Horomanski is a principal investigator in research supported by a grant from the Maternal & Child Health Research Institute. This aligns with her deep interest in how vasculitides affect young women, their fertility, and their decisions regarding if and when to have children.

“We’re actually talking about a collection of pretty heterogeneous diseases. Because vasculitides are all different, they affect very different populations. One of the vasculitides is Takayasu arteritis, for example. More than 80% of patients with Takayasu arteritis are women, and most of those women are under the age of 40, so it primarily affects people in their childbearing years. We don’t know enough about the maternal and fetal outcomes associated with pregnancy in vasculitis patients. A component of our current research involves the use of large databases to help answer such questions about these rare diseases,” Horomanski says.

Horomanski also has a particular interest in ultrasound and performs musculoskeletal ultrasound to evaluate for various rheumatologic and other joint musculoskeletal complaints in the Immunology and Rheumatology Clinic. In the past 20 years, specialists have recognized the value of vascular ultrasound to both diagnose and monitor large vessel vasculitis, and Horomanski received additional training in August 2022 to perform vascular ultrasound for patients with large vessel vasculitis.

“The best part about ultrasound is that it is noninvasive. Frequently these conditions need to be diagnosed by biopsy, and often temporal artery biopsy, which can be challenging to coordinate and schedule. And of course, it is an invasive procedure. If we can quickly and accurately diagnose people by ultrasound, it is a huge benefit to the patients,” she says.

As the clinic grows, greater involvement in clinical trials is expected, too.

Currently, Horomanski is working under principal investigator Matthew Baker, MD, assistant professor of immunology and rheumatology, on several trials related to IgG4-related disease and sarcoidosis, both of which can present with vasculitis. Horomanski, who did additional training during her fellowship on clinical trial design and management, is very interested in pursuing other vasculitis trials as the clinic continues to expand.

“That was one of the main objectives of this clinic. Stanford has a robust infrastructure to run these types of clinical trials, and we are looking forward to great things in the future,” she says.

Referrals come from throughout California, Oregon, Nevada, Hawaii, and even the East Coast, but most patients live in California’s Central Valley, where providers do not have extensive experience with these rare illnesses. Horomanski tries to share care with each patient’s local rheumatologist, which allows the patient to see their nearby physician, while also getting the care they need from a large academic center.

She fell in love with hematology on her first day of medical school. Hematologist May Chien, MD, remembers feeling that she had “found her dream.”

Chien, who is clinical assistant professor, pediatrics–hematology & oncology, and medicine–hematology, recalls that “I loved all the mechanisms of blood diseases and all the thought processes hematology involves.” Today, she’s living her dream.

Chien is board-certified in both internal medicine, hematology, and pediatric hematology-oncology, which gives her an unusually broad perspective from which to manage patients with classical (nonmalignant) blood disorders.

“Until recently, patients with blood diseases such as hemophilia and thalassemia did not survive past childhood,” she notes. “But today, with improved treatment options, many children born with these diseases grow into adulthood.” And since hematologists who treat adults don’t always have a lot of training in childhood diseases, her breadth of skills enables her to care for patients with blood disorders and follow them from birth through adulthood.

For example, she may help a woman with a bleeding disorder get through pregnancy and birth, and then find that the child has inherited the same disease. Chien can help them both manage their conditions and has done so numerous times.

often present options you didn’t know existed. I went to medical school at the University of Southern California Keck School of Medicine. Some colleagues I most admired there were doing a combined internal medicine (IM) and pediatrics residency. I applied for that program and got in.”

Four years later, she came to Stanford for fellowship training. “Stanford was wonderful for allowing me to create my own combined fellowship program in both IM and pediatrics. It was the perfect answer to finding a place where my intellectual and clinical interests could intersect,” she says.

Chien was the first fellow in the Stanford Department of Medicine to complete two fellowships concurrently. “One of the best things about Stanford is that if you dream it, people can make it happen,” she says. “I had an idea and found complete support for it here.”

Not only did she need faculty approval for the combined fellowship, but also she had to secure consent from the two board-certifying organizations involved: the American Board of Internal Medicine and the American Board of Pediatrics, both of which approved her proposed fellowship program.

A native of Southern California, Chien graduated from Amherst College in Massachusetts before returning home to pursue what she thought would be a career in laboratory research. “I was not living my best life at a laboratory bench,” she says. “I realized I was more interested in working directly with people.” So, she applied to medical school and found her “best life.”

Research in Classical Hematology

“Classical hematology is about intricate pathways,” says Chien. “Finding the correct diagnosis is like solving a fascinating puzzle, since there are numerous mechanisms for coagulation and other beneficial events to occur and possibly go wrong.”

Stanford researchers are pursuing new and novel treatments for conditions classified as classical hematological disorders, including hemophilia, thalassemia, pyruvate kinase deficiency, and sickle cell disease. Some of these involve gene therapy or stem cell transplantation.

“Inherited blood diseases are especially amenable to treatments like these,” says Chien. “Some are currently in clinical trials, but we have a way to go before they can be universally applied.”

For example, hemophilia A is an inherited genetic disease that results from a gene mutation that prevents the liver from making enough of a clotting factor called factor VIII. The result is excessive bleeding.

“Research in hemophilia is very exciting right now,” says Chien. “Gene therapy is starting to show promise in providing a potential cure for the disease.” Hemophilia is an ideal candidate for gene therapy because it arises from mutations of a single gene and because a patient doesn’t need a lot of the clotting factor to bring about a change from severe disability to wellness.

“Unlike stem cell replacement, successful gene therapy would entail one infusion into the liver to stimulate production of factor VIII,” Chien explains. “This not only would add years to patients’ lives but also could actually cure the disease.”

She is also interested in thalassemia, a type of anemia in which the entire hemoglobin portion of the blood is abnormal. Currently, blood transfusions are the main therapy used to treat thalassemia. The challenge with this approach is the possibility of overloading the liver with more iron than it can handle. A clinical trial underway at Stanford is exploring the potential of an oral drug that could extend the lifespan of a red blood cell, thereby boosting red blood cell levels and reducing or possibly eliminating the need for transfusions.

Looking forward, Chien is eager to continue her work in decreasing the burden of inherited blood disorders such as hemophilia, thalassemia, and sickle cell disease. “My goal is to continue to improve life expectancy and quality of life for adults and children with these conditions,” she says.

Ten years ago, Miriam Gutierrez, 47, was diagnosed with lupus. “Though I took medication for that condition,” she recalls, “my kidneys started to fail, and I was put on home dialysis.” She had a catheter attached to her abdomen, which enabled nightly cleansing of her blood.

Gutierrez was told she had about a 1% chance of getting a donated kidney because of the complex nature of her case, which included elevated antibodies, a blood type that would be difficult to match, and having had many blood transfusions.

In 2020, after eight years on dialysis, her physician referred her to Stanford for evaluation. Using the parameters of the Transplant Readiness Assessment Clinic (TRAC), she began monthly visits to monitor her compatibility with potential donated kidneys. Two years later, she remembers, “I received a phone call on a Friday night saying I had matched with a donor kidney. I went to Stanford Hospital on Saturday morning and had the transplant surgery that day.”

“I’m very grateful,” she says. “Now my life is back to normal, and I’m looking forward to visiting my family in Mexico soon.”

“It may be any time, day or night, far or near. And if a potential recipient is found, he or she must get to Stanford immediately for an updated physical and psychosocial evaluation.”

If it’s been a long time since the patient’s most recent clinical assessment, they may have experienced illness or other physical challenges that could affect their likelihood of success with a donor kidney. “By the time the evaluation is completed,” notes Cheng, “the kidney may no longer be viable, or we may have found out that the patient and the organ are not a good match.”

Pre-transplant Readiness Improves Kidney Transplant Rate

Cheng and the kidney transplant team began reviewing the Tier 2 patients. They wanted to determine if, by reevaluating those patients before a kidney became available, they could prepare the patients to be ready for surgery with very short notice. This involved doing all the necessary medical workups and education needed in advance of a donor kidney becoming available.

In making these assessments, Cheng and the transplant team rely on the Kidney Allocation Score (KAS) to determine a patient’s priority for kidney transplant according to national allocation policies. The KAS is a composite of the amount of time the patient has been on dialysis, the amount and kind of antibodies the patient has, the patient’s blood type, and other factors.

Using the KAS, Cheng and her colleagues established wider parameters for eligibility for a kidney transplant. Doing this kind of evaluation for every person on the waiting list would be very time-consuming and not necessarily result in an organ match. But when focusing on the patients who would more likely be offered a donor kidney based on their KAS, even one that is not considered “perfect,” the pool of possible recipients becomes more manageable and results in a group of patients that is more likely to succeed.

“Our team meets weekly to review the patients who were seen that week who may qualify for this proactive management. With input from transplant surgeons, we can see trends developing so we can predict who on our lists might be eligible for an organ and ask those patients to come in for a clinical workup so they’re ready if an organ does become available.”

For Renu Dhanasekaran, MD, PhD, assistant professor of gastroenterology and hepatology, being a physician-scientist isn’t merely a profession. “It’s a calling,” she says. Dhanasekaran began her career as a physician in India, then went back to graduate school at Stanford and earned a PhD in cancer biology. Her lab at Stanford School of Medicine studies the molecular biology of liver cancer, with the goal of identifying novel biomarkers and molecular-targeted therapies for the disease.

Liver cancer is the fastest-rising cause of cancer death in the United States, according to the American Association for Cancer Research. And rates are expected to continue to rise through at least 2030. Risk factors include viral hepatitis B or C, fatty liver disease, and alcohol use. Worldwide, hepatitis B is the most common cause of liver cancer, but thanks to routine vaccination that began in 1982, fewer than 5% of liver cancer cases in the United States are caused by the virus. Obesity and diabetes are part of the reason, but “we’re not talking enough about it,” she says. “It’s an underrecognized issue. Liver cancer can happen to anyone.”

Dhanasekaran chose to be a physician because she wanted to help people. But it was only in medical school that she truly began to understand the “gravity of the profession” — how physicians can change and save lives.

Stanford was a really open community, and I felt very supported by my mentor and my division.” As faculty at the university, she had her own clinic already, but she managed to complete her PhD while maintaining her commitment to her clinic as well as teaching students and residents. “It was very interesting because I was going to early-morning classes with 20-year-olds,” she says. “I had two kids already, and I had so many hats to wear while doing all that. But I think Stanford is unique in that a faculty member is able to pursue a PhD.”

Dhanasekaran’s research is focused on liver cancer for two reasons: There are not many treatment options available for the cancer; and there is stigma around liver cancer because sometimes patients already have alcoholic liver disease or hepatitis C and may be, or have been, IV drug users. Because of the stigma, Dhanasekaran says, there isn’t as much attention or funding for liver cancer as other cancers.

Patients at the Heart of Research

Besides her research, Dhanasekaran runs a liver cancer clinic. This allows her to keep track of how her patients are doing. She says this has been humbling, because her patients often don’t survive past five years. “It’s very disheartening that I don’t have a set of patients I can follow long-term because of this disease. I come back into the lab after clinic and think, We really need to do something about this.” Keeping the science so close to the patients is important to her. “It’s so connected because these are the patients I see,” she says. “They inspire me.”

Dhanasekaran also feels that she learns from her patients, sometimes finding a clue from them that can lead her research in a particular direction. She recalls one patient who had a very aggressive type of liver tumor and was expected to survive only weeks or months. But a month later, the tumor had spontaneously resolved. “I had never seen anything like that,” she says. She explained to the patient how unusual her case was and that she wanted to try to understand why. The patient agreed to enroll in a study, and they determined that her immune system was extremely robust and was able to fight and clear the cancer. “We were able to do the science to show how this might have happened,” says Dhanasekaran. “I continue to follow her.” Her story is now published as a case report.