Renewed Hope

Issue 28 | November 2017

Baylor Scott & White Health has made great strides to become the leading provider of organ transplant services in Central Texas. The transplant program is now set for even greater achievements with the arrival of new clinical and laboratory leadership. Its new leader is Bruce Kaplan, MD, who comes to the health care system from the Mayo Clinic in Arizona. Dr. Kaplan is an international authority in transplant medicine and has over 300 peer-reviewed publications as well as serving as Deputy Editor for the American Journal of Transplantation, the premier journal in transplant. Before his tenure at Mayo Clinic, he led several prestigious transplant institutes and has received more than $40 million in research funding throughout his distinguished career. Dr. Kaplan joins Baylor Scott & White Health – Central Texas as vice president for transplant services. He arrived in May and has set high goals for the transplant team. “We want to be the most clinically innovative center in Texas and one of the true clinical innovators in the country,” he says. “We also want to be considered the center that treats patients with the greatest compassion and respect.” He has a team in place who share his vision, and is putting together the additional resources to help realize it.

A transplant program is a major undertaking for a health system, and requires a large investment. About 100 people make up the support system or the “infrastructure” as Dr. Kaplan calls it. Beyond the surgeons who perform the transplants, the group includes cardiologists, nephrologists and other physicians, coordinators, specialty trained transplant nurses, lab technicians, nutritionists, social workers, financial assistants, and many others. Dr. Kaplan oversees teams of clinicians who provide kidney, pancreas, and heart transplants to patients with end-stage organ failure. Corneal and blood stem cell transplants are also available.

The organ transplantation program is expected to grow in the future, driven by innovative initiatives and, hopefully, an increase in organ donations. Providing organ transplant services in Temple offers hope to patients with failing organs, says Department of Surgery Chairman Harry Papaconstantinou, MD. “End-stage organ disease—congestive heart failure, kidney failure, and also chronic diabetes with pancreatic failure—can be very debilitating or even fatal for patients,” he says. “Providing an opportunity for transplantation can actually give people a new lease on life, and can give them a much better quality of life.”

Welcoming the new leader

Dr. Kaplan says he accepted the position with Baylor Scott & White Health because it offered him an opportunity for strategic leadership. He also appreciated the system’s commitment to patient care, and was excited to work with hospital leadership and members of the transplant team already in place. “It was the right mix of people and opportunity,” he says.

Dr. Papaconstantinou believes Dr. Kaplan will “lead the group to innovations, to increase options for transplantation, and also to maintain and augment our high-quality outcomes.” Other leaders in the transplant program also praised Dr. Kaplan’s arrival. Chittoor Bhaskar Sai-Sudhakar, MD, division chief of cardiothoracic surgery and surgical director of the heart transplant program at Scott & White Medical Center – Temple, says “He brings a wealth of experience. He is well-known in the field and will bring a different dimension to the transplant program.” Dr. Kaplan will also be actively recruiting additional team members to help cardiology leadership.

“This is a pivotal change for the program,” says Jacqueline Lappin, MD, surgical director of the kidney and pancreas transplant program at Temple. Dr. Lappin, who leads the kidney and pancreas transplant program, says Dr. Kaplan’s vast transplantation knowledge and experience will drive the Temple program to greater heights. “Transplant is not just about doing great operations,” she says. “You also need to have great infrastructure and great teams, and great intellectual guidance in understanding the whole process of transplant, and that’s where Dr. Kaplan comes in. He really is a world-class leader in transplantation.”

A shared goal for growth supported by laboratory efforts

Dr. Papaconstantinou says hospital leadership is committed to expanding transplant services while raising standards of patient care. “We all have a common vision,” he says, “to develop an innovative transplant program that provides the highest quality outcomes and provides services to a diverse and broad population base that extends beyond Central Texas.” Dr. Kaplan says, “Our goal is to get more organs for people who need them and treat them with great human dignity and decency.”

One way to do that is through the continued development of an immunology laboratory, because surgically placing a donor’s organ in a recipient’s body is actually not the most challenging aspect of transplantation, Dr. Kaplan says. “The most difficult part is working out how to overcome the immune system’s desire to rid itself of a foreign protein,” he says. “The single greatest factor in how long someone will live [after transplantation] is how quickly they get a transplant. But, this natural immune system response is one of the things that makes finding a good organ match so difficult, and why some patients have to wait so long for a transplant.”

To help transplant surgeons overcome these barriers is the transplant immunology laboratory, which recently welcomed a new director, Marcelo Pando Rigal, PhD. Like Dr. Kaplan, Dr. Pando arrived in May from the Mayo Clinic in Arizona. “He is one of the best histocompatibility experts in the country. It was quite an achievement for the system to bring someone like that here,” Dr. Kaplan says.

Dr. Lappin looks forward to the advancements Dr. Pando will contribute to the program. “When you see an organ and you see a patient, the question always asked is if it’s safe to transplant this patient with this organ, and Dr. Pando can answer that.” She explains that understanding the compatibility between the organ donor and the recipient is very important for minimizing the chances of organ rejection.

A leading researcher in immunology, Dr. Pando wants to find ways to better predict whether an organ will be a good match for the recipient. “The tools we currently have to assess compatibility work well, but I think they can be better,” he says. Currently, Dr. Pando is able to examine antibodies from the recipient and the antigens from the donor organ to predict whether they will be compatible. This “virtual cross matching” can shave four hours off the crucial time between the offer of a donor organ and the start of surgery.

At Scott & White Medical Center – Temple, Dr. Pando directs a lab with a staff of four, and is excited about the advantages of working with a smaller team. “At other labs, you don’t get time for innovation,” he says. “Here, I think I have that opportunity.” He also sees the chance for growth. “Here we have a big opportunity to build this transplant program and this transplant laboratory,” Dr. Pando says. “We can build the lab at the same pace the program is increasing.”

Kidney transplantation

Wait time for a kidney transplant at Scott & White Medical Center – Temple is down to a year or less. Dr. Kaplan says the average wait time is five years in Austin, four to five years in San Antonio, and three to four years in Dallas. The kidney transplantation program has experienced a big increase in the number of organs transplanted. The program is on pace to transplant 130 kidneys this year, Dr. Kaplan says, a much higher rate than the average of 30 to 40 kidneys per year. He credits that increase to Dr. Lappin taking a more aggressive, pioneering approach that reflects a change in philosophy toward kidney transplantation.

Dr. Lappin explains that many organs from deceased donors have some injury, and may not be “fit” to transplant. But the kidney is a hardy organ, and an imperfect one can recover after a successful transplant, says Dr. Lappin. Transplant surgeons at Temple now take a closer look at donor kidneys that may be imperfect. “Instead of thinking about why you should not use a kidney when you get an organ offer,” she says, “you look at the organ offer and see why you should use it. We ask the question, ‘What potential does this organ have, and who can I get off dialysis with this kidney?’”

Getting patients off dialysis is a priority for the transplant team. “The right thing to do is push the envelope for these patients rather than letting them die slowly on dialysis. And they will,” Dr. Lappin says. She stresses that patients are told the circumstances of the donor kidney and make the decision with their doctors. “There is full partnership with the patient, full disclosure.”

Pancreas transplantation

Dr. Lappin’s team also performs pancreas transplants, a less common procedure. “Pancreas transplant is one of the best kept secrets in the world,” she says. “Pancreas transplant benefits a very small population in a huge way.” The pancreas produces insulin and other enzymes that play a role in breaking down food and regulating the body’s sugar levels, functions that affect diabetes. A kidney failure patient who also has diabetes may be a candidate for a pancreas transplant, which is almost always done in conjunction with a kidney transplant. “It’s very labor-intensive,” Dr. Lappin says. “Everything has to be done just right.” After the transplant, patients will have greater control over their glucose, which will greatly minimize the effects of their diabetes. “When it works, it’s transformative,” she says.

Heart transplantation

Heart transplantation is also growing at Temple, with plans to offer this highly complex and specialized care to patients as far away as 150 miles. However, the transplant team cannot be as aggressive with heart transplantation as with kidneys, because patients are often much sicker than patients on dialysis. “You don’t have the same flexibility with heart transplants as you do with kidneys, because the heart has to work right away,” Dr. Kaplan says.

Dr. Sai-Sudhakar says surgeons plan to do 15 to 20 heart transplants this fiscal year, compared to other hospital centers that typically do 10 to 12. In the next few years, he anticipates the team will perform 18 to 20 heart transplants a year to meet the needs of an aging population in Central Texas.

The heart transplant program also encompasses implanting mechanical devices to keep the heart pumping. These include LVADs (left ventricular assist devices) and ECMO (extracorporeal membrane oxygenation), which keeps the lungs as well as the heart functioning. These devices are often used as a bridge to transplant, and within the next two years Dr. Sai-Sudhakar plans to add a total artificial heart program as another way to prolong the lives of patients with heart failure.

The future of transplantation in the new Surgical Sciences Building

Soon transplants will be performed in a facility designed around the rapid innovations and changing needs in surgery. The transplant program will begin performing surgeries in the new Surgical Sciences Building scheduled to open in 2018 at Scott & White Medical Center in Temple. Because transplantation involves many variables, such as donor organ availability and matching, scheduling a transplant surgery can be difficult. With new operating suites, readily equipped with the necessary state-of-the-art technology, scheduling will be more flexible and surgeries more efficient.

Additional clinical expertise

One of Dr. Kaplan’s goals is to continue the trend of recruiting “high-quality people from high-quality places.” “We’re recruiting, almost on a weekly basis,” he says. A transplant nephrologist from Johns Hopkins will be joining the team soon, and Dr. Kaplan is looking for someone to help the leaders of the heart transplant program expand their efforts. He stresses the importance of recruiting people who share Baylor Scott & White Health’s commitment to patient care. “In the long run, we want to bring in talented people who also fit into a culture of compassion,” he says.

Patient care remains at the heart of all goals, even as the team strives to make Baylor Scott & White Health a regional transplant center. “Growth is good, but only if you can maintain the highest quality,” Dr. Kaplan says. “We have to make sure that we’re giving the patients the excellent care we’re known for.”

Read more in this issue