14 LEADING MEDICINE: ADVANCED ORGAN FAILURE MANAGEMENT AND TRANSPLANT
BREAKING DOWN THE BARRIERS TO LIVER TRANSPLANT Houston Methodist Hospital has the largest liver patient waiting list of any transplant center in Texas. At Sherrie and Alan Conover Center for Liver Disease & Transplantation at Houston Methodist J.C. Walter Jr. Transplant Center, physicians and transplant surgeons under the direction of R. Mark Ghobrial, MD, PhD, continue to explore the treatment boundaries of what is safely possible to help patients in dire need. Multidisciplinary teams have been specifically trained in all stages of liver transplant care. This unique combination of skills allows the team to extend the criteria of limitations that could disqualify extremely sick patients from the benefit of a liver transplant. A summary of several research studies presented throughout 2014 and 2015 — referred to as “pushing the envelope” by Howard P. Monsour, Jr., MD, chief of hepatology — addressed how Houston Methodist successfully treats patients who would otherwise not be considered candidates for liver transplant. Monsour and his colleages, David Victor III, MD, transplant hepatologist and director of clinical research, and Maha Boktour, MD, MPH, epidemiologist, first presented at the International Liver Transplant Society 20th Annual International Congress in June 2014. At the core is the need to evaluate patients individually, and not rely on a set of standard criteria. One primary area of focus was age. Many centers will not transplant patients over the age of 70. “Our group showed that if you highly select these patients — as we did in our septuagenarian study — they will actually have the same or better survival rate than in patients younger than 65,” Monsour said.
Monsour contended that the same philosophy of treatment extends to patients with a high body mass index (BMI) as well. “We demonstrated that we were able to successfully transplant patients with a BMI greater than 40 with the same success and complication rates as patients with lower BMIs,” Monsour said. Perhaps the most significant criterion for liver transplant viability is a patient’s Model for End-Stage Liver Disease (MELD) score. According to Monsour, throughout Europe and in many transplant centers around the United States, most patients are transplanted with MELD scores in the 20s. “At this time, we are transplanting patients with MELD scores greater than 40. So these are very sick patients,” Monsour said. “When we went back and looked at these high-MELD patients, we found that their survival was the same. Most importantly, their functionality at six months and one year was similar and not statistically different than patients with lower MELDs.” Monsour believes successful liver transplantation in high-risk patients shows the intense resources that have been provided by Houston Methodist. “We are able to take these patients who were turned down at other centers and give them a good quality of life due to our surgical intensive care unit, the liver intensive care unit, the technical capabilities of our surgeons, and our postoperative care and management,” he said.
Monsour believes successful liver transplantation in high-risk patients shows the intense resources that have been provided by Houston Methodist.