Transcription:
At Hume-Lee Patients With Severe Alcoholic Hepatitis Are Treated With Compassion

Scott Webb (Host): For those suffering from severe alcoholic hepatitis, the VCU Health Hume-Lee Transplant Center has a multidisciplinary team of compassionate experts that treat patients holistically, treating both their addiction as well as their disease. And joining me today to tell us about the program is Nicky Keller. She's a Transplant Nurse Coordinator at the VCU Health Hume-Lee Transplant Center.

This is Healthy with VCU Health. I'm Scott Webb. Nicky, thanks so much for your time today. We're talking about the Hume-Lee Alcoholic Hepatitis Transplant Program today, but before we get there, let's start here. What is severe alcoholic hepatitis?

Nicky Keller, MS, BSN, RN (Guest): Severe alcoholic hepatitis is an inflammation of the liver due to alcohol consumption that occurs suddenly and can lead to liver failure and death. And it's different than your run of the mill alcohol cirrhosis, which also is caused from drinking alcohol. But that often is damage to the liver that occurs over time, with alcohol consumption.

Host: Okay. And you're a Transplant Nurse Coordinator. So, tell me about that role. What exactly do you do?

Nicky: So, there's a team of us. There's six coordinators that work with our liver transplant patients. We work with them both before transplant and then after. Currently I work with the inpatient team to streamline the evaluation process for patients that are currently in the hospital. So, I make sure that their testing and consults are all in place. And then do a lot of education with the patient and families about the process, both before and after transplant and then act as their contact person, both while they're in the hospital and then after they get discharged up until the time of transplant, when they get assigned to a post-transplant coordinator. And then all of us rotate on an on-call basis, to call in our transplant patients when a liver becomes available and then as an after-hours point of contact, for both pre and post patients that have concerns after hours.

And then specific to our alcohol hepatitis patients, I coordinate a comprehensive group of specialists and we meet every other week, to discuss patients that have been recently transplanted or those listed, and what we do is we go through their recovery program and identify and work through any barriers that we may be having. And this group is made up of hepatologists, surgeons, social workers, psychologists, care coordination, administration. And we keep adding new members to the group as the program is growing.

Host: Yeah, and it really sounds like a great multi-disciplinary team. So, it sounds like patients are in good hands there. And at what point do you begin interacting directly with patients?

Nicky: So, usually it's before transplant when they are identified as having liver disease, due to their alcohol use. And sometimes, the first time we see them is in the hospital, when their symptoms of liver disease has required an admission to the hospital. So, as the patients are being treated for that, for their liver disease, often the hepatologists will initiate the liver transplant evaluation in case their liver does not get better and we have to go that route.

Host: Tell me about Hume-Lee's Severe Alcoholic Hepatitis Transplant Program. Tell us about the program and really what's involved for patients.

Nicky: So, it is very holistic and very patient-specific. We've learned that what works for one person doesn't work for the next. So, each of our patients being evaluated goes through a thorough psychosocial evaluation, in addition to their medical evaluation, to make sure that they can physically withstand the operation. And everyone, unfortunately is not a candidate for transplant. But we start their evaluation with social work, a transplant psychologist, and then an addiction medicine consult. And they all do amazing work. They have lots of tools that they use to screen these patients for mental health. They identify stressors. They, you know, try to identify the likelihood of relapse, whether the patient has insight into their alcohol use. And then at the same time, we bring in our care coordination team to try to determine what type of post-transplant, treatment would be the best fit for this specific patient. We also require that they have a strong social support, be it family or friends. They of course have to agree to participate in a post-transplant alcohol use disorder treatment plan. And then we do toxicology screens both before and after transplant. And sometimes before is not an option, it's after transplant that we do those screens.

Host: Yeah. So, I'm sure not all centers provide these life-saving transplants. So, how unusual is it to have a center that's providing these transplants and if others aren't doing it, why aren't they doing it?

Nicky: So, the standard for transplanting patients with cirrhosis due to alcohol has been six months of sobriety and in some places still is. There's a six-month waiting period that you have to be abstinent before you can be considered for a transplant. And the original purpose for the six months of sobriety was actually to determine if the liver would improve if the patient abstained from alcohol. But over time it became the standard for sobriety without any data to really support those six months of sobriety equates with decreased chance of relapse. So, in fact, studies into alcohol use disorder, not specific to our transplant population, but in the general public, indicates that it takes years, up to like five years of sobriety before the risk of relapse is low.

And our patients may not live years. They may not even live six months to meet that criteria. So, some other centers are transplanting with less than six months of sobriety. But it is certainly not the norm at this time.

Host: Yeah. And as you're outlining there, you can understand why that the likelihood of relapse is so great with very little sobriety. And so, it does seem like a bit of a catch 22 and sounding like there's a big need for this kind of care for these transplants. Do I have that right?

Nicky: Yes. So, being able to offer this to patients, give them a chance at life that they may not otherwise have. We're already transplanting patients for cirrhosis due to alcohol, like all centers are, this isn't new, you know. It's a known cause, some people have such severe liver disease that they won't live six months to prove their sobriety. And like I said, there's a little research into those six months sobriety as being a standard or gold standard. And there's also a lot of research being done to understand alcohol cirrhosis because you can have two people who drink the same amount, have very similar backgrounds and everything, and one will get liver cirrhosis and the other will not. So, there's a lot of unknown and a lot of research to still be done into this disease.

Host: Yeah, it seems so. And just, you know, having been at bars and restaurants in my life, the alcohol seems to affect people differently. You know, there is no one size. Yeah. There's just no one size fits all. And you've talked about the compassionate care, the holistic care, really the individual approach and care, the multidisciplinary team. So, it sounds like great work you're doing there. And along those lines, how did this program begin? Why did you begin this program and what have the outcomes been?

Nicky: these patients are doing amazing things. Cause we follow them closely. They've gotten new jobs or been able to go back to work. Some of our patients have reconnected with family and friends that they maybe had strained relationships due to their alcohol use. And we've even had some who are going out as peer counselors to people in the community with alcohol disease and not just specific to liver cirrhosis patients, but all kinds of substance abuse disorders and if we hadn't started this program or we hadn't offered this for these patients, some of them may not still be with us.

The other thing is so we obviously keep a record of the toxicology screens for our patients with less than six months of sobriety, as well as those without, and the amount of positive alcohol screens is minimal. In fact, we're getting more referrals from our colleagues, for patients who had hit that gold standard of six months of sobriety and have returned to drinking.

But they have admitted to it in a clinic visit or they've had a positive screen at a clinic visit. And so, I think that the multidisciplinary team approach and the close follow-up with adherence, that we've been giving to these, what we consider high risk patients, is really setting them up for better success. And hopefully we can use what we've learned with this population, to provide all of our patients with alcoholic cirrhosis, with a more holistic plan of care and treat both their liver disease as well as their addiction.

Host: Yeah, that's really the key, right? It's not just treating the disease or getting the transplant, but it's really treating the addiction. And so, I guess I'm wondering what's that road, like, you know, after transplant.

Nicky: It's very patient-specific. They do the undergo a major surgery and so it does take some time for them to get back to like a baseline activity level. At first we thought, we need to go in right away and they need to go into inpatient rehab, you know, right as soon as they're discharged and   their focus right those first couple of weeks after transplant is really being able to walk without pain and that kind of thing. So we learned, and this has definitely been a process we've learned as we've gone, that waiting a couple of weeks once they're medically stable is the right time to start introducing and going back to getting them into counseling. We work with the Motivate Clinic. That's part of VCU, that's substance abuse specialists.

And then, we also will refer patients out to other community service boards or other substance abuse programs. We have patients who come far from Richmond. So, coming back to Richmond or doing a program here is not really the ideal situation for them. Our care coordinator works with their insurance and with their location to find programs that are a good fit for them. And then of course they see our team, on a pretty regular basis, right after transplant as well. So, they see our social workers and their transplant coordinator and the surgeon, and then hepatologist as well.   They see a lot of people.

Host: It does sound like they get to see a lot of people. And if it's people like you, that's probably a good thing. So, Nicky, as we wrap up here, what are your takeaways? What do you want patients and listeners to know about severe alcoholic hepatitis?

Nicky: So, I think what we're offering these patients is truly holistic care. And as we've developed this program, we've been able to provide these patients with treatment for, like we said, for their addiction, in addition to their liver disease.

Host: Yeah, well, you're doing amazing work, lifesaving work, as you've mentioned here today. So, Nicky, really great having you on today and you stay well.

Nicky: Thank you so much.

Host: And thanks for listening to Healthy with VCU Health. To learn more about the VCU Health Hume-Lee Transplant Center visit VCUhealth.org/transplant. Or call 804-828-4104. I'm Scott Webb. Thanks for listening.