients and a 10% incidence of donor complications
Biliary complications among recipients were reported most frequently, affecting 18% of patients. Complications ranged from anastomotic leaks and strictures (affecting the connection between bile ducts) to parenchymal leaks, or leaks at the cut edge of the liver.
An additional 43 centers that intend to initiate living donor liver transplantation within the next six months will also participate in the registry. Over time, the results from all institutions will help educate patients about the risks and complications associated with living liver donation.
Organ Shortage Prompts Living Donor Consideration
Nearly 16,000 patients are listed on the UNOS waiting list for a liver transplant. This volume, coupled with the fact that about 11% of patients die while waiting for transplantation, has raised interest in living-donor transplantation. The living-donor procedure can optimize transplantation timing, enabling patients to avoid long waiting periods and disease progression.
To donate a liver, a person must be in good health, have a blood type compatible to the recipient and be altruistically motivated to donate. California Pacific Medical Center evaluates potential donors interested in living liver donation, paying particular attention to the donor's health. If our physicians decide there is too great a risk to the donor, we will not go forward with the procedure.
For more information on living liver donation, contact our "Living Donor Liver Transplant Line" at 415/600-1015 and leave a detailed message with your inquiry. We will return your call within one day. For email inquiries, write to us at: email: cpmcldlt@sutterhealth.org.
New Immunosuppressives Improve Transplant Outcomes Top of Page
The success of organ transplantation has been achieved in large part by the development of drugs that prevent a recipient's immune system from attacking and destroying the donor organ. The immune system has two major branches that fight threats to the body's health: the innate and adaptive immune response. The innate response is a non-specific and early reaction while the adaptive response is a very specific and powerful one, taking several days to occur. The T cell is the major player in orchestrating the adaptive response and, as a result, is the target of many drugs designed to prevent allograft rejection.
The following are common categories of immunosuppressive medications, including examples of drugs used by California Pacific's liver transplant team. An additional and well-known category is corticosteroids, but these are cautiously used because of multiple and severe side effects.
Inhibitors of T cell Activation and Function
Prograf (FK506 or tacrolimus)
Tacrolimus prevents rejection by blocking the production of IL-2, an important T cell growth factor. California Pacific's Liver Program has found this medication very effective, despite side effects such as nephrotoxicity, hyperglycemia, neurotoxicity and hirsutism. Tacrolimus is well tolerated by patients and is one of the mainstays of our Program's immunosuppressive regimen.
Neoral/Gengraf (cyclosporine)
Cyclosporine blocks T cell activation by binding calcineurin and also prevents the production of IL-2. Side effects may include hypertension, nephrotoxicity, neurotoxicity and hirsutism, California Pacific's Liver Program rarely prescribes cyclosporine. If used, Neoral and Gengraf are the formulations of choice due to greater bioavailability and more reliable absorption.
Rapamycin (sirolimus)
Sirolimus is a new, FDA-approved immunosuppressive agent for transplant recipients. Sirolimus prevents T cells from responding and proliferating to signals derived from numerous cytokines, thus blocking T cell function. Because this agent has proven very powerful in preventing rejection in renal transplant patients, California Pacific is beginning to use it in certain populations of liver transplant recipients. Sirolimus does not have the nephrotoxicity or neurotoxicity associated with cyclosporine or tacrolimus. Its side effects include hyperlipidemia, hypertension and thrombocytopenia.
Inhibitors of Cell Proliferation
CellCept (mycophenolate mofetil)
Mycophenolate mofetil blocks T and B cell proliferation by interfering with purine synthesis. Due to its tolerability and efficacy, mycophenolate has replaced its predecessor, azathioprine, as the anti-proliferative agent of choice in immunosuppressive post-transplant drug regimens. Key side effects include bone marrow suppression and gastritis/ulceration requiring the concomitant use of proton pump inhibitors for protection.
Combination Therapy
Combining agents from the above classes currently provides transplant physicians with the best opportunity to prevent both innate and adaptive T cell-mediated immune responses from destroying the transplanted organ. Thus, the use of a broad-acting corticosteroid such as prednisone, plus Tacrolimus and CellCept is the most commonly used immunosuppressive regimen by California Pacific's Liver Program. This triple therapy is generally used immediately post-transplant and modified after several months or years to either a two-drug or single-drug regimen in order to minimize long-term side effects.
California Pacific's Liver Program is working hard to individualize each patient's immunosuppressive regimen. In doing so, our goal is to optimize the balance of adequate immunosuppression with minimal side effects, thereby continuing to improve transplant outcomes and quality of life.
New Liver Physician Brings Women's Issues to Forefront Top of Page
The Liver Disease and Transplant Program recently announced the addition of Natalie Bzowej, MD, PhD, to its medical staff. Dr. Bzowej, a gastroenterologist and hepatologist who comes to California Pacific Medical Center from UCSF, will work in partnership with other hepatologists to manage the care of patients with acute, chronic and end-stage liver disease. Because of her research interests surrounding the prevalence and course of liver disease in women, Dr. Bzowej will specialize in women's hepatology issues.
"The high incidence of liver-related autoimmune conditions in women--combined with hepatitis C variations and pregnancy problems related to liver or gastroenterological conditions--demands further attention," says Bzowej. "By focusing our research on the course of liver disease in women, the Liver Disease and Transplant Program can better serve women facing these conditions and tailor their treatment accordingly."
In addition to women's issues, Dr. Bzowej's research interests also include hepatitis C viral diversity and treatment strategies. She holds her M.D. and a Ph.D. in pharmacology from University of Toronto.
Look for further information and research highlights on the role of gender and ethnicity in liver disease patients in the spring issue of Liver Review.
California Pacific's Transplant Outcomes in the Top Among Transplant Centers Nationwide Top of Page
With both one- and three-year liver transplant graft and patient survival outcomes significantly higher (10%) than the national average, California Pacific Medical Center's liver transplant results are in the top among transplant centers nationwide, according to new data from the United Network for Organ Sharing(UNOS).
UNOS' data, available online at www.unos.org, shows that California Pacific's one-year patient survival is 94.9%--10 percent above the expected survival given the characteristics of our recipients and donors--and the three-year patient survival is 86.1%, 10 percent better than expected. Graft survival rates are also significantly higher than expected. The following details our outcomes:
As always, our philosophy is to provide top transplant results from the most patient-friendly program in California. For further information on our statistics, including indications for transplant, waiting time and length of stay, visit our Stats section.
Herbal Remedies and Liver Disease Top of Page
With a growing interest in herbal medicines, more patients are seeking treatment with alternative interventions, yet little testing or standardization has been done.
Certain herbs such as milk thistle have been used for centuries for liver complaints and the silymarin found in the milk thistle plant seed has been shown to prevent liver damage from a variety of toxins. According to Amy Saltzman, MD, clinic physician at California Pacific Medical Center's Institute for Health and Healing, "The therapeutic effect of milk thistle (silymarin) in treating liver diseases such as cirrhosis, chronic hepatitis, chemical- and alcohol-induced fatty infiltration has been suggested by small, early clinical, laboratory and histological data."
While milk thistle has shown to have an anti-inflammatory effect, it has no antiviral effect and will not cure viral hepatitis. Most herbs have been found to cause a variety of liver problems ranging from hepatitis to liver failure and patients with liver disease should not consume them.
See our patient handout for a list of common herbal medications that carry a risk of toxicity for liver disease patients.
New Telemedicine Program Expands Community Outreach Top of Page
To enhance patients' accessibility to liver disease and transplant care, California Pacific Medical Center's Liver Program has introduced telemedicine to our Fresno outreach clinic. This technology will supplement monthly outreach visits by enabling patients to see and interact with their liver team via live television through a network of high resolution audio and video hook-ups.
While telemedicine is already used in various medical fields, California Pacific is the first institution to offer this state-of-the-art technology for transplant patients. We invite physician practices or hospitals to contact us if you are interested in developing a liver telemedicine site in your area. Contact Dr. Robert Gish.
State-of-the-Art Liver Unit in Development for Transplant Patients Top of Page
To meet the growing volume of liver disease and transplant patients, California Pacific Medical Center will unveil a new transitional care unit in November 2000. The nine-bed unit, which has the flexibility to increase to 12 beds, is designed for the specific needs of pre- and post-transplant patients. It will feature private rooms with new equipment and state-of-the-art wireless technology that enables patients to easily move around while connected to portable, compact monitoring equipment.
With the development of this new space, moderately acute pre- and post-liver transplant patients will now be centralized in one area of the hospital, with a specialized nursing staff. The need for such a unit was recognized because the continuing shortage of livers has necessitated a lengthier hospital stay for patients awaiting transplantation. Five years ago, patients undergoing liver transplantation typically spent five days in the hospital pre-transplant whereas today, patients are spending 14 days on average as inpatients while waiting for a donor liver.
Liver Review is a quarterly publication of California Pacific Medical Center (CPMC). ©Copyright 2000 by CPMC. All rights reserved.