The liver transplant program at UK Transplant Center offers comprehensive care for transplant patients and treats patients with end-stage liver disease and liver tumors.
Malay Shah MD, FACS shares what conditions lead to transplant, as well as indications for referral to a transplant center. She discusses what the process looks like when a patient gets to UK's transplant center and what makes the liver transplantation program at UK stand apart from others in the state as well as the nation.
Selected Podcast
The Liver Transplant Program at UK Transplant Center
Featured Speaker:
Learn more about Malay Shah, MD
Malay Shah, MD, FACS
Malay Shah is the Surgical Director of the Liver Transplant Program. He is from the Cincinnati area and attended college at the University of Cincinnati. While in Cincinnati, he worked closely with individuals who were involved in transplant and immunosuppression outcomes research.Learn more about Malay Shah, MD
Transcription:
Melanie Cole (Host): Great progress has been made in the filed of liver transplantation over the past two decades. The progress, however, also brings up a next set of challenges. Organ shortage remains a major limitation and accounts for a large proportion of the wait list mortality. My guest today, is Dr. Malay Shah. He’s the Surgical Director of Liver Transplant Program at UK Health. Dr. Shah, it’s a pleasure to have you join us today. Tell us a little bit about the UK history with liver transplants.
Malay Shah, MD, FACS (Guest): Well I appreciate you having me on. I’d love to talk to you more about it. So, the University of Kentucky started a transplant program a couple of decades ago. And it was a big need in the area at the time. I mean there is obviously – in the state of Kentucky, there’s a lot of people with advanced liver disease due to their medical comorbid conditions such as diabetes, obesity, hepatitis C. we have some of the highest rates of Hepatitis C in the country. And so, there was an imminent need for the University of Kentucky to have a liver transplant program because if you look on a map, you can see where UK Healthcare is, and it’s situated kind of in the middle of the state. So, a large portion of the patients we serve are patients from central Kentucky and eastern Kentucky, West Virginia, so Appalachia and now we’re actually drawing patients in from western Kentucky more recently.
But I think that’s why – that’s kind of the genesis towards why UK developed the liver transplant program is just simply for the need that these patients need somebody to manage their liver disease and provide transplant options that they otherwise would not be able to receive.
Host: So, Dr. Shah, for other providers, give us some indications for referral to a transplant center. What would you like other providers to know about that?
Dr. Shah: Well what I tell people – there’s some common sense guidelines I use which is what I tell providers when I go out on outreach for instance is if you think you need a liver transplant – if you think your patient needs a liver transplant evaluation just send them. We are happy to see everybody. Some patients just want one just kind of for peace of mind whether or not they need a liver transplant, or they’ve been seen for liver transplant evaluation.
And sometimes providers, it helps them kind of give their patients a peace of mind and a second opinion as to a transplant evaluation and whether it’s needed or not. More objectively, what I tell gastroenterologists and their providers is that if people have a MELD score of anywhere from 10 or higher or they have evidence of hepatocellular carcinoma which is a – something that can happen as a result of cirrhosis; to go ahead and send the patient in and let us start the process of evaluation.
Even though patients typically don’t get a transplant until their MELD score is higher than 15; our program has a mindset that it’s good to get the patient in early because the problem with liver disease is that patients can be doing well for a period of time and then just unexpectedly fall off the cliff. And so, rather than wait until the patient falls off the cliff where it may be to late to actually provide a service for the patient; I’d rather have the patient here already evaluated, already on the list and we are kind of ready to step in and do a transplant if needed.
So, those are kind of the general things I tell providers on the outside is just send them when you think they need to be sent and if their MELD score is higher than 10 go ahead and send them on in.
Host: Then what does the process look like when a patient gets to the UK Transplant Center?
Dr. Shah: So, when they come to our clinic, they meet with one of the surgeons who will do a comprehensive history and physical examination. They’ll meet with one the hepatologists who will also likewise do the same in terms of the history and physical exam. They’ll meet with one of our liver transplant nurse coordinators at that visit. Those are the three main people that they are going to see.
And so, all of us will talk to the patient regarding different aspects – all of us talk to the patient regarding liver transplant or their candidacy but all of us addressing it from a different perspective. The surgeon is obviously, addressing it from the perspective of the surgical procedure and postoperative care. The hepatologist is addressing it from the perspective of medical management of the liver disease and what we need to do to keep the patient healthy – as healthy as possible until time of the transplant and then the nurse coordinator is going kind of through all of that stuff and then basically our nurse coordinator, we have five of them, but one of them will be assigned to any given patient and that nurse coordinator is going to be that patient’s point person through the entire journey of liver transplant; pretransplant and posttransplant.
So, that’s kind of what patients can expect if they are coming in to our outpatient clinic. Inpatient, of course, is different. If someone is sick in the hospital when we initially receive the consult, we’ll go see them as a consult and kind of decide whether or not we want to evaluate them for a liver transplant.
Host: As I said in my intro, there’s a problem and challenges certainly with organ shortage. Tell us a little bit about what you see on the horizon as far as organ shortage or what you see going on now, some of the challenges that you might face.
Dr. Shah: That’s a great question. So, when patients get on the list of course, even – the demand for liver transplant far exceeds the supply, meaning there’s more patients that are on the wait list than there are organs available for transplant. And that actually is getting worse as time goes on nationwide, that disparity between the supply and demand is getting worse. And so, there’s a lot of researchers exploring different avenues for creating xenotransplants is something that people have been working on for 20 to 30 years at least which is using animal livers and putting them into human beings and there is just a lot of immunologic challenges associated with that. And that’s something that’s out of my area of expertise.
But I think the biggest thing going on right now and I’m proud to say that UK is at the leading frontier of this field about improving OPO, so organ procurement organizations performance. So, we have been doing a lot of research and collaboration with colleagues from Emory and from Miami and Vanderbilt on ways to identify more donors in more locations and more hospitals throughout the country. And we are trying to expand our view on what we think are suitable donors. So, as an example, 20 to 30 years ago, people may not – and this predates me being in transplant, but 20 to 30 years ago, people may not have used a donor from somebody that was 55 or 60 years old thinking that well we have enough donors for the amount of patients we have on the wait list.
And so, why use older donor when we can wait for a donor that’s potentially younger. Well, obviously, now that the disparity between the supply and demand is just ever increasing; people have been looking for different ways to use all sorts of different donors. And so, we use older donors who for livers as an example, older donors, as long as the liver is normal; it actually doesn’t make a difference how old the donor is. We can use an older liver if you will from an older donor and put it into a young recipient and there’s basically very little to no consequence from doing that. So, I think we’re expanding the way we are all thinking about how to approach donation and maximally utilize donors available.
And then, going back to the research I was talking about, I think that there is a lot of opportunity for the donation and transplant communities to find potential organ donors in places that we never looked before. And so I think that – it’s an exciting time in many ways because my team and many other teams out there that I mentioned earlier are exploring all these different ways to identify donors. So, that’s where I think it’s going to go in the future is that just more and more donors. We’ve got to find more.
Host: Well give us a similar explanation about rejection and what do you see as far as research and or exciting things and tell us a little bit about some of your outcomes Dr. Shah.
Dr. Shah: So, our outcomes are great actually. So, all transplant programs are measured by one year patient graft survival and it’s measured by an organization called SRTR and so our one year patient and graft outcomes are actually around 94 to 95% which is outstanding, and I think a lot of it has to do with the care that we are able to provide these patients before surgery and after surgery.
You mentioned rejection. What I tell patients because that’s a question that frequently comes up in a clinic evaluation is patients will ask heh what is the risk of rejection. What can happen? And honestly, in liver transplant, I don’t worry too much about rejection. The only rejection in liver transplant s I worry about are when patients stop taking their medicines and thankfully, that’s very small number of people because we have a very just like all transplant centers; we have a kind of a highly selective process where we are trying to identify the patients that are least likely to be noncompliant with their care. But occasionally, there’s going to be one or two that stop taking their medicines and then they have horrible rejection.
But overall, for as long as patients are taking the medicines they are supposed to take after a liver transplant; even if they have a little bit of rejection; it’s not that big of a deal. We generally give them just some extra dose of steroids and it clears it up and it’s generally not a problem.
Host: Wow, really amazing. As we wrap up, Dr. Shah, what makes the transplantation program at UK stand apart from others in the state as well as the nation?
Dr. Shah: I think a bunch of things. Actually from a clinical standpoint, I think that we have patient-centered and family-centered care. I think that patients enjoy their experiences here and I think we make sure that that happens because as you know, as you mentioned, I run the liver transplant program so patient experience and family experience is an important part of it. Is that I want patients to come and feel like they are at home because it’s a very scary time for patients that come to the big transplant center to talk about getting a liver transplant and that’s scary stuff. And so, they need to be – they need to feel at ease with the care that they are going to receive and so I think that’s part of why what sets us apart is that we try to be very compassionate with patients. We try to get them in quick. When a referral comes in, we don’t say okay we’ll give you an appointment two months from now. No, if a referral comes in, the patient is offered an appointment within the next week. Which is actually phenomenal and what I’m told is that people in the community like that. Because they get their patients in quick. They have easy access.
I think that in terms of what set UK also uniquely apart from many other transplant centers is kind of the research that my boss and several of his collaborators do with regard to basic science and tolerance in terms of rejection. Tolerance is one of those things that’s kind of been the holy grail of transplant meaning that you can get a liver transplant or a kidney transplant or anything and you basically don have to take any immunosuppression or very little immunosuppressive medications because your body is tolerant to the organ that you receive and that’s – he’s kind of doing some novel stuff which is only I believe three or four centers in the entire country are doing.
So, that’s really neat stuff and it’s cutting edge. It’s being funded by the NIH and other entities and it’s great stuff. And I think the third thing that sets us apart is all the advocacy and that’s the stuff I’m involved in. Is just making sure that organ – procurement organizations are maximally identifying potential donors out there. Me and several of my colleagues we also advocate for allocation policies of organs that don’t disadvantage rural or socioeconomically poor people if you will. And so, I think that that’s what sets us apart is that we’re trying to – on a national level when it comes to research and advocacy for our patients and then like I said, going back to the clinical aspect, we get patients in and we treat them as if they are our own parents or loved ones.
Host: Absolutely amazing. Thank you so much Dr. Shah. What a great comprehensive program that you’ve got there. Thank you for all of your expertise. That wraps up another episode of UK HealthCast with the University of Kentucky Healthcare. A community physician can refer a patient to UK Healthcare with UKMDs at 1-800-888-5533. Or you can head on over to the website at www.ukhealthcare.uky.edu. If you found this podcast as informative and educational as I did, please share with other providers. Share on social media. Share with your patients. And be sure not to miss all the other fascinating podcasts in the UK Health library. Until next time, I’m Melanie Cole.
Melanie Cole (Host): Great progress has been made in the filed of liver transplantation over the past two decades. The progress, however, also brings up a next set of challenges. Organ shortage remains a major limitation and accounts for a large proportion of the wait list mortality. My guest today, is Dr. Malay Shah. He’s the Surgical Director of Liver Transplant Program at UK Health. Dr. Shah, it’s a pleasure to have you join us today. Tell us a little bit about the UK history with liver transplants.
Malay Shah, MD, FACS (Guest): Well I appreciate you having me on. I’d love to talk to you more about it. So, the University of Kentucky started a transplant program a couple of decades ago. And it was a big need in the area at the time. I mean there is obviously – in the state of Kentucky, there’s a lot of people with advanced liver disease due to their medical comorbid conditions such as diabetes, obesity, hepatitis C. we have some of the highest rates of Hepatitis C in the country. And so, there was an imminent need for the University of Kentucky to have a liver transplant program because if you look on a map, you can see where UK Healthcare is, and it’s situated kind of in the middle of the state. So, a large portion of the patients we serve are patients from central Kentucky and eastern Kentucky, West Virginia, so Appalachia and now we’re actually drawing patients in from western Kentucky more recently.
But I think that’s why – that’s kind of the genesis towards why UK developed the liver transplant program is just simply for the need that these patients need somebody to manage their liver disease and provide transplant options that they otherwise would not be able to receive.
Host: So, Dr. Shah, for other providers, give us some indications for referral to a transplant center. What would you like other providers to know about that?
Dr. Shah: Well what I tell people – there’s some common sense guidelines I use which is what I tell providers when I go out on outreach for instance is if you think you need a liver transplant – if you think your patient needs a liver transplant evaluation just send them. We are happy to see everybody. Some patients just want one just kind of for peace of mind whether or not they need a liver transplant, or they’ve been seen for liver transplant evaluation.
And sometimes providers, it helps them kind of give their patients a peace of mind and a second opinion as to a transplant evaluation and whether it’s needed or not. More objectively, what I tell gastroenterologists and their providers is that if people have a MELD score of anywhere from 10 or higher or they have evidence of hepatocellular carcinoma which is a – something that can happen as a result of cirrhosis; to go ahead and send the patient in and let us start the process of evaluation.
Even though patients typically don’t get a transplant until their MELD score is higher than 15; our program has a mindset that it’s good to get the patient in early because the problem with liver disease is that patients can be doing well for a period of time and then just unexpectedly fall off the cliff. And so, rather than wait until the patient falls off the cliff where it may be to late to actually provide a service for the patient; I’d rather have the patient here already evaluated, already on the list and we are kind of ready to step in and do a transplant if needed.
So, those are kind of the general things I tell providers on the outside is just send them when you think they need to be sent and if their MELD score is higher than 10 go ahead and send them on in.
Host: Then what does the process look like when a patient gets to the UK Transplant Center?
Dr. Shah: So, when they come to our clinic, they meet with one of the surgeons who will do a comprehensive history and physical examination. They’ll meet with one the hepatologists who will also likewise do the same in terms of the history and physical exam. They’ll meet with one of our liver transplant nurse coordinators at that visit. Those are the three main people that they are going to see.
And so, all of us will talk to the patient regarding different aspects – all of us talk to the patient regarding liver transplant or their candidacy but all of us addressing it from a different perspective. The surgeon is obviously, addressing it from the perspective of the surgical procedure and postoperative care. The hepatologist is addressing it from the perspective of medical management of the liver disease and what we need to do to keep the patient healthy – as healthy as possible until time of the transplant and then the nurse coordinator is going kind of through all of that stuff and then basically our nurse coordinator, we have five of them, but one of them will be assigned to any given patient and that nurse coordinator is going to be that patient’s point person through the entire journey of liver transplant; pretransplant and posttransplant.
So, that’s kind of what patients can expect if they are coming in to our outpatient clinic. Inpatient, of course, is different. If someone is sick in the hospital when we initially receive the consult, we’ll go see them as a consult and kind of decide whether or not we want to evaluate them for a liver transplant.
Host: As I said in my intro, there’s a problem and challenges certainly with organ shortage. Tell us a little bit about what you see on the horizon as far as organ shortage or what you see going on now, some of the challenges that you might face.
Dr. Shah: That’s a great question. So, when patients get on the list of course, even – the demand for liver transplant far exceeds the supply, meaning there’s more patients that are on the wait list than there are organs available for transplant. And that actually is getting worse as time goes on nationwide, that disparity between the supply and demand is getting worse. And so, there’s a lot of researchers exploring different avenues for creating xenotransplants is something that people have been working on for 20 to 30 years at least which is using animal livers and putting them into human beings and there is just a lot of immunologic challenges associated with that. And that’s something that’s out of my area of expertise.
But I think the biggest thing going on right now and I’m proud to say that UK is at the leading frontier of this field about improving OPO, so organ procurement organizations performance. So, we have been doing a lot of research and collaboration with colleagues from Emory and from Miami and Vanderbilt on ways to identify more donors in more locations and more hospitals throughout the country. And we are trying to expand our view on what we think are suitable donors. So, as an example, 20 to 30 years ago, people may not – and this predates me being in transplant, but 20 to 30 years ago, people may not have used a donor from somebody that was 55 or 60 years old thinking that well we have enough donors for the amount of patients we have on the wait list.
And so, why use older donor when we can wait for a donor that’s potentially younger. Well, obviously, now that the disparity between the supply and demand is just ever increasing; people have been looking for different ways to use all sorts of different donors. And so, we use older donors who for livers as an example, older donors, as long as the liver is normal; it actually doesn’t make a difference how old the donor is. We can use an older liver if you will from an older donor and put it into a young recipient and there’s basically very little to no consequence from doing that. So, I think we’re expanding the way we are all thinking about how to approach donation and maximally utilize donors available.
And then, going back to the research I was talking about, I think that there is a lot of opportunity for the donation and transplant communities to find potential organ donors in places that we never looked before. And so I think that – it’s an exciting time in many ways because my team and many other teams out there that I mentioned earlier are exploring all these different ways to identify donors. So, that’s where I think it’s going to go in the future is that just more and more donors. We’ve got to find more.
Host: Well give us a similar explanation about rejection and what do you see as far as research and or exciting things and tell us a little bit about some of your outcomes Dr. Shah.
Dr. Shah: So, our outcomes are great actually. So, all transplant programs are measured by one year patient graft survival and it’s measured by an organization called SRTR and so our one year patient and graft outcomes are actually around 94 to 95% which is outstanding, and I think a lot of it has to do with the care that we are able to provide these patients before surgery and after surgery.
You mentioned rejection. What I tell patients because that’s a question that frequently comes up in a clinic evaluation is patients will ask heh what is the risk of rejection. What can happen? And honestly, in liver transplant, I don’t worry too much about rejection. The only rejection in liver transplant s I worry about are when patients stop taking their medicines and thankfully, that’s very small number of people because we have a very just like all transplant centers; we have a kind of a highly selective process where we are trying to identify the patients that are least likely to be noncompliant with their care. But occasionally, there’s going to be one or two that stop taking their medicines and then they have horrible rejection.
But overall, for as long as patients are taking the medicines they are supposed to take after a liver transplant; even if they have a little bit of rejection; it’s not that big of a deal. We generally give them just some extra dose of steroids and it clears it up and it’s generally not a problem.
Host: Wow, really amazing. As we wrap up, Dr. Shah, what makes the transplantation program at UK stand apart from others in the state as well as the nation?
Dr. Shah: I think a bunch of things. Actually from a clinical standpoint, I think that we have patient-centered and family-centered care. I think that patients enjoy their experiences here and I think we make sure that that happens because as you know, as you mentioned, I run the liver transplant program so patient experience and family experience is an important part of it. Is that I want patients to come and feel like they are at home because it’s a very scary time for patients that come to the big transplant center to talk about getting a liver transplant and that’s scary stuff. And so, they need to be – they need to feel at ease with the care that they are going to receive and so I think that’s part of why what sets us apart is that we try to be very compassionate with patients. We try to get them in quick. When a referral comes in, we don’t say okay we’ll give you an appointment two months from now. No, if a referral comes in, the patient is offered an appointment within the next week. Which is actually phenomenal and what I’m told is that people in the community like that. Because they get their patients in quick. They have easy access.
I think that in terms of what set UK also uniquely apart from many other transplant centers is kind of the research that my boss and several of his collaborators do with regard to basic science and tolerance in terms of rejection. Tolerance is one of those things that’s kind of been the holy grail of transplant meaning that you can get a liver transplant or a kidney transplant or anything and you basically don have to take any immunosuppression or very little immunosuppressive medications because your body is tolerant to the organ that you receive and that’s – he’s kind of doing some novel stuff which is only I believe three or four centers in the entire country are doing.
So, that’s really neat stuff and it’s cutting edge. It’s being funded by the NIH and other entities and it’s great stuff. And I think the third thing that sets us apart is all the advocacy and that’s the stuff I’m involved in. Is just making sure that organ – procurement organizations are maximally identifying potential donors out there. Me and several of my colleagues we also advocate for allocation policies of organs that don’t disadvantage rural or socioeconomically poor people if you will. And so, I think that that’s what sets us apart is that we’re trying to – on a national level when it comes to research and advocacy for our patients and then like I said, going back to the clinical aspect, we get patients in and we treat them as if they are our own parents or loved ones.
Host: Absolutely amazing. Thank you so much Dr. Shah. What a great comprehensive program that you’ve got there. Thank you for all of your expertise. That wraps up another episode of UK HealthCast with the University of Kentucky Healthcare. A community physician can refer a patient to UK Healthcare with UKMDs at 1-800-888-5533. Or you can head on over to the website at www.ukhealthcare.uky.edu. If you found this podcast as informative and educational as I did, please share with other providers. Share on social media. Share with your patients. And be sure not to miss all the other fascinating podcasts in the UK Health library. Until next time, I’m Melanie Cole.