UNMC liver transplant program not resting on its laurels

Posted: 10/07/2012 1:00 AM

The University of Nebraska Medical Center carved out a reputation for excellence 25 years ago through its pioneering liver transplant program.
Now the challenge of UNMC and many transplant hospitals is how to carve a niche in a field that has become cluttered with competitors.
About 240 U.S. hospitals have performed organ transplants this year while the number of available livers, kidneys, hearts and other organs has remained almost static over the past six years.
The Nebraska Medical Center, UNMC’s hospital partner, continues to perform large numbers of kidney and liver transplants and is a national leader in transplanting intestines.
But administrators are looking at other specialties to save more lives and maintain their program’s status.
The medical center intends next year to get back into lung transplants. Administrators also are considering creating a “national pediatric transplant center,” although no specific plans have been disclosed.
When Jennifer and Aaron Crook of the Union, Neb., area considered where to take their infant daughter, Maddy, for an intestinal transplant six years ago, medical professionals recommended hospitals in three cities: Pittsburgh, Miami and Omaha. Their proximity to Omaha made the choice obvious.
Maddy had a genetic disorder that affected her intestines, bladder and digestive system in general. Early on, it was clear she would need a transplant. She underwent two surgeries in her first two months of life and went on the waiting list for transplantation.
She was exhausted, her liver function was awful and her skin was yellow-orange. She was dying.
Five months into Maddy’s wait, her mother said, organs became available from the death of another girl. Maddy received a small intestine, pancreas and liver.
She was extremely puffy from fluids after the transplant, but her mother was delighted. “She had pink, rosy cheeks,” Jennifer Crook said. “It was amazing.”
The medical center performed its first intestinal transplant in 1990, and that program, along with the intestinal rehab clinic, has become one of the nation’s biggest and best.
But the hospital’s golden age of transplantation, when it was viewed as a rare center of excellence in the middle of the nation, belongs to the past. Transplants generally are no longer on the cutting edge of medical science, and many hospitals, including four in Iowa and eight in Missouri, have transplanted organs this year.
Dr. Alan Langnas, director of transplantation at the Nebraska Medical Center, said aspiring transplant surgeons used to read “The Right Stuff,” Tom Wolfe’s 1979 book about experimental jet pilots and the first astronauts. But transplantation is more commonplace and no longer dramatic enough to be compared to rocket testing, he said.
Nevertheless, Langnas said, the medical center continues to do excellent work in the field.
“I think we’re pretty special,” said Langnas, who has headed the program since 1997. “We don’t rest on our laurels around here, I can assure you of that.”
The medical center started its liver transplant program in 1985, when few hospitals in the Midwest were transplanting livers. Administrators recruited Dr. Byers “Bud” Shaw, who had worked under Dr. Thomas Starzl, the transplant star in Pittsburgh.
Dr. Charles Andrews, UNMC’s chancellor at the time, said it was a real advantage to be in the middle of the country and able to procure livers from east and west. The program bolstered UNMC’s reputation.
“It was something new, exciting and great and all that stuff, which was really vital for us back then,” said Andrews, who retired in 1991. “Everybody likes to be with a winner, and we were winners in liver transplants.”
In 1988 – the first year a federal agency tracked numbers of transplants – the medical center ranked third in the nation in liver transplants, with 119, behind the University of Pittsburgh and UCLA. Last year the medical center ranked 21st, having done 90.
Patients awaiting transplants are listed on a national database, and available organs generally are allocated to extremely ill people in the state where they came from or, if no suitable match is found in-state, people in the region from which the organs were procured.
The competition for livers in the region has become far more intense since 1988. That year, the University of Kansas, St. Louis University and the University of Colorado did a total of 11 liver transplants. Last year, those three institutions did a total of 212.
Numbers of available organs have increased little, if at all, over the past few years. Traffic fatalities in the United States, a key source of organs, declined about 25 percent from 2005 through 2011.
Nationwide, 6,342 livers were transplanted last year, down from 6,444 in 2005. When all organs are considered, 28,537 were transplanted last year, up slightly from 28,118 in 2005.
UNMC Chancellor Harold Maurer said the medical center has won international recognition for transplantation and generated pride within the state. The hospital transplants five organs, including hearts.
Maurer said transplant hospitals are all over the country. “But people still go to the best place with the best results,” he said.
Statistics from a Minnesota agency that tracks results, the Scientific Registry of Transplant Recipients, indicate the medical center has average outcomes when compared with other hospitals and when adjusted for difficulty of case.
Langnas generally agreed with that assessment, saying the medical center produces the results that are expected of such a transplant center.
“We are at the national average in outcome,” he said.
Given that the quantity of available organs has flattened out while the number of people on the waiting list has risen, scientists and physicians are devising diverse strategies to avoid transplantation.
At the medical center, for instance, medical professionals work with patients suffering intestinal disease to preserve their intestines through surgeries, nutrition, medications and monitoring. The intestinal rehab program is the “biggest competition we have for our transplant program,” Langnas said. “Which is fantastic.”
Heart surgeons are making strides with ventricular assist devices to not only delay transplantation, but even render it unnecessary.
Dr. A. Joseph Tector, chief medical officer for Indiana University’s busy transplant program, said his institution is making progress in dealing with pig organs and rejection challenges. Testing pig organs in humans most likely will take place within 10 years, Tector said.
“If it worked, we could use it for all organs,” he said.
But human organ transplantation continues to be a life-saving treatment for many.
Langnas said the medical center is one of the few comprehensive programs in the nation that take on numerous patients who are comparatively ill even for people on organ waiting lists. “We are a port of last call,” Langnas said.
A Minnesota-based transplant consultant agreed that the Omaha medical center is among hospitals that accept really tough cases. But the consultant, Roger Evans, questioned whether it’s wise to do so when the number of available organs is virtually stagnant and the number of patients on waiting lists is growing.
Evans, who called the medical center “an excellent program,” argued that patients who will receive maximum benefit from the limited supply of organs should receive highest consideration.
Transplant surgeons talk at conferences about how to transplant elderly people or incredibly ill patients, he said. Early next year, for instance, a meeting in Miami will discuss, among other topics, how to “transplant the untransplantable.”
Langnas said the medical center won’t place organs into just anyone. But balancing getting the most years out of an organ with saving an extremely ill person can be difficult, he said. That’s why an ethicist sits in on the program’s patient selection discussions, he said.
“We take our responsibility as stewards of the organs very seriously.”
Next year, the medical center intends to get back into lung transplants. Officials successfully recruited Dr. Michael Moulton, a cardiothoracic surgeon who performed lung transplants at the University of Arizona. The Nebraska Medical Center hasn’t done a lung transplant since 1998.
The medical center also is considering creating a “national pediatric transplant center,” said Glenn Fosdick, CEO of the Nebraska Medical Center. That would most likely mean organizing his hospital’s considerable pediatric transplant resources into one spot.
Fosdick said it wouldn’t mean building new facilities but connecting children’s inpatient and outpatient space for liver and intestine transplants.
Over 2010 and 2011, the medical center did the second-highest number of intestinal transplants in the nation, but the number was fairly low: 38. Children received many of those transplants.
Only Indiana University Health’s 55 exceeded the local total over those two years.
The Nebraska Medical Center’s expertise and location made it attractive to the Crooks when infant Maddy needed an intestinal transplant.
“Otherwise, we would have been traveling a long, long way,” said mom Jennifer Crook.
The Crooks live on a hill between Plattsmouth and Nebraska City. Six-year-old Maddy roams that wooded rise with her brother, 9-year-old Cole, and their cat, Mittens.
Although Maddy eats and drinks, she still has a feeding tube in her nose for additional nutrition. Her mother said the feeding tube will eventually be permanently removed. An ileostomy in Maddy’s abdomen collects waste. That necessity will remain with Maddy throughout her life.
“I think, all things considered, that’s pretty minor,” Jennifer Crook said of the ileostomy, which empties the waste into a discreetly situated pouch.
Jennifer Crook showed a photo album containing shots of Maddy’s battle for her life six years ago. Her mother said she had doubted Maddy would make it to her first birthday.
On Friday, Maddy and her parents, brother and grandparents celebrated with ice cream cake and gifts the sixth anniversary of her transplant. They call the anniversary Tummy Day.
Contact the writer: 402-444-1123, rick.ruggles@owh.com, twitter.com/rickruggles
Jennifer Crook describes how her daughter, Maddy, 6, received a pancreas, liver and lower bowel transplant six years ago. On the anniversary of Maddy’s transplant, the family celebrates Tummy Day.

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