Having an inspiration like Caydence, a double-lung transplant miracle, has changed Kelsea Zukauckas’s life.
Would you ever think as a pharmacy resident that you would have the opportunity to be involved in the care of a patient who received a second chance at life through a triple-organ transplant? I am guessing you answered no.
I would have answered this question similarly, but then I discovered the endless possibilities in solid-organ transplant (SOT) pharmacy. I had the chance to assist in the care of a patient undergoing the first-ever triple-organ transplant consisting of a heart, liver, and kidney in the state of Utah. Never in a million years could I have imagined this—just saying it out loud is mind-boggling!
How did I get so lucky?
I love to be challenged and strive to be challenged daily as a pharmacist. For these reasons, I knew I wanted to pursue residency and specialize in infectious diseases or SOT. When searching for residencies, I looked for programs with opportunities to have rotations in these two fields.
Ultimately, I decided to pursue a career in SOT because of a little girl named Caydence, whose life I was fortunate enough to be a part of when she was a recipient of a bilateral lung transplant. I got to see how the transplant pharmacist made an impact in her daily life, and this made me eager to pursue the field.
I enjoy the continuity-of-care piece in SOT because you really get to know your patients when caring for them in both the inpatient and outpatient setting. I also love the complexities in SOT pharmacy. As a pharmacist, you must optimize your pharmacokinetic and pharmacodynamic knowledge in many scenarios to ensure patients have the best possible outcomes, since primary literature is scarce.
Multiple surgeries in a limited time frame
Triple-organ transplants are extremely rare because of the likelihood of complications with the organ allocation process, surgical complexity, and organ cold ischemic time. To date, approximately 26 total triple-organ transplants have been completed worldwide.
The first heart, liver, and kidney transplant was conducted in 1989 at the University of Pittsburgh, according to Ebong and colleagues in the September 2019 issue of the Journal of Heart and Lung Transplantation. The majority of triple-organ transplants in the United States—six total—have been completed at the University of Chicago Medical Center.
Triple-organ transplants are considered on an individual-candidate case-by-case basis. To ensure the most successful outcome, all organs should come from the same donor. This adds complexity because the heart, liver, and kidney must all be viable; thus, the patient may spend prolonged time on the deceased organ donor transplant list. In addition, a triple-organ transplant requires multiple surgeries within a limited time frame to implant the organs. These surgeries may lead to complications, such as infection and bleeding.
Cold ischemic time—defined as the time in which perfusion to the organ from the donor is stopped to the time in which the organ is reperfused in the recipient—also factors into the surgical time. The ideal cold ischemic time for a heart is less than 6 hours; for a liver, less than 10 hours; and for a kidney, less than 24 hours.
Typically, the heart is transplanted first, followed by the liver, then the kidney. Surgeons dictate incisional closure and specific time to next transplant surgery; they may implant one organ and move directly to the next or give the patient some time to recuperate by closing the incisions and taking the patient to the intensive care unit for close monitoring. Surgeons then bring the patient back to the operating room, permitted the cold ischemic time of the organ allows for breaks between surgeries.
Pharmacist’s role in triple-organ transplant
Pharmacists have an instrumental role on the SOT team. For this triple-organ transplant, the pharmacy team was tasked with creating the patient’s immunosuppressive and infective prophylaxis plan. Our team consulted primary literature to assist with recommendations and communicated with other SOT centers for advice. Immunosuppressive plans included agents for induction and maintenance immunosuppression. Infective prophylaxis plans included agents and duration recommendations for antifungal, Pneumocystis jiroveci pneumonia, and cytomegalovirus prophylaxis.
I was involved with editing this protocol and proposing it to the surgery, cardiology, hepatology, and nephrology teams. Once all teams approved the protocol, I ensured that it was followed. I gave recommendations on immunosuppression daily based on drug levels, and educated the patient about new drug therapies. In my education points, I explained the rationale for each drug, directions and duration of use, and potential adverse effects. I completed multiple educational sessions with the patient to ensure comprehension and answered any questions the patient had about drug therapies.
Interested in SOT?
If you are interested in an SOT residency, I recommend searching for opportunities to shadow an SOT pharmacist and obtaining clinical rotations in SOT. Coming from a small town and pharmacy school, I did not have these options readily available, so I made sure that the residency programs I pursued had the opportunity for exposure to SOT.
Next steps include applying to a PGY2 in SOT or committing early if your current program offers a PGY2 in SOT. I took the route of early commitment for my career and am currently applying for SOT jobs around the country!