Comprehensive Management of Liver Disease at the Montefiore Einstein Center for Transplantation
Friday, September 02, 2011
The Montefiore Einstein Center for Transplantation emphasizes research and provides state-of-the-art preventive, diagnostic and therapeutic services for a wide range of liver disorders.
Photo: Dr. Kinkhabwala, Chief of the Division of Transplantation, and Dr. Wolkoff, Chief of the Division of Gastroenterology and Liver Diseases, discussing a complex liver case. Photo © Don Dempsey, White Light Photography
Since 1974, the Marion Bessin Liver Research Center at Albert Einstein College of Medicine — with support from the National Institute of Diabetes and Digestive and Kidney Diseases — has been a pioneer in advancing liver disease treatment through basic science research. The result of a partnership between Albert Einstein College of Medicine and Montefiore Medical Center, the Montefiore Einstein Center for Transplantation was created to offer a clinical component to the research being conducted, allowing patients access to the latest techniques and technologies.
“The Marion Bessin Liver Research Center is a highly respected and internationally renowned research facility that performs revolutionary work in the fields of liver transplantation and stem cell research,” says Milan Kinkhabwala, M.D., Surgical Director of the Montefiore Einstein Center for Transplantation, Chief of the Division of Transplantation, Montefiore Medical Center, and professor of surgery, Albert Einstein College of Medicine. “The program needed a clinical arm to help advance the treatment of liver disease and provide direct benefits to patients. We brought together a team of highly trained hepatologists, hepatobiliary surgeons and gastroenterologists, and integrated those clinicians with the existing team of research professionals to create a truly interdisciplinary center featuring both clinical and research expertise that is dedicated to providing innovative, novel treatments for liver disease.”
Preventive and Diagnostic Care
The Montefiore Einstein Center for Transplantation offers comprehensive care for liver diseases, such as viral hepatitis, alcohol-related liver disease, drug-induced liver injury, portal hypertension, fatty liver, cirrhosis, sclerosing cholangitis, alpha-1 antitrypsin disease, Wilson’s disease and liver cancer.
Viral hepatitis B and C are two of the most common conditions treated at the Montefiore Einstein Center for Transplantation. If not properly managed, these conditions can lead to liver cancer.
“Viral hepatitis is a silent epidemic,” says Dr. Kinkhabwala. “Until the late 1980s and early 1990s, the blood supply utilized for transfusions wasn’t screened for hepatitis, leaving patients who needed transfusions susceptible to developing the disease. The blood supply is now much safer; however, it takes between 20 and 30 years for patients with hepatitis to experience symptom onset.”
Proper management of hepatitis begins with education and vaccination. The physicians at Montefiore Einstein Center for Transplantation provide education for both patients and referring physicians, covering topics such as screening and diagnostic methods, proper time for referral and advanced treatments available for viral hepatitis.
“We offer community lectures discussing the multiple aspects of liver disease, including screening and diagnosis,” says Paul Gaglio, M.D., Medical Director, Adult Liver Transplantation, Montefiore Medical Center, and professor of clinical medicine, Albert Einstein College of Medicine. “We also conduct seminars outlining referral criteria for providers. Physicians are encouraged to refer any patient experiencing complications of existing disease or who have abnormal results on blood screenings analyzing liver function.”
Once a patient is referred to the Montefiore Einstein Center for Transplantation, he or she undergoes a comprehensive evaluation that includes diagnostic testing performed by a hepatologist. Medical history — including a history of blood transfusions, prior surgeries and a family history of liver disease — will be considered, as well. Patients also often undergo diagnostic imaging, which could include liver ultrasound, liver MRI or CT scans. If suspicious lesions are discovered or liver cancer is suspected, a liver biopsy is performed.
Modalities Available for Liver Disease Management
In cases of liver disease caused by alcohol or drug abuse, counseling and substance abstinence are recommended. Montefiore Einstein Center for Transplantation employs a psychosocial support staff, providing patients the help they need.
For treatment of hepatitis, Montefiore Einstein Center for Transplantation offers the newest medications receiving FDA approval for the treatment of hepatitis C.
”Previous medical therapies used for hepatitis C treatment only had a 15% to 20% cure rate in our patient population. We are hopeful that these new drugs will increase the patient’s response to other available treatments, such as interferon,” says Dr. Kinkhabwala.
For management of fatty liver disease, patients see a variety of specialists from multiple disciplines, including nutritionists, physical therapists, bariatric surgeons, hepatologists and endocrinologists.
Treating Liver Cancer
In recent years, physicians have seen an increase in the number of patients with liver cancer, and these numbers are expected to rise due to the increase in patients with hepatitis. At Montefiore Einstein Center for Transplantation, patients have access to a dedicated hepatobiliary (liver) cancer team of surgical and medical oncologists, hepatologists, interventional oncologists and radiation oncology specialists with expertise in the management of liver malignancies. In collaboration with the Montefiore Einstein Center for Cancer Care, a variety of surgical and nonsurgical alternatives are considered for each patient.
“To develop an appropriate treatment plan for patients with liver cancer, we use a multimodal approach that is individualized based on each patient’s characteristics,” says Dr. Gaglio. “Modalities available for liver cancer treatment include surgical resection, transarterial embolization, ablation and radiation therapy. In many cases, these therapies are utilized as a bridge to liver transplantation.”
Physicians and surgeons at Montefiore Einstein Center for Transplantation are experienced in minimally invasive approaches to liver tumors, including interventional image-guided approaches and laparoscopic liver surgery. For example, ablation of liver tumors is often utilized as an alternative to conventional surgical resection and can be performed using laparoscopic surgical techniques or by interventional oncologists in an outpatient setting. Ablation involves placing a probe into the liver tumor and destroying it using microwave or radiofrequency energy. In addition to ablation and resection (surgical removal of a tumor), patients also have access to stereotactic body radiation therapy (SBRT). Using advanced SBRT techniques, physicians are able to precisely target and destroy liver tumors noninvasively. Patients are treated at Montefiore’s Moses Division and at the new Montefiore Einstein Center for Cancer Care outpatient facility at Jarrett Place, located adjacent to the Weiler Division.
Services in Place for End-Stage Liver Disease
The Montefiore Einstein Center for Transplantation team specializes in the management of complications arising from portal hypertension, including ascites, encephalopathy, spontaneous bacterial peritonitis and variceal bleeding. In cases of portal hypertension resulting in refractory ascites or variceal bleeding, transjugular intrahepatic portosystemic shunting (TIPS) may be indicated. TIPS is used to allow blood flow to bypass the liver by using a stent to connect the portal vein directly to one of three hepatic veins, which relieves the increased pressure in the portal vein. In some cases, TIPS may also be used as a bridge-to-transplant therapy, although it is not required in all liver transplant patients.
Identifying Appropriate Patients for Liver Transplantation
When a patient’s disease has failed to respond to conventional treatments or when patients are not eligible to receive conventional treatments, liver transplantation may be necessary.
“Certain patients with early-stage liver cancer may be put on a waiting list for transplantation, which would ideally allow them to receive their transplant before the cancer metastasizes,” says Allan W. Wolkoff, M.D., Chief of the Division of Gastroenterology and Liver Diseases, Montefiore Medical Center, and professor of medicine, Albert Einstein College of Medicine. “Patients with cirrhosis are also indicated to receive a liver transplant, as well as patients who have acute viral hepatitis and drug toxicity.”
MD News August 2011, Long Island