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Liver Transplantation for the GI Specialist: A ‘Matter of Communication’
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Liver transplantation remains the last curable option for many chronic and severe acute liver diseases. For gastroenterologists who wish to play a more active role in liver transplant cases, the key to good pre- and posttransplant patient care is to communicate with the local transplant center and develop a proper team dynamic. Working together, the GI specialist and transplant center can minimize unnecessary transfers and improve follow-up.
“The first thing gastroenterology specialists need to do is understand some of the basics about liver transplantation and what they can do locally,” Mitchell L. Shiffman, MD, director of the Bon Secours Liver Institute of Virginia, told Healio Gastroenterology and Liver Disease. “The best way to do that is for them to reach out and have conversations with the transplant program they frequently refer to and develop a set of conditions which the transplant program feels they are comfortable with the specialist handling at a certain MELD score. Outside those boundaries, the transplant center can clarify which patient changes they should be informed about.”
One way to avoid unnecessary transfers or quick turnaround of hospital discharges is to ensure patients have regular follow-ups. Regular monitoring of labs, especially MELD scores, and management of decompensating events can improve patient well-being while on the waitlist and ensure that patients are transferred at the optimal likelihood of receiving an organ.
“I think many large transplant programs don’t necessarily want community gastroenterologists to do more; they just want to know any time anything happens and to have the patient sent to the transplant center, which is both very costly and unrealistic,” Shiffman said. “If you’re interested in taking care of the patient with known liver disease — and there are many gastroenterologists who would like to do more with liver disease — it’s all a matter of communication and picking up the phone.”
However, Shiffman added that both transplant centers and gastroenterology education have grown over the last 20 years. While transplant centers may have felt protective of patients and wanted to handle everything, this era has seen several gastroenterologists now in the community who have been trained within centers that handle transplantation.
“Even though they probably didn’t do a special hepatology training or transplant year — which a vast majority have not — they are aware of the issues that need to be considered in transplant and they can continue to use that expertise,” Shiffman said. “I think a lot of transplant programs would, in this era, find that favorable and want to work with physicians in the community and develop relationships because it simply strengthens their program.”
Pretransplant Follow-up
Depending on MELD score, patients on the waitlist for liver transplantation typically have labs performed at least once every 3 months or as frequently as every week. Frequent follow-up can allow a gastroenterologist to capture a higher MELD score or acute change in disease that can move a patient up significantly on the waitlist.
“The natural history of patients with decompensated disease is to have decompensating events that are typically associated with increases in MELD scores,” Norah Terrault, MD, from the University of California, San Francisco, said. “Being on top of those labs as they come in and being mindful of changes in MELD scores, or in symptomatology suggesting worsening symptoms of liver decompensation is important. It is important to be aggressive about managing patients when they present decompensating events, and having a low threshold to admit them when worsening clinical status is noted.”
According to both Shiffman and Terrault, it is important to keep the transplant center aware of reasons for hospitalization, such as GI bleed or worsening of ascites, which often occur during a point in which MELD scores rise significantly. Gastroenterologists should communicate acute changes with the transplant center and request advice for local management vs. potential transfer.
“Sometimes there’s a bit of a disconnect between the transplant center and what’s going on locally,” Terrault said. “There shouldn’t be. Open communication during clinical events can ensure MELD labs are being captured to appropriately prioritize the patient on the waiting list and minimize the opportunity for transplantation. That to me is what gastroenterologists should focus on: recognize that transplant centers really need to know about changes in clinical status and MELD scores.”
One recent study published in Liver Transplantation and another published in Journal of Hepatology discussed the ‘transplant window’ within certain liver disease cases. In case of pediatric biliary atresia, patients younger than 6 months were at a significantly higher risk for waitlist mortality when their MELD score exceeded 20. Similarly, patients with acute-on-chronic liver failure grade 3 had similar 1-year survival posttransplant compared with lower grades.
“The most important thing is for the gastroenterologist to be contacting the transplant center to let them know the patient is now hospitalized, what the current events are, and determining if and when it is appropriate to transfer the patient,” Terrault said.
Transplant Center Distribution
Last year, the Organ Procurement and Transplantation Network and United Network for Organ Sharing board of directors approved a set of policy amendments designed to reduce geographic differences in liver transplant access and distribution.
Provisions in the amended policies included additional transplant priority for liver transplant candidates with a MELD or PELD score of at least 15 who live within a select donor service area, higher prioritization for candidates with a MELD score of 32 or higher, and broader offers from deceased liver donors aged 70 years or older.
The OPTN and UNOS board directors developed these amendments in response to ongoing geographic disparities in the U.S. for liver transplant distributions.
“There was a movement in the transplant community to try to change the way organs were distributed to mitigate the disparities between supply and demand in different geographic areas,” Jean C. Emond, MD, chair of the Liver Transplantation Special Interest Group at the American Association for the Study of Liver Diseases and vice chair and director of transplant services at Columbia University, told Healio Gastroenterology and Liver Disease. “The patients have the option to move to another area, if that will increase their chances of getting transplanted, but the centers are competing over the business that they get. Centers that were benefiting from the status quo were resisting change and centers that felt disadvantaged were advocating for change.”
Still, patients may live far from the nearest transplant center and miscommunication can lead to patients transferred with low MELD scores or events that could be treated locally.
According to Shiffman, patients can often live at least 50 miles from the nearest transplant center, and unnecessary transfers with long travel times can be detrimental to the patient’s quality of life and wellbeing.
“It takes a lot out of a patient when they have to travel hours to the transplant program, only to stay in the hospital one more day and hear that they are not that sick and can be discharged when they were just sent there the day before,” Shiffman said. “You can’t transfer the patient to the transplant center every time they come into the hospital.”
Treating Locally
In addition to the trouble and complications that travel can present for patients, transplant centers may not have room for patients that a gastroenterologist initially believes should be transferred.
“A lot of times, what happens at these large academic medical centers is that they don’t have a lot of bed space,” Shiffman said. “So, the gastroenterologist calls the center, says that a patient is sick and needs a transfer, but there are no beds. If the gastroenterologist then does a good job locally, the patient is better by the time the bed opens and is simply discharged the next day following transfer.”
Rather than settling on a plan of transfer immediately, Shiffman explained, it would be better if the gastroenterologist speaks with the transfer center regarding the current event and treats locally. In these cases, patients often improve under the gastroenterologist’s care.
“Over time, that gastroenterologist gets to a little bit more and now you’ve developed a working relationship with the transplant program, which facilitates better patient care,” Shiffman said.
From the other side, transplant centers look for communication and partnership with gastroenterologists in many cases. Especially in the case of smaller hospitals, according to Terrault, a patient might be seen by an on-call physician who may be unaware that the patient is on the transplant list.
“We always advise our patients that if they are admitted elsewhere to tell the doctors there to call us,” Terrault said. “We want to know when patients are admitted, and we may want to transfer the patient because they are high on the transplant list. We can also advise about management of the acute decompensating event and, at the very least, capture their updated MELD score that might really influence their access to transplant.”
Regarding local treatment, recent studies have highlighted predictive factors of liver failure that can be used to assess patients ready for transfer vs. those who can remain in primary care.
One study published in the Journal of Gastroenterology and Hepatology showed that levels of fibroblast growth factor 21, a protein encoded by the FGF21 gene, predicted the presence and development of acute-on-chronic liver failure in patients admitted for acute decompensated cirrhosis.
The study’s researchers recruited and followed patients admitted to the ICU. Higher FGF21 levels correlated with significantly higher MELD, MELD-sodium and chronic liver failure-sequential organ failure assessment scores, based on an FGF21 level cutoff of 309 pg/dL.
Similarly, stabilization of insulin-like growth factor 1 levels predicted long-term survival posttransplant and correlated with graft and liver function, according to a study published in PLoS One. Patients whose IGF-1 plasma levels normalized within 15 days posttransplant had significantly better 3-year survival rates.
“I think good local care is important, because when things go wrong, or a patient has a new complication of their liver disease, that’s where they’re going to be seen first,” Terrault said. “When the patient gets transplanted, care usually shifts to the transplant center, especially in the first many months, but local gastroenterologists can still be active in their follow-up.”
Making Use of Nurse Practitioners
A recent review published in the International Journal of Health Services Research and Policy, discussed the major role that nurses can have in tackling organ and tissue shortages during organ donation and transplantation processes.
According to the review, studies showed that formal training on organ donation can influence student nurses’ attitudes, encourage communication and registration behaviors, and improve knowledge about donor eligibility and brain death. Nurses with an in-depth knowledge of donation understood its clinical and technical aspects as well as moral and legal considerations.
“Nurses are not recognized members of the team for the preparation of transplanted liver,” Željko Vlaisavljević, BScN, PhD, from the University of Belgrade in Serbia, told Healio Gastroenterology and Liver Disease. “Numerous studies indicate that nurses are a very important part of the team in preparing patients for transplantation, posttransplant care, and procurement of organs. Complex and severe patients are mostly in contact with a nurse. The relationship between nurses and staff can be improved, so the nurse would have a special title, salary supplement, greater autonomy in work, and officially involved in the transplant process.”
Shiffman and Terrault agreed that educating nurse practitioners and middle-level providers on the basics of liver disease progression and labs could aid gastroenterologists during both pre- and posttransplant care.
“There’s good data that shows that nurse practitioners can take on complex disease management with training, so that could very well be a good mechanism to have this additional resource within a GI practice for managing liver patients,” Terrault said.
“Nurse practitioners in the clinical practice can certainly take care of posttransplant patients once they’re clinically stable,” Shiffman explained. “Once immunosuppression is stable, once liver enzymes are normal, once the patient is doing well, we only need periodic monitoring.”
Shiffman posed that nurse practitioners could easily handle sending labs to the transplant center periodically and advise the center if there are any sudden changes, such as increases in laboratory values or renal dysfunction, and ask for recommendations about altering immunosuppression as needed.
“Again, creating a team atmosphere, so that the patient doesn’t have to suddenly drop everything to drive to the transplant center, only to be told that everything is fine, will improve quality of care,” Shiffman said.
Posttranplant Care
While the transplant center will often take over patient management and immunosuppression posttransplant, gastroenterologists may be needed in cases of recurrent disease.
“When a patient undergoes transplantation, generally their liver disease is cured or resolved, but occasionally patients get recurrent liver diseases and may need their gastroenterologist again,” Terrault said. “For example, if a patient develops hypertension or dyslipidemia, the transplant center may want the primary care physician or gastroenterologist to manage this.”
According to a study published in Liver Transplantation, risk factors associated with hospitalization within 6 months following liver transplantation include age 55 years and older, Asian ethnicity, high BMI, hepatitis C, end-stage renal disease, diabetes, current dialysis, and a history of transjugular intrahepatic portosystemic shunt.
The same study showed that African-American and Hispanic ethnicity, high BMI, HCV, hepatocellular carcinoma, life support at transplant, end-stage renal disease and livers from donors aged 50 years or older correlated with a significantly higher risk for mortality within 6 months posttransplant.
Each hospitalization within the first 6 months after liver transplantation increased mortality risk by 22%.
Other assessment tools for posttransplant include the Braden Scale, which predicts disability-related outcomes and greater length of hospital stay, and hepatobiliary MRI, which can reliably predict hepatocellular carcinoma recurrence.
Large academic transplant centers are often short of empty bed space, Shiffman explained. Without clear communication, patients could end up shuffled unnecessarily between hospitalization, transfer and discharge.
“You have a patient that’s sick, you call up and say you need to transfer the patient, and they say they would accept the patient, but they have no beds, so you’ll have to care for them until there are beds,” Shiffman said. “And you know what happens? You do a good job locally, the patient gets better, a bed opens, the patient is transferred, and now they’re discharged the next day because they’re all better. That patient didn’t really need to be transferred at that point.”
A New Era for Transplantation
As young gastroenterologists receive training that includes caring for patients with liver disease and senior physicians develop better relationships with their local hepatology specialists and transplant centers, patients will inevitably receive even greater care.
Terrault advised new models of care are needed to continue improving multispecialty patient management and that hepatologists and the transplant centers need to be able to easily share their knowledge about transplant eligibility, the rules around MELD scores, and changes in legislation about organ sharing.
“I don’t know exactly what those models will be,” she said, “but there is a clear need for transplant physicians to work more closely with local gastroenterologists or even primary care physicians, especially in rural areas, to improve quality of patient care prior to and after liver transplant. We need to keep the larger community of gastroenterologists and primary care physicians educated about the changes in transplantation so they’re referring people at the right time.” – by Talitha Bennett
- References:
- Artru F, et al. J Hepatol. 2017;doi:10.1016/j.jhep.2017.06.009.
- Kim AY, et al. J Hepatol. 2017;doi:10.1016/j.jhep.2018.01.024.
- Nicolini D, et al. PLoS One. 2015;doi:10.1371/journal.pone.0133153.
- Ruiz-Margáin A, et al. Liver Transpl. 2018;doi:10.1002/lt.25041.
- Sharma P, et al. Liver Transpl. 2017;doi:10.1002/lt.24813.
- Sundaram V, et al. Liver Transpl. 2017;doi:10.10002/lt. 24789.
- van der Doef HPJ, et al. Liver Transpl. 2017;doi:10.1002/lt.25025.
- Vlaisavljević Ž, et al. J Heart Lung Transplant. 2018;doi:10.23884/ijhsrp.2018.3.2.07.
- For more information:
- Jean C. Emond, MD, can be reached at em2601@cumc.columbia.edu.
- Mitchell L. Shiffman, MD, can be reached at mitchell_shiffman@bshsi.org.
- Norah Terrault, MD, can be reached at norah.terrault@ucsf.edu.
- Željko Vlaisavljević, BScN, PhD, can be reached at kcszeljko@gmail.com.
Disclosures: Emond, Terrault and Vlaisavljevic report no relevant financial disclosures. Shiffman reports being an advisor, speaker and receiving research funding from AbbVie, Gilead and Merck.