Chapters Transcript Video Liver Transplantation: Indication, Allocation, and Inequity Sharad Wadhwani is a pediatric hepatologist and an assistant professor of pediatrics at the University of California San Francisco. He is also a chomi having completed his pediatric residency at CHO in 2014, he completed his G I fellowship at Cincinnati Children's and returned to the Bay Area to complete his transplant and Hepatology fellowship at U CS F in 2020. His research lies at the intersection of pediatric hepatology, population health and health systems improvement. WWAS research has been funded by a ASLD the Stars Network for Excellence in pediatric transplantation, a G A American Society of Transplantation and the NIH. Presently, he leads the NIH funded Multi center Social TX study focused on understanding how social determinants of health influence outcomes for Children undergoing liver transplant. With the goal of using this knowledge to improve post transplant outcomes. Beyond his professional commitments, Sharad is a devoted father to two young Children. His leisure time is often spent engaging in outdoor activities, cooking or immersing himself in the captivating and not annoying melodies of children's music without further ado here is Doctor Wadhwani. Thank you so much um for that introduction. Uh I'm thrilled to be speaking uh with you all today. Uh especially since um I I trained at, at Children's Oakland and have really uh uh a special place in my heart for, for Children's Oakland. These are my disclosures. OK. So um I was asked today to, to provide uh an overview of liver transplantation uh for Children. Um So I'm gonna start by talking about indications for transplant. Talk about how we evaluate Children for transplant. Briefly, touch upon the organ allocation system that we have in the United States and then uh talk about some of the post transplant considerations, including complications and long term surveillance. And then I'll briefly touch upon some of the research that we've been doing uh around disparities and inequities in the transplant system. First, I wanted to start with just a little uh trivia question uh and ask the crowd in, what year was the first pediatric liver transplant with survival greater than one year? And you can either answer in the chat or you can um just think to yourself and I will um show you the answer in, in a couple of seconds. Um Let's see. So, um pediatric liver transplant, the first liver transplant occurred in 1963 by Thomas Starzl. He was uh is thought to be the founder of pediatric liver transplant. And what's remarkable about Thomas Starzl and the history of pediatric liver transplant is it wasn't until four years later in 1967 when we started when they started to see any sort of success uh from doing these transplants. And if you can imagine uh watching a medical procedure happen for four years with no success and patients just dying immediately after transplant, you could imagine the amount of pressure that he might have felt and the amount of public backlash he uh might have experienced um for doing this procedure that was just wack a do and crazy and, and taking a deceased person's organ and putting it into another body and, and that the patient dying um but he persisted and in the eighties, it has, it became standard treatment for Children and adults with vent stage liver disease. Really. I think one of the uh modern medical miracles that we have um uh in our, in our um tool kit. And so now in the United States, we do about 600 transplants per year in Children. Uh for various indications. The most common indication. Our sort of bread and butter indication for liver transplant is biliary atresia which uh you uh probably are somewhat familiar with. Uh and then our second biggest bucket of indications is metabolic genetic diseases like Aller syndrome. Um And then we do a smattering of transplants for acute liver failure, more and more for for tumors like capped blastoma. And then there's this bucket of sort of um indeterminant cirrhosis, et cetera, autoimmune hepatitis when we are. Uh there's sort of 22 ways that patients come to us for liver transplant evaluation. There's emergent or urgent indications and these are things like acute liver failure which you uh the residents may be familiar with in the IC U um metabolic crises, uh tumors and then um biliary atresia that uh is unresponsive to a KA I procedure. And then there's a chronic end stage liver disease um or or progressive deterioration of liver function that results in growth failure, uh complications of portal hypertension, like foal bleeding, intractable, ascites, incorrect coagulopathy or recurrent cholangitis. And so when a child comes to us for a transplant evaluation, uh when we evaluate them, we use a very structured process that is sort of mandated by our societies and by the governing body of um uh uh of the transplant system. And so we have a structured head to toe assessment. Here's our, our checklist of all the labs and all of the consults that we need to document in during the evaluation process. Uh And there's certain information we need to provide to patients and families about how organ allocation works. And then we uh discuss the candidates in a formal selection meeting where we talk about the indications for transplant, what additional risk factors. And then we, we come to a formal uh consensus on whether we're going to list someone or not. And this all has to be very um very well documented because uh we, we can be audited for doing this incorrectly. And then when someone gets uh the decision is made to list someone they get put it on, put on AAA liver transplant waitlist. Uh The OPTN is the body that oversees the allocation of organs in the United States. This is a public, private partnership between hers A and UNOS. Um If, if you guys have been paying attention to the news recently, you might have seen some articles. Uh Congress has been uh uh having intense scrutiny, scrutiny uh on Unos um a lot of this led by Elizabeth Warren. And so the whole transplant organ allocation system is undergoing major revamping. And it's um it's unclear uh what direction that we're heading in. But the way that livers are, are allocated as opposed to kidneys, um is they're, they're allocated to, to people based on their medical necessity and specifically, uh they're allocated based on who has the highest likelihood of dying within three months without a liver transplant. Uh as opposed to kidneys. Uh you know, where there's dialysis available for kidney for Children and adults with end stage kidney disease. We don't have any um artificial uh liver uh function tools available to use while while patients wait for uh liver transplants. And so the way that we determine someone's risk of mortality is using uh an established objective criteria uh called meld for adults or Peled for Children. And these are based on lab values and they've been, it's been really designed to predict your risk of mortality uh over the next three months without a liver. Um And then we have special designations uh called status one A for emergency transplants for acute liver failure. And then status one B for, for things like tumors where you don't really have uh a sick liver, but you have a tumor in your liver. And, and so that's a way to account for those. And so how does the system work for Children? Well, one of the interesting things that we've started to find is that um as I mentioned before, we use the P score for Children and the meld score for adults. And one of the interesting things is that both scores as the scores increase, they really predict risk of mortality really nicely. Um But what we found is that the pel score compared to the meld score um under predicts the risk of mortality, meaning that uh um what we see here is the expected mortality based on the pell score. And what we see here is the actual mortality uh for Children uh at these melds. And so, um both pell and mild have good discriminatory ability, but they are not aligned with one another. And so Children are at a disadvantage, a child at a, at a pel of 30 has a higher mortality rate than an adult at a mad of 30. And so there's a little uh calibration issue between uh children's access to livers compared to adults And so as a result of that, we in pediatrics rely on something called exception scores. And about two thirds of our patients um are listed with an exception score. And, and what exception scores are is we can write a little uh case vignette describing why a child is sicker than, than their pell score would suggest. And we can send this anonymously to a review board and they can vote whether they agree or not. And um we can get added points added on uh to, to some to a child's pel score. And so um one of um my partner is Emily Perito here at U CS F has been involved in a lot of work to update the pel score to improve discrimination and to improve calibration. So that uh the pel score aligns more closely with, with the meld score. Ok. So moving into a child now gets an organ, um how, how do we give the child the organ? Well, there's sort of three way three types of organ transplants, a child can like can receive, they can receive a whole liver. So, um and, and that works really nicely for our older adolescents who can accept uh uh an adult donor, liver. Um for babies often this limits their ability to get uh a transplant um because then they would need a, a baby or child donor. Um But increasingly uh with, with more surgical, with centers of, with more surgical expertise we're able to offer split liver and living donor transplants. So, split liver is where you take a segment of the liver. Usually in babies, we we will take the left lateral segment of the liver. And um we can also take the left lateral segment of a living donor. Um And we're fortunate here at U CS F to have um a lot of surgical expertise. And so we do a lot of split liver and living donor liver transplants. Um I would recommend, you know, we have a pretty active living donor liver transplant program on Netflix. There is a show called the Surgeon's cut and I think episode four highlights um Nancy Asher who's who's pictured here. Um but she runs our uh living donor liver transplant program and it's a really uh fascinating episode. Ok. So now the child has received a liver transplant. How do we uh manage um the medical care for this child? So our main questions are, is the liver functioning? Is the donor liver functioning? Are the the blood vessels patent? This becomes um very important in babies because they have small blood vessels. So the anastomosis are very small. Um what's their volume, volume status? And then all of the other things we think about when we're managing a critically ill child. So first question is the liver functioning. Um When Children are in the IC U following a liver transplant, our residents get very familiar with their Pesky Hepatologists bothering them constantly and incessantly, we're frequently checking inrs ammonia, lactates, making sure their lactate is clearing. Um Are they waking up from anesthesia? And are they starting to clear their bilirubin? Are the vessels patent? Um Children, especially small Children are at risk for developing thrombosis and their hepatic artery and this is a a life threatening complication from transplant. So we are watching closely, we're getting daily ultrasounds, we're monitoring their JP output. is it, are they starting to develop more ascites? Um And is their bir ribbon going up? Um And so we're watching these things very closely to make sure that their, their blood vessels are patent. And then of course, um some of the other considerations, they just had a major abdominal surgery, we're monitoring for bleeding. Um They're on profound immunosuppression immediately after transplant. So we're looking for infectious complications and then we're, we're titrating their immunosuppression. And so there's a lot of moving pieces, post transplant where you have the confluence of a major abdominal surgery and the, the normal risks of that. And then you're also having risks of thrombosis and we are managing immunosuppression. So, uh we have a lot of conversations between hepatologists, surgeons, the IC U um as well as any other consultants that need to be um informed and, and um so it's a pretty dynamic uh time period. OK. Just briefly talking about some of the complications we're looking for, as I mentioned to panic artery thrombosis is um something that we are very uh as uh carefully looking for. Um this because of the high mortality rates when there is a, a hepatic artery thrombosis. Um This is an indication for listing someone relis someone at status one A. Um and, and so the hepatic artery is the sole blood supply to the um bile ducts. And so we can start to see um rising billies and we can see infectious complications and sepsis as a result of of hepatic artery thrombosis. Um less urgent, we can see portal vein thrombosis. Um And, and so we're monitoring for those as well, but really hepatic artery thrombosis are, are something we are looking for and need to act quickly on briefly a little bit about how we immunosuppress Children after transplant. Um when they're on their day of transplant, they get a large dose of corticosteroids um about 20 mg per kilogram. Uh So, you know, an adult, an adult will max out at 1 g of steroids. Um So pretty large doses of steroids and then we also start CSP and tacrolimus, which is a Calcine inhibitor. Uh And then over the first year of transplant, we can really wean them off and uh uh to just one immunosuppressant. Tacho liis is our primary immunosuppressant. Uh And so, um so over the first year, uh Children are on a lot of medications, they're on all sorts of adjunct uh prophylactic medications as well as multiple immunosuppressants and then by about the f first, the end of the first year, most Children are on a single drug, which is tacrolimus. Ok. So, as we think about planning for discharge, you know, similar to, to other Children with chronic illness, we're thinking about whether they are safe to go home or if they need to stay close to the hospital. And a lot of that depends on, um, how far away they live and whether they need to keep a central line in when they go home, um whether they need supplemental and uh NJNG feeds and um making sure the family feels comfortable with this really complicated medical regimen that really just happened overnight. And so we monitor these kids very closely post transplant. We are getting twice weekly labs initially and those sort of space out over time and then often these kids need to come in for IV electrolyte infusions, blood transfusions, um et cetera. And so it's a, it's a pretty intense year after transplant as we get past the first year. Um most kids do remarkably well and as I mentioned earlier, they're on one drug tacrolimus. Um but there are late complications that we're learning more about and um and continue to cause problems. So when we think about the graft, um these Children are at risk for developing rejection episodes over the the course of their life, particularly when they um have troubles with medication adherence and taking their immunosuppression. They can have episodes of rejection. Um that if caught quickly, we can treat pretty quickly, but then they can develop um sort of harder to treat rejection. Uh what we call chronic or B cell mediated rejection. Uh They can develop de novo autoimmune hepatitis and they can also develop liver fibrosis. And there's a lot in the long term complications that we don't understand as well. On the other side of the scale is uh is de developing uh complications from the immunosuppression. Press of medications themselves, tacrolimus is not benign and long term tacrolimus use can lead to infection. Um malignancy, particularly what we call uh it's called PTLD or posttransplant lymphoproliferative disorder. Um These cards are at risk for developing diabetes, kidney disease, metabolic syndrome, hypertension and dyslipidemia. So, as we as kids are, are living their lives and, and moving into adulthood, it really becomes a balance of making sure they have enough immunosuppression to protect their graft but not too much immunosuppression that they start to develop these long term uh immunosuppression side effects. And then, um for reasons we don't quite understand yet. Um these kids are at risk for poor psychosocial neurocognitive and and decreased quality of life um extending into the long term survivorship, post transplant. So, what are some of the monitoring that we do long term? Um These kids get monthly labs for the rest of their life? They see um us every 3 to 6 months. Um They get annual screening labs, they get nutritional counseling. Um We monitor them close for hypertension. We get imaging annually and then every few years, uh we get surveillance liver biopsies. So U CS F, we do surveillance liver biopsy um about every five years. And, and the main reason we do this is because a certain a subset of patients can come completely off immunosuppression. A lot of this work has been led by Sandy Fang, a surgeon here. Um But we are increasingly learning that uh a certain subset of kids can come completely off of immunosuppression and have no um consequences to their all graft. And um so we're trying to learn more about who these kids are and how we can predict who will do well off of immunosuppression. Um But that, that's the reason why we do liver biopsies. We also monitor for CMV and EBV. Children are at risk of developing um uh EBV via over the course of their life while they're on immunosuppression. And if we don't detect this early, it can progress to PTLD or posttransplant proliferative disease, which is uh a cancerous uh side effect of EBVV that is not um tamp down from the native immune system. And then these kids are at risk for skin cancer and, and certain infections that are um endemic to specific areas. Finally, as we, as we think about transitioning these kids to adult care, um as, as you probably all know from, from other childhood, chronic illnesses. Um transition of care is a really vulnerable time for Children and that's no different in pediatric liver transplant. These Children experience higher rates of rejection and graft loss. Um maybe due to poor adherence, um they have issues related to sexuality and um and sexually transmitted infections. And then um there, there's needs to be discussions around contraception and pregnancy. Some of the immunosuppressive agents we use are teratogenic. And um so there's a lot of counseling that has to go into uh contraception and pregnancy as well as um substance use and mental health, as I mentioned earlier, for reasons that are not quite clear, these Children are at higher risk risk for poor um quality of life. And so, um we worry a lot about substance use and abuse. Shifting gears a little bit. I'll share a little bit about what my lab's research has been focused on and, and some of the inequities that, that we're finding in the transplant system and how we've sought to address them. So I've shared with you sort of the path of the child as they, they get a transplant and it starts with the recognition that they need a transplant, getting waitlisted, getting evaluated and waitlisted, getting transplanted, getting transplanted, and then um having excellent posttransplant outcomes. And so a lot of my early work, a lot of our early work has relied on us Census Bureau data. And so the US Census Bureau every five years conducts something called the American Community survey where they go out into communities and they survey uh households to learn more about health and vitality of neighborhoods. So they will ask figure out you know how many households are vacant, how many households live below the poverty line in the neighborhood? And you can get these very granular neighborhood level data from the um US Census Bureau such as as I mentioned, percent of the population that lives below the federal poverty line percentage of the households that are vacant, et cetera. And there's been sort of a proliferation of this research looking at how neighborhood level measures of um social disadvantage influence health outcomes. And the, the specific neighborhood level measure that we've used is something called the neighborhood deprivation index. And it's a composite index of these six variables that II I show here on the screen. Um And the index ranges from 0 to 1 with values closer to one indicating neighborhoods with more deprivation. So this is just a map of the deprivation index and the deprivation index we've used was developed in Cincinnati Zoomed in here as the city of Cincinnati. Uh And I put this map here to, to show you how much variability there is in deprivation within a city to really show you that, that this deprivation index captures neighbor neighborhood level attributes. So when we've looked at, um so when we've looked at different phases of transplant, when we've looked at the waitlist period. What we know as I've, I've shared with you before is that organs are allocated by the pell or mild and, and medical necessity. And then we also use exception requests. And as I mentioned before, we can also offer living donor liver transplant, that's more technically challenging, but we can offer that transplant earlier on in a child's disease course and, and have better outcomes. And so we did a study that we wanted to understand how race and ethnicity influences weightless outcomes. And, and then using race and e and ethnicity, we conceptualize these as social constructs that, that capture the ill effects of racism in the US and wanted to see how neighborhood deprivation impacted that relationship between race and waitlist outcomes. Excuse me. Um And so what we found was that black Children and Hispanic Children were at increased risk for weightless mortality. Mm um But that this risk started to decrease when we added other social determinants like neighborhood deprivation insurance and the initial disease severity when they were listed their pelt and me suggesting that neighborhood deprivation, um individual socio-economic status and how late in their disease process that they were listed really drove some of those disparities. Similarly, when we looked at access to living donor transplant, we found that black and Hispanic Children were less likely to uh have access to living donor transplant. But when we added these other variables in the disparity started to go away once again, suggesting that these factors were really just really driving the disparity we observed. So as we think about the possible contributors to these disparities, uh One study done by our colleagues, as I mentioned, um those non-standard exception points that we can get by, by filling out a case vignette. Um They, they found that if, if a center filled out a case request that it was most likely to be approved of case yet. But that um there's certain factors, Children with public insurance and nonwhite Children were less likely to have these exception requests submitted. So they were able to have, they had the same likelihood of having these exception requests approved. But it suggests that there's some provider and institutional factors like bias and racism that are impacting a center's decision to submit these requests on these children's behalf. So as we think about some of these disparities in in wait list outcomes, I think it has to do with decreased as access to living donor transplant, social determinants of health like neighborhood deprivation and individual socio-economic status, access to non-standard exceptions and then being listed further in their disease state or having uh uh delayed access to transplant. OK. Shifting gears to the post transplant period where most of my research has been focused on looking at neighborhood deprivation again and looking at a biomarker of poor medication adherence here on the Y axis. We found that Children from the most deprived quartile neighborhoods at about double the rate of medication non aer than, than the rest of the quart. And this is in a multi center study of about 200 Children. And when we looked across the United States at every child who received a liver transplant over a 10 year period, what we found was that neighborhood deprivation was associated with increased risk of graft failure and an increased risk of death. In in other studies that um some of my mentees have have looked at Holly Schiffman. Now at Boston children's did a study looking at what the impact of living in a health professional shortage area um led to and found that uh living in a health professional shortage area, uh increased your risk of graft failure and death. Health professional shortage areas are defined by HSA as areas with not enough primary care access. And um she adjusted for the socio-economic conditions of where they lived uh like neighborhood deprivation and and similarly found this increased risk. Another uh mentee Jared Yalong, a medical student at U CS F, did a study looking at the impact of air pollution on transplant outcomes and found that Children living in high air pollution neighborhoods had a 56% increased risk of graft failure and death over a 10 year period following transplant. And this uh finding also persisted when he adjusted for the socio-economic conditions of the neighborhoods. Really suggesting that maybe air pollution has an impact on on transplant outcomes for reasons that we don't understand yet. So how can we adjust these disparities? Well, one strategy that we've been developing uh as part of my research program has been a health advocate uh intervention. Health advocates uh have been um implemented in, in various uh clinics most notably oncology. Um And but health advocates can help families coordinate care, they can help facilitate financial assistance, they can uh help identify community based resources. Um In this trial here, uh that was done um by my colleague, Laura Gottlieb and and um also Dana Long from children's Oakland uh in pediatric primary care clinics. Um patients who had a health advocate compared to controls had a decreased incidence of hospitalization in, in the year following the intervention really driving home, the point that these, these, this model could be a strategy to improve health outcomes for, for pediatric patients. So, in adapting and designing this health advocate role for our patients, we uh engaged a, a group of patient stakeholders, caregiver, stakeholders and transplant team members across uh the US in a human de de uh centric design project to really understand what everyone's behaviors need. Its values and preferences were and um tried to build the intervention around that. So we conducted a number of qualitative interviews with um transplant providers and and caregivers of pediatric liver transplant patients. And what we found when we talked to caregivers is that there's a really high uh care burden post transplant, which is obviously not unexpected. Um But often one parent needs to leave the workforce to care for their child and they experience a really high financial burden as a result of that. And so they really depend on the generosity of their, their social network to help them sort of finance the posttransplant period. Uh but this support dries up. So they, they talk about how there's a, a lot of support immediately after transplant. But uh that, that support from their community, uh from friends, neighbors, family kind of dries up over time. When we talk to team members, uh various team members on the transplant teams that we work with. We found that they rely heavily on the pretransplant psychosocial evaluation to guide their understanding of hardships that families are facing. But that they're ill equipped to discuss new social risks that may have emerged post transplant. And so they rely heavily on our transplant. Social workers to help identify new social risks that may arise in the post transplant period. But when we talk with social workers, we found that social workers feel overburdened by both the number of referrals they get and the quality of referrals that they get suggesting that there's really a gap in the delivery. And so, um as we thought about this health advocate model, what families and and transplant team members have told us is they need help, communicating with schools, provide support, counseling, resources for, for parents and caregivers who are experiencing a lot of stress, help families manage their clinical appointments and then help families get connected to uh community based resources. And so we've been uh um carrying out a pilot program that's really geared as a feasibility and acceptability program. It's a 90 day intervention and we're collecting a lot of quantitative and qualitative data to understand how we can um strengthen this program. So I'll give you just a, a brief case study of the kind of work that our health advocate has been doing. So, we had a four year old female who was transplanted at six months of age and on our social determines of health screener, the family uh uh said that they had financial strain. They had fear of eviction, food insecurity, transportation challenges and utility channel challenges. They had a lot of hardship they were experiencing. The mom doesn't have a job uh because she's been caring for her daughter and um the family lost their cow fresh because the mom got COVID and did not renew. Uh They also had bedbugs, the landlord treated the bedbugs but had the family sign an agreement to cover the cost of the extermination. The family is Spanish speaking and uh didn't really understand what they were signing uh when they agreed to cover the cost of extermination. So the first thing our health advocate did was help the family complete their c fresh application so that they could start to get their food, um stamp benefits. Uh And then the health advocate got a copy of the contract, the landlord had them sign and found a free legal aid set up and attended the 1.5 hour call with the family to really help the family understand their options. The mom, the health advocate helped mom form out a resume and the mom was able to secure a job. And when we spoke with the mother, she told us, you know, we met a social worker at the hospital and we stayed connected with her. But the bond was not as strong as with you folks. And sometimes due to situations you feel depressed, but now you have someone who can help you. Sometimes that person cannot help you with everything but still and so with that, I thank you uh for your time and I these are all uh our collaborators. Um Thank you to the, the funders who have funded this work and I I welcome your questions and uh my email is there on the screen as well. If, if anyone has questions after this talk. Thank you so much for that excellent talk, Doctor Wadhwani. Um Such a great overview of the structure around liver transplantation and the impact um of disparities involved in the process. We do have a few questions in the chat. Um Do you mind going back to your um initial slide so that people who have not scanned the QR code can do so. Hm Let me see. Right. It's going in here. Throw away. Ok. Can you see it or did I? Mm No, we can't see your screen anywhere. Yeah. Um OK, let me see if I can. How's that? Perfect. Thank you. Um OK, so our first question for you in the Q and A um is does immunization schedule need to be adjusted for Children and teens undergoing transplant and aftercare? Um Great question. Um The short answer is is yes. So we don't, we don't currently give live vaccines post transplant. So we will try to do an accelerated vaccine schedule particularly for babies um with in partnership with infectious disease to give live vaccines. You know, before a year, if, if someone's approaching transplant, there's newer literature suggesting that post transplant, live vaccines are safe. Um Our group is is evaluating that literature now and and coming to consensus on whether we're gonna offer live vaccines in the post transplant period. But right now, uh we don't offer live vaccines, post transplant. Interesting. Thank you. Um Another question. Um Does a living donor get free health care related to donating a liver? Um Great question. The the living donors transplant procedure and post trans uh and post donation care is all covered by the recipients insurance. Um I don't know the specifics but I do think that that coverage ends at like three years post transplant. Don't quote me on that exact number but there is a um a time period when the insurance starts stops covering uh the the donors, any complications that arise from the donation. And so I think, you know, one of the things to remember is is that in contrast to kidney donation, which is a pretty straightforward surgery, uh liver donation is, is a major operation that the donor recovers in the IC U. Uh And, and they're at risk for biliary complications. Um You know, past that, that time period. Uh And so what we call non directed or anonymous uh living donation is not as common as for kidney donation though, you know, we are getting better at getting more non directed liver donors. Um A and so that, that's something we've been trying to, to grow at our center as well as other centers have been trying to grow that. Um But it is a, it's a, it's an amazing big sacrifice for donors. Thank you. Um A few questions um regarding the transplantation process itself. Um First question in pediatrics, we see frequent Tylenol overdoses. Does si or intentional overdose count against likelihood of receiving a transplant? Uh No, not in pediatrics. We will um we will transplant for intentional Tylenol overdose. Ok. Um And then in the posttransplant period as a PC P. Um What symptoms should we be looking out for? Um status post liver transplant? What should we be worried about? Great question. Um You know, I think routine health care maintenance is a, is a really um important role that we, we look to our uh general pediatrician colleagues to help with. And I think um any sort of uh if there's concerns for poor adherence, we'd want to know about it. If there's, you know, just close, I think the most important thing is really close communication with, with um the transplant team having a, a really good relationship. There is really important. I know that our, I can speak for our team. We're very motivated to work with PC PS. Um So any sort of questions related to health, we'd be happy to help uh troubleshoot. Um But if, if patients aren't getting their labs on time, that would be something we could use, help with. Um helping monitor the graft. But a lot of the, the complications we see post transplant, uh unless there's sort of biliary complications, they don't really have a lot of symptoms associated with them like rejection, for example, um until it's progressed, you know, pretty far along. Thats tricky. Um OK. Moving through, um the next question is, what are your recommendations for different Ssris and treating youth who have had liver transplantations? Um There should not be any uh restrictions in using Sssris post transplant. I mean, if, if the, the liver is functioning well, we really don't have any restrictions on medications. We try to limit the only medication bucket that we try to limit is, is actually nephrotoxic medications because tacrolimus, as I mentioned earlier, over time can cause chronic kidney disease. And so we limit NSAID use, um, pretty strictly. Um, but, but other medication buckets, we don't really limit because they have a fully functioning liver. And if they need CS Ris for their mental health, we, we find that to be important. Ok. And then I think the last question in the chat is, um, how do you fund health advocates long term, given the um limited support, long term for these interventions that you had mentioned. Yeah, great question. Uh You know, I think the first thing we need to do is demonstrate that it's um effective in improving transplant outcomes. And then, you know, I think subsequent studies will have to focus on cost effectiveness. And you know, if it's cost effective, who is it, who is it saving money? Um Are we saving the health system money by, you know, preventing admissions for rejection when and clogging up the inpatient system when, when more high uh revenue generating procedures could be, could be put in place instead? Um So could we serve more patients by preventing complications from transplant? Um or is it saving health insurers money? Um You know, where, where I think after we de demonstrate health benefit, we then need to figure out how to who, who are we saving money and then, and then go to them and, and try to get this pushed through. But there are I think the California Medicaid is increasingly looking to fund uh programs that address social risk factors. Um And so, so potentially working with state state Medicaid to fund this is one strategy, but I don't think we're there yet, but it's a great question and one that we get asked often. Um OK. And then another question popped up. Um So back to the basics sometimes on C MP screens done as part of general health screening. Um The LFTs might be slightly off. How off should LFTs be if the child is over well, well appearing. Um And do we need to repeat um the C MP or um consider other testing at that time? Um And I assume this is for a child after liver transplant. It's I think this is where, you know, talking with the transplant team is really important because it's so dynamic and so individualized based on a child's complication history. Um We're looking at just at so many variables. Have they had a, a recent, um have they had a recent viral infection that can, that can increase their A ST and a LT slightly? And are we OK to watch, you know, for a few weeks, do we feel confident that the, that the child is getting their medications on time? You know, what's our, so there's just a lot of variables and I think talking with the transplant team is the most important thing. Oh, not in a child after transplant healthy kid. Um I think it just really depends on what the risk factors are. I mean, I think is that if you see a hepatitis or, or elevated A ST and a LT checking an inr to reassure yourself that the child is not in liver failure, um is is always a reasonable thing to do. Obviously, we're seeing a huge obesity i epidemic and um and also increase incidence of Mazal in pediatrics. So that's another bucket we frequently seeing elevated liver enzymes. But I think some of this is sort of hard to answer um without more context of the specific child, but you can always call us um if you have questions. OK. And then I think last question before wrapping up. Um Have you tried referring medical Children for enhanced care management and new benefit post transplant? Is there any training for ECM workers that might help them do a better job for these Children? Um I have not. Um and um it looks like Noemi said that she has sent a child there, but I I have not sent the child to enhanced care management. And I don't know if Lisa Gallagher, a nurse practitioner who follows all of these Children post transplant has I will certainly check with her um and see if there's anything we can do to partner with them. Ok, I think that's all the questions. Thank you so much, Doctor Wadhwani for the great um talk. Thank you. So much for having me. Created by
