April 17, 2020
Mayo Clinic Transplant Center's patient-centric design allows patients and caregivers to stay in one centralized location while providers from a multidisciplinary team come to the center to provide integrative care. Specialties that support the center include endocrinology, cardiology, pulmonology, nephrology, gastroenterology and hepatology, dermatology, psychiatry, pharmacy, social services, diabetes education, and dietetics.
"Our transplant endocrinology team consists of four physicians, three nurse practitioners and one certified diabetes educator," notes Julie L. Probach, APRN, C.N.P., Endocrinology, Diabetes, Metabolism, and Nutrition at Mayo Clinic in Rochester, Minnesota. "Providers rotate through the center and work off a shared calendar, so no patient is managed by one specific provider."
Each of the endocrinologists brings a unique subspecialty expertise to the practice. Providers see recipients of solid organ and bone marrow transplants both pre- and post-transplant; each organ provides unique management challenges from an endocrine perspective.
During the pre-transplant evaluation, patients are assessed for any reversible endocrine issues that may have contributed to organ failure, such as acromegaly or thyrotoxicosis. A full review of existing endocrine disorders is also completed, optimizing care where appropriate to improve surgical outcomes and postoperative recovery.
The pre-transplant visit is also an opportunity to obtain a screening for bone mineral density and optimize calcium and vitamin D supplementation. Many patients require high-dose vitamin D replacement therapy, particularly before liver transplant. Patients with low bone mineral density or a history of fragility fractures may be candidates for initiation of anti-resorptive therapy pre-transplant. Patients in end-stage renal disease are assessed for the need for denosumab therapy. In addition to disease management, the provider will also educate the patient and caregivers on how the endocrine system may be impacted post-transplant.
"Patients with existing diabetes will also see our diabetes educator during their pre-transplant evaluation. We will assess patients' and caregivers' knowledge base regarding diabetes management, while stressing the importance of active caregiver involvement," explains Jeanette F. Lorang, R.N., C.D.E., from Endocrinology, Diabetes, Metabolism, and Nutrition at Mayo Clinic in Rochester, Minnesota. The diabetes educator will then stay in close contact with patients either via portal messaging, phone calls or face-to-face visits to optimize glycemic management through use of diabetes protocols and close collaboration with the provider team.
A team of hospital providers and diabetes educators manages patients during their perioperative transplant course. This team focuses on glycemic control and adjusts the patient's insulin regimen on a daily basis. Team members establish individualized plans for dismissal, order follow-up visits with an outpatient diabetes educator to occur two to three days following dismissal, and place orders for a transplant endocrine provider to see patients two to three weeks following dismissal.
Immediate post-transplant visit
"It is crucial to have close follow-up after dismissal from the hospital" states Pankaj Shah, M.D., Endocrinology, Diabetes, Metabolism, and Nutrition at Mayo Clinic in Rochester, Minnesota. "Patients and caregivers are typically overwhelmed, with difficulty retaining the large amount of information that is shared with them. Patients may be on high doses of anti-rejection therapies, which often contribute to hyperglycemia." The diabetes educator will see the patient within two to three days following dismissal to optimize glucose management and reinforce diabetes education that was given during the hospital stay. Providers then see the patient two to three weeks following dismissal. The main focus of this visit is to reassess treatment regimens, often resuming calcium and vitamin D supplements that have been held during the time of transplant and optimizing glycemic control.
4-month post-transplant visit
The provider team will see patients again at their four-month post-transplant evaluation. Patients are generally stabilized at this point; many have been able to taper down to maintenance doses of glucocorticoids or are even steroid-free at this point. The focus of this visit is to simplify and optimize the diabetes regimen, decreasing disease burden whenever possible.
"We have found use of GLP-1 receptor agonists and SGLT2 inhibitors to be safe in the majority of these patients based on retrospective analysis, with benefit in weight management with a hope of reduction in renal and cardiovascular disease," says Dr. Shah.
Patients typically return annually following transplant. The transplant team pre-schedules necessary consults, bloodwork and standard tests in preparation for this visit. Patients will have the majority of their tests completed the day they arrive, so results are available by the time of their provider appointments. This scheduling allows regional, national and international patients to limit their stay in Rochester to an average of two to three days.
When a transplant endocrinology consult is requested, the provider will again complete a comprehensive endocrine assessment. A bone density assessment is standard at the first annual visit to assess for rapid decline in bone density, which can be observed within the first year following transplant. Scheduled testing for subsequent years is much more individualized. There is also ongoing screening for endocrine disorders in the absence of previously existing endocrine disorders. The provider also works with patients and caregivers to establish expectations for routine care locally; if local care has already been established, our role is often to provide recommendations rather than to prescribe changes in therapy.
For more information
Transplant Center. Mayo Clinic.