Transplant Digest Spring/Summer 2016, Issue No. 20
A Successful Kidney Transplant Patient Symposium Meriam Jayoma-Austria, RN,BScN, CNeph(C) On March 23, 2016, St. Michael’s Transplant Program hosted a pre transplant patient symposium. The patients who were invited to attend are those who are on the upper 35% of the list. These are the patients who might be called either as a primary recipient or back up for a potential kidney transplant within the next 18 months. The purpose of the event was to better equip our patients with knowledge about kidney transplantation and the kidney allocation system in Ontario. It served as a medium for re-educating our patients on what to do while they are waiting for a kidney, how to deal with psychosocial issues pre transplant and what happens and what to do when they are called for a transplant. The post-transplant nurses provided an overview about life after getting the kidney transplant. The living donor program also shared some latest initiatives in the living donation process. The symposium was well attended by patients and their significant others. As matter of fact the venue was half full before the registration started at 8AM.
In this issue ... A Successful Kidney Transplant Patient Symposium From the Editor’s Desk Contact Information A Reflection on Organ Donation and Kidney Transplantation Behind the Scenes in the Transplant Clinic Growing Your New Kidney in the Lab High Cholesterol after Kidney Transplantation
Many thanks to all our speakers Dr. Zaltzman, Dr. Prasad, Suela Cella, SW, Sarah Mattok, RN, Fernanda Shamy,RN and Maureen Conelly,RN. Thank you to Mona Udit and Susie Par for helping organize the event and for the support of our manager, Jonathan Fetros. Last but certainly not least, thank you to all our referring dialysis centers for reminding the patients to attend.
Zika Virus: Just the Facts
We wish all our patients the best and a successful kidney transplant.
Cost of the Transplant Medications
Post Transplant Chat - Blood Pressure and Kidney Transplantation
Grapefruit and other Citrus Fruits Could Cause Serious Adverse Effects Kidney Recipient and his Family Hold Fundraising Dinner Event Events Transplant Digest is 10 years old! A Big Thank You to Families and Friends Meet our Team
TRANSPLANT DIGEST SPRING/SUMMER 2016, Issue No.20
From the Editor’s Desk Welcome to our 10th Anniversary issue of Transplant Digest! Since 2006, our twice yearly publication has provided important information to patients and their families, as well as other health care providers on a reliable schedule. Hopefully there has been some entertainment for you along the way too. I’m not sure how many of you remember our first issue or some of the earlier issues, but in case you don’t, or have received your transplant more recently, all our previous 19 issues are available for download on the St. Michael’s website. I’m personally interested in knowing if you have a favorite article from the past, or if you have any other suggestions about improving Transplant Digest for the next ten years.
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As part of our celebration, this issue is picture-heavy. Many new staff joined us over the past ten years. There is a nostalgic article written by our Director Dr. Zaltzman. We have also run through the whole gamut of medical topics, and so it is time to start the series again with articles about high blood pressure (as part of PostTransplant Chat) and high cholesterol. There is an article LEVEL 1 on Zika virus for transplant patients. There is a long overdue 61 Queen St. E. BONDin STREET St. article on behind-the-scenes activity the Transplant Clinic, andHealth aMichael’s special thanks to families and friends Centre of our patients. There is an especially wide range of events covered, through the assistance of our Senior 8 Li Ka Shing 55 Queen St. E. International News Correspondent 6Galo Meliton. We 7 always need more articles from patients. Remember, the Digest BOND WING Healthcare Education existsCentrebecause of you, and is about you. SHUTER WING
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Please send your comments or suggestions of topics for future publication to: jayomam@smh.ca Disclaimer Note: Views presented in this newsletter are those of the writers and do not necessarily reflect those of St. Michael’s Hospital or the University of Toronto. Subject matter should not be construed as specific medical advice and may not be relevant to individual patient circumstances. For all questions related to your own health please contact your health care provider.
A Reflection on Organ Donation and Kidney Transplantation Dr. Jeff Zaltzman
As I write this article for our 10th Anniversary Transplant Digest edition, I look back at my own time as a transplant physician at St. Michael’s. When I began my career in 1994, we were performing 40-45 kidney transplants annually. Today in 2016, St. Michael’s does 130-140 transplants per year. In some years we perform more deceased donor kidney transplants than anywhere else in Canada. The adult Toronto Transplant centers at University Health Network and St. Michael’s are the two largest programs in the country. How has all this happened? First, since its establishment in 2001, the Ontario organ donation network, Trillium Gift of Life, has been able to make tremendous strides in increasing organ donation. In 2001, there were on average 140 deceased donors
per year. In recent years that number has been greater than 250 deceased donors with 265 in 2014 and 269 in 2015, both record years! Ontario has led the country in all best practices in organ donation with a strong leadership role in the promotion of organ donation after cardiac death. Twenty-nine percent of all eligible Ontarians have registered as organ and tissue donors. Trillium Gift of Life now plays a role in transplantation as well as organ donation. With regard to kidney transplant, two years ago the Ontario kidney transplant programs reached an agreement as to how to better and more equitably allocate kidneys to Ontarians on the kidney waiting list. Today kidneys are shared among programs, allocated to the patient truly most in need. The use of better 3
donor-recipient matching techniques has helped to improve transplant outcomes. The results after 2 years show that our goals of improving equitable access to kidneys and better outcomes are being realized. At St. Michael’s we have invested a lot of resources and developed and implemented new technologies to improve our program and patients’ experiences. We are proud to have a dedicated team of nurses, allied heath professionals, clerical staff, a research team and laboratory and radiology partners. We currently have 5 transplant surgeons, 3 posttransplant nephrologists and 3 living kidney donor nephrologists. All the nephrologists at St. Michael’s are involved in the care of our transplant recipients when they are admitted to hospital. We work closely with our referring dialysis centers to help manage the patients on the wait-list, in addition to those who are being evaluated, and recipients who are coming forward with living donors. Our staff has been involved in local initiatives and educational events, in addition to provincial and national programs. We were pioneers in Canada in using minimally invasive surgery for kidney donation. Along with University Health Network, we were the first program in the country to do kidney paired donation for incompatible donor/recipient pairs. This initiative laid the ground work for a very successful national kidney paired donation program. Since 2008, there have been close to 400 kidney transplants that otherwise would not have been done. St. Michael’s is the only hospital in North America to use special proprietary columns to do transplants between donors and recipients with incompatible blood types. There are challenges however. Most of the growth in deceased donors has come from the use of older donors with more co-morbidities. In addition the average age of our kidney recipients has increased from 45 to 55 years old. Today it is not uncommon to
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transplant patients who are in their mid 70s. When I started in 1994 it was unheard of for any patient who was greater than 65 years old to be considered for a kidney transplant. Our donor and recipient populations are both older and sicker. This means that we, as well as our patients must accept higher risks related to transplantation. The best transplant outcomes are achieved through living donation. With living donation we can plan the date of the surgery, the kidney transplants last considerably longer and the waiting is much shorter. Despite better organ donor rates, annually 2% of those on the Ontario kidney wait-list die every year and additional 3.5% must be removed from the waitlist because they are too ill. We need to continue to promote living donation. While the 1-year kidney graft survival rates are ~95% for the average patient, the kidney transplant community worldwide has not been able to have a significant impact on long-term survival. Keeping kidney transplants lasting longer has been a major challenge. With increasing number of transplants being done, our post- transplant clinic care in terms of patient numbers is becoming a challenge. When I started in 1994, we were looking after 300 patients. Today we follow approximately 1700 post-transplant recipients. Our clinic space has not grown! Despite these issues, we continue to adapt to the challenges. It is our goal to have better clinic space to help care for our patients. In addition, we will need to better work with our community nephrologists to help with co-managing of our patients. My last message to you today is to promote organ and tissue donation. Make sure your friends and family are aware. Everyone can register to be a donor at www.beadonor.ca.
Thanks for a great 22 years so far!
Behind the Scenes in the Transplant Clinic Dr. Ramesh Prasad The typical transplant patient sees only a few parts of the Transplant Clinic on the 9th floor of 61 Queen. These are the waiting area and the examination room, and maybe the doctor’s office, washroom, and urine lab. But what is going on behind the ominous closed doors to your left, when you enter the Transplant Clinic? If you are eager to know, here is some of what goes on there. There are a number of desks, each with an Administrative Assistant, Nurse, or Nurse Coordinator. There is a HUGE photocopier and a laser printer. We do have some indoor plants though. Everyone has a telephone. Needless to say, there are a lot of phone calls that come in throughout the day. These are directed by one of our Administrative Assistants to the right person. Most, if not all calls are returned in a timely manner. There are piles of paper and lots of mailboxes. The paper includes lab reports, radiology reports, faxes from pharmacies for repeat prescriptions, reports from other hospitals, and charts of pre-transplant patients in various stages of processing. All of these flow in and out, in a steady, systematic manner so that the right decisions can be made by the right person with the help of the right information, and the right action taken. Clinic hours and seeing patients represent only a small part of the total activity in the Transplant Clinic. Is there really a need for secrecy? Patient confidentiality is of course extremely important. The main reason these doors are closed is because the space inside is quite tight. It would be unsafe for there to be too much movement inside by visitors. It’s as simple as that. If you have a need to speak with someone, please ask at the front desk and we can at least pass on a message, if the concerned person is unable to come out right away.
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The Future for Kidney Transplantation: Growing Your New Kidney in the Lab Dr. Darren Yuen Kidney transplantation has revolutionized the care of patients with kidney failure, allowing people to live longer and better. And despite this major advance, we still face major challenges, including a huge shortage of high quality kidneys for transplantation, and the need for drugs to prevent rejection. What if we could solve these problems? What if we could increase the numbers of kidneys, and make them personalized for you? It may sound like science fiction, but researchers in Toronto and around the world are working on these exact problems. While scientists have long pondered how to grow organs, the ability to do so has seemed, even for those us working in the lab, far fetched. However, two major advances have made what would have seemed impossible even 10 years ago, a realistic goal to strive for.
The first step: growing stem cells from skin
In 2006, Dr. Shinya Yamanaka was the first to show that cells grown from a small skin biopsy could be coaxed into becoming “induced pluripotent stem cells” (iPS cells). These cells have the remarkable potential to differentiate into any cell of the body. Using mice, Dr. Yamanaka was able to take skin cell from a mouse, and to generate a genetically identical mouse from that one cell. This discovery, earning Dr. Yamanaka the Nobel Prize in 2012, has revolutionized our understanding of stem cells. Scientists around the world are now racing to use this iPS cell technology to grow cells that make up each organ in the body. For people in the kidney field, this has meant taking skin cells, producing iPS cells, and then coaxing them to become the various cells that make up the kidney. Excitingly, the first reports that kidney cells could be generated using this iPS technology were reported by researchers in Australia and the United States in 2015. Why are these discoveries important? A critical problem in the organ transplant world has been our reliance on transplanting someone else’s kidney into a recipient. Unless the donor and recipient are identical twins, the recipient’s immune system will recognize the donor kidney as being “foreign”, and will try to reject it. This immune response is the reason why we need to use powerful anti-rejection drugs to keep kidneys from undergoing rejection. Being able to take a small skin biopsy from a potential recipient, and grow kidney cells from that skin, would theoretically eliminate the need for anti-rejection drugs, as these cells would be derived from the recipient, not from someone else.
The second step: reassembling a complete kidney Growing kidney cells is only the first step. We next have to assemble these kidney cells into a functioning organ. Until recently, scientists have had difficulty in organizing the billions of cells that make up an adult kidney into their proper locations. A key discovery, made by Dr. Doris Taylor in 2008, has provided a possible solution. She reasoned that cells need to be guided to their proper location by a scaffold, in much the same way that the wood frame of a house guides the location of the walls, plumbing, and electrical wires. For organs, the scaffold is a protein and carbohydrate matrix that the cells sit on. In a landmark study, Dr. Taylor took a rat heart and washed away all the cells in a process called “decellularization”, leaving only this matrix scaffold. She then took heart stem cells and infused them into the scaffold to “recellularize” it. Remarkably, the cells were able to organize themselves along this scaffold to create a beating heart, populated with the heart cells that she had infused. Using this same strategy, various groups in the United States, have gone on to produce prototype recellularized lungs and kidneys. Impressively, the recellularized kidney was able to produce urine in the lab.
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What does this mean?
This ability to recellularize organ scaffolds, combined with Dr. Yamanaka’s discovery that has allowed scientists to create a personalized repertoire of our own stem cells, has revolutionized the field of regenerative medicine. Scientists are now envisioning the ability to take organs from pigs, decellularize them, and to repopulate them with cells grown from your skin. In this way, we could potentially have an unlimited supply of organs that could be personalized to the patient. Since the organs would contain the patient’s own cells, they would theoretically not be at risk of rejection, and so anti-rejection medications may not be required.
The remaining challenges
While these advances are certainly exciting, a number of important challenges remain. While regenerative medicine researchers have been able to create a prototype kidney that produces urine in the lab, the function of the kidney was low. The urine output was only monitored for a short time, and it was only tested in the lab. We currently do not know if the kidney would function well enough if it is actually transplanted into a recipient, and how long it would last. Moreover, the actual organization of the cells within the kidney was quite rudimentary, lacking the many important but subtle features of a normal human kidney. Scientists here in Toronto and around the world are now working hard to try to address these challenges.
A future of unlimited, personal kidneys for transplantation
Despite these limitations, these advances have offered new hope for patients with kidney failure. Instead of waiting on the list for years awaiting a kidney from a suitable donor, patients may in the future be able to have a small skin biopsy that could be used to “grow” a kidney that requires no anti-rejection drugs. Future work, being conducted both here in Toronto and around the world, will hopefully bring this possibility closer to reality.
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High Cholesterol after Kidney Transplantation Dr. Ramesh Prasad
Among the risk factors for heart disease after a kidney transplant, high cholesterol, or “hyperlipidemia” occupies an important place. It is discussed quite often in the Transplant Clinic. We have known that high cholesterol, especially the “bad” cholesterol or LDL, is associated with heart disease specifically in kidney transplant patients for more than ten years now, just as in the general population. This benefit of heart disease lowering appears even when the right medication is started a few years after the transplant. A high cholesterol may even affect the survival of your transplant, although the data for this are not as strong. S o m e t i m e s patients develop high cholesterol for the first time after a transplant. Why is this so? It may be a genetic reason, and appears only because you are getting older. It may be related to diet of course, along with other effects like gaining too much weight. Transplant drugs also have a role. Cyclosporine and sirolimus, as well as prednisone and to some extent tacrolimus are all associated with high cholesterol levels. Patients with diabetes and a fat abdomen who are sedentary or have protein in the urine may also be at higher risk for high or abnormal cholesterol (called “dyslipidemia”). We check the blood cholesterol level after 8-12 hours of fasting, at least once every six months. Repeat testing is performed to confirm the diagnosis, and assess the response to treatment. Testing itself
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serves as a powerful motivating force for patients. Although there are some recommendations that fasting is not needed in the general population, this is not true for transplant patients because the risk for heart disease is increased in general. Also, the drugs may alter the way different types of cholesterol are related to one another. We look not just at the total cholesterol and LDL cholesterol, but also the “non-HDL cholesterol” and triglycerides. If you would like to know more about these cholesterol subtypes, please ask during your Transplant Clinic visit. Does high cholesterol have to be treated? This depends on your heart disease risk. It is possible that if your risk is low you can defer treatment for some time, but this is unusual since kidney disease itself is associated with heart disease. Most of the time however, a high cholesterol cannot just be wished away because you can’t “feel” a high cholesterol. A medication like a statin is often started. Statins are typically safe to use when properly monitored, although the doses we use in transplant patients are often lower in transplant patients because of an interaction with the anti-rejection drugs. While a healthy diet is obviously encouraged, please stay away from herbal medications to treat high cholesterol. The amount of statin-like substance present in these is not standardized in type and amount, and so the reaction inside your body can be both unpredictable and dangerous.
Zika Virus: Just the Facts Sarah Mattok, RN, BScN, C Neph (C) What is it?
Zika is a virus that is transmitted by a specific type of mosquito, called the Aedes mosquito. This is the same species of mosquito that transmits the Dengue and Chikungunya viruses. There is no known vaccine or medicines to treat Zika virus at this time.
How can I catch it?
Zika virus is transmitted by mosquito bites in affected countries. In some rare cases, the disease can be transmitted through sexual intercourse, or from a pregnant woman to her fetus. It has spread quickly through South and Central America, including popular vacation spots such as Dominican Republic and Mexico. The only infections in Canada and the United States have been in people who have travelled to affected countries. For the latest information on affected areas, see www.cdc.gov/zika/geo/
How does it affect transplant recipients?
We do not know how severe the Zika disease could be in transplant recipients. We have not seen anything so far. According to reports in non-transplant patients, some could have no symptoms, some may have a mild case, and it could be severe in some cases.
How do I know if I have it?
Symptoms usually appear a few days after being infected. Only about 1 in 5 people will develop symptoms. These may include: fever, rash, joint pain, body aches, headaches, or red eyes. For most people, these symptoms go away after about a week. It is not known if it affects transplant recipients differently. If you have these symptoms and have been to an area where Zika is found, see a healthcare provider.
How is it treated?
There is no cure for Zika. Treatment involves relieving the symptoms with medications to treat the pain, fluids, and plenty of rest. Remember that kidney transplant patients should not take anti-inflammatory medicines (sometimes called NSAIDs) because they can damage your kidney. Tell your healthcare provider about all the medicines you are taking.
How can I prevent it?
Think carefully about whether you need to travel to an affected country. If you do decide to travel to a country affected by Zika, it is very important to prevent mosquito bites. The mosquitoes that carry this virus usually bite during the daytime. Be sure to wear mosquito repellent with DEET at all times. You can also cover up with light-coloured long-sleeved pants and shirts. Make sure there are screens on your windows when you are sleeping, or sleep under a mosquito net. Men and women who have travelled to areas where Zika virus occurs should use safer sexual practices for at least four weeks after returning home. Pregnant women whose partners have returned from these areas should use safer sex practices throughout their pregnancy, including always using condoms, or abstaining from sexual activity.
How can I find out more?
We recommend you visit a Travel Health Clinic at least 6 weeks before your trip, to find out more information about your destination. For the latest information, you can also visit the World Health Organization’s website: www.who.int/csr/disease/zika/en/.
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Post Transplant Chat - Blood Pressure and Kidney Transplantation Sarah Mattok RN, Fernanda Shamy RN, Jennie Huckle RN, Michelle Gabriel RN, Kevin Bradley RN 1) What is blood pressure? What is a normal blood pressure? When the heart beats, it pumps blood through your arteries. Blood pressure is a measurement of how hard the blood is pushed against the walls of the arteries when it is pumped by the heart. There are two numbers in a blood pressure. The top number (the systolic) is the pressure in the artery walls during a heartbeat. The bottom number (the diastolic) is the pressure in the artery walls between heartbeats. Normal blood pressure is different for everybody, but for most people 120/80 is best. 2) What is high blood pressure? High blood pressure (also called hypertension) is when the heart is working harder to pump blood. Most people don’t have any symptoms of high blood pressure, but it can cause damage in your body without you knowing it. It can lead to problems like heart disease, heart attack, stroke, kidney damage, and blindness. For people with kidney transplants who do not have diabetes, blood pressure should be under 140/90. For those with a transplant and diabetes, blood pressure should be under 130/80. 3) W hy do you check the blood pressure every time I come to clinic? We are checking that your blood pressure is not too high or too low. This can tell us if you need more medicine or if your medicines need to be changed. 4) Why do you check the BP in more than one position, like sitting and standing? Why check it multiple times? Some people’s blood pressure drops when they stand up. This can make them dizzy and more likely to have falls or feel unwell. We check the blood pressure sitting then standing up to help us see if this happens to you. If we check your blood pressure and it is high, we may repeat the blood pressure several times. For many people, once they have a chance to sit quietly for a few minutes, their blood pressure goes back to normal range. 5) Is it useful if I check my BP at home? Yes! For many people, coming to a doctor’s visit can be stressful, which can make your blood pressure high. 10
If you check your blood pressure regularly at home, write down the readings and bring them to clinic with you. This gives us a better idea of what your blood pressure is on a normal day, and whether you need help achieving a better blood pressure. 6) What is ambulatory BP monitoring? People’s blood pressures fluctuate. It may be helpful for some people to wear a blood pressure cuff for 24 or 48 hours. This will record several readings throughout the day and night. This can show what your blood pressure is really like on a normal day for you. If you require this service, there may be a cost to you. 7) Does high BP always have to be treated? Usually this is the case. There may some rare exceptions, but most people need to have high BP treated to prevent long-term complications. 8) How many medicines are usually needed to control the BP? This is different for everybody. Some people can lower their blood pressure with changes to their diet and weight loss. Other people need several medications to control their blood pressure. Although 2-3 medications is usual, requiring up to 5-6 medications for high BP is not uncommon. 9) Why are my BP medicines and their doses sometimes switched? There could be many reasons. The dose may be increased because you need more of the same medicine to control your blood pressure. Sometimes medicines are switched because they are no longer effective in controlling your blood pressure or you have side effects that are bothersome. 10) My BP at home is high right now. What should I do? Check several readings at different times of the day. If you are concerned, consult a healthcare provider as soon as possible. If you have a severe headache, blurry vision, nausea, chest pain, weakness, or other serious symptoms you should go to the nearest Emergency Room. 11) Is there such a thing as low BP? Is this harmful? Low blood pressure (also called hypotension) is usually defined as less than 90/60. This can happen for many reasons, such as dehydration, not enough salt in your body, too much blood pressure medicine, or heart disease. It could be dangerous if it makes you feel dizzy or weak, and could lead to falls and injury. It could also impair blood flow and oxygen delivery to your organs which damage them.
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Cost of the Transplant Medications Suela Cela,MSW
One of the important things that you should consider with a kidney transplant is the cost of the medications you must take after your kidney transplant. In order for you to keep your new kidney healthy you will need to take medications for the rest of your life. The cost of post-transplant medication is often a source of concern for many individuals who are planning to receive a kidney transplant in the future. That is why it is essential to address this prior to your kidney transplant. Your medication coverage is discussed in detail during your pre-transplant assessment with your Pre-Transplant Social Worker. What are the costs of transplant medicines? The cost of your transplant medicines will be covered when you are in the hospital. However, when you go home you must be ready to pay for your medications. The cost of medications can be from $1,200 to $3,000 per month. St. Michael’s Hospital does not have a drug assistance program. We will not give you medications for you to bring home. Private drug coverage or provincial plans will cover most of the costs for your medications. Some private plans expect you to pay for your medications first. Then you have to send your receipts to get the money back later. If you are on this type of plan, it may help to get a credit card and have payment options in place.
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Are there other programs that can help me with the cost? The only programs that cover 100% of your medication costs are: • Private Plan with no limit and 100% coverage • Ontario Drug Benefit plan as a senior citizen (65 years of age or older) • Ontario Drug Benefit plan while on Ontario Works • Ontario Drug Benefit plan while on Ontario Disability Support Program There are times when your private insurance may not pay for 100% of your medicine and/or you may have no access to Ontario Drug Benefit (ODB) plan. In this case, you must apply for the Trillium Drug Program. You should submit a medication list to your insurance company for pre-approval. This list is part of your pre-transplant package which you receive at the beginning of the work-up process. Also, you can request this list from your Pre-transplant Social Worker. You need to have Medication coverage to be eligible for a kidney transplant and it has to be in place before approval for transplant. Medication coverage and available programs will be discussed with you when you meet with Pre-Transplant Social Worker during your transplant evaluation process.
All patients must have medication coverage BEFORE being placed on the transplant deceased donor waiting list or proceeding with a living donor transplant.
How does the Trillium Drug Program work? The Trillium Drug Program (TDP) is a provincial government drug benefit program that helps people with the cost of their medicine. You must complete an application form before being accepted into the program. When you are going to use the Trillium Drug Program, you must pay a fee 4 times per year (deductible). This fee is based on your last year’s family income. Even if you do not need to use the program to pay for your medicines, we still suggest you apply to the program. You will not be charged a fee unless you need to use the program. There is no cost to register with the TDP. The application takes only a few minutes to complete. You can get applications online or through your Social Worker. You can download the application
for the Trillium Drug Program at: http://health.gov. on.ca/en/public/programs/drugs/opdp_forms.aspx. REGARDLESS OF DRUG COVERAGE THROUGH PRIVATE INSURANCE, YOU MUST HAVE ONTARIO DRUG BENEFIT (ODB) COVERAGE – TRILLIUM, SENIORS BENEFITS, OW/ODSP – IN PLACE before your kidney transplant surgery. Please remember: Paying for your medication posttransplant is your responsibility. If you do not have 100% medication coverage and are not enrolled with Trillium Drug Program before transplant, please contact your Pre-Transplant Social Worker: Suela Cela at: 416-867-7460 ext. 8244 or via email: celas@ smh.ca.
Did You Know….Grapefruit and other citrus fruits could cause serious adverse effects Galo Meliton, RN, C Neph (C), Senior News Correspondent An article in the Canadian Medical Association Journal by D. Bailey et al in March 2013 outlined a summary of available scientifically valid evidence from articles that discussed the interaction between grapefruit with several medications, including those used in preventing kidney rejection (anti-rejection medications). The article described the interaction between chemicals in grapefruit called furanocoumarins increasing the drug level, potentially causing serious adverse effects. Some of the adverse effects mentioned include severe kidney damage. In as much as the anti-rejection medications are good in preventing rejection, double or triple the amount of it in your system could potentially damage your kidney transplant. This is why it is very important we follow your drug levels. Because the chemicals furanocoumarins are natural in grapefruit, all forms of the fruit (freshly squeezed, juice, frozen concentrate, and whole fruit) have the potential to cause the same adverse effects. The article mentioned other citrus fruits that could also cause the same adverse effects: Seville oranges (often used in marmalades), limes, and pomelos. Varieties of sweet orange, such as navel or valencia, do not contain furanocoumarins and do not produce the same interaction. We welcome any questions you may have about this issue. Kindly address them by calling the post -transplant clinic or when you are being seen in clinic. Thanks go to Lucy Chen, Clinical Pharmacist and Jenny Accettura, Registered Dietician for reviewing this article for the Transplant Digest. 13
Kidney Recipient and his Family Hold Fundraising Dinner Event Galo Meliton, RN, C Neph (C), Senior News Correspondent
Angelo and Maria Gwendolyn Caputo and family held a fundraising dinner and dance event on Saturday, June 30, 2016 in Woodbridge, Ontario toward the Kidney Transplant Program at St. Michael’s Hospital. The event was attended by 234 people. The Caputo family graciously donated the funds raised at the event totaling $ 15,460 to the St. Michael’s Hospital Kidney Transplant program. After a buffet antipasto was had by all, the evening started with Angelo, a kidney recipient, describing how he met Gwen, and how they fell in love and eventually getting married in the very hall that the fundraising event took place. Angelo spoke that evening about how transparent he was with Maria from day one when they first met, that he had kidney disease and that he was on chronic dialysis, and yet, much to Angelo’s surprise, she still wanted the relationship going. Another surprise to Angelo was when Gwen proposed that she donate a kidney to him! They found out that they were not blood group compatible (her A to his O). They also found out later on that they were not candidates for the blood group incompatible direct kidney donation using the Glycosorb Columns®, an initiative unique to St. Michael’s Hospital in North America, as Angelo’s blood group A antibody count was way too high!!! Their only other option was to take part in the Kidney Paired Donation Program. Luckily for them, they were matched not long after they were registered in the KPD registry. Luck still on their side, they were both matched to have their surgeries at St. Michael’s Hospital!!! A very delicious dinner was then served and yours truly had the privilege of speaking on behalf of the St. Michael’s Hospital Kidney Transplant program on the many initiatives that our program is currently involved in. Several attendees approached me expressing their gratitude for the information they heard that evening. After a raffle was held for a number of door prizes, the DJ played a variety of tunes and the crowd danced the night away!!! The Renal Transplant Program at St. Michael’s Hospital would like to extend its gratitude to the Caputo family for this very generous gesture. 14
Events Congratulations to Dr. Baker and St Michael’s Hospital! The waiting time in Ontario for organs specifically kidney is fairly long. The “Be a donor” campaign is one of the initiatives implemented by Trillium Gift of Life Network (TGLN), government agency that coordinates and manage organ and tissue donation, in order to raise awareness for the importance of organ and tissue donation and to register their consent for donation. TGLN, awarded Dr. Andrew Baker, Chief, Department of Critical Care Medical Director, Trauma Neurosurgery Program at St. Michael’s Hospital for a Lifetime Achievement Award. Dr. Andrew Baker’s strong advocacy has significantly contributed to the advancement of organ donation in Ontario. Further, his leadership in donation science has illustrated his dedication to advancing donation practices. St. Michael’s Hospital is the recipient for the Hospital Achievement Award from TGLN. The hospital’s conversion rate of more than 80% in 2014/2015 greatly exceeded the provincial target of 67%.
Dr. Baker with his wife Jane Merkley
Kudos to everyone involved in the conversation with patients and families about organ and tissue donation during end-of life decision making. You are the unsung heroes of all the patients on the wait list waiting patiently for their turn to receive that life saving and life changing organs.
World Kidney Day World Kidney Day aims to raise awareness of the importance of our kidneys to our overall health and to reduce the frequency and impact of kidney disease and its associated health problems worldwide.
World Kidney Day organization
St Michael’s Staff…raising awareness on kidney care Dr. Phil Mcfarlane provided a talk on Early Kidney Disease: Signs and Prevention. St. Michael’s home dialysis staff involved in organizing the event. William Osler Health Care Center had various booth displays in their auditorium. Some staff from SMH were invited as guest speakers for the day.
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Research Education and Innovation Event (REIE)
On February 26th the Diabetes Comprehensive Care Program (DCCP) held it bi-annual Research, Education, and Innovation Event (REIE). It was an opportunity to showcase some of the amazing work that DCCP staff and physicians have been involved with over the past two years. The theme of the event was on enhancing the Patient Experience. Dr. Robert Bear, former Chief Medical Officer and Executive Vice President of St. Michael’s Hospital, was the keynote speaker and delivered a thought proving presentation on how healthcare organizations can better foster patient centred care. During the poster exhibit, the Renal Transplant team proudly shared the many projects and initiatives that have taken place, including the Post-Transplant Patient Symposium and the development of new Living Kidney Donation Guidelines.
Lunch with Ella Ferris St Michael’s Hospital Executive Vice President, Programs, Chief Nursing Executive & Chief Health Disciplines Executive Ella Ferris is retiring this year after 43 years of service.
All the best to you Ella!
16
Transplant Digest is 10 years old!!!! Congratulations on the milestone “Congratulations on the 10th Anniversary publication of Transplant Digest. The Digest has consistently chronicled the issues important to the renal transplant program – and done so with the compassion and clarity that patients, donors and their families expect from St. Michael’s. It has also showcased well all the clinical and academic strengths of our transplant team and is used as an educational tool for staff and physicians.
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On this special occasion, I want to thank all the contributors over the past ten years. Taking the time to provide your advice, guidance and expertise has lead to better patient care, improved patient outcomes and marked us as a leader in quality care. A special thank you to Dr. Ramesh Prasad, the Digest’s editor for his excellent editorial insight.” Bob Howard President and CEO
“Congratulations to Dr. Prasad, Editor, and Meriam Jayoma-Austria, Newsletter Coordinator, and the entire renal transplant team at St. Michael’s Hospital, on this 10 year anniversary milestone of Transplant Digest. Each issue brings a wonderful variety of topics relevant to kidneys and kidney transplant health after transplantation. From personal stories of live kidney donation to medical and technical aspects of care, every member of the team including nephrologists, urologists, and the health discipline care team ensures that they tap into important aspects of kidney transplant care for each journal issue. Transplant Digest has provided relevant and useful educational material for patients and providers for the last 10 years, as a result of this team’s commitment and dedication to not only clinical care and research, but also to transplant education. Thank you for reminding all of us that care goes well beyond the date of discharge, and that educating patients and providers is an ongoing element in ensuring our patients live healthier lives. Congratulations again to Ramesh Prasad and his team and I look forward to the next 10-year chapter of Transplant Digest.” Jill Campbell RN, DHA, CHE Regional Director, Ontario Renal Network Program Director, St. Michael’s Hospital
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A Big Thank You to Families and Friends Donation After Cardiac Death (DCD), finally in Toronto
SMH Renal Transplant Program Shows Excellence From the Editor’s Desk Message from... Transplant Trends Paired Kidney Exchange
Nursing Column Overview of the Kidney Transplant Work up
Food for Thought Osteoporosis, “The Silent Thief”
SMH Excellent Team Award Winner 2005 1st Row Left to Right: Dr. Prasad, Dr. McFarlane, Dr. Pace, Dr. Stewart, Dr. Zaltzman, Dr. Honey, Galo Meliton, Jenny Huckle, Farida Basaria
Program Events 2nd Row Left to Right:
Maria Tersigni, Anne Augello, Dorit Najgoldberg, Jacinda Frazer, Meriam Jayoma, Mimi Cheng, Maria Salanga, Michelle Nash, Susie Par, Rose Luong, Trixie Williams, Thelma Carino, Fernanda Shamy, Karen Burleigh, Erin Irving, Lindita Rapi, Niki Dacouris, Lyn Doak
Psychosocial Standpoint Managing Psychological Stress of Transplantation: One Day at at Time.
Transplant Rx Prednisone: Unwanted Steroid?
Issue 3 Fall 2007/Winter 2008
Recognizing Our Heroes
As most of you may know, the shortage of kidney donors has led to long waiting times for a kidney transplant, especially in Toronto. The only source for a viable kidney for those who are on the waiting list is from people who, unfortunately, had accidents or medical events that damaged their brains so severely that they have been declared “brain dead”. However, not all those people who were declared brain dead have been considered as kidney donors. Only those who signed their donor cards, or whose family has consented to donate the organs of their loved ones to someone on the waiting list, are considered donors. Thus, donor shortages persist. In a pioneer effort to help reduce the waiting time for our patients, Dr. Zaltzman and Dr. Andrew Baker, working with The St. Michael's Organ Donation Committee and in conjunction with Trillium Gift of Life has done tremendous work to implement DCD (Donation After Cardiac Death) donation at St. Michael’s Hospital. DCD kidneys have been used in Europe and the United States. Under the leadership of Trillium Gift of Life, with policies derived at St. Michael's Hospital, Ontario became the first province in Canada to have a DCD program. On January 27, 2007, St. Michael’s Hospital transplanted the first Donation after Cardiac Death donor kidney. We are the first in Toronto and ninth in Ontario to do a DCD kidney transplant. DCD provides another possible pool of kidney donors. These kidneys are not any different from kidneys obtained from brain dead donors, and are allocated in the usual way. Hopefully, this will decrease the waiting time for kidney transplants. This is great news for patients who have been on the waiting list. This is a major milestone for the SMH Renal Transplant Program. For more information about DCD, please see the article of Dr. Zaltzman under Transplant Initiatives. Jennifer Meriam Jayoma, RN, C. Neph (C)
Post Transplant Chat
Donation After Cardiac Death (DCD), finally in Toronto From the Editor’s Desk... Milestones Hypertension After Kidney Transplantation Kidney Transplant Workup What it all Means
Transplant Trends Latest Kidney Translpant Initiatives
Post Transplant Chat Peer Support Program Income Tax for Kidney Patients Contact Information
Staff Directory
On Monday, April 16, 2007 the St. Michael's Hospital Renal Transplant team hosted the first Live Kidney Donor Recognition and Education Night. This event was held at the Crown Plaza Hotel in downtown Toronto. We were successful in gathering 204 wonderful individuals who are live kidney donors along with their guests. The Ontario Minister of Health, the Honorable George Smitherman was in attendance at the event, as were members of the media. The Recognition and Education Night was titled, “Your Gift is Life”. Our wish was to truly celebrate and honor our living kidney donors by highlighting the generosity and selflessness of these brave individuals who through selfless sacrifice have enhanced the lives of patients living with chronic kidney disease. The night consisted of presentations from our Nephrologists and Surgeons. Dr. McFarlane gave an account of the history of the live donor program, Dr. Pace described the surgical process, and Dr. Prasad outlined some of the live donor research initiatives at the hospital. A lifetime achievement award was presented by Dr. Zaltzman to Dr. John D’A Honey, who has been performing transplant surgery at St. Michael’s Hospital for over 25 years. Each live kidney donor was honored with a specially designed medal to recognize and commemorate their invaluable contribution to society. The Renal Transplant team recognizes each kidney transplant that takes place as a unique event that is different from every other. The living kidney donation process can never be “taken for granted”. The primary goal of the Live Donor Process is to secure the health of the Donor. Our dedicated staff through many months of planning as well as countless meetings was able to pull together a seamless event. Special thanks goes out to Sharon Lee, Social Worker for the Live Donors; Linda Ahn, Clerical Assistant for the Live Donor team, and Fernanda Shamy, Registered Nurse for the Live Donor who guided the committee through the planning and execution of this successful event. The true heroes in this world indeed are the donors who selflessly give their time, money and effort, enduring great sacrifice and the small possibility of risk to their health in order to enhance the lives of fellow human beings.
SMH Contact Information
Trixie Williams, Clinical Leader/Manager
Questions and Answers About Live Kidney Donation Kidney Allocation
Who is eligible for reimbursement?
Living Donors from the Eye of a Veteran Nurse
PRELOD is available to eligible living organ donors who donate or intend to donate an organ in Ontario to an Ontario resident in need of organ transplantation. A person is eligible for PRELOD as a potential or actual living organ donor if a health history has been completed, reviewed and accepted by a Transplant Service and blood typing has indicated that the person is suitable to proceed with further clinical assessments. PRELOD is eligible to living organ donors who have travelled from outside of Ontario (Canada and International) to donate to an Ontario resident.
From the Editor’s Desk... Contact Information
Congratulations!!! Dr. John Honey and Dr. Jeff Zaltzman Renal Transplant Symposium 2008 Acute Rejection Live Donation What Goes Into a Decision From A Psychosocial Standpoint
Post Transplant Chat
SMH Donor Party
Dr. Andrew Baker Medical Director of Trauma and Neurosurgery Program and Intensive Care Unit St. Michael’s Hospital
Dr. Jeff Zaltzman Medical Director, RenalTransplant Program St. Michael’s Hospital
Issue 7
Fall 2009/Winter 2010
Jennifer Meriam Jayoma-Austria, RN, C.Neph.C
Chronic kidney disease (CKD), leading to kidney failure, is increasing around the world. This has been attributed primarily to aging and increasing numbers of people with diabetes and hypertension. Much of CKD medicine applies to kidney transplant recipients as well. Early detection and prevention of CKD will help population health and conserve costs to the health care system. World Kidney Day, celebrated in March each year, highlights this growing epidemic by promoting screening, prevention and early detection of kidney disease. This is also a good means to increase awareness of the important functions of the kidney to the body and how we should take care of them. This year on March 18, St. Michael’s Renal Program joined the rest of the world in promoting kidney awareness. The event was made possible through the support of the three managers, Trixie Williams, Colleen Johns and Andrzej Gryka, and two pharmaceutical companies, Roche and Novartis. The Kidney Day Awareness event at SMH was held in the Victoria lobby. The purpose of conducting the event in that busy location was to be able to promote it to as many people as possible: not just hospital staff, but also patients, their families and visitors to the hospital From L to R: Jenny Huckle, RN, Jill Campbell coming from all walks of life. It was a half (SMH Diabetes Comprehensive Care Program Director), Jennifer Meriam Jayoma-Austria, RN, day fun-filled event. Staff from the Thelma Carino, RN dialysis unit and transplant unit were present to field questions from other staff and the public about different kidney diseases. The staff also provided information about the different functions of the kidney and how to keep it healthy through a jeopardy game, which proved to be a popular and enjoyable way of teaching and learning. The Risk Modification Center of the hospital conducted a body weight analysis for those interested in discovering their body muscle and fat content. The entire event was a grand success and we now plan to do this annually.
Issue 8 Spring/Summer 2010
Dr. Jeff Zaltzman From the Editor’s Desk…
40th anniversary of the Kidney Transplant Program
Contact Information
From the Editor’s Desk… Contact Information
On Nov 5 2009, the Kidney Transplant Program at St. Michael’s celebrated its 40 year anniversary. The hospital performed its first kidney transplant in 1969. During the day a party was held at the hospital Marketeria for the recipients of kidney transplants followed at the St. Mikes transplant clinic. Over a 100 patients and family members attended, in addition to the transplant programs medical, nursing allied health, and other hospital staff. There was a very heartfelt video that was shown and a few of speeches by the staff. Many patients came up to the microphone to reflect on their own personnel experiences. A number of patients reconnected with each other after a long absence.
The Truth About Herbal Medications Have you heard about
The Transplant Companions® program? SMH Participation for World Kidney Day Letter to the Editor Announcement
During the evening, the celebration continued with an event held at the Downtown Marriott. Thanks to the organizational skills of Nordia Hynes with support by the Diabetes Comprehensive Care Program and our Pharmaceutical partners it was a tremendous success. The Transplant program was showcased for our guests which included representation from our partner dialysis and transplant hospitals, The Kidney Foundation of Canada, Trillium Gift of Life, the HLA labs, The Ministry of Health and colleagues from St. Mikes. A number of former physicians and nurses from the program were also present. Dr. Marc Goldstein was the M.C. and invited speakers included former SMH Transplant Nephrologists: Drs. Ed Cole and Bob Bear, SMH Transplant Surgical Director, Dr. Rob Stewart and Transplant Director, Dr. Jeff Zaltzman. All speakers highlighted the many accomplishments of the transplant program over the last 40 years. The guests had the opportunity to see the video and were treated to an excellent Key-note address from Dr. Sam Shemie. Dr. Shemie is a pediatric intensive care physician from Montreal who has dedicated his career to the promotion of organ donation. He gave an very insightful presentation on “Defining Death”, a topic very pertinent to organ donation.
My potential kidney donor lives outside Canada - what should I do next? Living Kidney Donor Experience Tuberculosis and Kidney Transplantation Post-Transplant Chat Why A Low Potassium Diet May Still be Needed After a Kidney Transplant Toronto ITNS Chapter Shares, St. Michael’s Represents About the Transplant Adherence Program Curbing the Cost of Post-Transplant Prescriptions and Other Medical Expenses 40th Anniversary Impressions
The 40th anniversary of the Kidney Transplant Program at St. Michel’s was an important milestone. It was a joy to reflect on the many clinical and academic achievements.
Transplant Digest Kidney Transplant Recipient Attempts to Break World Record Galo Meliton, RN, C Neph (C)
Every so often we hear of inspiring stories within the transplant community. This is one such story. It was submitted by Stephanie Fitch of the Transplant Companions Program. If you want to be inspired, read on. Dave Smith, a kidney transplant recipient, will attempt to break a world record by being the first kidney recipient to summit Manaslu, the 8th tallest mountain in the world. He is the current president of the Canadian Transplant Association, and is a kidney transplant recipient (this spring he celebrated the 15th anniversary of his transplant). This is not Dave’s first climb. He is currently the only transplant recipient in the world to reach an altitude of 6500m, which occurred when he climbed Mount Sajama in Bolivia in 2004. This fall he aims to shatter his existing record by reaching an altitude of 8165m when climbing Manaslu. Dave, an Edmonton native, has been involved with the Transplant Companions Program (an educational tool for pre-transplant candidates and their loved ones) for many years by participating as a patient facilitator while maintaining an active lifestyle since his surgery. Dave will be joined by his team mates Martin Boiteau, a mountaineer and guide, and Philippe Blanchette, a fireman, both hailing from Montreal, Quebec. Going by the name Les AltiMaitres, the team’s collective goal is to raise awareness for their respective organizations and sponsors: The Transplant Companions Program, La Maison des greffés Lina Cyr (the Quebec Transplant House), and La Fondation des pompiers du Québec pour les grands brûlés (the Montreal Severe Burn Unit). The team left for Nepal on September 2nd 2012, and will be sharing updates with us along the way. We invite you and your patients to accompany Dave on his incredible journey by following him on Twitter (@Manaslu_2012) and tracking the team’s progress through their Facebook Page: Les AltiMaitres. Both can be accessed by visiting the Transplant Companions website at www.transplantcompanions.ca.
Kidney Transplant Recipient Attempts to Break World Record From the Editor’s Desk Contact Information Announcements Seeing the Doctor in the Transplant Clinic Vaccination for Kidney Transplant Recipients Successful Youth Outreach Pilot Project The Liver in Kidney Transplant Recipients Organ Donation in Ontario: How we have begun to turn things around Post Transplant Chat: Nausea, Vomiting, and Diarrhea Eating Nuts for Heart Health Renal Transplant Symposium 2012: The Best One Yet
Contact Information
The event was attended by 175 Registered Nurses and Allied Health Professionals from a number of dialysis and pre-dialysis centres from Ontario and Quebec. The day was appropriately started by a talk from Dr. Frank Markel, Chief Executive Officer of the Trillium Gift of Life Network. He set the stage for the day’s events by speaking on the Recent Developments in Organ and Tissue Donation in Ontario.
Chronic Rejection Post Transplant Chat
Mysteries of the Tissue Typing Lab..... Revealed
Recurrent Kidney Disease After Transplantation Post Transplant Chat: Infections After Kidney Transplantation
Dr. Jeffery Zaltzman, Medical Director of the Diabetes Comprehensive Care Program, spoke on the other new initiatives recently implemented at St. Michael’s Hospital: Extended Criteria Donation, Donation after Cardiac Death, Paired Exchange and List Exchange Programs, and Anonymous Donation.
What expenses are covered?
Cardiac Screening Prior to Kidney Transplantation
Depression in Kidney Transplant Recipients
Dr. Kathryn Tinckam, Co-Director of the Histocompatibility Laboratories, had a discussion on Practical Transplant Immunology. She was followed by Galo Meliton, Transplant Nurse, who spoke on several desensitization protocols.
Announcement
Dr. Prasad gave an update on Out of Country Transplantation, focusing on St. Michael’s Hospital’s experience. His second talk was on kidney donor outcomes. Several Allied Health Professionals facilitated afternoon breakout sessions, addressing different aspects of pre and post transplant care.
Trillium Gift of Life Network officially launched PRELOD on April 1, 2008 and is now accepting applications for reimbursement. Potential and actual living organ donors from August 3, 2007 onwards may apply to PRELOD for reimbursement of eligible expenses associated with the living donation process.
Issue 6 Spring/Summer 2009
National Living Donor Exchange Registry Launched Canadian Blood Services Partners with Canadian Kidney Transplant Programs By Maureen Connelly, BScN, RN, C.Neph,C St. Michael’s Hospital Living Donor Coordinator
The Canadian Blood Services has been given the task of building a national computer database for living donor paired exchange (LDPE). The database went live on January 29 2009 as part of a pilot program with St. Michael’s as one of the pilot centres. Living donor paired exchange provides a way for kidney donors who are incompatible with their intended recipient to still donate and help a person with chronic kidney disease receive a transplant. In exchange, their intended recipient receives a transplant from another kidney donor. Donors may be incompatible with their recipient in two ways: 1) The donor’s blood type is not the same as their intended recipient.* 2) The recipient has proteins in his/her blood called antibodies that react against donor blood cells. • * Blood group “O” donors can donate to any blood type. • * Blood group “AB” kidney recipients can receive a living donor kidney from any blood type.
National Living Donor Exchange Registry Launched Contact Information From the Editor’s Desk… Pre Renal Transplants Commonly Asked Questions How Kidneys from Deceased Donors Are Made Available In Ontario Post Transplant Chat A Closer Look At Your Kidney Transplant Medications: Prednisone High Cholesterol and Transplantation Preceptorship is alive and well at the St. Michael’s Hospital Renal Transplant Program Transplant Research
Living donor paired exchange is not new, in fact St. Michael’s partnered with the University Health Network in 2004 to develop Canada’s first paired exchange program. Similar programs are in existence in other countries.
Dr. Kenneth Pace, Staff Surgeon, spoke about the Surgical Issues Affecting Suitability for Transplantation. He also gave an update on Laparoscopic Donor Nephrectomy. The Planning Committee would like to thank the corporate sponsors, Ms. Trixie Williams, Clinical Leader/Manager of the Ambulatory Clinics, and Dr. Ramesh Prasad, for their help and support toward the success of this event. The feedback from the attendees was excellent, making it very encouraging for the team planning another information filled event in 2010!
Transplant Digest
Fall 2010, Issue No. 9
The advantage of a national LDPE program is that the chance of finding a matching donor increases if there is a larger pool of potential
In this issue ...
Regular readers of the Transplant Digest, will notice that we now have an exciting new layout and design. This change is part of the roll out of renewed St. Michael’s brand. St. Michael’s new image captures its reputation for compassion and caring along with its reality as a modern, sophisticated, and innovative organization.
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Are the Risk Factors the same as the General Population? Dr. Samuel Silver, Resident in Internal Medicine Cardiovascular disease (CVD), involving such conditions as heart attacks and bypass surgery, is known to decrease dramatically after kidney transplantation. However, CVD is more prevalent in kidney transplant patients than the general population. Even young transplant recipients experience close to a 10-fold increase in CVD. Therefore, CVD is clearly a significant barrier to staying healthy post-transplantation.
In fact, research has shown that the FRS underestimates CVD in kidney transplant patients, especially those patients at the highest risk for developing CVD. This is likely because kidney transplant patients have other important risk factors to consider. These include:
In order to prevent CVD, doctors attempt to predict which patients are most at risk for developing CVD using the Framingham Risk Score (FRS). The FRS is the most common tool used to determine a patient`s CVD risk. It combines traditional cardiac risk factors (age, sex, total cholesterol, high density lipoprotein, smoking status, diabetes, and blood pressure) to identify high risk patients who would benefit from medications to protect their heart, such as aspirin, blood pressure drugs, and cholesterol-lowering drugs. Unfortunately, the FRS may not be an accurate indicator of risk in kidney transplant patients.
• Transplant-specific risk factors related to immunosuppressant medications, acute rejection, and infection
• Pre-transplant cardiac and chronic kidney disease • Post-transplant exposure to cardiac risk factors
At St. Michael`s Hospital (SMH), we are using information on our transplant patients to improve the FRS and identify cardiac risk factors that are specific to kidney transplant patients. We are now studying traditional, novel, and transplant-specific risk factors to determine which factors are most important in kidney transplant patients. Novel risk factors such as C-reactive protein, microalbuminuria, uric acid, vitamin D, and
In this issue ...
Husband Donates Kidney to His Wife
Love Filters Thru on Valentine’s Day
Galo Meliton, RN, C Neph (C) When Mr. James Voden found out he was medically and surgically cleared to donate a kidney to his blood group incompatible wife Isabell, he jokingly said that he would like to donate to her on Valentine’s Day, so he “won’t have to buy her a Valentine’s Day gift”. Everyone who heard this statement laughed. I am sure however, that everyone, deep in their hearts, thought that indeed there is no other gift one can give to one’s loved one than the precious Gift of Life. And that’s exactly how this story begins: with their deep love for each other. Married for 40 years, Isabell and James met at a dance gathering called the Broom ‘n Stone on Saturday, June 14, 1969. They got married 4 years later on June 17, 1973. They have 2 children and 2 grandchildren. In one of Isabell’s visits with her Primary Nephrologist (kidney specialist), he told her that she will have to prepare herself for impending dialysis, and that he had given instructions for the Nurse in the Kidney Care Program to arrange for her dialysis treatment, in this case, Hemodialysis. The first thing she did was call her husband James. He was taken aback. He thought for a moment, and thought of once again revisiting the Internet for what might be available as another option for them: for him and his beloved wife Isabell. Lo and behold, he came across an article in the local newspaper about a wife donating to her husband at St. Michael’s Hospital and she was blood group incompatible to him!!! He knew that he and Isabell were also blood group incompatible, and all along he thought that he could not donate a kidney to her directly because of this.
From the Editor’s Desk Contact Information Announcements Highly Sensitized Patients (HSP) Transplantation in Science Fiction Sexual Health After Renal Transplantation Sexual Health and Diabetes C-Reactive Protein and the Kidney Transplant Post Transplant Chat: Sexual Health after Transplant 14th Annual Research, Education and Innovation Event a Huge Success Preceptorship Program at St. Michael’s Hospital Extends its Wings
He thought: how could this be possible? As he read the article, he began to understand the process of what he and Isabell eventually went for, which is blood group incompatible direct kidney donation. She was referred to the Renal Transplant Program at St. Mike’s and they attended the pre-transplant group class where they learned more about the blood group incompatible process. Isabell had to have a cleansing process of her Antibodies she had that were of James’ blood group, thru a filter, called a Glycosorb Column. In just a few months after they decided that this was the route they wanted, they had their surgeries on Thursday, February 14, 2013. Both of them are doing very well.
World Kidney Day From the Editor’s Desk
March 10, 2011 is World Kidney Day (WKD). WKD is a joint initiative of the International Society of Nephrology (ISN) and the International Federation of Kidney Foundations (IFKF). Its main objective is to raise awarenss on the importance of kidney function in overall health. More than 5% of the adult population have some form of kidney impairment, and millions die each year from heart diseases linked to Chronic Kidney Disease (CKD) (www.worldkidneyday.org). This year’s theme focused on the link between CKD and cardiovascular disease, hence the slogan: Protect Your Kidneys and Save Your Heart. St. Michael’s Renal Transplant program joined our global partners in raising kidney health awareness by conducting an interactive health information session for the hospital community. The event was made possible with the sponsorship of Astellas Pharmaceuticals, SMH Risk Modification Department through Dr. Vuksan’s team, the support of the managers within the Diabetes Comprehensive Care Program (Trixie Williams, Colleen Johns, and Pam Robinson), and all the staff in the Renal Program who helped during the information session.
(con’t on page 3)
Spring/Summer 2012, Issue No. 12
Fall 2011, Issue No. 11
In this issue ...
St. Michael’s Hospital participates in World Kidney Day
Winners of the Kidney Jeopardy Game during the World Kidney Day Event at St. Michaels Hospital
Transplant Digest
Transplant Digest
Spring/Summer 2011, Issue No. 10
New Image of Transplant Digest
Contact Information Commercial Kidney Transplantation Kidney Transplant Stats Mark Your Calendar Pre-Transplant Clinic Implements Change in Process General Foot Care Travel-Post Transplant Post Transplant Exercise Persistent Hyperparathyroidism and Hypercalcemia Following Kidney Transplantation Generic Transplant Drugs are Coming to Ontario Guests in the Transplant Clinic Research Projects Letter to the Editor
St. Michael’s first in North America to use blood-cleaning procedure for kidney transplant Procedure allows man to receive kidney from brother with different blood type By Leslie Shepherd, SMH Senior Public Relations Specialist St. Michael’s Hospital is the first in North America to have used a novel device that cleaned the blood of a kidney patient and allowed him to receive a transplant from a donor with a different blood type. Transplants involving a donor and recipient with different blood types are rare. Most people have natural antibodies in their blood that would cause their immune system to reject an organ from someone with a different blood type. Andre Cossette, a Grade 4 teacher at Ange-Gabriel Elementary Catholic School in Mississauga, Ont., was on dialysis for three years before undergoing a procedure called plasmapheresis at St. Michael’s. He then received a kidney transplant from his brother, who has Type AB blood, even though Cossette has Type A blood and antibodies against Type B. Plasmapheresis is similar to kidney dialysis, which removes waste products from the blood. Plasmapheresis separates plasma from patient’s blood, and runs it through a column-shaped device containing synthetic carbohydrate beads that trap the blood group antibodies. The “washed” plasma is then returned to the patient’s body. St. Michael’s was the first hospital in North America to perform plasmapheresis using a device known as the Glycosorb ABO, developed by Glycorex Transplantation, a Swedish company, and approved by Health Canada last year. It has been used once in Canada for a recent heart transplant in Alberta, but this was the first time for a kidney patient. The device is used in 21 countries, mainly in Europe, for kidney, liver, heart, lung and stem cell transplants. “I get to get my brother’s kidney,” Cossette said, shortly after beginning the first procedure, which lasted about four hours. “I won’t have to be on a waiting list, waiting for a call to come to the hospital within four hours because there may be a kidney available.”
In this issue ... St. Michael’s blood-cleaning procedure for kidney transplant From the Editor’s Desk Contact Information Welcome Approaching Life After A Kidney Transplant Save the Date (Living Kidney Donor Celebration) Mark Your Calendar (SMH Renal Transplant Symposium) Coordinating ABO Incompatible Transplant: Easier With Great Team Work Post Transplant Chat (Laboratory Testing) Why don’t kidney transplants last forever? Transplant Ultrasound Kidney Transplantation and the Metabolic Syndrome Update on the National Paired Exchange Program
Cossette underwent the procedure a second time to get rid of all the antibodies. He will also receive medications to prevent his immune system from making more antibodies and attacking the transplanted kidney. Dr. Jeff Zaltzman, director of the hospital’s kidney transplant program, said the procedure could expand the number of living organ donors. More than one-third of potential live donors are turned down because their blood types are not compatible with the person to whom they wish to donate their kidney. “Every time you have a living donor, you’re helping someone who would otherwise be on a transplant waiting list for a long time,” Dr. Zaltzman said. “That’s also one more person who is not taking an organ from a deceased donor, which could then be given to someone else.” Dr. Zaltzman headed the transplant team that also included Dr. Katerina Pavenski, a hematologist, and Dr. Ramesh Prasad, a nephrologist at St. Michael’s Hospital. In Ontario, 1,075 people are on a waiting Dr. Jeff Zaltzman of list for a kidney transplant, according to the St. Michael’s speaks to Trillium Gift of Life Network, the province’s Andre Cossette after the organ and tissue donation agency. plasmapheresis procedure
St. Michael’s Transplant Program Living Kidney Donor Celebration and Recognition Event By: Maureen Connelly RN BScN Living Kidney Donor Coordinator Sharon Lee, MSW, RSW Living Donor Social Worker The St. Michael’s Transplant Program held a recognition event on April 26, 2012 to honour individuals who donated a kidney to a friend, relative or stranger in the past five years. It was wonderful to see the many donors who have given so selflessly to improve the life of another individual. Our previous event was held in 2007 and honoured our donors since the start of living kidney donation at St. Michael’s. The event this past April, recognized and honoured the 221 living kidney donors from April 2007-April 2012.
to promote the national post donation living donor study. Also on hand at the celebration was the Honourable Deb Matthews, Minister of Health, Trillium Gift of Life Network CEO, Ronnie Gavsie and Susan McKenzie, Senior Director of Development at the Kidney Foundation of Canada and recipient of a living donor kidney transplant.
In this issue ... St. Michael’s Transplant Program Living Kidney Donor Celebration and Recognition Event From the Editor’s Desk Your Transplant Admission St. Michael’s Hospital Renal Transplant Program Milestones Being Admitted to the Hospital Kidney Transplant Biopsy Can we grow organs in the lab?
Generic Anti-Rejection Medications and the Kidney Transplant Patient: What You It was a very moving and joyous event Need to Know that provided an opportunity for donors to meet each other and share their Post Transplant Chat The event coincided with the National experiences with fellow donors and the Organ and Tissue Donation Awareness St. Michael’s staff. Week. Our external stakeholders from the Kidney Foundation and Trillium Gift The following is a speech by Stephen Zaluski, life circumstances allow it? What better way of Life Network were able to provide kidney donor in 2010 that eloquently sums is there to respond to the call of our common humanity? information about organ donation at up the experience of being a kidney donor: their respective booths. The research “I am genuinely honoured to be here tonight The second common reaction is to express coordinator Lindita Rapi was also on hand and to say a few words as a donor. some version of wonder at the donor’s courage. To me this is also misplaced. The I don’t claim to speak for all donors since I real courage is that of individuals and their suspect our experiences are about as varied families who live with chronic debilitating as those of our recipients. But I’ll just offer a kidney disease, and who face each day couple of thoughts from my own experience with fortitude, hope, determination and which will hopefully have some resonance grace. Those are the people who inspire and for others. reinforce belief in the human spirit. And There are two prevailing reactions that one nobility lies not in the act of the donor, but encounters as a donor: in the lived life of the recipient. First and most obvious is – why? “What made you decide to do it?” Life may have many mysteries, but to me, this isn’t one of them. In my books, nothing could be more basic than the human desire to help. Often, though, we feel helpless to do anything. The world’s problems are too vast, or the pain or need of others – whether loved ones or strangers is beyond our ability to reach.
Donating my kidney was a wonderful experience. I was tremendously supported by family, friends and by the fabulous care team here at St. Mike’s who were so terrific throughout the entire process. I came away feeling recharged about life and about living it fully. My only regret is that I don’t have another kidney to give, for the time being. But I’ll always be grateful for having been given And then suddenly, there’s a way we can the chance to donate once. While it may have help, in a real tangible way and without made a difference to someone else’s life, it much jeopardy to ourselves. So the real most surely made a difference to my own. question is why wouldn’t you donate, if your How nice to share that bond with you.”
TRANSPLANT DIGEST FALL 2011, Issue No.11
L to R: Shirley Marges, Mina Kashani, Lody Manlapaz and Christine Blundell
TRANSPLANT DIGEST SPRING/SummER 2011, Issue No.10
Transplant Digest
Fall 2013/Winter 2014, Issue No. 15
Love Filters Thru on Valentine’s Day
James and Isabell Voden
From the Editor’s Desk…
The objective of the Symposium was to inform front line staff from referring centres of the new initiatives recently implemented by the St. Michael’s Hospital transplant team that have positively impacted our patients, their friends and families.
Galo Meliton, RN, C.Neph(C)
Transplant Digest
Transplant Digest Spring/Summer 2013, Issue No. 14
In this issue ...
Renal Transplant Symposium 2008: A Huge Success
New-Onset Diabetes Mellitus after Transplantation
Potential and actual living organ donors may apply to PRELOD to assist with out-of-pocket expenses for travel, accommodations, parking, meals, and meal allowance during assessment and immediate post-surgery period. In addition, persons who will be off work following surgery and during their recovery period may apply for a loss of income subsidy. Applicants must meet the PRELOD eligibility criteria and provide supporting documentation to receive reimbursement.
TRANSPLANT DIGEST Fall 2010, Issue No. 9
Fall 2012, Issue No. 13
The second Renal Transplant Symposium hosted by the St. Michael’s Hospital Renal Transplant team held on May 9, 2008 at the Grand Hotel in downtown Toronto was a huge success. The event was entitled “Current Trends in Renal Transplantation: Advancing Care Together”.
Kidney Donation Surgery: The Benefits of Laparoscopic Donor Nephrectomy
Anjeet Bhogal
Heart
Pre Renal Transplants Commonly Asked Questions
Post Transplant Chat
Contact Information
Issue 5 Fall/Winter 2008
Renal Transplant Symposium 2008: A Huge Success!
continued on page 2
ST. MICHAEL’S CELEBRATES THE 40TH ANNIVERSARY OF THE KIDNEY TRANSPLANT PROGRAM
Pregnancy After Kidney Transplantation
From the Editor’s Desk…
Policy & Living Donation Advsior Trillium Gift of Life Network
Transplant Digest SMH Transplant Program Participates In World Kidney Day
Program for Reimbursing Expenses of Living Organ Donors Launched in Ontario
To learn more about PRELOD (including eligibility criteria) or to download an application package, visit the Trillium Gift of Life Network website at www.giftoflife.on.ca. If you have any further questions or comments, please feel free to contact PRELOD at prelod@giftoflife.on.ca, or at 1-888-9PRELOD.
Some of the guests in the live donor recognition party. From L to R: Dr. Bob Howard (SMH VP for Medical Affairs and Education) Dr. Art Slutsky (VP SMH Research) Mr. George Smitherman (Ontario’s Minister of Health)
Renal Transplant Symposium 2006 Left to Right: Galo Meliton, Maria Salanga, Rose Luong, Linda Ahn, Tiffany Camota, Fernanda Shamy, Mona Udit, Dr. Prasad, Thelma Carino, Meriam Jayoma, Jenny Huckle, Dr. Zaltzman, Trixie Williams
Issue 4 Spring/Summer 2008
PROGRAM FOR REIMBURSING EXPENSES OF LIVING ORGAN DONORS LAUNCHED IN ONTARIO Living organ donation is an act of kindness that reduces wait times for patients in need of a lifesaving kidney or liver. By agreeing to become a living organ donor, potential and actual donors travel to and from a transplant hospital for a variety of tests and surgery that may result in financial loss, including income. In an effort to reduce the financial loss associated with the living donation process, the Ministry of Health and Long Term Care established the Program for Reimbursing Expenses of Living Organ Donors (PRELOD), as part of the Government of Ontario’s Organ Donation Strategy. PRELOD reimburses living organ donors up to a maximum amount of $5,500 for reasonable out-of-pocket expenses and loss of income incurred through the living organ donation process. PRELOD aims to offset financial burdens that may prevent someone from becoming a living organ donor.
Recognizing Our Heroes
TRANSPLANT DIGEST SPRING/SUMMER 2012, Issue No.12
D
D
Spring/Summer 2014, Issue No. 16
In this issue ...
Traveling Road Show in Timmins, Ontario, a Huge Success
Traveling Road Show in Timmins, Ontario, a Huge Success
Galo Meliton, RN C Neph (C), Senior News Correspondent Dubbed as the Mother of all Road Shows, four members of the Renal Transplant team, headed by Dr. Ramesh Prasad, Maureen Connelly, RN, Living Donor Coordinator, Galo Meliton, RN, Recipient with Living Donor Coordinator, and Mari Vella, Social Worker in the Recipient Program went to Timmins, Ontario on September 17, 2013 and met with several members of the Nephrology Program at the Timmins and District Hospital and did a Road Show for their pre-transplant patients, families and friends. Penny Onlock, RN, who organized this event along with Galo Meliton, warmly greeted the team from St. Michael’s Hospital and gave a tour of their newly refurbished unit. Dr. Prasad commented how impressed he was seeing the changes that have been made to their unit since he was there last about 6 years ago as a visiting doctor. We were then met by the rest of their team, headed by Dr. Malvinder Parmar, their Primary Nephrologist. After both teams discussed individual patient cases in work up as well as process issues, Dr. Prasad presented “Assessment of Patients for Renal Transplantation” at their Education Rounds. The Road Show then proceeded, led by Dr. Prasad who gave a talk entitled: “An Introduction to Renal Transplantation”. Maureen Connelly spoke about the Living Donor process, and the Paired Exchange Program. She also spoke about the process of getting on to the Deceased Donor list. Mari Vella then spoke about insurance coverage and travel issues, both topics very relevant to a patient population that is so far away from our Transplant Center. Galo Meliton then spoke about the blood group incompatible direct kidney donation using Glycosorb Columns as an option for those pairs in whom the Paired Exchange Program does not work out.
From the Editor’s Desk
In this issue ...
A Milestone for Trillium Gift of Life Network Meriam Jayoma-Austria,RN, C.Neph.C February 12, 2014 was a historical day for Trillium Gift of Life Network. It was the day that the new deceased donor kidney allocation system in Ontario was officially implemented
A Milestone for Trillium Gift of Life Network From the Editor’s Desk Contact Information
Contact Information
Hong Kong Visitors
St. Michael’s Renal Transplant Symposium 2014
Pregnancy and Kidney Transplantation
What You Can Do (or not do) To Help Us in the Transplant Clinic
Understanding BK (Polyoma Virus) Repeat Kidney Transplants
Post Transplant Chat: Cancer after a Kidney Transplant Repeating Laboratory Tests
How to Read a Transplant Article
Facebook Posting: “I need a kidney, can you help?
Post Transplant Chat : Diuretics MRI and Kidney Scarring
Vaccinations and Transplantation
SMH Renal Transplant Nurse Coordinators Represent at CANNT
Invitation for Healthy Volunteers to participate in a Living Kidney Donor Research Study
Generic Medications: What are they? Are they safe for my kidney transplant?
Delayed Graft Function The Long Term Effects of Becoming a Living Kidney Donor Research Study
Introducing New Staff
What is plasmapheresis? Letter to the Editor
This event was a huge success, and it would have not been possible without the kind sponsorship from Novartis Pharmaceuticals represented by Jennifer Cardella, Specialty Sales Representative in Transplant. We would like to thank Lorna Green, Program Manager to the ICU/ER/Nephrology and Pharmacy, and Dr. Parmar for their very warm reception and hospitality. A big thank you also goes to Jonathan Fetros, our Clinical Leader Manager who was very supportive throughout this entire process.
2) Allocation to be made based on a negative Virtual Crossmatch (the absence of Donor Specific Antibody): This replaces the current system of allocation method based on a negative crossmatch (see Appendix A for more details). The methods will be congruent with what is currently used by the National Living Donor Paired Exchange Program and the National HSP registry.
3) Allocation based on a point system: While we have kept the priorities unchanged from the previous allocation system, we have gone from binary values to a continuous metric. As an example, patients within the previous allocation system with a PRA of 81% get much greater priority than those with a PRA of 79%. Moving forward, within all categories of priority the points will be based on the simple formula below: ALLOCATION POINTS= 0.1 point per 30 days waiting + [(cPRA/100) x 4]
TRANSPLANT DIGEST FALL 2012, Issue No.13
TRANSPLANT DIGEST SPRING/SummER 2013, Issue No.14
TRANSPLANT DIGEST FALL2013/WINTER 2014, Issue No.15
TRANSPLANT DIGEST SPRING/SUMMER 2014, Issue No.16
We’ve been publishing Transplant Digest for 10 years now. Most our articles have been dedicated to health issues for our kidney transplant recipients, although there have been some dedicated to kidney donors, and some to non-transplant health care professionals. There have also been many articles about news events. But among all of these, we have not given too much attention to families and friends. To all the families and friends of our patients, please accept our heartfelt thanks! It’s quite clear that patients who have good family and friend support systems do better after a transplant than those who do not. More sets of eyes and ears at the time of the pre-transplant assessment, to take in all the information that is being given, is very helpful. Helping the patient take their walks after a transplant, making sure they follow the prescribed diet and fluid intake, bringing them to the Transplant Clinic or to the outpatient lab sometimes in the worst of weather, getting prescriptions filled, and hearing and repeating, as well as most importantly, understanding what is said during the Transplant Clinic visit are all invaluable services to our patients. These make the transplant work and keep our patients alive. We could not do what we do without all your help.
Congratulations to everyone who help reach this milestone. Thank you to Hoffmann-La Roche Limited. The publication of Transplant Digest in the last 10 years was made possible through their support.
18
r u o t e Me
m a e T
Dr. John Honey Professor of Urology, Division of Urology Director of Endourology, University of Toronto
Dr. Robert Stewart Transplant Surgeon Associate Professor, Division of Urology University of Toronto
Dr. Jeffrey Zaltzman
Head, Divison of Nephrology Director, Renal Transplant Program Medical Director, Diabetes Comprehensive Care Program Medical Director for Trillium Gift of Life Network
Medical Staff Dr. Ramesh Prasad Director of Kidney Transplant Program (effective July 1,2016) Associate Professor of Medicine University of Toronto
Dr. Michael Ordon Kidney Transplant Surgeon Assistant Professor, Division of Urology University of Toronto
Dr. Kenneth Pace Transplant Surgeon Head Division of Urology Associate Professor, Division of Urology University of Toronto
Dr. Jordan Weinstein Staff Nephrologist Assistant Professor of Medicine University of Toronto
Dr. Darren Yuen Staff nephrologist Assistant Professor of Medicine University of Toronto
Dr. Jason Lee Associate Scientist, Li Ka Shing Knowledge Institute Robotic & Laparoscopic Surgery, Endourology, Renal Transplantation Assistant Professor, Division of Urology University of Toronto
Dr. Phil MacFarlane Director of Living Donor Program and Home Dialysis Program
19
Administration Jonathan Fetros RN, MN, CHE Clinical Leader/ Manager,Diabetes and Renal Transplant Program
Dana Whitham RD,Ms.C, CDE Case Manager, Diabetes and Renal Transplant Program
Nurses and Allied Health
20
Jenny Accetura Dietitian
Tess Montada-Atin NP, Post Transplant Program
Meriam JayomaAustria RN, Pre Transplant Assessment Program
Kevin Bradley RN, Post Transplant and Living Donor Program
Thelma Carino RN, Post Transplant Program
Suela Cela MSW, Pre Transplant and Diabetes Program
Maureen Connelly RN, Living Donor Program
Jennie Huckle RN, Post Transplant Program
Michelle Gabriel RN, Post Transplant Program
Nurses and Allied Health (continued)
Sharon Lee MSW, Post Transplant and Living Donor Program
Galo Meliton RN, Pre Transplant Assessment Program
Sarah Mattok RN, Post Transplant Program
Lindita Rapi Research Coordinator
Weiqiu Yuan Research Coordinator
Tifanny Camota-Reis Admin Assistant to Jonathan Fetros
Elizabeth Couto Medical Secretary to Dr. John Honey and Dr. Michael Ordon
Fernanda Shamy RN, Post Transplant Program
Research Program
Michelle Nash, M.Sc.
Research Manager
Clerical/Admin Staff
Sheila Buencamino Post Transplant Program
21
Clerical/Admin Staff (continued)
22
Genny Couto Medical Secretary to Dr. Jason Lee
Andrea Dedrick Living Donor Program
Lynn Doak Medical Secretary to Dr. Ramesh Prasad and Dr. Phil MacFarlane
Erin Irving Medical Secretary to Dr. Jeff Zaltzman and Dr. Kamel
Luisa PetruzzoKwok Medical Secretary to Dr. Robert Stewart
Rosemary Luong Medical Secretary to Dr. Jordan Weinstein and Ron Wald
Susie Par Pre Transplant Assessment
Marketa Schoralkova Medical Secretary to Dr. Ken Pace
Anna Mendoza-Tan Kidney Stone Clinic
Mona Udit Pre Transplant Assessment
Senyo Williams Reception
Yue (Sissi) Xi Post Transplant/ Reception
NOTES
23
St. Michael’s Nephrology Team
Cool Guys!!!