The Day Arrives

An individual's years-long wait for a liver ends when an Organ Procurement Organization (OPO) notifies the hospital that a liver is available. Three Transplant Coordinators - Patricia Harren, RN, Linda Irwin, RN, or Diane LaPointe-Rudow, RN - take turns on call, so that the program is ready 24 hours a day to receive a transplantable organ. Patricia Harren describes the steps the coordinators follow: "We find out everything we can about the donor - blood type, age, to whom it's being offered, what happened to the donor, his or her whole hospital course. We contact the surgeon on call and we run over information on the patient it's being offered to. We get everyone set to go the operating room and we arrange a flight, if needed, to rush the organ here."

Make Sure It Works

Once a patient has undergone the transplant operation - which can take anywhere from 6-18 hours - another life-and-death battle begins: doctors must tame the patient's immune system which wants to attack tissue it does not recognize. NYU Medical Center, with 15 other major medical centers, is currently participating in a study of a new immunosuppressant for liver transplantation called Cellcept, that may improve this process for patients in several crucial ways.

"We believe that Cellcept is going to decrease liver rejection," Dr. Teperman says. "Everyone gets a rejection episode: the patient feels tired and looks a little yellow, as lymphocytes attach the new liver. We bring the patient in for a biopsy, and usually treat with steroids. We rarely retransplant for rejection. We're hoping that, with this drug, patients won't even have the episode. I believe that, on smaller doses, patients won't have chronic, or gradual rejection. We'll use larger doses for acute rejection."

Cellcept may also reduce the medications that patients must use regularly after transplantation. "The mainstay of post-transplant drugs hurt the kidneys," Dr. Teperman says. "Kidney function generally decreases 50% of normal. We're looking to Cellcept to enable patients to use fewer drugs, and thereby keep more of their kidney functioning. We're also hoping to decrease the use of steroids, which weaken bones, and can affect the patient's appearance."

It's A Team Effort

"Great results don't happen by chance," says Donna Campbell, RN, Head Nurse of the transplant unit since its inception in 1990. "It takes a lot of talented people to make things go right consistently."

Immediately after the transplant, the patient goes into intensive care where highly trained nurses tend to the patient's acute needs. At this crucial stage, the nurses' attention to detail and alertness to changes in the patient is crucial to the outcome.

"Once the critical phase is over, the patient's job begins - and it's not an easy one!" says Assistant Head Nurse Margaret Frank-Bader. "We have a team whose function is to make each patient an expert on caring for their liver," said Head Nurse Campbell. To manage at home, the patient has a lot to learn. Thorough training about medications, blood pressure monitoring, signs of rejection and infection is provided. Social workers, physical therapists and nutritionists all provide crucial services to the transplant patient.

"We all pull together as a team," says Campbell. "That's why our patients usually go home one week after surgery, confident in themselves but knowing we're always here for them."

A New Liver

NYU's liver transplant patients are able to return home after the operation sooner than was previously possible, thanks to the expert coordination of the Program's specially trained nurses, social workers, physical therapists, and nutritionists. Helping patients adjust to the realities of life with a new liver, in fact, is a process that begins before they are admitted for the surgery.

Patients come to all-day group orientations, where they meet nurses, nutritionists, and social workers," says Head Nurse Campbell. "They have a tour of the unit before they get here, and everyone has met them. We're also doing discharge teaching right from the beginning." Patients and their families are taught the signs and symptoms of organ rejection, and learn about nutrition and the monitoring of glucose and blood pressure. They also receive intensive instruction on how to properly administer their medication - a crucial element for avoiding organ rejection due to medication error.

The coordinators currently work with about 950 patients at various stages of the odyssey, arranging pre-transplant testing, adjusting post-operative medication, and monitoring every other aspect of patients' health care, to ensure that all their medical care is in harmony with the requirements for maintaining a transplanted liver. "In one sense," says Coordinator Patricia Harren, "we never discharge patients from our care."