Dr. David Shaffer talks with patient Craig Stevens, who became the 100th person this year to receive a kidney transplant at Vanderbilt. Jeanne Hopkins, RN, and nurse practitioner Laura Butler, part of the kidney transplant team, look on. (photo by Dana Johnson)
Transplant program sees new growth
Vanderbilt’s kidney transplant program has itself been transformed. Now, more people who require the procedure are receiving it here. Also, for the first time, a system is in place to routinely offer pancreas transplants to people with severe Type-1 diabetes, giving them the best chance to beat the disease.
In June 2001, the average number of patients being evaluated at Vanderbilt for kidney transplantation was about 10. None came for pancreas transplants because the closest center performing that more demanding procedure on the more surgically delicate organ was in Memphis.
July of that year saw a low of five kidney transplant evaluations, but August marked the beginning of a steady climb in volume when 17 patients were seen.
Fast forward to 2002: In October alone, 38 patients came here for kidney transplant evaluations (the average for the past six months is 34).
On Nov. 5, Craig Stevens, a 42-year-old supervisor in the chemical transport business before his kidneys failed, became the 100th person this year to receive a kidney transplant. (The last time VUMC reached that mark was 1989.) Besides a little soreness, the procedure was relatively easy, Stevens said from his hospital bed, three days post-transplant.
“The hardest part was going to the doctor (a nephrologist in Florida, where he lived at the time of diagnosis in 2001) and being told ‘you’re out of work starting tomorrow.’ I’ve been working since I was 16. That was a tough pill to swallow,” he said.
Stevens moved to his hometown of Abingdon, Va., just across the Tennessee border, and started looking for a place to receive a transplant. He passed up centers closer to home at the University of Virginia and Johnson City Medical Center. He called Vanderbilt in January to schedule an evaluation. He said he couldn’t imagine getting better care from the nurses and the surgical team at Vanderbilt.
But nobody’s resting on a century-mark laurel. As of Nov. 11, 103 patients received kidney transplants at Vanderbilt and at the Nashville VA Hospital (staffed by Vanderbilt surgeons), six more than in all of 2001. And, five patients have received a new pancreas since December 2001.
The reasons for the boost are a revitalized kidney transplant program and a new pancreas transplant program. Dr. David Shaffer, professor of Surgery and Stevens’ surgeon, leads a new team of transplant coordinators, Laura Butler, Tommy Johnson and Jeanne Hopkins, and a new surgeon, Dr. Tarik Kizilisik, who came in March and who, with Shaffer, is transplanting pancreata.
Also, Dr. William A. Nylander, associate professor of Surgery and a VUMC veteran, has begun laparoscopic donor nephrectomy — extracting a donor kidney through a small incision, a technique new here but standard practice in some other centers — that increases options and volumes, and improves outcomes.
“Dr. Shaffer and the rest of his team have worked through a patient care improvement process from start to finish, and they have had great success with their program,” said Dr. C. Wright Pinson, H. William Scott Professor and Chairman of the Department of Surgery, chief of staff of Vanderbilt University Hospital and surgical director of the Vanderbilt Transplant Center.
Shaffer, who came here from Beth Israel Deaconess Medical Center in Boston, recruited Kizilisik specifically for pancreas transplants. Nylander has increased the number of living donor kidney transplants each year; now they account for more than half of all kidney transplants. Stevens’ donor was his sister, Phyllis Stewart.
“We have a well integrated team with a lot of experience,” Shaffer, professor of Surgery, said recently. Efficiencies in the program have yielded improved patient outcomes and more satisfaction by patients and referring physicians, he said.
Credit is also due to the non-surgical staff, Shaffer says. Dr. Anthony Langone, assistant professor of Nephrology who recently joined Dr. J. Harold Helderman in transplant nephrology, has spearheaded the medical evaluation of potential living donors and helped improve outcomes post-transplant. Also, Dr. Kathy Jabs, chief of Pediatric Nephrology, is largely responsible for growth in the pediatric transplant program. “As surgeons, we play a very supportive role to her efforts,” Shaffer said. “With the new [Monroe Carell Jr.] Vanderbilt Children’s Hospital, this will be an era of new growth for kidney transplant as well. It’s exciting to me personally to be able to participate in the expansion of this area.”
A busier transplant center also translates into more opportunities. New health insurance companies that base contracts with medical centers on volume have signed on, which in turn begets even more patients. And drug manufacturers are more attracted to busy programs; there are now two ongoing clinical trials for new immunosuppresive drugs.
Shaffer’s goals for kidney transplant volumes this year is 110. Twenty people are on the pancreas transplant waiting list; half of them need pancreas only.
Kidney transplants are indicated for a variety of diseases that lead to end-stage renal disease. Replacing the pancreas goes to the root of diabetes; defects in the organ cause the depletion of insulin that leads to the disease, so pancreas transplants are indicated only for patients with a long history of Type 1, insulin dependent diabetes and who do not have significant cardiac or peripheral vascular disease. Currently, Kizilisik and Shaffer are transplanting pancreata only in combination with kidney transplants and subsequent to a kidney transplant.
Criteria for pancreas transplants have relaxed; the United Network for Organ Sharing has eliminated HLA matching, making ABO compatibility and negative T cell and B cell crossmatch the only requirements.
According to the Organ Procurement and Transplantation Network more than 100 medical centers across the country performed kidney/pancreas transplants in 2001. But less than one-third of them performed more than 10.
Shaffer and Kizilisik say their program will start slowly, and will likely complete five to 10 pancreas transplants by the end of 2002, then move steadily toward 15 to 20 a year. “We want our results to be perfect, so we’re going to be a little bit conservative. A transplant team is a process. … Once we catch that harmony, the success (and volume) will come,” said Kizilisik, who came here from the University of Tennessee in Memphis, where 50 or more pancreata were transplanted annually.
Creating the option for pancreas transplants also opens the door for future islet cell transplantation. A few research programs have shown preliminary successes with the technique. At Vanderbilt, Christopher V. E. Wright, D. Phil., professor of Cell and Developmental Biology and vice chair of the department, is investigating the possibility of developing pancreas cells from stem cells.
Kizilisik was also trained in islet cell transplantation, having worked with the team in Edmonton, Alberta Canada who were among the first to widely publish their successes. But, widespread clinical application is still years away, he cautions.
Stevens, having had diabetes for 23 years, wasn’t a perfect candidate for a new pancreas, and his new kidney is working fine. He might need a pancreas transplant in the future, and he’s aware of islet cell research. But, he says, “Right now I’m going to keep taking insulin and do the best I can… And once I get healed up I’m going to go back to work.”