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 Jared R. Pennington, PA-C, MHS
Jared Pennington is the chief physician assistant in the department of transplantation and liver surgery at Geisinger Medical Center, Danville, Pa. He has indicated no relationships to disclose relating to the content of this article.
I began my career as a PA in 2004, and my first job was in emergency medicine. I stayed for about 6 months, until I realized that I wanted to pursue a career in surgery. I’m also a paramedic and I enjoy taking care of the prehospital patient—but I had to move on. My current position in the department of transplantation at Geisinger Medical Center has given me a wonderful opportunity to flourish as a PA working in surgery. I have roles as a clinician, a patient advocate, and a researcher, and the combination is what makes my days ever-changing and always exciting. Transplantation is one of those specialties within medicine and surgery where you can actually turn patients’ lives around. Freeing patients from hemodialysis is one the greatest rewards .
6:00 AM
I start the day by rounding on the inpatients. Today we have five patients on our service, and only one of them is postop from last week. Our inpatient list is usually filled with posttransplant patients with urinary tract infections or dehydration. Posttransplant patients who have even the slightest increase in serum creatinine level without a definite cause are admitted to the hospital under our service. We also admit transplant patients who had kidney, pancreas, liver, or multivisceral transplantations elsewhere. Our postop patient in house today underwent a living-related-donor (LRD) renal transplant 4 days ago and is now ready to go home. We frequently transplant kidneys donated by family, friends, or even acquaintances of the patient. Today’s patient has membranoproliferative glomerulonephritis (MPGN). This form of glomerulonephritis is characterized by thickening and reduplication of the glomerular basement membrane. Type I disease is relatively benign, but type II disease is autoimmune, and affected patients have an IgG autoantibody. Our patient has type II disease. Patients with type II MPGN usually develop end-stage renal disease (ESRD) over 5 to 10 years.
Our renal transplant patients, particularly the LRD transplant recipients, will spend 4 to 5 days postoperatively in the hospital if all goes well. Patients who receive a cadaveric kidney, however, may have delayed graft function for 5 to 7 days and may need extra time in the hospital with close observation.
7:00 AM
Once a week, the transplant and nephrology departments have a meeting to discuss annual evaluations of old patients, evaluations of new patients, new transplants, and patients who were recently admitted to the hospital. Many issues are brought to the table during this hour regarding eligibility for transplantation and donor selection.
8:00 AM
This is when I go to my office and review the morning laboratory results. Most of the time, all the basic labs are back, except for tacrolimus or cyclosporine levels, which usually come in around noon. Tacrolimus is the drug of choice in our program, and it has been shown to be 10 times more potent than cyclosporine. Tacrolimus can cause severe nephrotoxicity with a mild increase in the trough level, however, so monitoring levels is important.
After reviewing the labs, I change IV fluid rates and concentrations, add or discontinue medications, and order laboratory or diagnostic studies for the following day. I also check laboratory data on patients with renal transplants who are scheduled to undergo renal biopsies for that particular day. Most biopsies are done to rule out acute rejection, but some are performed as protocol biopsies throughout the postoperative course, depending on the study projects that we’re working on.
9:00 AM
Rounds begin with the attending surgeon and nephrologist. In transplantation, as in other medical and surgical subspecialties, it is very important to approach the patient as a team. Along with the surgeon and nephrologist, rounds are attended by the transplant nurse, the nephrology pharmacist, the general surgery resident assigned to our service, and me. During rounds, we discuss the patient’s progress through the past 24 hours, current medications, risk of infection, and hydration status. In most transplant programs, an hour or more each day is set aside solely to review medication regimens. Posttransplant patients not only take immunosuppressive medications but also take prophylactic antibiotics to prevent the infections that immunocompromised patients commonly acquire.
10:00 AM
This is the time when we go into the operating room, if we haven’t been there already. One of the surgeons I work with has a great interest in dialysis access surgery, including arteriovenous (AV) fistula placement, AV grafts, and peritoneal dialysis catheter placement. He is the only surgeon in the hospital who performs upper-extremity AV fistulas, so we operate on a fair number of patients with ESRD. We also commonly perform permanent hemodialysis catheter placement and Mediport insertions for other services in the health system. Patients are frequently referred to our department from outside and by internal nephrologists for dialysis access. One benefit to having our center perform access surgery for ESRD is that patients have a chance to meet our team before they are placed on our kidney recipient list when they are in need of a transplant. Most of the time, I first-assist on all cases if I am not taking care of a patient in-house.
We also schedule LRD renal transplant cases throughout the month and typically perform 2 to 4 of these per month. I first-assist on transplant cases, including LRD and cadaveric kidney/pancreas transplants. In addition, we perform surgery for portal hypertension, including peritoneovenous shunts, and perform liver tumor surgery. In March of this year, we began a liver transplant program.
1:00 PM
After surgery, we review all biopsy results with our transplant pathologist and discuss the results. In almost all cases, the patients who underwent biopsy are already being treated if rejection has been found on frozen section or permanent specimen. We bring the biopsy specimens to our renal pathology meeting, which happens once a month, for further review and discussion.
The author and Sayeed Malek, MD, in surgery
2:00 PM
Now the surgeon and I round on our patients for a third time. This is when we adjust tacrolimus or cyclosporine levels based on the results of morning lab tests and check the general progress of the patient. We again assess hydration status and make changes as needed. It is very important to have trough levels of tacrolimus or cyclosporine drawn in the morning because even a small deviation can be detrimental to the patient and/or the grafted organ. We also follow up on any consults that occurred that day.
3:00 PM
I return to my office and review journal articles to present to our transplant journal club. I also double-check diagnostic studies and make note of biopsies, surgeries, and clinic patients scheduled for the next morning.
5:00 PM
I check my e-mail and talk with the transplant coordinators to see if we are accepting any potential donors in our organ procurement organization.
5:30 PM
Hopefully, by this time I am traveling a good hour to get home to see my wife, Nicole, our 8-year-old and 9-month-old daughters, Taylor and Olivia, and our dog, Denny. I wish I could say that I won’t be returning to work until the morning. Often, though, we will be called to harvest an organ within our six-county region sometime during the night. These donated organs may be for one of our own patients or for a patient at another center within our organ procurement organization.
Transplantation is a busy and demanding field. Overall, however, it is extremely rewarding, with an enormous amount of information to be learned and many patients who need to be provided with the best care possible.
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