LLU&MC Scope, Autumn 1997, Transplantation

Donald J. Hillebrand, MD, assistant professor of medicine, associate medical director, liver transplantion (standing, left); Waldo Concepcion, MD, director, liver, pancreas, and kidney transplantation (standing, right); and Bruce A. Runyon, MD, professor of medicine, medical director, liver transplantion, director of hepatology, worked together to rewrite the protocol for treatment at the Transplantation Institute.

Founded in 1992, the Loma Linda University Transplantation Institute has gained a reputation for excellence in the areas of liver, kidney, and kidney/pancreas transplantation.

Organ transplantation first took place at LLUMC 30 years ago in October of 1967, with a kidney transplant. Since that time, the Transplantation Institute has performed a total of 877 transplants, with high survival rates in all areas.

At Loma Linda, candidates for organ transplantation have a network of support made up of a multispecialty team which includes liver and kidney specialists, surgeons, social workers, nurses, physicians' assistants, and dietitians.

Other specialists in diverse disciplines also aid in specific cases. While transplantation can improve one's quality of life, it also demands that individuals are active in the maintenance and preservation of their own health.

"Our goal at the Transplantation Institute is to restore patients to a high quality of life," points out Waldo Concepcion, MD, director, liver, pancreas, and kidney transplantation. "It is also important that patients learn how to care for themselves properly."

In the last year, the Transplantation Institute has implemented strict guidelines for evaluation and treatment of patients with liver and kidney diseases. The modality of treatment has also been expanded for the treatment of liver diseases.

In restructuring its program, the Transplantation Institute has taken a more conservative approach to the treatment of liver disease. Emphasizing education and prevention more than traditional therapies that have been practiced, the transplant team has seen very positive results. Several patients have improved so much that they have been able to go back to work, and some have even improved enough to be taken off the transplantion waiting list.

Education is not only implemented in the first stages of care, but as an on-going process.

"We have implemented a very aggressive patient education program that focuses on the many needs of the transplant patient and his or her family," states Dr. Concepcion. "We have patient education courses in various areas that may be of concern."

Prevention is also an important area that the Transplantation Institute has addressed.

"We have developed a program to make the community aware of the risks of Hepatitis C, liver disease due to obesity, and alcohol/liver diseases," Dr. Concepcion remarks. "All of these are important for the community. We are not just interested in getting patients to transplantation, but we want to make a difference in the community as a whole."

Through education, the goal of the Transplantation Institute is to introduce early or preventive treatment, so that people do not progress to the point where they need a transplant.

"More and more, the type of liver disease we see is Hepatitis C," says Donald J. Hillebrand, MD, assistant professor of medicine, associate medical director, liver transplantion. "There is a lot of patient information available regarding Hepatitis C, and we are creating a patient education room to facilitate patients' access.

"We will have videos and written literature so that patients can learn more about liver disease and the steps they can take to decrease or prevent their risk of progression of their disease."

With Hepatitis C, in particular, it is important not to drink alcohol at all. Many studies have shown that people who drink are more likely to progress quicker to cirrhosis (hardening of the liver).

A screening program has also been designed to detect disease early and to educate the public about Hepatitis C.

"We go to some of the alcohol and substance abuse treatment centers in the area and talk to the clients about liver disease," Dr. Hillebrand says. "Primarily, we talk about Hepatitis C because it is the disease that affects that particular population more than others.

"We discuss what the disease is, how it is transmitted, and what they should do to protect themselves."

An important part of the conservative approach of the Transplantation Institute is the use of support groups. In these groups, transplantion recipients tell their stories and give encouragement and support to those who are waiting for a transplant, or to those who have already received one.

Emphasis is placed on living life to the fullest and not focusing on the fact that one has a disease. One of the major goals of the transplantion team is to have patients focus on the positive.

"Chris Neighbors, our social worker, has been doing a fantastic job working with the patients," Dr. Hillebrand explains readily.

"Though they have to deal with the fact that they have a chronic illness, she shows them that they can still be active and live a normal life."

One of the most important areas established in the new program is an Alcohol and Substance Abuse Protocol. Candidates must be completely abstinent from alcohol and drugs for at least six months, attend Alcoholics Anonymous (AA) meetings, and participate in random drug screenings. When they are evaluated for transplantation, a compliance agreement is signed stating that they will comply with these requirements. If they are noncompliant or do not pass the drug screening, they are taken off the waiting list.

"It is a much more conservative approach than previously taken here at LLUMC," Dr. Hillebrand points out, "but it is more consistent with the approach of the University. Using this approach, the risk of returning to substance abuse after transplant is fairly low--about 5 to 10 percent."

What researchers and physicians have discovered most about liver disease is that its causes are habit related.

"Needle sharing in the form of drug use, tattoos, acupuncture, body piercing, and alcohol use puts one at risk for liver disease," states Bruce A. Runyon, MD, professor of medicine, medical director, liver transplantion, director of hepatology.

A silent and unrecognized problem that Dr. Runyon notes is obesity-related liver disease. This is seen as a co-factor in alcohol and viral liver disease. In some cases, however, patients get cirrhosis from obesity alone.

"If you have a strong family history of high lipids, diabetes, and hypertension, there is potential for this disease," Dr. Runyon warns. "We are seeing more and more overweight children who have little physical activity. They just sit in front of the computer or television for hours, and we are seeing consequences of that inactivity."

Bruce Runyon, MD, co-invented the ascites pump that removes ascitic fluid from the abdomen.

Dr. Runyon's area of specialized research is liver failure--ascites, in particular. Together with an inventor in Pennsylvania, Dr. Runyon created a pump that removes the ascitic fluid from the abdomen in less time than with the standard vacuum bottle.

"When you have patients who come in once a week or every other week for this procedure," Dr. Runyon explains, "they want to get in and out as rapidly as possible. If you can cut their treatment time in half, they are happier with that."

New ways of treating liver tumors are also being designed. Dr. Runyon adds, "Currently, protocols using protons are being developed. Only one or two centers in the world use this type of procedure. The options for the treatment of that tumor are not very good, and proton therapy seems to be beneficial in the treatment of this type of cancer."

Maintaining that education plays a vital role in the prevention of disease, Dr. Runyon states, "A dollar spent on education about liver disease is a dollar well invested. I believe it is important for prevention education to start in childhood."

By replacing organs that cease to function properly and by caring for the whole person, the Transplantation Institute is continuing the mission of Loma Linda University.

"The multidisciplinary faculty from various areas are working together to make this a center of excellence," Dr. Concepcion concludes. "The institution is working hard and supporting our efforts in assuring that our dreams for this Center become reality."