Time Stamps

  • 03:49 Intro
  • 07:13 Dialysis vs. kidney transplant morbidity and mortality
  • 11:44 Eligibility for kidney transplant and when to refer
  • 21:34 Pre-transplant evaluation process
  • 25:38 How long are wait times on the transplant list?
  • 36:21 What benefits of living donation? What are risks to the kidney donor?

CME-MOC

Sponsor: Glass Health builds a medical knowledge management platform that helps physicians learn medicine faster and leverage their knowledge to provide better patient care. Use promo code COREIM for 1 month of free access to Glass Pro!

Link: https://glass.health/coreim
Promo Code: COREIM

This episode is part of the NephMadness PodCrawl 2023. Fill out a bracket for NephMadness and check out all eight NephMadness PodCrawl participants at NephMadness.com/podcrawl

Show Notes

 Pearl 1: Why should we favor kidney transplant over dialysis?

  • Kidney transplant improves quality of life, as dialysis can be quite cumbersome
    • Patient usually physically going to a dialysis center
  • Transplant also offers a mortality advantage, after approximately 240 days
    • Early after the transplant, there are increased risks related to the surgery and immunosuppression. 

Pearl 2: Who is eligible for kidney transplant, and when should we start referring them?

  • Patients must have a GFR<20 to be listed on the transplant list
    • Even if the GFR  <20 is from AKI or CKD and improves, the patient can still be listed and accrue waiting time
      • That’s why early referral and evaluation for transplant is important
        • Patients can accrue adequate waiting time before they actually need transplant or dialysis
  • Eligibility criteria are based on the Organ Procurement and Transplantation Network policies, but may vary from center to center
  • Patients should be referred for transplant when GFR <30 (expert opinion), as pre-transplant evaluation may take a few months 
    • Discussion for transplant may start earlier and at the same time as the conversation about dialysis, especially if there a rapid decline in the GFR
  • To avoid bias in referral, patients should be referred to a transplant center when in doubt about eligibility

Pearl 3: What is the pre-transplant process?

  • Patients are evaluated by a multidisciplinary team, including the transplant surgeon, nephrologist, pharmacist, nurse coordinator, social worker, financial coordinator and more depending on the center
  • Patients must also undergo an extensive medical work-up
    • All patients must go through an age-appropriate cancer screening, including colonoscopy, pap smears, mammography, as well as PSA for some centers.
    • Patients must also have a cardiovascular testing, which may include an EKG, echocardiogram, and/or nuclear stress test, to ensure that patients are healthy enough to go through surgery and anesthesia
    • Lung function may also be assessed, and patients who smoke may require PFTs and/or low dose chest CT
    • All potential transplant patients and donors must also undergo psychological evaluation, and need to have a caregiver/support system.
    • Other relevant medical work-up is evaluated on a case-by-case basis

Pearl 4: How long do patients wait on the transplant list?

  • Patients can be on either the active or inactive waiting list
    • Since kidney transplants last a certain number of years, patients should ideally wait until they are close to needing renal replacement therapy (such as with subtle uremic symptoms) before being put on the active list
    • The inactive list is therefore for asymptomatic patients 
      • Patients start accruing time on the transplant list without being activated.
  • Multiple factors affect wait time on the list:
    • Blood type 
    • Sensitization to HLA antibodies 
    • Geographic location also matters, as kidney transplant availability varies by location
      • It can range in Midwest America as 1-2 years wait compared to northeast or California of 8-9 years
  • How can you help your patients decrease wait time?
    • Listing at multiple sites, including areas with shorter wait times, can accelerate the transplant process
      • However, this requires the financial means to travel fast to that location for evaluation, follow ups, and ultimately the kidney transplant, which is unfeasible for most patients
    • Consenting for a transplant from a Hepatitis C donor
      • In majority of cases, treatment for Hepatitis C ensure a sustained viral response, which allows non-infected patients to receive a Hepatitis C infected kidney
    • High Kidney Donor Profile Index (KDPI) kidneys

Pearl 5: How do living donation work, and what are the risks?

  • Who is eligible to be a living donor?
    • Donors must be at least 18 to 21 years old, depending on each transplant center
    • Donation must be voluntary
      • Potential donors are evaluated by a social worker and psychologist to ensure that donation is free from coercion
    • Patients with medical conditions that affect the kidney, such as diabetes, lupus, or active drug use, will not be eligible for donation.
      • Some centers also have a BMI cut-off, as obesity may predispose to health conditions such as hypertension and diabetes that may affect the kidney
  • Potential donors must undergo a medical evaluation
    • Medical work-up for the donor and the recipient is done by 2 different teams to avoid conflict of interest
    • Donors undergo kidney imaging with ultrasound and abdominal CT scan to assess the number of vessels. Some centers also perform nuclear scans to calculate each kidney’s contribution to the total GFR
  • A psychosocial evaluation is also done, where the surgeon informs the donor of surgical risks and where a social worker will ensure adequate support for recovery
  • If a donor and recipient are not compatible, they may enter a paired kidney exchange 
    • Through an algorithm, the National Kidney Registry creates of a chain of transplants to maximize the number of recipients and donors that can be paired at a time
  • Living transplant offer multiple advantages
  • Being a donor also has associated risks
    • The risk of death from surgery is low at 3/10,000 patients. However, considering that this is a surgery that is not required for the donor, it is a non-negligible risk
    • Kidney donation also increases blood pressure by 5-10 mmHg over 5-10 years after donation, which can cause hypertension
    • Kidney donation also has a small risk of ESRD
      • After surgery, the donor loses 50% of their GFR. Over time, the remaining kidney will hypertrophy slightly to compensate, but a permanently loss of 25-30% of kidney function remains
      • The risk of ESRD post donation at 15 years is about 30/10,000 patients, which is low but not non-existent
    • There does not seem to be an increased mortality risk with donation, although data is scarce.
  • Although there are risks for kidney donation, donors receive psychological benefit from donating

Transcript

Dr. Martha Pavlakis: So the role of the internal medicine doctor really, I would say number one is to be curious about what the patient has heard often when somebody comes to me for their very first transplant evaluation. I start with the question. When did you first hear that the kidney problem was so bad that you might end up either on dialysis or getting a transplant? And the answer is fascinating to me. You’ll have somebody with a clear cut decline over the past five years. And they were just told a month ago. And to me, that’s somebody who is freshly processing this news and potentially in denial, or, you know, just, maybe doesn’t even believe it.

M: That’s Dr. Martha Pavlakis, a transplant nephrologist at Beth Israel Deaconess Medical Center.  Welcome to Core IM 5 Pearls Podcast, bringing you.

S: High-yield evidence based pearls

M: Today we will be talking about the bean. Specifically, the new beans – that is transplant nephrology.  I am Marty Fried, I’m an academic primary care doctor at THE Ohio State University.  And you know Shrey.  This episode it’s also worth pointing out I am the proud son of a kidney donor.  

S: Aw! Props to Momma Fried! 

M: No doubt Shrey.  Doctor Momma Fried saved the day.  I do  still remember those 24-hour collections and frankly pre-adolescent Marty is still a little haunted by those refrigerated urine jugs… but Shrey – I am super excited to introduce a great friend and FORMER resident, new friend of the pod and master of the beans, Dr. Tomas Guerrero.

T: Thank you Marty, and yes, we love the urine jugs! Hi everyone, my name is Tomas Guerrero, I am a private practice nephrologist, recently graduated from UNC Nephrology fellowship. 

S: And rest be assured, there will be a POST-renal transplant episode coming up where we will talk about all things regarding immunosuppression meds, complications, and more

M: Lets get into the pearls we will be talking about today. As you listen, quiz yourself by pausing after each of the 5 questions. 

S: Remember the more you test yourself, the deeper your learning gains. 

Pearl 1: Transplant vs. dialysis

Why should we favor kidney transplant over dialysis?

Pearl 2: Transplant eligibility and referral

Who is eligible for kidney transplant, and when should we start referring them?

Pearl 3: Pre-transplant evaluation

What goes into the pre-transplant evaluation? and how can you help that process?

Pearl 4: Factors for transplant waiting time

How long do patients wait on the transplant list and what factors can affect it?

Pearl 5: Living donation

How do living donor kidneys work, and what are the risks?

Pearl 1: Why should we favor kidney transplant over dialysis?

M: Tomas – set us up here, we’re doing a whole episode on renal transplant – sell me on this. Why  is this topic important.  I mean dialysis stinks, but it works. everyone knows someone who has been on dialysis

T: Marty, there is absolutely no doubt in my mind, that patients who can receive a transplant, should. 

Dr. Karin True:  I would say that there is quality of life for most people. The quality of life is better with a kidney transplant. Obviously dialysis is very cumbersome. It’s as far as, as time that you have to give to dialysis and sort of you’re limited in your ability to move about the world. 

T: Everyone, that’s Dr. Karin True, a transplant nephrologist at UNC. And that totally make sense, I’ve heard it frequently described as gaining a new sort of freedom. 

S: I think the natural next Q is yes transplant gives you that freedom to not be tied down to dialysis center 3 times a week but what about peritoneal dialysis?

T: True but people on PD – or – peritoneal dialysis, are depending on a machine that’s larger than the average printer. And that’s not even considered and the bags of dialysate fluid. Some people use 15L of fluid in a single night, that’s like – 30 pounds. Imagine putting all of that into an RV? 

M: I do watch a decent amount of Tiny House Nation and I know that you can put a lot into an RV but it sounds like PD and travel is pretty much a no-go. 

T: I mean you can travel, it’s not impossible. It just takes extra coordination, and you likely have a pretty limited distance you can go. 

S: Yeah it sounds everything comes with drawbacks – 

T: Yeah even transplant has its drawbacks. With transplant, you are taking a lot of new medications – you have to monitor and control the levels of those medications in your blood. Which means watching what you eat, and frequent blood draws, especially at first. At the end of the day, you are trading one hassle for another, but I at least have personally seen a substantial improvement in quality of life for my patients.

Dr. Martha Pavlakis: We used to tell patients that the transplant would improve their quality of life, but we didn’t tell them it would improve their length of life because we didn’t have that evidence. And around 20 years ago, we got really good evidence that is still true to this day, that with a kidney transplant compared to being on dialysis, you will live longer. Despite the immune suppression, despite the increased risk of infections in certain kinds of cancers, not only will you feel better, but you will live longer. So hands down, if you can get a transplant, you should get a transplant.

T: So there is no question that the long-term benefits are there.  But, and there’s always a but,  it does take some time to really see that mortality benefits come to fruition. You know, for that investment to start paying off.  

Dr. Karin True: We have to remember that that improved mortality does not happen on day one of kidney transplant. I mean, they’re having a surgery, they’re in the hospital, they’re getting massive medicines that suppress their immune system. So their mortality risk is much higher for quite a while. And it takes about a hundred ish days or so before survival is equal to just staying on dialysis and about for all comers, about 240 something days before you reach a mortality advantage to dialysis. So if you don’t make it today, 240, whatever, we have not done you a favor by giving you a kidney transplant, but most people do make it to 244 days

M: So you know those 26.2 marathon bumper stickers … I sort of think we should have those stickers, but for kidney transplants.  It’s like listen everyone, I want EVERYONE to know that I did it.  240 days.  Boom.  

K: Yeah it’s like a badge of honor. I would hand them out in the clinic … like here you go you get one!

S: Ok to summarize this quick pearl on favoring transplants over dialysis: there is a hassle with both dialysis and transplant and with transplant it’s good to counsel our patients that with kidney transplant there is a immunosuppressive meds, bloodwork, appointments that we will get to later but the big takeaway boils down to kidney transplants do not not offer a better quality of life but also mortality benefit! What’s not to love about that! 

Pearl 2: Who is eligible for kidney transplant, and when should we start referring them?

M: Man, so it sounds like it’s pretty clear that we should be transplanting patients who are eligible

S: Yeah but I honestly can’t remember the last time I brought up kidney transplant with a patient, I am often prepping patients with “oh at some point you’ll need vein mapping to get a fistula to start dialysis” not even mentioning transplant as a branch point anywhere.

M: Ya know Shrey, when you’re right you’re right.  As we were putting together this episode I just felt like there were probably a lot of missed opportunities for me in clinic sort of watching my patients kidney function slowly decline, and I probably could have been forecasting transplant a little instead of asking Tomas to do all the hard work there… 

T: Marty, that’s why – they pay us – the big bucks.  But seriously, as nephrologists, we appreciate as many hands on deck to help prep the conversation – as soon as dialysis even comes up, transplant should be a potential option down the line, at least for the patients youd think would make a good candidate. 

Dr. Martha Pavlakis: Um, for the patient who is a clear cut great candidate, let’s say you’re type one diabetic with, you know, rapidly declining GFR over the years. They’re only in their thirties or forties. You see it coming that they’re gonna end up on dialysis or the patient with CKD who really even has a family history of people ending up on dialysis. You know, there’s lots of examples of, of clear cut people who are heading that direction. What I would say is, I’m glad you’re seeing a nephrologist for your kidney failure care. Have they brought up to you the possibility of eventually needing a transplant? What have you heard about transplant from your nephrologist? 

S: So if someones GFR is declining fast down the CKD path, refer to transplant on the sooner side. But, of its someone with the slower progressing CKD, our expert nephrologists and reviewers all had a bit of different practice patterns but the general thought is to bring up transplant at the same time you start talking about dialysis as a paraellel option. And when we really pressed them for a GFR number cutoff, once that GFR hits <30 refer to transplant since it does it take time to complete all the evaluation and you wanna try to get this done before their GFR drops even more and  hits the magic number of 20

Dr. Karin True: So to be listed for kidney transplant, um, actively listed where we would actually consider offering somebody a kidney, they have to have a GFR of 20 or less. That doesn’t mean that everyone with a GFR of 20 is ready to get a kidney transplant, but they can start accruing time on the waiting list at a GFR of 20 or less. There’s a lot of, of steps to the evaluation but it, you know, it can take three, six months to get all the testing done, you know, depending on how far people live from the transplant center, all of those things take time. And so it’s not unreasonable to go ahead and refer someone for transplant when their GFR is in, you know, the mid to low twenties. Like we’re not gonna say we’re not evaluating them. We don’t wanna start on a day that their GFR is 20. Cause we wanna start their waiting time on the day, their GFR hits 20. 

T:  And that totally makes sense because we want to really really minimize the amount of time people are on dialysis, of any kind.  All of that pre-transplant testing that Dr. True is referring to needs to happen BEFORE they are listed.  So we want to have all of our ducks in a row for the day that GFR hits 20. 

Dr. Karin True: If somebody had, uh, acute kidney injury episode five years ago  and their GFR was 17 and then an improved to 40 that’s 17 counts. So we can use historical GFR. It’s a little bit of, of gaming the system. Um, but it, it does count, um, you know, you have to do that within your own ethical framework obviously. Um, but if they’ve had something recent where it dipped and got a little bit better, we would certainly consider using that to list somebody.

M: Oh snap!  AKI counts?  That’s crazy.  I feel like I’ve been lied to… 

T: Yep! everyone feels this way. Any AKI counts, well as long as the GFR dips under 20

S: Wild! So any GFR < 20, even for 1 day means they accure time on the waitlist so again reiterates the importance of referring them early to get complete their whole evaluation process on the sooner side. And that i know more about mortality benefits of transplant, In an ideal world, id love to talk to all my patients about transplant but any reasons why a patient may be turned away from transplant?

T: I would say one of the most common reasons people are not candidates, age and weight. 

Dr. Karin True: So we, um, there are different sort of age cutoffs for different centers. So there are some centers that have absolute age cutoffs. Like we don’t evaluate anyone over 70 or 75 or whatever the case may be. Um, we sort of look at older patients on a case by case basis. There’s pretty good data that shows that in the seventies and even the eighties, if you choose the right patients, they still, you know, have a, these patients still have a survival benefit versus staying on dialysis. So I don’t wanna to, to say age and frailty are equal. They are not. So not all old people are frail and not all young people are UN frail. I had a patient who, who came to us for listing. I think he was 74 years old. I mean, this guy wanted a kidney transplant so that he could get his pilots license back because they didn’t give you a pilot’s license if you’re on dialysis. So this was a very, he was, he’s a pastor. He was still preaching, very active guy, you know, looked great. Didn’t have a living donor though. But I continued to see him every year, while he was on the waiting list. He continued to do well. And we gave him a deceased donor kidney at age 79. He is now 81 and he is flying his plane. Maybe he’s up there right now. I don’t know.

M: love the idea of Dr. True’s patient listening to this podcast right now in the cockpit of his little cesna twin engine.. it seems like a great victor redemption story.  Ok age cutoffs seem to be center-dependent and, from what it sounds like, sort of arbitrary…  What are we thinking about BMI cutoffs?  

Dr. Karin True: So much like age cutoffs, a lot of centers, us included have cutoffs for maximum BMI to be actively listed on our kidney transplant waiting list, um, to be able to get an organ offer.  And our BMI cutoff here at UNC is 40 or less. We prefer a BMI of 35 or less cuz there is some data that shows that the wound complications are higher, particularly in, for BMI above 35, particularly for diabetics. When a kidney doesn’t work right away, we call that delayed graft function. And that’s patients who have a higher BMI or at a, a higher risk of that cuz of the physically having to get the kidney in takes longer in somebody with a higher BMI. So they’re more likely to have what we call delayed graft function, which can reduce the, the life of the transplant down the road.

S: Oo its good to know the context for BMI cutoff! 

T: Yeah but remember, shouldn’t ever get too caught up in the numbers, and I’m saying that as a nephrologist.. Personally, I try to be aggressive about who I’m referring for evaluation, because the last thing I would want is for someone to not start accumulating waiting time when they could have been, because I didn’t send them. Or for me to have incorporated some sort of unconscious bias that prevented me from referring them in the first place. 

Dr. Martha Pavlakis: You know, anytime there’s triaging and prioritizing, there’s always the risk of bias creeping in. So I’m always, um, a little leery of saying only send us people that you think would be good transplant candidates, because that is a very vague and subjective thing. My biggest, um, caveat for people not being referred for transplant is somebody you don’t think is going to live five years because of their other health issues. Um, somebody in the extremes of old age frailty dementia. I think only those extremes that I would say do not think about transplant referral for that person. And really rather than put this on the internists and the nephrologists, I personally would prefer that those referrals came in and what happens is the nurse coordinators screen all the referrals.And then they put the ones that they think are questionable on my desk. And I sort through them, this is a very typical non-billable hour function of the medical director of kidney transplants is to make sure that we’re evaluating all the people we should and then some.

S: ok so when there may be questions, refer away, transplant centers have a process to screen and better have to have multiple layers to weed out any bias that may creep in. So other big takeaways from this pearl on transplant eligibility is refer before their GFR drops to 20 because it does take 3-6 months to go through the evaluation process that we will talk about in pearl 3 and then as soon as their GFR is <20, even if its just for a day in the setting of an AKI they can be listed for a kidney and they can start accruing time on the waiting list!

M: I also learned the easiest way to get Tomas’ BP up to 180s systolic is talking about CG equation.  I mean who needs levophed… just whisper “cockcroft-gault”

T: Marty – you’re not wrong. That and uh tunneled catheter being in for a year without having seen a vascular surgeon! Drives me crazy. 

Pearl 3: What is the pre-transplant process?

S: Something I’m curious about though, is what happens after the patient makes it to the transplant office? It seems like kind of a black box, between the transplant referral and when they finally get a kidney. What actually goes into a transplant evaluation?

Dr. Martha Pavlakis: Many programs, including our start with a multidisciplinary evaluation, um, where the patient comes to the transplant center and in one big day gets a class meets with, gets blood drawn meets with the surgeon, the nephrologist, the social worker, the transplant nurse coordinator, the transplant pharmacist, the transplant financial coordinator, um, all sorts of, of different members of the team, the transplant nutritionist, frailty testing, all the rest to get them started down their path towards, to transplant. That multidisciplinary evaluation day is a huge expenditure of effort by the whole team. So we only bring in four people, but it’s a six hour event, um, with multiple team members, um, evaluating the patient. 

M: That sounds like a hectic day! So how can the PCP or other specialists involved help nudge that transplant process along? 

Dr. Martha Pavlakis: I can’t tell you how many people come to us and have never had a colonoscopy. And it’s not that it hasn’t been brought up, but the patient has said, Hmm, I really don’t wanna do that. And then they get referred for transplant and then they hear from us. You have to do it well, actually, you don’t have to do it, but we’re not gonna list you. If you don’t have all your cancer screening done. So that is a super helpful thing to do. That will speed up the process. If, if your patient gets to the transplant referral and everything is up to date, Pap mammo and colonoscopy, you will have just moved a process forward. 

T: Also, the PCP notes were super helpful as a fellow, especially when I had to track down all the pre-transplant requirements, even more so at night. 

M: Ha! Someone does read my notes!  

S: It sounds like someone does! Not just you (laughter)

S: Yes, anything we can do to help Tomas. So that cancer screenings, what other testing do these patients need to go through?

Dr. Karin True: So most patients will get an echocardiogram, at least, um, almost all of our patients also get some kind of cardiac stress testing, usually a nuclear stress test. Um, if patients are smokers will do PFTs and then if they fall into the category of needing low dose chest, CT cancer screening will do that as well. 

T: So as you both can see once they are referred, it’s a pretty extensive process. A whole committee meets before someone gets added to “the list” and it is  NOT just the transplant nephrologist who gives the ok on transplant candidacy. The team includes the financial counselor, the surgeon, the social workers and case managers and everyone to agree on that that x patient is a good candidate.  Every now and then we do have a patient who received a transplanted, who maybe shouldn’t have. Either due to frailty, or you know, psychosocial reasons. 

M: What do you mean by that? psychosocial reasons

T: The patients are referring to are like those without a support system or dont have the capacity to understand that they can’t miss medication doses, that they need to go to all their appointments, that they will have blood work drawn frequently. They just… you know, need to know what they’re getting into.  

M: Yeah I mean that certainly makes sense to me from a shared decision-making perspective.  So to wrap this section up, it really sounds like outside of getting patients to the transplant office early, getting them there with a full set of scopes, paps and mammos is one of the most important things we can do.  

T: Marty, that would already be incredible. Now, the stress testing and PFTs I think happen on a more individualized basis, so I would just let the transplant people determine just because they are less standardized tests.

Pearl 4: How long do patients wait on the transplant list?

S: So Tomas, once our patient is on this list, what happens then? How does it work once they are listed

T: Yeah that gets pretty complicated. There’s a lot more demand for kidneys than there are kidneys available, hence the waiting list. 

M: Now Tomas, remember, if I ever have a GFR less than 20, I want you to make sure I’m listed. 

T: Marty, we can definitely figure something out. But if you did, you would probably be listed as inactive. 

S: Wait, what does that means? there is an an active and inactive listing?

T: Yeah I know, it’s kind of confusing, but I’ll let Dr. True explain. 

Dr. Karin True: So we can list people inactive, which means they are on the list. Their counter is going, the ticker is ticking, but we wouldn’t, they’re not in a, in the list where if a deceased donor came available, we would give it to that patient. So why would you do that?  

Dr. Martha Pavlakis: You don’t wanna transplant people too early. You transplant somebody feeling well at a GFR of 19. You’re starting the clock on that transplant a little bit early. And the drugs that we give to protect the kidney from rejection are actually somewhat nephrotoxic. So you are speeding up the failure of their native kidneys. It’s better to let somebody ride. Now, when’s the ideal time to do a transplant, 14, 13, 12, as somebody’s heading towards, I would expect them to start getting symptomatic and starting to go towards dialysis. That’s when I’d love to do the transplant. Now, some people are symptomatic. It’s 16, 18, and there’s always a conversation, but we don’t go right from evaluation listing, evaluate the donor and do the transplant. We sometimes pause if the person is what we call too well for transplant. And sometimes, you know, 20% of our list is on hold, cuz they’re too well for transplant.

S: So so I understand the reasoning to preserve the function of the transplanted kidney for as long as possible but gosh, I can imagine it’s tough to hear we are now gonna wait till your GFR drops enough to start feeling crummy!

M: Wait a minute, what does it look like for these patients? Are you just following up quarterly with transplant nephrologist waiting to be listed as active?

T: Well, most patients are assigned a transplant coordinator that checks in regularly and instructs the patient to reach out if anything changes in their health. I mean, at the end of the day, everyone wants to activate these patients. 

S:  Isn’t this risky tho? Waiting for them to be symptomatic and crossing fingers they get a kidney in time? 

T: Shrey, That’s a great point, and a great question! But when people get to this level of this kidney dysfunction, its usually a pretty slow progression. im sure you teach on rounds all the time, or at least I hope you do, the acute indications for dialysis, AEIOU (Acidosis, electrolytes, intoxication, overload and uremia) Well in the outpatient setting, Volume, Potassium and Uremia make up 99% of the reasons we pull the trigger to dialyze, and for two of those, we have augmenting medications of sorts, you know, diuretics and potassium binders, so we get to buy time. It’s when people become diuretic resistant, have persistent hyperkalemia, or we start getting subtle uremic symptoms like  “you’ve lost 5lbs and you are sleeping 12 hours a day?” that we start to really consider dialysis. Its kind hard bc a lot of signs of early signs of uremia look like depression so sometimes I’m trying to tease out if someone is depressed, or they are building up, you know, compound of x that their kidneys cant filter out. My point is, the progression is usually slow, and the transplant people can kind of strategically activate people when first warning signs are showing signs of symptomatic renal failure, but theyre still not on dialysis. 

S: So in the outpatient setting,  its gonna be subtle signs we are going to look for to start dialysis and pull the trigger for active waiting listing. So say they  get on the active list for a transplant then what happens

T: We could be talking years in some cases. 

M: Years… Is the waiting time similar for everyone? 

T: You would think it’s pretty similar, given that everyone has to pass a standardized screening criteria. But the answer is… like so many things in medicine. Kind of. Certain blood types, presence of HLA antigens and where they live and where get listed have a lot of weight in how fast a patient gets a kidney off the transplant  list. 

S: So let’s break that down a little more and start with blood type. How much does that really influence?

Dr. Karin True: So the most common, um, blood type, uh, waiting for transplant is blood typo, as you would imagine. So if you have blood type O, you’re probably gonna wait longer. Um, also blood type B is overrepresented on the kidney deceased donor transplant waiting list, largely due to, uh, patients with black race being more likely to have blood type B. So that is another blood type that waits a little bit longer, um, for transplant ..A and AB are, are less time. So if you happen to develop a lot of HLA antibodies to very common HLA antigens in the population, then it’s going to be harder to find a kidney that matches for you.

M: Hah, it didnt really occur to me transplant waiting times another factor in the many health disparities that our patients of color face

T: Yeah this is something we are becoming increasingly aware of and   — this is one of the reasons why we don’t take race into account when giving an estimated GFR because many times it was leading to many patients NOT being able to be listed because their GFR was hanging right above the 20 threshold

S: Thats a great point and its humbling to know that other socio demographic factor like geography that plays into a huge factor.

Dr. Karin True: So if you are in the market for a deceased donor transplant, you want to live somewhere where there’s not a lot of kidney disease. Cause you can imagine if your community has a lot of kidney disease, when those patients potential donors pass away, if they already have kidney disease, they will likely not be acceptable, kidney donors. So in somewhere like, um, in the Southeast, um, up in New York, the waiting times in California are very long. So those, those do influence how long patients wait in the Midwest or the center part of the country, the waiting times are a lot lower. Like California’s, it can be eight or nine years. And then in the Midwest it may only be one or two. Um, so yeah, it’s, it’s pretty crazy

M: Whoa 1-2 years compared to 8-9 years!

T:  I know its nuts to think how much longer people have to wait based on where they live. For this reason I’ve encouraged my patients, and had patients who are listed in multiple sites.  And thats something the primary care side can encourage too, because a lot of times, the patients look at me like they’ve never heard that before. 

S: But what that means you need to travel fast to any location to get the kidney in time if it becomes available, which also where health disparities can really creep in

Dr. Martha Pavlakis: I mean, the, the disparity in access based on where you live was indefensible. And we are working on diminishing that. But if I see a patient who has an option to list at a center in a place where the list moves faster, I will absolutely support them going there less than 5% of the list is my understanding multiple lists. And the reason for that is that it costs money. You, if you’re gonna multiple lists in Iowa, you have to be able to fly there and meet the team, fly home, again, go out periodically to update your workup. And then when they have a kidney and they call you, they have to be able to get on a plane and go straight there. And most people don’t have that kind of excess cash. So multiple listing outside of your immediate area is probably the best way to expand your, your pool of, uh, organ donors, but the least accessible to people.

M: You know I appreciate that strategy but that does does seem like it would benefit a select demographic. Are there any other strategies for getting a kidney faster?

Dr. Martha Pavlakis: So a very straightforward way of expanding the pool of donors is signing up for, and you have to sign a consent for hepatitis C infected donor. This is a surgery we would never have done in the past with our poor therapies for Hep C. But now that we have such wonderful therapies, Hep C donors, um, are not only a very good option for a Hep C naive person, but really a very good way to expand the list of the pool of donors. You have access to the caveat is that you will most likely, although not a hundred percent get hepatitis C from the organ, we will pick it up almost immediately. And we will begin treatment three months of which rarely six will result in a sustained viral response. And, and that’ll be that. 

S: Another reason to be grateful for the new Hep C treatments. Anything else we can do to increase access for our patients to kidney transplants!

T: And the last thing that comes to mind is KDPI and that basically scores a donor kidney gets. It’s give a number 0 to 100% where the higher the percentage, the more frail the kidney is. So its like reverse percentage that we are used to since here, a high number is worse

Dr. Karin True: Whereas a standards a standard standard deceased stone or kidney, would it be expected to last 12 to 14 years on average, a higher KDPI kidney. It may only be seven, eight or nine years, but if you are coming to me and you’re 75 years old, you don’t need a kidney necessarily that’s gonna last you the next 40 years, whereas you do when you’re 20. Um, so for certain patients who are at a higher risk for having a medical complication while waiting for a standard criteria, sort of standard KD P kidney, those are the patients we would potentially approach for a high KDPI kidney

S: So my big take aways is once a patient is listed for a kidney transplant, how much time they have wait for a kidney  depend  on their blood type, if the have HLA antigens, where you live, the wait time can be anywhere from 8-9 years or less if you are in an area with less demand/kidney disease. but we often wait until their GFR drops a bit more in the teens and for a patient to become symptomatic though subtle uremic symptoms for active listing

   Pearl 5: How do living donation work, and what are the risks?

S: The conversation so far is all about transplants from a deceased donor but one part we have not covered is getting a kidney from a living donor that might be a match  

Dr. Martha Pavlakis: So starting off with living donation, that is the best hands down. Number one, the transplant can be scheduled. So it’s not a surprise in the middle of the night. Number two, it’s usually a healthier kidney because the person is living in well versus somebody who’s died. And the family’s donated the organs. Number three, you can usually get it faster because there’s no waiting on a list for a live donor kidney. You just have a donor. And then we schedule the surgery when the time is right. So living donor transplant always the best 

T: I got to experience this first hand actually. One of my first patients in fellowship went through this exact scenario, and he had 4 friends lined up to donate. And  in North carolina at least his waiting time would have been 6+. And that’s 6 years he wouldn’t have to do dialysis.

M: No doubt that’s amazing.  So cutting down wait time is a major bonus, but there are other benefits to living donor. 

Dr. Karin True: Overall they last longer. So whereas a deceased donor standard deceased donor kidney may last, the half life we talk about, which is half of them are working. Half of them aren’t might be around 12 – 13 years. Uh, living donor kidney could be 15, 16, maybe more so they work better and last longer overall. 

T: I think the record I heard in fellowship was a patient with like 25 years or something from a living donor kidney, and going strong! I mean if you think about it, the surgery can be timed up to minimize the amount of time the kidney is not receiving blood. 

Dr. Karin True: You know, that’s what we call cold ischemia times. So the number of hours that the kidney is out of the body on ice are being pumped with cold solution. Um, the longer, the cold ischemia time, um, the higher, the risk that the kidney won’t work right away or potentially, um, won’t work as well for as long. So if you can imagine, if you have a living donor that’s in the, or right next to you, or, um, the kidney is out of the body a lot less long, the cold day ischemia of time is, is nothing. Um, so those kidneys tend to work right away. 

M: See that makes a ton of sense to me.  So we’re seeing that a living donor kidney is for sure better, but can we talk about who actually qualifies to give up one of their beans?

T: Definitely, super important. In terms of who is eligible, patients need to be over the age of 18 or 21 in some hospitals, and have to be considered stable from a medical and psychological perspective. From a medical perspective, they really want the healthiest living donors because of small, but still present risks

S: Yeah we’ve focused so much on the recipient here, we don’t really stop and think from the donors point of view. What are some of those risks?

Dr. Karin True: So there’s been some data that shows that over the five or 10 years after donation at patient’s blood pressure might rise by about five or 10 millimeters of mercury. So if you have somebody who is sort of borderline high blood pressure after donation, they may be pushed into a, a realm where they’re actually hypertensive now.

S: I guess 5 to 10 mmhg may not be that clinically significant but i guess higher blood pressure makes sense if we think of the fact that the donor is actually losing one of their kidneys

Dr. Karin True: Then sort of letting them know that now they do technically have chronic kidney disease, right? They have roughly 50% less GFR than they had. Although over time, the remaining kidney will, um, hypertrophy free, slightly and take over some of that lost renal function from the kidney that got taken out, but they will permanently lose about 25 to 30% of kidney function following donation

T: That being said, I do make sure to clarify to any potential donor the actual length and quality of life they will have going forward really doesn’t vary thaaaaat much, if at all.

Dr. Martha Pavlakis: So in quoting risks to donors, when I first started in this field, we used to say somewhat tongue in cheek that donors live longer than the general population. Not because donating kidney makes should live longer, but because you’re joining a select group of very healthy people and people with heart disease and diabetes and C O P D and et cetera, et cetera, are not allowed to donate. Then some data came out showing that donors, if you compare them to say broad groups of, uh, healthy adults without hypertension, that they had no different survival, no different kidney survival, no different overall survival.  And then some data came out suggesting that a subgroup of young African American donors who donated to family members actually did have a small but slightly increased risk of renal failure going forward. And this was largely if you looked at a more granular level people who then developed diabetes and hypertension, uh, after donation. So we no longer quote to donors that donation won’t impact their long term health. But we say that there is a very slight increase in the risk of long term kidney health … ending up on dialysis or needing a transplant. And we do our best to counsel people to avoid the conditions or to treat them immediately if they’re found, um, that would lead to any kidney damage such as the common ones, hypertension, heavy NSAIDs, use of smoking, things like that.

M: I am definitely familiar with some of the older literature about the quote protective effect unquote of being a kidney donor, which as Dr. Pavlakis points out was related to the selection bias in donor identification, so it’s interesting that newer literature questions some of that… but let’s talk about that workup – how to we prepare folks who are considering kidney donation? 

Dr. Karin True: Um, we order tons of labs looking for, you know, borderline diabetes, you know, other, other problems. We do screening imaging, including chest x-ray native kidney ultrasound. They get a CT scan of their abdomen and pelvis looking at the number of vessels that they have to each kidney, because that’s important if there’s multiple vessels, that can be a more complicated surgery for the donor and for the recipient.

S: I’m glad the transplant team does this extensive workup to really really make sure the living donor isn’t at higher risk of kidney failure in the future, but I can imagine that the psychological aspect is equally as important

Dr. Karin True: They see our social worker and psychologist… it’s very important on the living donor side to make sure, um, people aren’t feeling coerced into being a donor. As you can imagine, if you have a family member that needs a kidney transplant, there could be a lot of pressure within the family or within friends, for people to be donors. And we, we like to make sure that even if somebody is feeling pressure 

T: We really, really, need to make sure that donors don’t feel exploited. And one of the ways they make sure someone isn’t caving to pressure from family, friends, or the medical team, is that a completely separate team than the team evaluates patient and that separate team’s job is to be the donor’s advocate. 

Dr. Karin True: and then they also see our social workers to make sure that they have adequate support both for the medical recovery and for potentially the financial, um, cost of being a donor. If you have somebody, for instance, who is, you know, a ups driver who has to pick up heavy packages as part of their job, they would have to take probably four to six weeks off after donation before they’re able to physically perform their job. And so the question is, do you have the paid leave or resources to, um, sort of make up for that lost income because that if they don’t, that might be a reason why we would turn them down as a donor.

M: So what I’m hearing is that for all the prepping we do for folks about to get a new kidney, there is just as much attention to the donor.  I’ve definitely been in the situation where my primary care patients have asked me about being a donor and the idea that there might be these hidden costs like lost work is something to talk about head on.  

Dr. Karin True: It’s the only surgery we really do that has no medical benefit for the person having the surgery. Um, but they do get psychological benefit from it. There’s pretty good data that shows whether the, the transplant is successful or not that most living donors don’t regret the decision, uh, to be a living donor. And they very much, um, are glad that they did it.

S: Okay so to summarize the big takeaways on this pearl is that living kidney donation is the best option in minimizing waiting list, being able to schedule the surgery and having a longer life out of that donated kidney from a living person than a deceased person. A donor needs to essentially have a PMHx of basically nothing more so their long-term health with living with only 1 kidney is as good as it can be. There can be a slight increase in their BP (5-10 mghg), but no increase in mortality in these cherry picked healthy individuals. 

M: And that’s a wrap for today’s episode. If you found this episode helpful, please share with your team and colleagues and give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us! If you want to add any of your own tips or share challenges, tweet us and leave a comment on our website page, on instagram or facebook page. 

S: Thank you to our peer reviewer Dr. Surya Mannivanan.    Thank you to  Daksh Bhatia for the audio editing and Dr. Rahul Maheswari for the accompanying graphics. As always we love hearing feedback, email us at hello@coreimpodcast.com. Opinions expressed are our own and do not represent the opinions of any affiliated institutions.

References

Tags: , , , , , ,