The Milton S. Hershey Medical Center’s abdominal transplant program provides comprehensive care for central Pennsylvania residents through kidney and liver transplantation and offers deceased and living donor transplantation for both kidney and liver patients. Hershey Medical Center also has the region’s only adult live donor liver transplant and pediatric kidney transplant programs. Expertise in transplantation is available for medical professionals and their patients close to home, without the need to travel to major cities.
“We have a strong, well-informed team of specialized physicians, nurses, staff members and coordinators who are highly trained in transplantation,” says Zakiyah Kadry, MD, chief of the Division of Transplantation and surgical director of liver transplantation and the live donor liver transplant program at Hershey Medical Center. “This level of comprehensive care outside a major metropolitan area is truly exceptional.”
Currently, more than 113,000 Americans are waiting for a lifesaving solid organ transplant, according to the United Network for Organ Sharing (UNOS) website.
The most common reasons patients are referred for kidney transplantation are diabetes and hypertension. Other conditions include, but are not limited to, focal segmental glomerulosclerosis (FSGS), IgA nephropathy, polycystic kidney disease, systemic lupus erythematosus (SLE) and congenital obstructive disorders that lead to the development of hydronephrosis and renal failure. Renal failure is classified by stages. (See Figure 1.)
“The best time to refer a patient for transplant is when they are in early stage 4 renal failure,” explains Fauzia Butt, MD, FACS, transplant surgeon and assistant professor of surgery at Hershey Medical Center. “This is because patients can start gaining time on the waitlist for a deceased donor organ once their glomerular filtration rate (GFR) is ≤ 20 mL/min. Also, they can start exploring the option of a living donor with their family and friends, allowing time for a complete evaluation. They can be ready for a transplant before they actually need to start dialysis or develop complications associated with dialysis.”
The stages of renal failure:
- Stage 1: Normal or high GFR (GFR > 90 mL/min)
- Stage 2: Mild CKD (GFR = 60–89 mL/min)
- Stage 3A: Moderate CKD (GFR = 45–59 mL/min)
- Stage 3B: Moderate CKD (GFR = 30–44 mL/min)
- Stage 4: Severe CKD (GFR = 15–29 mL/min)
- Stage 5: End-stage CKD (GFR < 15 mL/min)
The benefits of transplantation over dialysis include an improvement in quality of life and more cost-effective care in the long term.
Zakiyah Kadry, MD, chief, Division of Transplantation at the Milton S. Hershey Medical Center, and her team perform a live donor liver transplant.
“Patients experience liberalization of their dietary restrictions after transplantation,” Dr. Butt adds. “When they are on dialysis, patients are given phosphate binders for elevated phosphate levels. As the transplanted kidney starts working, phosphorus levels decrease, and patients may need medication for supplementation. I prefer to have them replace their phosphorus through diet at first, if the levels are not too low, because it is more enjoyable for the patients. I once told a patient he could have a slice of pizza and a dark diet soda on the way home from the hospital, and he was so excited, he could hardly wait. Patients experience an increase in their energy level after kidney transplantation, and they are able to return to work and travel again. Many patients also experience an improvement in fertility, although female patients are cautioned to avoid pregnancy for at least one year after transplantation, as certain medications will need to be adjusted. Transplantation is truly a life-changing gift!”
Once a patient is referred for transplant, a Hershey Medical Center transplant coordinator reviews the patient’s records — his or her medical history in particular — with a physician to ensure he or she is an appropriate candidate. The patient is then scheduled for an appointment with several members of the transplant team: a nephrologist, surgeon, coordinator, pharmacist, dietitian, financial counselor and social worker. The selection committee reviews each candidate thoroughly to ensure the candidate is medically, surgically and psychosocially able to safely undergo transplantation.
“The patients are discussed from each team member’s perspective to confirm that they will thrive, and this includes having adequate social support post-transplant,” Dr. Butt says. “Since patients will be restricted from driving immediately after surgery, especially while on pain medication, they will need someone to drive them to weekly clinic appointments. If the patient is ready to be listed, the committee will activate them on the transplant list and notify the patient and their nephrologist. If the patient is not a candidate for transplantation, they will also be notified. Occasionally, a patient may have a temporary medical condition that precludes them from being a suitable candidate at that time, but they can be considered in the future. Patients may also develop conditions while on the waitlist and need to be placed on inactive status until the condition resolves. Inactive status means that the patient will not actively be receiving deceased donor organ offers, but they will continue to gain time on the waitlist.”
Living Kidney Donation
Kidneys from living donors offer significant medical and logistic advantages for patients and their families. Most notably, living donor kidneys typically function sooner and last longer for the recipient. In addition, these are elective procedures and can be scheduled at the optimal time for both the donor and the recipient. Deceased donor organs can become available at any time, and the surgery has to be scheduled immediately, without advance notice. The wait time for a deceased donor kidney can be five to eight years, depending on the patient’s blood type and antibody status.
“I can have a living donor worked up in a couple of months, whereas the wait for a deceased donor can take years,” says Amy Wildasin, a living donor transplant coordinator at Hershey Medical Center.
Living donation can also reduce the wait time for the organ, which allows the operation to be scheduled before the patient’s condition deteriorates or before additional complications occur that affect his or her ability to undergo surgery.
“Since patients are on the waitlist for years, waiting for an organ from a deceased donor,” Dr. Butt says, “they can develop uncorrectable medical conditions that may no longer allow them to proceed with transplantation. A kidney from a living donor may allow the recipient to be transplanted in a more timely fashion, before such conditions develop.”
“I always say that two patients are transplanted with every living donor kidney transplant because the patient receiving the kidney is transplanted, but it also means they are no longer waiting for a deceased donor organ, and that deceased donor kidney can go to someone else who is also able to get transplanted,” Wildasin adds.
In general, one-third of all kidney transplants in the U.S. are from living donors, and two-thirds are from deceased donors. At Hershey Medical Center, approximately 50 percent of kidney transplants are performed with living donor kidneys.
Deceased donor kidneys can be less predictable than those from living donors.
“You don’t always get immediate urine production or function with deceased donor kidneys,” Dr. Butt says. “It varies because there are different qualities of deceased donors. There are deceased donors who are young and healthy. There are deceased donors who are older with a history of medical problems that can affect kidney function. There are also DCD — donation after circulatory death — donors, and those kidneys sometimes take a little bit longer to begin functioning fully. Living donor kidneys usually enjoy immediate function, and the creatinine drops abruptly.”
After a patient is approved to receive a kidney transplant, he or she is encouraged to look into living donation. All potential donors contact Wildasin, who performs an initial screening of the donor’s medical and surgical history. It is important to verify that the living donor is acting independently.
“The donor has to make the first move in calling the transplant center, as it’s very important to have no type of coercion,” Dr. Butt says. “To ensure this, we have an independent living donor advocate whose sole job it is to make sure the donor is doing this on a purely voluntary basis — that there’s no pressure, monetary exchange or anything expected in return. An advocate also explains to the donors that if they change their mind, the process can stop at any time.”
After the initial phone screening, the potential donor receives a thorough medical, surgical and psychosocial assessment, similar to that performed for recipient candidates. Multiple blood tests are performed to ensure that the donor is healthy, without any kidney disease or any other medical condition that would preclude living donation. Other testing includes urine tests to look for any abnormalities, a chest X-ray, EKG and abdominal imaging to evaluate kidney size and anatomy. All maintenance health screenings must also be current. Compatibility testing with the intended recipient is also performed with a blood type and a crossmatch, which ensures that the recipient does not have any antibodies against the donor. Recipients can be sensitized through previous transplantation, blood transfusions and pregnancy, as women can develop antibodies against the antigens of the father. Further testing may be necessary, depending on the patient’s specific circumstances or initial results.
“If the donor is a smoker, for example, we examine more fully his or her lungs, with pulmonary function tests and a pulmonary consult. They are also strongly encouraged to quit smoking if they want to pursue living donation.” Dr. Butt says. “At other times, frequently with altruistic donors, the social worker may ask for a psychiatric evaluation. We want to make sure they’re doing it for the right reasons, since it is kind of amazing that someone would want to donate a kidney to a person they don’t know.”
“My father was also a transplant surgeon, so transplant is in my blood. When I was about 12 years old, I had the opportunity to observe a transplant between a canine donor and recipient in the dog lab, and it made such an impression on me that I reportedly went home and told my mother, ‘I’m quitting school. I know what I need to do. I’m going to be a transplant surgeon.’”
— Fauzia Butt, MD, FACS, transplant surgeon and assistant professor of surgery at Hershey Medical Center
Fauzia Butt, MD, FACS, joined the Milton S. Hershey Medical Center abdominal transplant team in 2018 from SUNY Upstate Medical University in Syracuse. She is an award-winning, second-generation transplant surgeon who trained at two of the busiest transplant programs in the country.
Kidney Swaps and Transplant Chains
If an eligible donor is a match for his or her intended recipient, the entire process can take as little as one to two months from initial call to transplant, according to Wildasin. However, if a donor is not a match for that recipient, he or she may still be able to help the recipient receive a live donor kidney through a swap or transplant chain.
A swap is a direct exchange in which two living donors are incompatible with their intended recipients but are compatible with the other donor’s intended recipient. Both patients are able to receive a live donor kidney, though from different individuals than originally planned. (See Figure 2.) The National Kidney Registry and UNOS assist the transplant team at Hershey Medical Center in finding opportunities for these swaps.
A chain involves a potentially unlimited number of incompatible donor/recipient pairs, also matched by algorithms run by national registries. It begins with a kidney donation from an altruistic donor, who starts the transplant chain by donating to the first incompatible recipient in the chain. That recipient’s incompatible donor then donates to the recipient of the next incompatible donor/recipient pair, and so on. (See Figure 3.) To date, the longest kidney chain in the U.S. has provided transplants for more than 100 recipients.
It is estimated that one-third of all recipients who have willing living donors will be incompatible with those donors due to blood type or the presence of antibodies.
“If a recipient has a viable living donor who’s incompatible because of blood type or the recipient has a positive crossmatch — meaning they have antibodies against that prospective donor — swaps and chains allow these recipients to still be transplanted with high-quality living donor kidneys, even though the kidneys they receive do not come directly from their originally intended donors,” Dr. Butt says. “These opportunities potentially enable the recipients to get transplanted sooner than waiting for a deceased donor kidney.”
After the transplant, living donors can often return to their normal activity levels after a week or two. For recipients, recovery is typically longer, as their bodies adjust to the new immunosuppressive medication regimen and they have a larger incision. Some recipients feel better right away, but the average recipient gets back to normal in about four weeks.
Transplant surgeons continue to care for their patients regularly in the year following transplant surgery. At approximately the one-year mark, transplant patients transition to a Hershey Medical Center transplant nephrologist, in addition to being seen by their own nephrologist. Pediatric transplant patients transition to the pediatric transplant nephrologist after six weeks and then continue to see a transplant surgeon annually.
Expert, compassionate support from the transplant team continues, even as the frequency of patients’ visits lessens.
“Once we perform a transplant, the patient is with us for life,” Dr. Butt says. “We know them. Our team is familiar with the procedure they had, with the medications they take after transplant and with any potential complications. I tell patients, ‘You have a team of people here to support you. Use that team.’”
In addition to the kidney transplantation program, Hershey Medical Center is home to the only comprehensive live donor liver transplant program in central Pennsylvania, which provides an additional and important therapeutic option to patients on the Penn State liver transplant waiting list.
“Institutions outside the area that offer live donor liver transplants require patients to travel farther to undergo the operation, separating them from their families and the psychological support that families provide,” Dr. Kadry says. “Our patients stay in the area not only for surgery but also for the full range of care they need before and after transplant.”
Patients who have been diagnosed with cirrhosis of the liver are most commonly referred for liver transplants. While previously there was a high association with hepatitis C, that is no longer necessarily the case, according to Dr. Kadry. Conditions such as primary biliary cirrhosis, primary sclerosing cholangitis and nonalcoholic steatohepatitis are responsible for the majority of liver cirrhosis cases she now observes.
Once physicians refer patients to Hershey Medical Center for possible liver transplant, patients undergo an examination by a hepatologist.
“Those who are transplant candidates are directed to our clinic for further testing,” Dr. Kadry says. “We take the burden of those decisions off referring physicians. They can simply make the referral, and we direct patients appropriately.”
Patients who present issues that preclude a liver transplant, or for whom it is simply too early, are cared for at the Penn State Health cirrhosis clinic, where the hepatology team also maintains close collaboration with referring physicians.
Liver transplant candidates decide early in the process whether or not they will seek a live donation, Dr. Kadry adds. Living liver donation is available for recipients in earlier stages of liver disease who do not require a full-liver transplant. It can offer many eligible patients reduced wait times and a very healthy liver graft. For living donors, 40 to 60 percent of the liver is surgically removed from the donor and transplanted to the recipient. The liver then begins to regenerate in both the recipient and donor.
“It’s the only organ in the body that actively regenerates to the size that the body mass or body surface area requires. In about two weeks, the liver is approximately 75 percent of its previous size. In one month, it’s 90 percent of its previous size,” Dr. Kadry says. “However, it doesn’t regrow the part that’s been removed. What you have is a half-liver that is larger in size.”
“Many deceased donors may have other health issues or a fatty liver,” Dr. Kadry says. “In a live donor, we make sure the fat in the liver is at a minimum. We can reduce the risk of complications significantly because we have the luxury of being able to complete a very detailed evaluation.”
In every case, the best interests of both donor and recipient are the priority. For example, if a high-quality liver from a deceased donor becomes available prior to a planned live donor operation, the transplant team proceeds with the deceased donor’s organ to avoid a healthy person undergoing unnecessary surgery, Dr. Kadry notes.
“Liver transplantation gives patients a new lease on life. Patients have told me, ‘I want to be able to see my grandchildren grow up,’ or ‘I want to be there for my daughter’s wedding.’ We’re in the business of second chances.”
— Zakiyah Kadry, MD, chief of the Division of Transplantation and surgical director of liver transplantation and the live donor liver transplant program at Hershey Medical Center
Living Liver Donation
Prior to initiating the live donor process, potential donors receive a preliminary evaluation, and a thorough medical, surgical and psychosocial assessment is completed. This includes factors such as body mass index, as obesity can increase the risks of surgery and may be associated with excessive fat deposition in the liver, affecting the amount of functional liver volume, and whether the liver volume is enough to ensure the donor’s and recipient’s safety.
Following surgery, donors spend five to 10 days in the hospital, whereas recipients stay in the hospital for about two weeks.
With people dying every day while waiting for an organ transplant in the U.S., live donor liver transplants provide an additional option that can be lifesaving and life-transforming, according to Dr. Kadry.
“The complications of cirrhosis are often disabling. When patients undergo a liver transplant, they’re basically cured of their cirrhosis and can return as functioning members of the community,” she says. “I deeply admire those who come forward to donate. There’s such a shortage of organs that the liver transplants made possible by living donors make a tremendous difference. Several hundred liver transplants nationally are being performed that wouldn’t have been otherwise, and those patients could have died on the waiting list.”
Lifelong Support Close to Home
Building on a decades-long legacy of providing local access to advanced care, Hershey Medical Center’s kidney and liver transplantation programs relieve patients of the otherwise daunting challenges they would face traveling to large metropolitan areas for the transplant surgery process, as well as post-surgical care.
“There are many benefits to caring for patients in Hershey,” Wildasin says. “For instance, parking at Hershey Medical Center is free and readily accessible. That and the lack of traffic congestion typically experienced in larger cities are all factors that patients see great value in having.”
Dr. Kadry agrees.
“If there is an emergency or complication, it is recognized much earlier and taken care of right away, here. It’s far more difficult to transport someone from hours away than to just bring them here by ambulance,” she says. “And — most importantly — we can provide patients excellent local service in terms of both deceased and live donor transplantation, with personalized care both before and after the procedure.”
To refer a patient for kidney or liver transplantation or to speak directly with a member of the transplant team for more information, call 717-531-6092 or visit hmc.PennStateHealth.org/transplant-surgery.