By Thomas Crocker
Thursday, August 18, 2022
Nurses play an indispensable part in helping the Upstate Transplant Program at Upstate University Hospital burnish its reputation as one of the leading kidney and pancreas transplant providers in New York state.
One of the first programs of its kind in the Northeast, and the only approved pediatric transplant program in Central New York, the Upstate Transplant Program has a long history of providing adult and pediatric kidney transplants. In 2016, it broadened its scope to include adult pancreas transplants, making it the second-largest pancreas transplant program in the state.
Upstate Transplant surgeons and nephrologists have, combined, more than 150 years of transplant experience, with more than 1,000 deceased donor kidney transplants and more than 400 living donor kidney transplants. The program’s location in the geographic center of New York state makes it a convenient choice not only for patients across the state but also for those in neighboring states.
Shorter-than-average wait times and excellent outcomes are hallmarks of the Upstate Transplant Program. For example, from Jan. 1, 2016, to June 30, 2021, 37.5% of the program’s adult kidney transplant patients received a transplant within two years of listing compared with a national average of 25.7%, according to the Scientific Registry of Transplant Recipients (SRTR). The program’s transplant success rates equal, and in many cases surpass, national averages, according to the SRTR and United Network for Organ Sharing.
“Transplant is perhaps the most highly specialized field in medicine,” says Reza Saidi, MD, FACS, FICS, Chief of Transplantation at Upstate University Hospital and Associate Professor of Surgery at Upstate Medical University. “Patients require extensive evaluation and workup not just from a medical standpoint, but also from psychosocial, dietary, financial and postoperative standpoints. This is why we have a large, multidisciplinary transplant team of more than 40 clinicians and other professionals. Nursing is an integral component.”
Dedicated to helping determine patients’ candidacy and to educating and shepherding them through a years-long continuum of care, the 14-person nursing team — half of whom are master’s-prepared — includes seven RN transplant coordinators. Three of the transplant coordinators are certified by the American Board for Transplant Certification; the remaining four are currently pursuing certification in clinical transplant coordination. These transplant coordinators serve as patient advocates, navigators, liaisons and educators along every step of the transplant process.
“Nurses are at the center of everything,” says Janine Morris, EdD, MPH, RN, Administrator at the Upstate Transplant Program. “They establish contact with patients following referral, and explain and help patients navigate the process for getting waitlisted. If difficulties arise, nurses help patients obtain what they need to continue moving toward waitlisting. Our nurses have a deep knowledge of the multidisciplinary team, and they know when another member of the team, such as a social worker or pharmacist, is best positioned to help with a specific issue.”
“Our program gives a chance to patients who might otherwise be rejected as transplant candidates by other programs. Our physicians are extremely skilled at finding the right organ for the right recipient, even in complex cases. As a result, we waitlist and transplant sicker patients than do other programs, and we’re able to offer specialized forms of care.”
— Janine Morris, EdD, MPH, RN, Administrator of the Upstate Transplant Program
From Referral to Listing
From the moment patients enter the Upstate Transplant Program’s care, a pre-transplant nurse coordinator starts building a relationship with them.
“The best word to describe the transplant coordinator’s role is ‘advocate,’” says Galina Rivera, BSN, RN, CCTC, Transplant Coordinator at the Upstate Transplant Program. “We advocate for patients in all phases of the transplant process. We get to know patients deeply and comprehensively, whereas other members of the multidisciplinary team may only see patients through the lens of their area of expertise.”
For prospective organ recipients, the transplant process begins following referral from a specialist in the community or dialysis center. Patients attend a two-hour virtual education session with the pre-transplant coordinator, a nephrologist and other members of the multidisciplinary team.
“Once patients complete their pre-evaluation education session, they make an in-person visit to our clinic for a medical intake appointment that includes meeting with the pre-transplant coordinator and other members of the team,” Rivera says. “We discuss all aspects of the requirements to be listed for transplant. Afterward, the pre-transplant coordinator helps facilitate any testing that patients need, such as cardiac testing, imaging or a colonoscopy. If necessary, we work with patients to improve compliance if they have a history of noncompliance with dialysis. Our goal is to help patients get to the point where they’ve done everything they need for the selection committee to consider them for listing for a new organ.”
The pre-transplant coordinators present patients during the selection committee’s weekly meetings, when the multidisciplinary team gathers to discuss candidates for transplant. They summarize each patient’s history and evaluation process for the committee.
“Once listing takes place, we maintain an active wait list of patients, which currently features more than 300 people on the adult kidney transplant list alone,” Rivera says. “We maintain up-to-date information for each patient and help ensure that they continue to undergo any necessary routine testing. Our objective is to make sure every patient on the list is always ready to receive a transplant if an organ becomes available.”
After receiving a transplant, patients transition into the care of a post-transplant coordinator.
“Before patients are discharged from the hospital, we educate them on how to document their temperature, blood pressure and heart rate; how to recognize signs and symptoms of infection; and what rejection means,” says Lavell Jones, MSN, RN, CCTC, Living Donor Coordinator at the Upstate Transplant Program. “This helps them stay on the right track to have a successful transplant.”
The post-transplant coordinator also ensures patients leave the hospital with the medications they need to maintain the donated organ and prevent rejection. A patient meets with the post-transplant coordinator and a physician in the clinic on a regular basis, as often as twice a week at first. The post-transplant coordinator monitors the patient’s lab results, discusses the results with the physician, and relays changes in therapy — such as adjustments to immunosuppressant dosage — to the patient. Moving forward, the post-transplant coordinator serves as the patient’s point of contact for questions about symptoms, medications and lab results.
“Initially, patients follow up with the transplant surgeon, and then later, long-term follow-up takes place with the transplant nephrologist,” Rivera says. “Consequently, the transplant coordinators work closely with the physicians in our program. Once patients are stable, few medication changes are necessary. If a referring nephrologist is interested in assuming that aspect of long-term care for the patient, our team works with the nephrologist to facilitate the transition of care back to the community nephrologist.”
Living Donor Care Coordination
The Upstate Transplant Program’s volumes are increasing, and that’s especially true of living donor transplants. In 2021, the program’s organ transplants increased by 50%, and living donor transplants rose by 78%. Living donors work with a living donor coordinator as they move through the donation process.
While Jones assists with care coordination for organ recipients, she specializes in living donor coordination, caring for the donor from referral to donation.
“When a referral arrives, I screen the donor for factors that might rule out donation, review their cases with another provider on the team to determine whether we can move forward, and then coordinate lab testing, collection of a 24-hour urine test and evaluation,” Jones says. “After evaluation, the selection committee determines whether to clear the candidate as medically and psychologically appropriate to be a donor. Once the donors receives clearance, we schedule them for surgery based on their availability.”
The living donor coordinator follows up with the donor on the first postoperative day and stays in touch through discharge and recovery at home.
“We place follow-up phone calls to check on living donors and encourage them to reach out to us anytime,” Jones says. “We follow up seven to 10 days after donation and again at six months, one year and two years after surgery.”
For Jones, the most challenging aspect of her role as a living donor coordinator is informing patients that a medical condition or another factor will preclude them from donating a kidney to a loved one.
“When people aren’t a candidate to be a living donor, I encourage them to maintain their health to avoid becoming someone in need of a transplant,” Jones says. “I educate them about maintaining a healthy lifestyle, and I encourage them to be a donor champion for their loved one to see if someone else can step forward and donate an organ.”
The need for organ transplants continues to grow. In 2021, new Upstate Transplant Program waitlistings increased by 54%, the number of transplants increased by 50%, and the number of living-donor kidney transplants increased by 78%. The program is well-positioned to meet this expanding need. Advances in care — including robotic surgery for kidney recipients (see “A New Era for Transplant Surgery in Central New York”) and evolutions in treatment that allow for the use of organs from hepatitis B- and C-positive donors — allow the program to offer transplants to more patients.
“We recently added an outreach coordinator to our staff, which further connects us to our community partners and brings our assistance closer to them,” Morris says. “As a result, we hope to be able to waitlist even more patients in our area and beyond. In addition, we are part of the National Kidney Registry, which helps us assist transplant candidates in finding better living-donated kidney matches. We have the expertise to pick the right organ for each patient and transplant it well.”
As the Upstate Transplant Program grows, its nurses are poised to play a central role.
“Referring nephrologists and other providers can count on us as a strong nursing team with many years of experience,” Jones says. “We’re a caring group of nurses who will give our all to help every patient succeed in our program.”
A New Era for Transplant Surgery in Central New York
Minimally invasive techniques have significantly altered the surgical landscape for organ donors and recipients alike.
“There have been many advances in surgical techniques,” says Reza Saidi, MD, FACS, FICS, Chief of Transplantation at Upstate University Hospital and Associate Professor of Surgery at Upstate Medical University. “We see many patients with complex anatomy because of previous disease or previous transplantation, and we have an experienced surgical team equipped to handle these cases. In the past, people who wanted to donate a kidney had to undergo an open procedure. With the advent of minimally invasive techniques and robotics, we can do this operation in a less invasive manner, with patients enjoying rapid recoveries.”
Surgeons with the Upstate Transplant Program have performed robotic donor nephrectomies for about five years. Currently, these procedures require only a one-night hospital stay, and patients can return to their normal activities in two weeks, according to Dr. Saidi.
The use of robotics to perform transplant surgeries has trailed its application to donor nephrectomies due, in part, to the greater complexity of the former. Soon, however, prospective kidney recipients in Central New York and neighboring states will have access to robotic surgery. Later this year, the Upstate Transplant Program will begin performing robotic transplant surgery using the da Vinci Xi surgical system.
Robotic transplant surgery improves surgeons’ ability to connect blood vessels. It also reduces complications. Crucially, robotics improve safety for patients with a high BMI.
“The main advantage of robotics is for patients who are obese,” Dr. Saidi says. “For these patients, open transplants are more difficult, and sometimes, they’re associated with morbidity. Using the robot, we can operate on these patients in a much safer manner and improve access to transplantation for this population. Any transplant patient can be a candidate for robotic surgery, but patients who are obese are especially good candidates because open procedures are so challenging for them.”
With demand for organ transplants high, Dr. Saidi views the addition of robotic kidney transplant surgery as another way Upstate can expand patients’ access to transplantation.
“I’d like referring physicians to know that if they have a challenging patient who’s waited many years for a transplant, they should consider offering their patient the opportunity to come to our program,” Dr. Saidi says. “We can significantly improve the patient’s access to transplantation.”
For more information, visit upstate.edu/transplant.