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Striving for Perfection: Liver Transplant Outcomes

Bill Klaproth: Children's Health offers one of the longest running, most experienced pediatric multi-organ transplant programs in the nation and is currently ranked one of the top two programs nationally for pediatric liver transplants. In this podcast, Striving for Perfection; Liver Transplant Outcomes. We'll talk about how Children's Health achieves great outcomes, the collaboration of teams, how post-transplant progress is monitored, and the cutting edge technology used by Children's Health. This is Pediatric Insights, Advances in Innovations with Children's Health, where we explore the latest in pediatric care and research. I'm Bill Klaproth. With us to talk about the comprehensive treatment provided by the Solid Organ Transplant Center at Children's Health is Dr. Dev Desai, Director and Chief of Pediatric Transplantation at Children's Health and Professor of Surgery at UT Southwestern. ranked one of the top two programs nationally for pediatric liver transplants as I just mentioned, with a 100% survival rate at 30 days, one year and three years. Can you talk about the different teams and how you all work together to achieve great outcomes for patients?

Dr. Desai: Liver transplantation is a complex procedure and it requires the input of number of different specialists, as well as staff that have different areas of expertise in the care of patients with liver failure. And then in the care of patients after a liver transplant, you know, prior to liver transplantation, these patients required specialized care to manage their liver failure and liver disease. And so we work very closely with liver physicians, you know, hepatologist, as well as other physicians such as infectious disease doctors, kidney doctors, ICU physicians or involved in the care of these patients. Because many of these patients with liver failure present very acutely, you know, are very sick, and are in the intensive care unit with not just liver failure, but sometimes that can lead to respiratory failure and kidney failure. And so we have specialized teams of physicians in the specialties that we work with that are not only experts in their area, but they're also experts in how liver failure affects those other organs that they have medical expertise in.

And so we work very closely together. We have weekly meetings together. And when patients are in the hospital, we see these patients together as a multidisciplinary team. So that way everyone is there. We discuss how the patient is doing and we can come up with a plan that has an input from all of the specialists. And yeah, we can all convey this plan to the family, which reassures them that everyone and all of the specialists are talking to each other and that, you know, we are not forgetting anything in terms of the care of the patient. Additionally, we have a lot of other staff who work just with our team or part of our team including transplant pharmacist, transplant dieticians, a child life specialist, a psychologist and social workers. Because it's not just the care of the patient, the medical care of the patient that's critical. It's also being sure that the patient's psychosocial needs are being met and that the parent's social needs are being met, you know, because this is a very stressful time for the entire family.

Host: So, with all of these teams that you just described, what does that collaboration look like before, during, and after transplant surgery? And how do you work best with these other teams?

Dr. Desai: Right. So we have weekly meetings where we review all of our patients that are awaiting transplant, those that are in the hospital, either due to complications while still waiting for a transplant, or in the hospital after a transplant. And then we also at our weekly meetings review all of our patients who have had transplants to discuss any patients that may be having medical or you know, nonmedical issues, you know, school issues, other issues that may require interventions by our social workers and child life specialists, you know, problems at school, things like that. So we're about caring for the entire patient, not just caring for the liver itself. And then in addition to our weekly meetings, we have multidisciplinary rounds where our entire team gets together and we see all of the patients that are in the hospital together. So we meet with the families and the patients and we discuss any issues that may be going on with the patient. And we come up with a plan that is based on the input from everyone on our team. And I think that is, you know, very important in achieving the best outcomes that you can. You know, when care is fragmented, you know, and you have patients being seen by different specialists at different times or at different locations. Sometimes the communication is delayed or sometimes things are missed in that communication about the patient and that can result in serious complications or delayed care.

Host: So I love that line about caring for the entire patient, not just the liver itself. So a couple of times you referred to after surgery, so how do you monitor and connect with patients after transplant in order to track their progress and enhance their experience post-transplant?

Dr. Desai: Yeah, so we see these patients fairly regularly in our clinic, as one of really three pediatric liver transplant programs in Texas and the surrounding region. You can imagine that we see patients from throughout the state. Some of these patients actually live in different time zones even. And so that certainly can be a challenge. If patients come to us from far away right after their transplant. They do stay locally in Dallas and we help make arrangements for these families for housing, whether it be at the Ronald McDonald house or in a medical apartment. And our social workers work with the families very closely to make sure that they can afford this housing. You know, would they help with the housing itself, housing costs, meals, you know, transportation. Because it does require sometimes the families to be a part. Where someone may be back at where they live because after work, while one of the parents and the child may be here at Dallas, so we work with the families to really make sure that they can be here in Dallas and we help with those logistics. But eventually those patients will return back home.

And again, for patients who live far away, we do things such as tele-health visits. So we'll do video clinic visits with the patient. Additionally, we do outreach visits as well. We see patients down in Austin, Texas. We have an outpatient, we have a clinic to see patients who live in that region of Central Texas. So that way they don't have to drive up to Dallas. We do a lot of clinical monitoring remotely. Patients get their blood work done locally where they live and we'll review the results. We work very closely with the patient's local pediatricians, their offices, to ensure that patients receive the care that they need without having to make a, a long, expensive and disruptive trip back to Dallas. Not only when the families have to travel here, does it impact the parents' work schedules, but it also impacts the children's schooling, you know, missing days from school. And we want these patients to feel just like their peers, you know, we want them to be in school and be part of school activities, participate in organized sports or other, organized activities. So we really do want to try to keep them in their local environment as much as possible.

Host: And that sense of normalcy I bet is very important for their recovery as well. So you mentioned tele-health, I would imagine you're using cutting edge technology that helps you achieve these great successful outcomes. Can you talk about the role of the cutting edge technology in the liver transplant program?

Dr. Desai: Yes, certainly. Tele-health is one of those technologies. We were really the first program or department at children's health to use tele-health to follow our patients. This involved the families getting a secure encrypted iPad, which the only function on that iPad was to be able to communicate with us. And so we could do secure visits with the patients. The patients could check in and ping us if they had questions. We would set up as well, sort of reminders for the patients about refills, about whether they had taken their medications, things like that. So a lot of these things become somewhat automated and really helps the families to become, you know, independent, and these children, especially the teenagers, to become a little bit more independent in their own health care as they transition to adulthood. Additionally, we were the first pediatric program in the country to work with a company called Proteus Health, which makes digitize medications. And what I mean by that is that the patient's medication is embedded with a very tiny sensor made up of natural materials that, when ingested that sensor releases a signal which is captured by a Band-Aid like device that the patient wears on their abdomen.

And that device tracks when these patients take their medications and it, you know, if they don't take their medications, the device would then send an alert to the patient, to the parent, and, or as well as us, that the patient may have missed their medication. So it helps again, prevent a medication, non-adherence, which is one of the leading causes of rejection and loss of a transplanted organ in adolescents and young adults. And so we were the first to utilize this technology of digitize medication. In addition, the device itself also, has many of the functions that are, say in some of the fitness devices that people wear on their wrists. So it attracts steps. It tracks sleeping, activity levels, heart rate. So, you know, it's also a tool that helps patients, you know, track overall health and exercise. So we think that this additionally helps our patients to do better in the long run.

Host: Well, technology certainly has become an important tool and obviously you are using it there to achieve these great outcomes. Dr. Desai, thank you so much for your time today. This has been very informative. Thank you again.

Dr. Desai: Thank you so much. My pleasure speaking with you.

Host: That's Dr. Dev Desai, and thanks for listening to Pediatric Insights. For more information, please visit childrens.com/transplant that's  childrens.com/transplant. And if you found this podcast helpful, please rate and review or share the episode and please follow Children's Health on your social channels. This is Pediatric Insights, Advances and Innovations with Children's Health. Thanks for listening.