Clinical Collaboration Leads to Multi-Organ Transplant Success Story

A multidisciplinary approach to a unique transplant case

Four years ago, after being rejected by two transplant programs because he was too high risk, a patient came to Cleveland Clinic for a double-lung transplant. Jason Turowski, MD, Associate Director of the Adult Cystic Fibrosis Program in the Respiratory Institute, worked with the patient from his first visit and knew that based on his underlying pathologies, it would be a complicated road ahead.

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Addressing underlying pathologies

The patient was diagnosed with hereditary idiopathic pulmonary fibrosis, a type of lung disease that results in scarring, or fibrosis, of the lungs for an unknown reason. Over time, the scarring gets worse and it becomes difficult to take a deep breath and the lungs cannot take in enough oxygen. The patient’s mother passed away from the same condition at the age of 55. He also suffers from hereditary hemochromatosis, which causes him to have too much iron in his blood. The excess iron is stored in the body’s tissues and organs, particularly the skin, heart, liver, pancreas and joints.

“The patient received a bilateral lung transplant for his underlying disease, and after years of immunosuppression, including tacrolimus and prophylaxis, he eventually suffered combined liver and renal failure,” explains Dr. Turowski. “We brought him here, identified the multiple issues and realized it was time to move toward transplantation.”

Coordination of care for back-to-back transplants

A few years after his lung transplant, we took on the difficult task of performing back-to-back transplants after a bilateral lung transplant. This would be our first patient to receive a double-organ transplant after a double-lung transplant. To successfully accomplish this, Dr. Turowski worked with David Goldfarb, MD, staff Urologist in the Glickman Urological & Kidney Institute, and Koji Hashimoto, MD, PhD, Director of Living Donor Liver Transplantation, in the Digestive Disease & Surgery Institute, to ensure that the multiple transplants went smoothly.

“We communicated in a variety of ways to prepare the patient for the transplantations,” says Dr. Turowski. “We spoke regularly with the consultative services, the nephrology team, as well as hepatology in order to monitor changes. I also communicated with the patient’s liver coordinator and virtually attended his selection committee meeting when he was brought to liver selection.”

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Dr. Hashimoto performed the liver transplant, and because the patient was receiving a kidney transplant the next day, Dr. Hashimoto and his team had to work closely with anesthesiologists and intensivists to optimize the patient’s condition for the upcoming kidney transplant.

“Our teams communicated closely to establish a daily plan and monitor a postoperative course, including immunosuppression management,” says Dr. Hashimoto. “That was true multidisciplinary patient management.”

Following the liver transplant, he was put on chronic immunosuppressive treatment, which increases the risk of infection, metabolic disorder, blood pressure abnormality and high blood sugar. These chronic medical conditions make patient management difficult, resulting in additional challenges for the planned kidney transplant.

Dr. Goldfarb performed the kidney transplant and was surprised by the patient’s rapid recovery. “He was in remarkably good shape,” says Dr. Goldfarb. “We do liver transplants, followed by kidney transplants quite often and we are well-equipped to ensure the patient is taken care of properly.”

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Due to the anti-rejection medication, it is common for patients to undergo a kidney transplant after another organ transplant, but this case was unique in that he had a liver transplant and kidney transplant after a bilateral lung transplant. “It is the only transplant of this kind that I have done in my 28-year career,” says Dr. Goldfarb.

A good outcome

Following the kidney transplant, the patient’s recovery went smoothly. He reported overall improved energy and functionality. He has become a Cleveland Clinic advocate and has vowed to dedicate his life to organ donation awareness, as well as helping other transplant patients.

“I am always amazed to see how transplant patients recover from organ failure,” says Dr. Hashimoto. “After years of a tough time with illness, they start gaining strength, go back to school or work, enjoy life with family and friends and help others. I am pleased to be a part of the team to help them as a transplant surgeon — their well-being fuels me every day.”