Organ transplant candidates always require a high level of care from a multidisciplinary team. But some present with a host of medical issues that can challenge even the most experienced specialists. That was certainly the case with a patient who received a simultaneous liver and kidney transplant at the Emory Transplant Center. A multidisciplinary team of critical care medicine specialists, nephrologists, cardiologists, electrophysiologists, hepatologists and surgeons worked diligently to care for this patient prior to, during and post-transplant.
Case Background
The patient was referred to the Emory Liver Transplant Program in November 2019 for decompensated cirrhosis and liver failure due to non-alcoholic steatohepatitis. He presented with some complications, including mild symptoms of encephalopathy and esophageal varices that had required band ligation. His medical history also included hypertrophic obstructive cardiomyopathy (HOCM), for which he had received a preventive pacemaker defibrillator in 2017.
The patient’s lab tests indicated adequate liver function with a low MELD score; therefore, he was not recommend for transplant evaluation at the time. The patient instead continued a medical management course with Emory Hepatologist, Giorgio Roccaro, MD and planned to follow up in May 2020.
Initial Management
In the ensuing six months, amidst the start of the COVID-19 pandemic, the patient’s health declined. Unbeknownst to the Emory care team, he underwent emergency surgery for an incarcerated hernia and had been admitted to another medical center due to cellulitis. He was also being treated for refractory ascites with regularly schedule paracenteses.
The Emory team learned about these issues during the patient’s six-month follow-up appointment. For the next several months, the patient’s liver disease was managed medically, relying on follow-up telehealth video visits and frequent lab tests to guide care. The patient’s MELD score was a relatively low 13 through the summer of 2020.
Despite increased diuretics and weekly paracentesis, his ascites remained poorly controlled. Further, by September 2020, he began to develop progressive kidney dysfunction. His MELD score increased to 20 and he was becoming weaker and more deconditioned. At that point, the Emory Liver Transplant team initiated a comprehensive liver transplant evaluation.
Possible Barriers to Transplant Emerge
As part of the evaluation, the patient underwent magnetic resonance imaging, which led to a diagnosis of hepatocellular carcinoma. Imaging revealed a single tumor, which did not disqualify him for transplant. He also developed hepatorenal syndrome as a result of the refractory ascites and cirrhosis. This led to renal failure and the need for a simultaneous liver and kidney transplant.
In mid-December, the transplant selection team approved the patient for a liver and kidney transplant. Four days later, as part of his treatment course for hepatocellular cacrinoma, he underwent transarterial chemoembolization (TACE).
The patient was admitted to Emory University Hospital on Jan. 2 with increased fatigue, decreasing urination, symptoms of encephalopathy and a MELD score of 24. He progressed to significant renal failure and developed a cardiac arrhythmia due to volume overload. He was moved to a 30-bed liver intensive care unit, where all providers are very familiar with critical care medicine as it pertains to patients with chronic liver failure.
The critical care team, in collaboration with specialists in cardiology, electrophysiology, nephrology, hepatology and transplant anesthesiology, managed his care. The patient received an emergent pacemaker wire to pace his heart rhythm. He was started on continuous dialysis for several days. During this time, he was deactivated from the transplant list as he was too unstable.
However, on Jan. 11, his condition stabilized. He was re-activated with a MELD score of 30 and underwent combined kidney and liver transplant surgery on Jan. 12. The six-hour surgery was a success. The patient remained in the ICU for four days and returned home on Jan. 20.
Discussion
In addition to addressing myriad medical challenges, the transplant team navigated COVID-19 restrictions during his care. Typically, a patient whose kidney function is declining would be seen in person, but the transplant team was able to manage this patient appropriately via telehealth until the decision was made to pursue a transplant evaluation. This reliance on telehealth was possible in part because of the patient’s treatment adherence, notetaking and consistent communication with the care team.
Also critical to the patient’s outcome was the care team’s swift action and persistence when his condition worsened in the surgical ICU. His cardiac issues could have been perceived as disqualifying him from surgery. But Emory’s electrophysiologists, cardiologists and transplant anesthesiologists worked together to understand his underlying physiology, stabilize his condition and manage him effectively through surgery.
Follow-Up
The patient continues to see Emory transplant specialists and a cardiologist for follow-up care and is being surveilled for cancer recurrence. His liver function is excellent and his kidney function is improving with changes in immunosuppression. The patient reported at his three-month follow-up that he feels well and enjoys an excellent quality of life.
For more information about the Emory Kidney Transplant Program or to refer a patient, call 1-855-EMORY-TX (366-7989) or visit emoryhealthcare.org/txrefer.
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