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When Should You Refer for Lung Transplant? · UF Health MedEd Cast

• 0:03
  Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with
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  UF Health Shands Hospital.
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  I'm Melanie Cole.
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  And today, we're highlighting lung transplant
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  indications for the general pulmonologist, knowing when to refer.
• 0:16
  Joining me is Dr.
• 0:17
  Moustafa Younis.
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  He's an Assistant Professor of Medicine in the Division of Pulmonary, Critical
• 0:22
  Care, and Sleep Medicine at the University of Florida College of Medicine.
• 0:26
  Dr.
• 0:27
  Younis, thank you so much for joining us today.
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  Many people think lung transplant is only a kind of an end-of-the-line option.
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  At what point in a patient's disease course—and we'll talk
• 0:37
  about some different diseases here today—should general pulmonologists
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  begin thinking and talking about transplant as a possible future step?
• 0:47
  Dr. Moustafa Younis:
• 0:47
  Thank you for having me, Melanie.
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  So, it's a misconception that lung transplant is only an
• 0:53
  end-of-the-line option, especially when it comes to referral.
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  So, it should not be viewed as a last resort.
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  The goal is to refer patients as early as possible and early enough
• 1:03
  that they still have options, not when they're already in crisis.
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  As a general principle, we begin thinking about lung transplant when a patient's
• 1:11
  lung disease carries an estimated two-year mortality of around 50% or
• 1:16
  more despite optimal medical therapy.
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  So, I want to underline that.
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  So, they have to be on the right medical therapy for their disease.
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  And despite that, they are progressing or there are certain
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  markers within their disease that is associated with worse progression.
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  And therefore, they should be referred at that point.
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  Aside from where they are at this point, you should also look at
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  the trajectory of the disease.
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  And for example, there are certain diseases that referral almost
• 1:44
  immediately after diagnosis, because they can progress very unpredictably.
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  For example, IPF or MDA5-associated ILD, patients with short telomere
• 1:53
  syndrome or PVOD, patients with pulmonary veno-occlusive disease.
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  These are just to mention a few.
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  These have very unpredictable progress, and they could very rapidly deteriorate.
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  And therefore, for some of these diagnoses, as soon as they're diagnosed,
• 2:07
  they should be referred irrespective of how they're doing at that second.
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  But generally, for the general pulmonologist, there's a common theme,
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  irrespective of the diagnosis of when there are certain markers that you should
• 2:18
  consider for referral for lung transplant.
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  One of which is oxygen need.
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  If a patient's on oxygen need as a result of their lung disease,
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  whether at rest or on exertion, irrespective of their disease, they
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  should be referred for transplant.
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  If they have pulmonary hypertension, specifically group 3 pulmonary
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  hypertension as a result of their disease, they should be referred for transplant.
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  If they are hypercapnic outside of their acute exacerbations, and they
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  require non-invasive ventilation.
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  If they're obviously, on mechanical ventilation or ECMO as a result of
• 2:46
  their end-stage lung disease, they have frequent hospitalizations or exacerbations
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  and, most importantly, if they have significant decline in their exercise
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  capacity or their quality of life.
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  Another point I want to highlight here is referral is not the
• 3:00
  same as listing for transplant.
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  The evaluation process may take several days.
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  And usually, what I tell patients is it has three different outcomes.
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  Either the patient is a perfect candidate for transplant if they
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  need it at this point, which is unfortunately rarely the case.
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  Or the second option, which is the complete opposite, they have
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  a significant major barrier that prohibits them from being a candidate.
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  Or third of all, which is the most common option where we land for most patients,
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  is they have certain modifiable barriers that need to be addressed before listing
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  or considering them for transplant.
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  For example, part of our workup for patients at risk of coronary artery
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  disease is they get left heart caths as part of their transplant eval.
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  Some of them truly do have CAD, and they need a stent, for example,
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  and they need to be on DAPT, a dual antiplatelet therapy, for at least three
• 3:47
  months if it was placed selectively.
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  And therefore, even if they need the transplant right now, well, we have
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  to wait for at least three months.
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  Another example, which is also very common, is extremes of BMI.
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  Patients need time to gain or lose weight.
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  It might take months, might take even a year, up to a year
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  to gain or lose that weight.
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  And therefore, these are just a few examples, just to mention a few of
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  certain opportunities that we can take advantage of when these patients
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  are referred very early on rather than in their critical illness.
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  In addition, from a patient's stand, you know, whenever they hear lung
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  transplant, they're shocked, right?
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  And they're very hesitant when it's first mentioned.
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  But after meeting with us, getting to know us, getting to know and more education
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  about the process, it gives them time to understand the process, getting to know
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  us, and they become much more comfortable making an informed decision at that point.
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  So bottom line, timing matters.
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  An early referral preserves options, allows optimization of
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  the patients to have the best possible outcome post-transplant.
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  Melanie Cole, MS: Thank you so much, Dr.
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  Younis.
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  That was a very comprehensive explanation and really understanding that point
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  that earlier is better for referral.
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  Now, when we think of certain conditions, COPD, CF, bronchiectasis,
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  what are the practical clinical and physiologic thresholds that really
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  should prompt a pulmonologist to refer a patient for transplant
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  evaluation as you were just discussing?
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  Dr. Moustafa Younis:
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  I'm glad you grouped all these disease together, because they're under that
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  obstructive lung disease kind of umbrella.
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  And the most important factor for these patients compared to like ILD and other
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  disease that are associated with a very high mortality, these patients, you
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  focus more a bit on the quality of life.
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  It matters the most.
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  Some patients might have severe disease but maintain an acceptable quality of
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  life, while others with slightly better lung function are significantly limited.
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  That's why symptoms and functional status remains an extremely
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  important aspect when we consider these obstructive lung disease.
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  Another important principle is that patients should already be receiving
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  optimal disease-specific therapy.
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  In this day and age, for example, the number of CF transplants has dramatically
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  reduced after the CFTR modulators like Trikafta for CF and so on, have been
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  developed and are more commonly used.
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  So, if a patient qualifies for Trikafta, they should have a
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  trial of Trikafta before even considering them for transplant.
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  And the same applies for COPD, if they're on inhalers, whether they need lung
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  volume reduction, whether endoscopic or bronchoscopic, rehab, oxygen therapy.
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  So, whatever the disease-specific therapy is, they should have received it.
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  Now, more specifically, when looking at COPD, patients should be referred when
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  they have a BODE score greater than 4.
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  So, a BODE score is a score that looks at FEV1, six-minute walk
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  test, a lot of different marks, MRC, dyspnea scale, and BMI.
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  So if they have a score greater than four, or they're progressing by one point over
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  two years, then they should be referred.
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  The FEV1 cutoff when looking at PFTs is less than 25%.
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  Again, quality of life despite maximal medical therapy,
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  as I mentioned previously.
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  And back to that common theme that I mentioned earlier, for all lung
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  disease, if they're having frequent severe exacerbations requiring
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  hospitalization, ICU admission, BiPAP, intubation, irrespective,
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  that's an indication for a referral.
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  If they're on oxygen, either at rest or on exertion, if they're hypercapnic
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  outside of their acute exacerbations, or if they have group 3 pulmonary
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  hypertension, they should be referred for evaluation for transplant.
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  As for CF, the threshold is a bit lower because these are younger patients.
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  Therefore, we want to give them the best chance and catch them early on.
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  So, the FEV1 cutoff for those patients is 30% or lower on its own, or 40%
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  and lower if they have additional high-risk features that's associated
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  with higher risk of mortality.
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  Again, hypoxia, hypercapnia, low six-minute walk test,
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  pulmonary hypertension.
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  If they're losing weight, that's an important point in patients with CF.
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  If they're progressively losing weight, that's an indication that their lung
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  disease is progressing, and that's despite nutritional optimization.
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  Again, exacerbations.
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  An additional two points that are not usually thought about when we think about
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  CF is if they're having massive hemoptysis requiring embolization, then that's an
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  indication for a referral, because you don't know if the next time you're going
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  to be able to control that hemoptysis.
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  And same thing for pneumothorax, secondary pneumothorax in the setting of
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  CF, that's an indication for referral.
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  And lastly, you can lower that threshold even more.
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  An FEV1 of 50 or less, but what you're seeing is they're fine right
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  now, but based on their trajectory, they used to be FEV1 80% a few months
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  ago, and they're rapidly progressing.
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  And you don't have any options for therapy.
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  They do not qualify for CFTR depending on their gene and so on.
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  Therefore, they should be referred too, even though someone might
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  think FEV1 of 50 is a bit too early.
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  And generally, females, patients with a BMI less than 18, they
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  also have concomitant diabetes or multi-drug resistant organisms
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  such as Burkholderia or abscessus.
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  These are also associated with worse survival.
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  And therefore, they should be referred upon diagnosis.
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  As for non-CF bronchiectasis, kind of similar criteria to
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  CF bronchiectasis, but non-CF bronchiectasis again is an umbrella.
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  It's a tree.
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  It has a lot of branches.
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  There's a lot of different causes with variable disease progression.
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  But overall, it tends to be slower and has a lower mortality risk.
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  For non-CF bronchiectasis specifically, there are two additional scores
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  in addition to the lung function similar to CF kind of criteria that
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  we mentioned, is to also consider the FACIT score more than or equal to 5,
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  or the bronchiectasis severity index, which is basically similar to the
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  FACIT score but includes BMI and FEV1.
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  The FACIT score looks at FEV1, age, colonization with pseudomonas, and the
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  radiological extent of the bronchiectasis, and then also the mMRC dyspnea scale.
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  So again, incorporates all these different markers, one of which is quality of
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  life or how symptomatic they are, their lung function, their imaging findings.
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  So, it's really a multidisciplinary kind of assessment of the patient.
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  Melanie Cole, MS: It certainly is.
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  And those are important points and very specific as well.
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  Now, you mentioned briefly interstitial lung disease and particularly
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  idiopathic pulmonary fibrosis.
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  You mentioned that umbrella a little bit.
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  What are some of the key red flag changes in lung function or symptoms
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  that signal it's time to refer, even if the patient, which can sometimes be the
• 10:24
  case, still feels functional day to day?
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  Dr. Moustafa Younis:
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  So specifically for ILD, it is probably the disease where we have
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  the lowest threshold for referral.
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  Some fibrotic lung diseases are very unpredictable, like I mentioned earlier.
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  Some may be completely stable for months, but have something as simple
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  as a viral infection, common cold, a flu, parainfluenza, whatever
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  viral infection, and that tips them over into an acute exacerbation.
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  Acute exacerbation of ILD, specifically IPF, to be more
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  specific, is associated with extreme higher mortality, more than 50%.
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  For that reason, specifically for IPF, they should be referred as
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  soon as the diagnosis is made, even if their lung function is great.
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  We know it tends to be a progressive disease.
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  That might change down the road as we are having new therapies now being released.
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  Now, for example, inhaled TYVASO is now also approved for IPF, and there's
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  nerandomilast in addition to the Esbriet and the Ofev, that we used to have before.
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  So, we're having more and more therapies.
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  But nonetheless, at this point in time, it still tends to be a progressive disease.
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  And all these medication tends to maybe slow the progression of the disease.
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  But overall, they still tend to have a bad outcome overall.
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  That's if they have an IPF diagnosis.
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  Well, what if they have definite or probable UIP on imaging, but they
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  don't really meet full criteria for IPF, or they have UIP because of a
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  different reason, rheumatoid arthritis or whatever other disease process?
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  Either radiologically or histopathological UIP is also an indication for referral.
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  As I mentioned earlier, patients with short telomere syndrome,
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  and one of my colleagues, Dr.
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  Jannsen, did a podcast on that, so you guys can go and watch that.
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  So, patients with short telomere syndrome also tend to have worse disease or
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  patients with familiar pulmonary fibrosis.
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  General theme for patients with ILD, aside from these diagnoses that I mentioned
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  earlier, if their FVC is less than 80% or their DLCO is less than 40% on their
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  PFTs, or you are seeing progression in their FVC by 10% or their DLCO by 15%
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  over two years despite therapy, then these patients should be referred.
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  And again, similar to the prior criteria, that general theme that I mentioned,
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  they're hypoxic, they're hypercapnic, which is not usually common in ILD
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  unless they have some other reason like neuromuscular weakness, for example,
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  or if they're having group 3 pulmonary hypertension, or exacerbations.
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  These are all signs of end-stage lung disease for which they should be referred.
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  Melanie Cole, MS: Dr.
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  Younis, when we think of pulmonary arterial hypertension and chronic
• 12:52
  thromboembolic pulmonary hypertension, and you mentioned these a little
• 12:56
  bit briefly as well, expand for us on the specific hemodynamic or risk
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  stratification markers that really should trigger that early transplant referral.
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  Dr. Moustafa Younis:
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  So, here when we talk about pulmonary hypertension, right?
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  Those are different groups.
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  There's five different groups of pulmonary hypertension.
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  Specifically, when we're looking at pulmonary arterial hypertension,
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  group 1 PH, then there are certain criteria that have been developed by
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  the European Society of Cardiologists and the European Respiratory Society.
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  Together, along with World Symposium on Pulmonary Hypertension, they came up with
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  kind of some scoring system for patients with PAH, and they risk stratified these
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  patients into low, intermediate, or high risk based on certain parameters.
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  These parameters include clinical parameters like their signs, symptoms,
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  syncope, angina, heart failure, and so on.
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  Exercise testing, such as six-minute walk test; biomarkers such as BNP or NT-BNP;
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  imaging criteria based on echo or cardiac MRI, like RV dilation, RV dysfunction,
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  pericardial effusion, and so on; and then right heart cath hemodynamics.
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  So, the goal in patients with PAH is to be able to achieve and
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  maintain a low-risk profile based on these criteria within six months.
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  If despite optimal therapy, which usually starts with dual therapy, despite
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  this therapy and you still have not been able to reach a low-risk profile
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  within six months, you should consider a referral for transplant evaluation.
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  Now, that aside, there's also a REVEAL score.
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  There's a REVEAL score 2.0.
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  So if you look at that, and that REVEAL score is more than or equal to 8, despite,
• 14:41
  again, appropriate PAH therapy, then these patients should be referred for
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  transplant eval if they have progressive RV dysfunction despite therapy.
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  If you're thinking about initiating IV therapy, then refer them for
• 14:53
  transplant evaluation and if they're being hospitalized because of their PAH.
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  Now, when you look at that kind of scoring system, what are kind
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  of features that are associated with kind of higher risk features?
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  So if they're very symptomatic, they're having significant heart failure
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  symptoms, significant anginal symptoms; if their six-minute walk test is very
• 15:10
  low, if the BNP is very elevated or the NT-BNP, and then when you look at the
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  echo, there's significant RV dilation.
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  There's increase of the RV to LV ratio, and you're seeing also RV dysfunction.
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  So if you're seeing a lower TAPSE, whether or an overall decrease in function of the
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  RV based on echo or cardiac MRI, that's usually a sign of a more severe disease.
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  And then, lastly, if you're seeing a pericardial effusion of PAH, that
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  is truly a sign of end-stage PAH.
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  When we're looking at right heart cath hemodynamics, there are certain
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  features associated with worse disease.
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  So if you're seeing a high right atrial pressure with a low cardiac
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  output, irrespective of what their mean PA pressure is, that's usually
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  a sign of pretty severe disease.
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  In addition, aside from these criteria, patients with PVOD or pulmonary
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  capillary hemangiomatosis tends to have very poor response to therapy
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  and tend to progress very quickly.
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  So, you need to refer these patients as soon as you consider
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  or think about a PVOD diagnosis.
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  Also, not as severe, but patients with familial scleroderma or
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  scleroderma-associated PAH tend to have worse disease, and patients
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  with progressive PA aneurysms, or if they're having a life-threatening
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  complication such as hemoptysis, that prompts urgent referral.
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  One thing that I wanted to mention here when it comes to PAH is that kidney and
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  liver dysfunction is often a consequence of severe disease or right heart failure.
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  You have bad heart failure, you have cardiorenal disease, and then also
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  you have congestion in the liver.
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  So, you tend to see some dysfunction in these two organs.
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  And when you look at the relative or increased risk factors when we're thinking
• 16:53
  about transplant in general, generally kidney disease or low GFR or patients
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  with liver disease, these patients that are increased risk and historically
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  used to be a contraindication.
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  Again, I'll talk about contraindications.
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  But here specifically, if you see these features, that's not
• 17:11
  a sign that these patients do not qualify for lung transplant.
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  These tend to improve with lung transplant, the kidney and liver
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  dysfunction, because the problem is truly the PAH and kind of
• 17:21
  poor perfusion as a result.
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  So most importantly, specifically for PAH, they don't have to
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  fail every available therapy.
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  If you start them on therapy and within six months, you can't get them
• 17:31
  to low-risk, go ahead and refer them.
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  Melanie Cole, MS: Dr.
• 17:34
  Younis, you just mentioned that you're going to talk
• 17:36
  about some contraindications.
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  Let's talk about those now.
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  Some of the absolute and relative contraindications to lung transplant.
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  So now, we're past the evaluation stage and we're looking at patient selection.
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  How strict are these in real-world practice?
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  Dr. Moustafa Younis:
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  So, that's changed a lot over the years, and that varies significantly
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  from one transplant center to another.
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  Generally speaking, there are still several absolute contraindications
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  that are fairly consistent across transplant centers.
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  One is as simple as the patient really doesn't want a transplant
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  or can't consent for a transplant.
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  If they have a malignancy that's high risk, stage IV, there's no treatment
• 18:15
  options, cannot get them in remission, they have poor survival as a result
• 18:18
  of their other disease process, not truly their lung disease, then that's
• 18:22
  a contraindication for transplant.
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  Patients with end-stage kidney or other organ disease, unless they are being
• 18:28
  considered for multi-organ transplant.
• 18:31
  Patients that are having an active heart attack, there's no way they're going to
• 18:34
  handle a seven or eight-hour surgery.
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  Their heart just won't tolerate it.
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  If they had a stroke within 30 days, we tend to wait at least 30 days thereafter.
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  And if they're in severe septic shock, severe bad infection, or they have
• 18:48
  some extrapulmonary disseminated infection that cannot be controlled
• 18:51
  or treated, you need to get that controlled before even thinking about it.
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  HIV, that has changed over time, but HIV with detectable viral
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  load and lack of controlled HIV is still a generally absolute
• 19:02
  contraindication across all centers.
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  Someone with, unfortunately, progressive cognitive impairment or severe dementia,
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  there's no way they're going to be able to take 10 to 20 pills daily or twice a
• 19:13
  day and measure labs and come to clinic.
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  And then, patients that have repeated episodes of non-adherence
• 19:20
  despite recurrent counseling.
• 19:22
  With lung transplant, there are certain medication that are like kind of your
• 19:26
  backbone of your immunosuppression.
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  If you miss a few doses, that might increase the risk of
• 19:31
  rejection and losing these lungs.
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  And in the end, we want to honor the patient, so we might be hurting them
• 19:36
  if we transplant non-adhering patients.
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  Again, it has to be a recurrent theme despite counseling.
• 19:43
  And then, if they're actively using, so if there are any substances such as tobacco,
• 19:48
  vaping, marijuana, or IV drugs, that is generally an absolute contraindication,
• 19:54
  which is across more institutions.
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  But the thing is, I think, the most pulmonologists are generally aware of
• 20:01
  what are the absolute contraindications.
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  But I think, what we call these relative contraindications or the relative
• 20:06
  risk factors, and that's where the majority of situations usually fall.
• 20:11
  And that's again, where practice differs considerably between transplant programs.
• 20:15
  Here at UF, we're fortunate to be one of the more aggressive transplant centers.
• 20:20
  We receive many referrals for patients who were declined elsewhere
• 20:23
  because we have extensive experience managing these complex cases.
• 20:27
  But it doesn't mean that we just transplant anyone and everyone.
• 20:30
  Instead, our multidisciplinary team asks just truly one simple question:
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  Are we going to help this patient or do we think we're going to harm
• 20:37
  them by exposing them to transplant?
• 20:40
  Instead of looking at one risk factor on its own, we just take
• 20:43
  a look at the overall picture.
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  What's their overall medical condition?
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  How frail they are?
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  How much support they have, especially when they have higher risk features
• 20:51
  associated, you know, we anticipate certain complications after transplant.
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  Do they have good psychosocial support?
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  Do they have good caregivers?
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  Are they generally adherent?
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  What are their other comorbidities?
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  And try to optimize them as a whole, even if they're complex or even if
• 21:07
  they have these increased risk factors.
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  So, a lot of these used to be considered absolute contraindications, like
• 21:14
  years ago, but we've evolved since then, and our experience has grown.
• 21:18
  And not only us, but the field in general continues to change rapidly.
• 21:23
  For example, if you look at the ISHLT Consensus document for selection of lung
• 21:27
  transplant recipients, you'll see that one of the increased risk factors or relative
• 21:31
  contraindications is age more than 70.
• 21:34
  Well, a good percentage of patients, we transplant are more than the age of 70.
• 21:39
  We've transplanted patients up the age of 75 and 76.
• 21:43
  Looking at that same table, if they have CAD that requires a CABG at
• 21:47
  the time of transplant, that used to be a relative contraindication.
• 21:49
  Well, here at UF, that's a very common thing that we do.
• 21:53
  Patients that have severe esophageal dysmotility, because it's associated
• 21:56
  with increased risk of reflux and reduction down the road.
• 22:00
  Well, we've developed a good protocol here to actually improve
• 22:03
  these patients' outcomes after transplant, similar to patients that
• 22:07
  do not have esophageal dysmotility.
• 22:08
  So for us, severe esophageal dysmotility is not a problem whatsoever.
• 22:13
  Certain BMI cutoffs, they used to be BMI less than 30.
• 22:16
  Used to be strict, less than 30.
• 22:18
  Well, now we're more a bit more flexible because we know that BMI is
• 22:21
  not the best marker to reflect overall central obesity and weight and so on.
• 22:25
  So, these are just some examples, just to mention a few.
• 22:28
  An additional one, Mycobacterium abscesses.
• 22:31
  Used to be a big no-no.
• 22:33
  If someone has Mycobacterium abscesses, that's a big no-no.
• 22:36
  Well, right now, we have a lot of different treatment options in which
• 22:39
  we are able to control these patients before sending them for a transplant.
• 22:43
  It really varies from one transplant center to another.
• 22:47
  But the field is changing significantly, and a lot of these
• 22:49
  relative contraindications are no longer contraindications.
• 22:53
  Melanie Cole, MS: Well, Dr.
• 22:54
  Younis, it certainly is an exciting time in your field.
• 22:58
  As we wrap up, I'd like you to speak a little bit briefly about timing
• 23:02
  and window of opportunity that affect those outcomes, the mistakes that
• 23:06
  you've seen in referral timing.
• 23:08
  But for clinicians in smaller or resource-limited settings, give us some
• 23:13
  practical strategies for building that relationship with regional transplant
• 23:17
  centers such as yourself and ensuring that smooth referral and co-management.
• 23:22
  Your best advice in summary here.
• 23:24
  Dr. Moustafa Younis:
• 23:24
  Definitely.
• 23:25
  So, the common theme or the two biggest mistakes I see, the
• 23:28
  first one is waiting too long.
• 23:31
  and that's why I actually wanted to talk about this topic, because it's one of
• 23:35
  the hardest conversations for us when we have to tell a patient that they're
• 23:39
  no longer a transplant candidate or they missed their window of opportunity, when
• 23:44
  if they were referred a bit earlier, they would have been candidates.
• 23:47
  I believe that we can help definitely way more patients if
• 23:50
  these patients are referred early.
• 23:51
  A second common mistake I see is that clinicians, again, decide in
• 23:56
  a way on their own that the patient is not a transplant candidate.
• 24:00
  It's evolving a lot, and every transplant program has a different threshold.
• 24:05
  And we're really pushing the boundary every day, and we're seeing
• 24:09
  good outcomes when we do that.
• 24:11
  You know, for example, patients that have a history of cancer.
• 24:14
  Well, we've actually transplanted a few patients that had
• 24:17
  chemotherapy-related pulmonary toxicity.
• 24:20
  So, they were just being treated for cancer, but we had to
• 24:23
  individualize and personalize that treatment for these patients.
• 24:27
  We had to discuss multidisciplinary, not only us from a pulmonary standpoint
• 24:31
  and the whole transplant team, but also involving the hem-onc team,
• 24:35
  different teams that are specialized in these kind of disease processes.
• 24:40
  All these rigid criteria are no longer as rigid.
• 24:44
  And therefore , unless it's something that's very obvious, a very absolute
• 24:48
  contradiction, like a patient doesn't really want a transplant, then think
• 24:52
  twice about before deciding on your own that the patient is not a candidate.
• 24:56
  So again, when in doubt, refer.
• 24:58
  And the worst outcome is usually referring too late, not referring too early.
• 25:02
  And then, as for how we build these relations, so actually the good
• 25:06
  news is the transplant centers in general, not only us, are increasingly
• 25:10
  viewing pulmonologists as partners.
• 25:12
  We don't take over care.
• 25:14
  We work in parallel.
• 25:15
  And here at University of Florida, we made outreach really a major priority.
• 25:20
  We're actually taking that step, and we're doing regular visits to community
• 25:24
  hospitals, pulmonary practices throughout the region to establish a relationship,
• 25:28
  and therefore make it easier and streamline that referral process.
• 25:32
  Our goal is to make that process as easy as possible.
• 25:35
  And we all work in parallel.
• 25:37
  We want what's best for these patients.
• 25:39
  And if there's any listeners, that would like to establish a relationship
• 25:42
  with our transplant program, or simply discuss a patient, whether a
• 25:46
  patient might benefit from referral, we'd be more than happy to help.
• 25:49
  They can reach out to our transplant liaison, Dr.
• 25:51
  Gries.
• 25:52
  Her phone number is 412-770-7636.
• 25:56
  She was very kind enough to share her personal number.
• 26:00
  So, that's really what our team is doing here.
• 26:02
  This is her personal phone number.
• 26:03
  You can reach out to her any time to discuss any patient.
• 26:06
  if you're not sure whether they would benefit or not, just reach out, and
• 26:10
  we can definitely help and make that process as smooth as possible and as easy
• 26:14
  as possible for physicians so that we can help as many patients as possible.
• 26:18
  Melanie Cole, MS: What great information, Dr.
• 26:20
  Younis.
• 26:21
  Thank you so much for joining us and really sharing your incredible
• 26:25
  expertise for referring physicians.
• 26:28
  And to learn more about this and other healthcare topics at UF
• 26:31
  Health Shands Hospital, please visit innovation.ufhealth.org.
• 26:35
  And to listen to more podcasts from our experts, please
• 26:38
  visit ufhealth.org/medmatters.
• 26:41
  That concludes today's episode of UF Health MedEd Cast with
• 26:44
  UF Health Shands Hospital.
• 26:46
  I'm Melanie Cole.