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The Greatest Gift

Written by Michelle Lindstrom

Dr. Lori West wears many hats in the realm of medical research, giving her a long list of professional titles. Through the University of Alberta, she is a professor of pediatrics, surgery and immunology as well as the director of the Alberta Transplant Institute; nationally, she is the director of the Canadian National Transplant Research Program. This is all in addition to her role at the Stollery Children’s Hospital as a pediatric transplant cardiologist.

“When I’m taking care of patients and doing clinical work, I’m looking after pediatric patients who either need or have had heart transplants,” West explains, adding that her director positions oversee transplantation for any age and organ.

After attending medical school at Tulane University in New Orleans, Dr. West did her pediatric training at the University of California Los Angeles. She also decided to train in pediatric cardiology and moved to Canada to study at the Hospital for Sick Children in Toronto.

It was in the late 1980s when pediatric transplantation started up and Dr. West’s interest was piqued. “There were two pathways I could take,” she explains. “One was, go somewhere to train on how to look after pediatric transplant patients or heart transplant patients in general, and the other was to become trained in the science of transplantation.”

She chose to do both.

“If I wanted to move the field forward and participate in something that was rapidly growing and changing, then I needed to understand the science in depth,” she says. “And if I really wanted to be a researcher who was trained to do cutting-edge research, then the best way to get that training was to do a PhD.”

She went to Oxford University in England for her PhD in transplant immunology before moving on the second phase of her training plan in various locations of the United States: learning how to look after the clinical care of pediatric heart transplant patients. She then joined the Hospital for Sick Children in Toronto as its medical director of the Heart Transplant Program, where she stayed for the following decade.

“In order to truly change medical care and not continue to do things the way we did 100 years ago, you’ve got to have people who are comfortable and credible in research as well as clinical care – people who can do both,” Dr. West says.

even with years of development, she explains that transplants are seldom a cure for a person, young or old. A new organ in a person’s body only changes his or her medical problems.

“All patients with new transplanted organs need to be looked after for the rest of their lives by someone with expertise in transplant medicine,” Dr. West says. “It’s not just to check and see if [the organ] is doing OK; it’s actually to take care of those patients because they’re on very complex medications to prevent rejection, for example.”

This means for Dr. West and the clinical heart transplant team at the Stollery – roughly 20 members led by Dr. Simon Urschel – there is an ever-growing population of patients to care for. In 2015, there were 12 pediatric heart transplants done at the Stollery; this number can vary widely from year to year. Those patients are added to the more than 150 pediatric patients Urschel’s team is already following.

“They’re always our patients until they get older and then they go to the adult transplant cardiology team,” Dr. West says.

As a strong believer in the relevance and critical importance of pediatric research, Dr. West made sure as the director of the Canadian National Transplant Research Program that there was a major focus on pediatric transplant research instead of inserting it in a small components of larger adult studies, which is common practice of research organizations.

She explains that the Stollery doesn’t make pediatrics an afterthought. “That’s really important because if you don’t have that commitment to pediatric research, then you’re going to be behind the 8-ball and always playing catch up,” Dr. West says.

She and her husband, Dr. Jeffrey Smallhorn, also a pediatric cardiologist, were recruited to the Stollery in 2005 by Terry Klassen, who was the department chair for pediatrics. “The reason we came here was because the Stollery Children’s Hospital Foundation was able to support the establishment of my lab and assist the University of Alberta with a package that would allow me the time and the support to do the work I wanted to do,” Dr. West says.

The Foundation, through the Women and Children’s Health Research Institute, has provided funding to Dr. West – from helping to set up her lab to ongoing funding towards her cutting-edge research.

Twenty years ago, Dr. West’s team introduced a new concept that babies could receive heart transplants from donors who had mismatched blood groups – something that had never been done before. Today that practice, which evolved from her ABO blood group transplant project, is an accepted procedure around the world.

“The project started in Toronto and I brought it here (the Stollery) to continue to evolve; over the past 20 years, it has had a real global impact,” West explains. “What’s really important to us now is to understand why it works so well because if we can understand that, we may be able to devise a way for the same kind of procedure to work in older children and in adults.”

As exciting partnership Dr. West’s lab developed in order to further their understanding of ABO blood group mismatched transplants is with chemists at the University of Alberta’s faculty of science. Since sugar structures make up the blood types of A, B and O, chemists can recreate those structures for Dr. West’s lab to study and understand certain aspects of the blood groups in transplantation.

There isn’t anyone else working on this topic to the extent that her lab is, Dr. West says. As a result, the lab is able to ask questions they’ve never been able to explore before because of the helpful samples and tools the chemists are providing.

For example, “When a baby has received a blood group mismatched transplant, we need to know whether they ever make antibodies to their donor blood type because that could be very dangerous,” she says. “But we didn’t have sophisticated tools to look at that, so [the chemists] made us those tools.”

She’s now looking to move these finding from the research laboratory into clinical use, which has widespread and direct clinical impact on children and adults as well.

Another project Dr. West is working on started in Edmonton directly with the help of the Stollery. The focus is to find naturally occurring suppressive cells called regulatory T cells (Tregs) instead of using chemical drugs to suppress the immune system after an organ transplant.

“Our patients are under long-term health care because they’re required to take drugs to prevent rejection of their transplanted organ, and every drug has side-effects, especially for children who start taking them in infancy,” West says. “We’re always looking for ways to decrease the reliance on immunosuppressive drugs; even if we can’t get away from them completely, using less means fewer side-effects.”

Other scientists are only exploring isolation of Tregs from blood samples but you need a lot of blood to get enough Tregs to work with. West’s lab began using discarded thymus glands removed from pediatric patients during heart operations (a common practice worldwide). “We discovered that you can get more Tregs from a single pediatric thymus than you get from the entire circulating blood volume of an adult human,” West explains, adding the significance is that Tregs are being explored not only to suppress rejection of transplanted organs but also to suppress autoimmune diseases. This could mean diabetes patients wouldn’t need insulin anymore.

“Research is also a surprise, or else it would be boring,” West said.

Published Summer 2016, Stollery Children’s Hospital Foundation