Ila Chakravarthy was six months old but weighed just ten pounds. Then, in October 2008, she began vomiting up big clots of blood, and the condition of her failing liver grew worse. The time had come, her doctors said. Though her size and fragile health would make surgery perilous, Ila urgently needed a liver transplant.
Ila and her worried parents were referred to Lucile Packard Children's Hospital at Stanford, home of the busiest pediatric liver transplant team in the nation. The hospital's team performed more liver transplants in 2008 – the most recent reporting period – than any other U.S. children's hospital, according to the United Network for Organ Sharing. They also did the largest number of surgeries in infants like Ila, who were younger than one year when they received a transplant. The team's success rate, measured by patient and graft survival, suggested that if anyone could save Ila, it was this team.
"We're known for taking care of very small children, transplanting much sicker patients, and treating more kids with cancer than any other institution in the country," said surgeon Carlos Esquivel, MD, PhD, chief of the division of transplantation.
Caring for the 45 children (including 18 infants) who got new livers at Packard last year required not just Esquivel's surgical acumen, but the expertise of dozens of medical professionals: hepatologists, nephrologists, gastroenterologists, anesthesiologists, physician assistants, social workers and nurses. The team prepares patients for surgery and provides years of crucial follow-up care. Their "bench-to-bedside" research gives patients innovative treatment options, such as kid-friendly immunosuppressive drugs, multi-organ transplants and a special clinic that helps teens take responsibility for their own care.
"When you’re doing a lot of transplants, especially difficult ones, you can get really successful at it and learn how to use your resources very effectively," said pediatric hepatologist William Berquist, MD. For patients who are transplanted as babies and followed at Packard through years of childhood and adolescence, he said, "we become like parents."
The Road to Transplant
Ila's liver began failing because of a congenital defect called biliary atresia – she lacked the tube connecting her liver and small intestine. Doctors told her parents, Maya Nanjundaswamy and Srinivas Chakravarthy, that Packard Children's had the expertise to perform a difficult transplant in a small infant like their daughter.
"We'll often take patients turned down by other centers," said Debra Strichartz, RN, the program's nurse manager.
The tiniest and sickest children, like Ila, need extra care at all stages of the transplant process. To make sure a child can handle surgery, the team's medical subspecialists concentrate on preparatory measures such as preventing infection, treating bleeding and maximizing nutrition. In the operating room, babies require extra surgical skill: the hepatic artery in an infant may be only one to two millimeters in diameter, for example.
Surgery and beyond
On Dec. 11, 2008, Ila finally received her lifesaving transplant. "What stays with me the most," Srinivas said, "is that after surgery, Dr. Esquivel told us, 'This was arguably the worst-looking liver I have seen in a kid that age in a long time.'"
"Soon after surgery, we see a transformation," Berquist said. Patients thrive and grow, making up for the slowed growth they experienced during liver failure. In "before" and "after" photos, Ila goes rapidly from scrawny and fragile to plump and grinning. "We had one Ila before transplant, and another after," Maya said. "Her disposition changed drastically – she's so much happier," added Srinivas.