A patient with a new kidney had been doing well until several months post-transplant when they developed a fever. All of the tests came back negative and the care team was at a loss as to what could be causing the fever. Montefiore Einstein’s eight infectious disease doctors who specialize in the care of immunocompromised transplant patients are a vital resource in cases like this.

“We deal a lot with opportunistic infections, which are a category of infections that occur in people whose immune systems are not fully functional,” says Margaret McCort, MD, assistant professor, division of infectious diseases. “We might call them the zebras of medicine. They can be hard to find. They can be hard to think of. So we have to keep an open mind.”

In this case, the immunocompromised transplant (ICT) team, part of the division of infectious diseases in the department of medicine, put in calls to a hospital where the organ donor had been treated and pored over the medical records, looking for a needle in a haystack. They discovered the donor had at one point contracted a rare tropical disease. Once they were in possession of this crucial piece of the puzzle, they were able to treat the infection successfully. The transplant patient made a fully recovery.

“Our challenge is not only finding out the cause of infection, but also how to manage it in someone who has a lot of different medications that could interact, as well as these very precious transplants,” says Rachel Bartash, MD, associate professor, division of infectious diseases. “Whether it's a stem cell transplant or a solid organ transplant, we have to make sure the medicines we choose won’t negatively affect the graft.”

A delicate balance

Transplant patients by nature reside in a precarious place. The same medications that prevent their immune systems from attacking the transplant that has saved their life, make them vulnerable to infectious pathogens, be it a gastrointestinal bug from a food cart, a common respiratory virus from a stranger on an airplane, or a mold they might encounter spending time outdoors.

“I meet with patients before transplant to explain the risks of infections and what patients can do to prevent them,” says Dr. McCort. “That might include lifestyle changes like eating safely, vaccines for them and their family members, taking certain precautions when traveling, spending time with pets, or engaging in outdoor activities, or avoiding those things altogether leading up to a transplant.”

The ICT team also takes the lead in developing protocols for the antimicrobial medications patients receive following their transplant. They help evaluate donor organs with documented or suspected infections. Following transplant, they help treat infectious complications that may arise.

“With a patient who hasn’t undergone a transplant, you see them with pneumonia, explain how to take the antibiotics, and then often you won’t see them again,” explains Dr. McCort. “But for these immunocompromised transplant patients, we follow them for the rest of their lives. So it's a nice job. We really get to know them.”

Team players

When Dr. Bartash started at Montefiore Einstein as a fellow in 2015, there were three ICT physicians—Yoram Puius, MD, PhD, Grace Minamoto, MD, and Victoria Muggia, MD, all of whom founded the service. In addition to their mentorship, she chose this as her area of focus because she was inspired by the great outcomes the team helped bring about in transplant patients. She also loved the intensely collaborative, multidisciplinary nature of their work.

“We're in constant contact with our transplant providers, surgeons and primary care teams to discuss and figure out how we can best help our patients, especially those with very complex needs,” says Dr. Bartash.

The ICT service has now grown to include eight physicians, all of whom see inpatients at Moses Hospital, as well as in the outpatient setting. A number of ICT team members are also embedded at care locations for specific types of transplant patients, like Dr. Bartash, who sees patients at the abdominal transplant center, and Dr. McCort, who spends time at the Comprehensive Cancer Center, where she sees bone marrow and stem cell transplant patients.

“These groups all have weekly meetings to discuss current patients as well as patients who are candidates for transplant,” says Dr. Bartash. “A member of the ICT team attends every one of those meetings to address questions and discuss challenging cases. It’s important to all be in a room together.”

Maria Ajaimy, MD, associate professor and medical director of kidney transplant in the department of medicine, also talks about the importance of this partnership. “In transplant, we are in a constant balancing act to prevent both organ rejection and infections. The collaborative and comprehensive work between our ICT team and transplant nephrologists is a consummate example for any other service,” she says. “Our heart, lung, liver, and other transplant physicians would say the same. It's really a lifetime commitment between us as physicians in caring for these patients.”

For HIV-positive patients, leading the way to safe organ transplants

In 2013, the HOPE Act was signed into law by then-president Barack Obama, making it possible for people living with HIV to receive lifesaving transplants from HIV-positive donors. While the procedures are still considered experimental and require special approvals from a medical center’s institutional review board, HIV-to-HIV kidney and liver transplants could become standard-of-care by early 2025, says Vagish Hemmige, MD, associate professor, division of infectious diseases.

Dr. Hemmige is one of our ICT physicians who sees patients at the Montefiore Einstein AIDS Center. He is also a key architect of the first-ever HIV-to-HIV heart transplant, performed at Montefiore Einstein in the spring of 2022. Montefiore Einstein has now performed three of these groundbreaking procedures and we remain the only institution in the world to have done so.

There are some unique concerns related to organ transplants in HIV-positive patients. Older antiviral regimens used to treat HIV sometimes have negative interactions with the immunosuppressive medications used to prevent organ rejection. In part for this reason, “the biggest concern is rejection,” says Dr. Hemmige. It is also harder to evaluate donor organs. “Because a lot of this is at the cutting edge and there's no real literature to guide you, people aren't always sure which organs they should accept,” he says. “We have a lot of real time discussions among our team, and then talk with the transplant teams and decide whether or not from an infectious disease perspective, we should move ahead with that offer.”

Post-transplant, HIV-positive patients’ outcomes are comparable to other transplant patients. Not only has the HOPE Act opened the door for HIV-positive patients to receive this lifesaving care, it actually helps all transplant patients, by adding to the pool of available organs. “Everyone moves up on the waiting list,” says Dr. Hemmige.

A growing need 

“The oncology landscape has changed a lot in the past five to 10 years,” says Dr. McCort. “People are living longer, but they are also in some ways sicker.” Thanks to changes in chemotherapy regimens, and the advent of CAR T-cell therapies, which use genetically modified T-cells to treat certain types of blood cancers, patients have highly suppressed immune systems for much longer than ever before. Solid organ transplant patients are also living longer and as they age, their risk of infections can grow. “This is the general trajectory for all of our transplant patients,” says Dr. Bartash. Given this evolution, the greater need for ICT experts, and the growth in Montefiore Einstein’s team, make sense.

For Dr. McCort, nothing matches the experience of witnessing the “before” and “after” of a successful transplant procedure. “When I first meet patients, it tends to be a few weeks before their transplant,” she says. “They've gone through extensive rounds of chemotherapy. They might be very weak, walking with a walker, nauseous all the time.”

In contrast, “Seeing them several months after transplant, when they start to really feel better and are able to go back to work, to take care of themselves, or when I'm able to tell them, your immune system is strong enough now that you can go on a trip—it's amazing to see that change,” she says.