Boy undergoes complex liver, kidney transplants — all before age 3

Dane Conrads was in excellent health when he was born, almost five weeks early, in April 2014 in San Francisco. But after being circumcised, Dane started bleeding, and it wouldn’t stop.

For Dane’s parents, A.J. and Ted Conrads, it was an unexpected shock. “A blood test showed that his liver enzymes were through the roof, which was a sign that his liver was failing,” A.J. recalled.

An ambulance rushed Dane to Lucile Packard Children’s Hospital Stanford. “It was all hands on deck,” A.J. said.

Janene Fuerch, MD, clinical assistant professor of neonatology at Stanford, was one of the neonatal intensive care unit fellows during Dane’s first several weeks at Packard Children’s. “He was in fulminant liver failure, and we knew he was most likely going to die. Neonates in severe liver failure often don’t survive,” she said.

Ultimately, he would undergo two separate transplants before his third birthday. He was fortunate to be treated at Packard Children’s, a longtime leader in pediatric solid-organ transplant. In 2017, the hospital led the way in pediatric transplant volume and outcomes nationwide, performing 117 pediatric organ transplants. Over the past five years, Packard Children’s has performed more pediatric liver and kidney transplants than any other U.S. hospital.

To help him survive his failing liver, Dane’s doctors stabilized him with several daily blood transfusions and continuous medical support. Over the next 10 days, rounds of testing revealed that Dane was infected with an enterovirus, a relative of the polio virus.

‘A desperately ill little guy’

“He was really a desperately ill little guy,” said William Benitz, MD, professor of neonatology and Dane’s attending physician in the NICU. “He demonstrated how sick a vulnerable baby can get from what would be a routine, ho-hum, everyday virus for most of us.”

In a premature baby like Dane, enterovirus can cause liver failure, which can lead to brain damage and heart failure. Enterovirus has no available medical cure, so Dane’s own immune system had to fight the disease.

The next six weeks were a harrowing, daily effort to keep Dane alive and help him grow healthy enough — and large enough — to receive a liver transplant. “We knew this was a stretch. He would be the smallest transplant the team had ever done,” Fuerch said. “But he wasn’t giving up, so we weren’t going to either.”

The team has a track record of succeeding with unusually challenging transplants. In 2017, 40 percent of Packard Children’s liver-transplant recipients weighed less than 40 pounds, making it the national leader in transplanting babies and small children. The hospital also had much shorter mean wait times than most transplant centers: 2.2 months, compared with 13.5 months nationwide.

And Dane needed a new liver quickly. Even as his care team worked to stabilize his blood levels every day, his failing liver was not doing its job of clearing his blood of protein byproducts like ammonia. This meant he needed continuous hemodialysis, which circulated his blood to clean it externally and return it to his body. “We had to balance the risks of bleeding, clotting and infection and work to optimize his nutrition,” said Cynthia Wong, MD, clinical associate professor of pediatric nephrology and medical director of chronic dialysis. “With his multiorgan failure, this was the only option to save his life.”

‘Tremendous moment of success’

“When the interventional radiologist put in a dialysis catheter, it was a tremendous moment of success,” said Waldo Concepcion, MD, professor of surgery and chief of pediatric kidney transplantation. “Being able to dialyze him so the medical team could stabilize him was very, very critical to his survival.”

In the early hours of May 23, 2014, 6-week-old Dane, weighing just under 5 pounds, received his new liver from a surgical team led by Carlos Esquivel, MD, PhD, professor of surgery and chief of the division of transplantation, and Concepcion.

About six weeks after Dane’s surgery and his slow, rocky recovery, A.J. and Ted were finally able to pick him up and hold him for the first time since his birth. But soon after his new liver stabilized, Dane’s kidneys failed. He now needed peritoneal dialysis to do the work of his kidneys.

It was a completely innovative process of doing the kidney transplant.

On Oct. 8, after six months in the hospital, A.J. and Ted were able to take Dane home, where he would need 11 hours of peritoneal dialysis each day until he could receive a kidney transplant.

Although they were concerned about their son, the family knew of Packard Children’s outstanding kidney-transplant track record. In 2017, the program performed 46 pediatric kidney transplants, as well as nine transplants in patients age 18 or older, making it a national leader in kidney-transplant volume. Patients come from across the Western United States and even internationally to benefit from the program’s expertise.

A.J. hoped to be a living kidney donor for Dane. But Dane needed a perfectly sized kidney, which could only come from a deceased donor. “The odds were stacked against Dane both in terms of the complexity of the anticipated surgery and the scarcity of potential donor kidneys,” Ted said.

On April 7, 2017, one day before Dane’s third birthday, Concepcion and Amy Gallo, MD, assistant professor of surgery, performed Dane’s pioneering kidney transplant.

“He was tiny, but we modified and tailored his own kidney vein to be able to drain the new kidney,” Concepcion said. “It was a completely innovative process of doing the kidney transplant using only what the patient had available, which was that one vein.”

It was one of the most complicated of the kidney transplants performed at Packard Children’s in 2017, though it was not unique: The team also transplanted two other children who had been referred from outside California due to challenging vascular access, as well as a patient who needed a second kidney transplant after becoming immunologically sensitized to the first transplanted organ.

Within 24 hours of his kidney transplant, Dane showed signs of dramatic improvement. He was discharged after 10 days.

Today, Dane loves playing with his little brother, Carter. “He’s just really happy now. He’s super-social and loves his toys and going to music class,” A.J. said. “Finally, after three years, we’re feeling relaxed — like, OK, he’s going to be OK.”