Transplant Digest Spring/Summer 2016/2017, Issue No. 21
St Michael’s Kidney Walk Team: Helping to create a better future for patients with kidney disease!
In this issue ...
Carmen Morris, MSW, RSW, Kidney Care Centre & Home Dialysis Clinics
St Michael’s Kidney Walk Team
Every year The Kidney Foundation Walk brings together communities across Ontario to raise critical funds for research, programs and services to help individuals with kidney disease and their families.
From the Editor’s Desk
St. Michael’s Nephrology Program organized our first Kidney Walk team in 2008. Since then we have walked every year. Each year our Team gathers pledges to raise awareness about kidney disease and take part in the annual 5.0 or 2.5 kilometer Toronto West Kidney Walk through the picturesque High Park. Participants included staff, patients, family, friends (and pets) from all areas of our DCCP/Nephrology Program. This year, because of the generosity of our donors, our Team achieved over $11,000.00 in donations. This is good news for our Team and the Kidney Foundation of Canada. Ultimately, it’s about providing a better future for patients with kidney disease.
Contact Information Pregnancy After Kidney Transplantation Insomnia Update on Kidney Paired Kidney Donation BK Virus Medication Highlight: Sulfamethoxazole/ Trimethoprim Post Transplant Chat: Dialysis After Transplant Did You Know? What Happens To Your Dialysis Access After Kidney Transplantation? Scarring in the Kidney
The St. Michael’s Angels’ 2016 Kidney Walk Team donned their ‘blue visors’ on September 24th, 2016 and walked to raise awareness for kidney disease and to show their support for the Kidney Foundation.
Food is Medicine. Medicine Heals. Congratulations All The Best To
Why We Walk?
Anyone who has watched a loved one deal with dialysis over the years understands how difficult that life can be. The fact that kidney disease is very under-funded meant that we had to do something; the fundraising aspect of the Walk provided the perfect opportunity for us to come together as a group to help raise needed funds for kidney research and programs that help support Canadians living with kidney disease. The Walk also provides a great opportunity for participants to meet others who are journeying through similar health struggles. When patients and family members come together at an event like the Kidney Walk they ought to realize they are not alone… and for some this can make all the difference.
Come Walk With Us!
Please support us in 2017 by signing up to join our Team with friends, family, or coworkers. If you are unable to walk, consider still donating. The Walk is designed for participants with limited mobility and pets are welcome. “We walk not just for ourselves, but for the thousands of individuals who have kidney disease.” Please join us in 2017! For information on how to donate to or join our team, please call Carmen Morris at ext. 3296; Mina Kashani at ext. 2387, or Nordia Notice at 416-864-5807. TRANSPLANT DIGEST FALL/WINTER 2016/2017, Issue No.21
From the Editor’s Desk Welcome to the Fall 2016/Winter 2017 issue of Transplant Digest. Over the past decade, Transplant Digest has served all our waitlisted patients, kidney transplant recipients and their donors, as well as family members, friends, and beyond. Health care providers from other hospitals in the Greater Toronto Area have also found Transplant Digest to be a helpful resource for transplant-related health information and news updates. Our hope is that Transplant Digest will also prove helpful to patients and their providers in non-transplant related areas of nephrology. Articles are written at different levels of complexity, since the readership is so broad. If you need help in understanding a particular article, please do not hesitate to ask. Also, we recognize that many of our patients are non-English speaking. While we cannot provide translation services, please ask in the Transplant Clinic about some available options so that you can understand the content of each issue.
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This issue covers areas as diverse as BK virus and the antibiotic Septra®, delayed graft function and use of the dialysis access after transplantation, living donor paired exchange, LEVEL 1 pregnancy, insomnia, scarring in the kidney, and malnutrition. We also celebrate the accomplishments of our St. Michael’s Kidney 61 Queen St. E. BOND STREET St. Michael’s Health Centre Walk Team. Please let us know if there are topics of particular interest that you would like to see in a future issue of Transplant Digest. 8 Li Ka Shing 55 Queen St. E. International 7 BestHealthcare wishes for the seasons ahead.BOND WING 6 Education
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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.
Pregnancy after Kidney Transplantation Dr. Ramesh Prasad Becoming pregnant is a major milestone for anyone, and for transplant patients and their partners there is no exception. Perhaps you are planning on becoming pregnant, or are just thinking about it. Maybe you are already pregnant. Here is some general information that you may find helpful. It is important to recognize that is very difficult, if not impossible to conceive while you are on dialysis. This is true for both mothers and fathers. The body’s endocrine system is very sensitive to the effects of kidney failure, and the delicate balance of hormones needed to conceive and maintain a pregnancy becomes severely disrupted. In other words, there is loss of fertility. However, a transplant can VERY quickly restore fertility. It is not unheard of for transplant patients to become pregnant within one month of receiving a transplant! Therefore, please inform your pre-transplant physician and nurse before the transplant, if you are planning to become pregnant after the transplant, because this will have major implications for your care after the transplant. It is best to avoid pregnancy for about one year after the transplant. This is because the dose of your anti-rejection medication is kept very high during the first year. It is best not to reduce the doses of these medications, or stop any of them, during the first year because the risk of rejecting the transplant is highest during this period. If rejection happens, treating it during pregnancy is also more difficult. Also, your body may not have fully healed from the transplant surgery itself. Once you are getting close to the end of the first year, be sure to inform your transplant doctor and nurse in the clinic about your plans for becoming pregnant. You can then have a detailed discussion with them about what needs to be done from the transplant perspective to prepare your body for pregnancy. Generally, this will involve stopping one of your transplant medications (such as Myfortic® or Cellcept ®), and increasing the dose of one or two of your other medications (such as Advagraf ®, Neoral ®, and prednisone) a few months in advance of becoming pregnant. Sirolimus is also usually stopped, and another drug called Imuran is sometimes started. These changes are complicated and it is necessary that you be completely comfortable with making these changes. The risk from making these changes depends on, for example, how well your transplant is doing, your own risk of sensitization (such as from preformed antibodies against your donor), your tendency to experience side effects from medication, your previous pregnancy history, and your previous transplant history, if any. Also, other non-transplant medications may need to be stopped or their dosage kept to a minimum. If you become pregnant by accident, inform the Transplant Clinic right away! Once you become pregnant, you have the option of being followed in a High Risk Pregnancy Clinic, and also be followed by a kidney doctor who specializes in pregnancy, in addition to, or instead of a kidney doctor who specializes in transplants. Be sure to discuss these options in the Transplant Clinic visit. You will need regular monitoring of your kidney function during pregnancy. Take your vitamins! Your drug levels will need to be checked. There are only a few blood pressure-lowering, and other medications that are proven to be safe in pregnancy. You will be expected to gain weight just like anyone else, and our dietician may be able to offer some advice in addition to whatever else your obstetrician advises. When it comes time for delivery, hopefully at full term, it is quite possible to have a normal vaginal delivery or a Caesarian section as deemed appropriate by your obstetrician. If needed, a nephrologist may be asked to see you in the hospital as well.
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Pregnancy after Kidney Transplantation (continued) After delivery, breastfeeding is certainly possible. It is true that the transplant drugs enter breast milk, so if you have any questions about this, you may receive some advice from the Transplant Clinic. You can book an appointment to come in whenever you feel you are ready. Once you are close to the end of breastfeeding, you can have a discussion about restarting your usual transplant medications. This will depend of course on many factors, so be sure to bring this up during your visit. If you have no intention of becoming pregnant again in the near future or ever at all, we can give some general information about contraceptive options. However, we don’t prescribe these. Finally, fathers and donors, we haven’t forgotten about you. While it may not be advisable to be a father in the first year for many of the same reasons, the restrictions on fathers are not usually as stringent as those for mothers. Be sure to review your medication list in clinic if you are planning to become a father, because some of your medications may need to be altered or stopped. For donors, as long as you have recovered from your surgery and are healthy enough otherwise, you can certainly become pregnant or be a father.
Insomnia Dr. Ramesh Prasad Insomnia, or inability to sleep, is a common complaint after transplantation, especially in the early days. There is the excitement of getting a transplant, and high doses of anti-rejection medications also contribute. Usually, insomnia gets better once you establish a new routine and the doses of your medications are lowered. Sometimes however, insomnia can persist and interfere with your daily living. Here are some suggestions to help you deal with your insomnia. There are two main facets of therapy for insomnia: sleep hygiene and stimulus control. Proper sleep hygiene included maintaining a regular sleep schedule, sleeping only as much as you need but not more (most adults need six to eight hours of sleep every day), waking up at a fixed time every morning including weekends, with the help of an alarm clock if needed, and no napping during the daytime. Stimulus control includes avoiding caffeine in any form after lunchtime, avoiding alcohol and smoking for at least a few hours before going to bed, avoiding hunger at bedtime, avoiding watching television or using the computer (or any light emitting device, even a smartphone) for at least a few hours before bedtime, going to bed only when you feel you are ready, and using the bed only for sleep and sex. If sleep hygiene and stimulus control prove to be inadequate, then further options include structured relaxation therapy and cognitive behavioral therapy. Please speak with your family doctor about a referral to specialists in those areas. Source: UptoDateÂŽ
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Update on Kidney Paired Kidney Donation: A Canadian Success Story Dr. Jeff Zaltzman Living kidney donation has been in existence since 1954 and in most Canadian kidney transplant centers comprises 30-40% of the transplant activity. Not infrequently, several individuals had come forward to be evaluated as possible living donors for a given patient. However, due to either ABO blood group or human leukocyte antigens (HLA) incompatibilities (i.e. the patient is sensitized to the potential donor) many living donors were excluded from further consideration and in the past the patient had no option but to be placed on the deceased donor wait-list. Nevertheless, if these living donors were willing to donate their otherwise incompatible kidneys to other compatible patients in exchange for compatible donor kidneys for their loved ones, there would potentially be a new pool of living donors, thereby increasing the total number of transplants performed in Canada. This practice could also enable such recipients to be transplanted more rapidly and with optimal organs, potentially improving their long-term survival. Finally, paired exchange would also remove these patients from the deceased donor waiting lists, thus improving access to transplantation for those remaining on the list. This has in fact been the reality in Canada for the last decade. The Canadian transplant community learned about “paired kidney donation” from colleagues from the Netherlands in the early part of the last decade where the practice in a small country had been in place for a number of years. The first 3 Canadian paired donations occurred in 2006 in Toronto between the 2 adult transplant programs; St. Michael’s and Toronto General. These were done using pencil and paper to try and match pairs. In 2008, under the leadership of Canadian Blood Services(CBS), a National Kidney Paired Donation (KPD) program began. Initially a few centers including St. Michael’s, were involved in a pilot program. By 2010 all of the living kidney programs in every province had joined, making this a true National program. The program’s continued success was based upon the development of a number of important guiding principles and practices, including: improvement and standardization of the HLA labs(the labs that test patients “tissue typing and antibody levels and matching), monthly telephone meetings with CBS staff and the transplant programs, annual face to face meetings, continuous optimization of practices, dedicated transplant coordinators at each site, standardization of living kidney donor criteria, and a sophisticated computer program that optimizes the most and best matches amongst more than 120 donor pairs thrice annually. One of the remarkable side stories of the Canadian KPD is that the success of the program is dependent upon remarkable anonymous altruistic kidney donors. These people come forward to a transplant program wishing to donate their kidney to a complete stranger. Unlike the typical living kidney donor situation whereby the donor is donating their kidney to a relative, friend or spouse, in these situations the donor does not have any intended recipient, nor will they ever meet the recipient of their kidney. Since these donors come in without a recipient, they are a catalyst for a chain of kidney paired donations with the last living donor kidney being allocated to some lucky person awaiting a deceased kidney on the wait-list.
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As of October 1, 2016 In Canada, there have been 455 transplants through KPD, including 371 paired transplants and an additional 84 patients who have been able to come off the deceased donor wait-list.
WHY PAIRED EXCHANGE? 1) Incompatible donor and recipient blood type 2) Recipient has antibodies against their donor 3) Recipient may want a younger donor 4) A pair may enter just to help the system
TYPES OF TRANSPLANTS IN KPD Paired
N-Way Exchanges
Incompatible Pair A
Incompatible Pair B
Incompatible Pair A
Incompatible Pair B
Incompatible Pair C
Recipient A
Recipient B
Recipient A
Recipient B
Recipient C
Donor A
Donor B
Donor A
Donor B
Donor C
Domino Exchanges
Non-directed Donor
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Incompatible Pair A
Incompatible Pair B
Incompatible Pair C
Recipient A
Recipient B
Recipient C
Donor A
Donor B
Donor C
Person on Transplant Waitlist
BK Virus
Sarah Mattok, RN, BScN, C Neph (C)
What is it? BK is a virus. Most of us have been exposed to it as children. It is named after the first person in whom it was found, whose initials were B.K. It does not usually cause problems for people with healthy immune systems because their immune systems can fight it off. People with kidney transplants are on medicines to weaken their immune systems, so they have a harder time fighting off the virus.
How did I catch it? Most people catch BK virus as a child. You probably felt like you had the flu, but got better quickly. After you recovered from the illness, the virus stayed in your body but it didn’t cause you any harm.
How do you know I have it? At St. Michael’s, we do a special blood test for the first 5 years after transplant, to catch growth of BK before it causes problems. This test is called the BK PCR. Your blood test may show that you now have the BK virus in your blood. Sometimes, cells infected with BK can be found in the urine too. These are called “decoy cells”.
Does it cause problems for me or my kidney transplant? You will not feel any different if you have the BK virus. There are no symptoms. It is not contagious and you cannot pass it on to other people. It is possible that BK can hurt your transplant kidney, but with regular blood tests, we usually find the virus before it does any damage. If your kidney starts to show signs of damage, then your doctor or nurse may talk to you about having a kidney biopsy to check if the virus has affected the transplanted kidney.
How do I get rid of it? You will be asked to come to clinic to talk about changing your medicines. We usually lower the amount of anti-rejection medicines you are taking, so that your own immune system can fight off the virus.
How will I know when it’s gone? Once you have the BK virus, it is very important that you do the special blood test (the BK PCR) every month. This shows us if the virus is still in your blood, and how much of the virus is there. This blood test can only be done at the St. Michael’s Hospital lab. You need to have 3 blood tests in a row that show the virus is gone, before we are sure it is out of your blood. 7
Medication Highlight: Sulfamethoxazole/Trimethoprim (Septra®) Francine Kwee, BScPhm, ACPR, RPh
What is Sulfamethoxazole/Trimethoprim?
Sulfamethoxazole/Trimethoprim is an antibiotic that is commonly used after kidney transplant to prevent infection. More potent medications that decrease your immune system (“immunosuppressants”) are used around the time of transplant surgery in order to prevent your body from rejecting the new kidney. Because of this, the first year after kidney transplant is an important time to prevent infection.
What is the brand name for Sulfamethoxazole/Trimethoprim?
Sulfamethoxazole/Trimethoprim tablets are only available in generic form, however you may still hear it referred to by its brand name, Septra®. You may also hear Sulfamethoxazole/Trimethoprim being referred to as “Co-trimoxazole” or “Sulfatrim”. Sulfamethoxazole/Trimethoprim is available in both single strength (400/80 mg) tablets and double strength (800/160 mg) tablets. The double-strength tablet contains twice the amount of the drug as the single strength tablet.
Why do you use Sulfamethoxazole/Trimethoprim out of all the antibiotics available?
Sulfamethoxazole/Trimethoprim is the antibiotic of choice after kidney transplant because it is known to be very effective in preventing a serious lung infection called Pneumocystis jerovicii pneumonia (PJP). This infection is very rare but is thought to more likely to develop when someone is on high dose immunosuppression. This antibiotic can also protect you from other infections, such as urinary tract infections, which is the most common type of infection to occur after kidney transplant.
What if I am allergic or intolerant to Sulfamethoxazole/Trimethoprim?
If you cannot take Sulfamethoxazole/Trimethoprim, do not fret! There are other types of antibiotics that can be used instead, which may include dapsone or atovaquone. If you have a “sulfa” drug allergy, this does not always mean you can’t take Sulfamethoxazole/Trimethoprim. Most non-antibiotic “sulfa” drugs are unlikely to cross-react and are safe, but always make sure you ask your pharmacist or doctor first.
How do I take this medication?
This medication typically is used once a day when it is used to prevent infection. However, dosing may be variable as this may also be used to treat an active infection and you make require a higher dosage for a short period of time. The transplant team may also ask you to take this medication less frequently than once a day depending on your blood work and your kidney function.
How long do I have to take this antibiotic after my kidney transplant?
Typically, patients will be on the lowest possible doses of immunosuppressant medications by the end of the first year from their kidney transplant. If you do not develop any infections during this time, you may be able to stop this, but always check with the transplant team first.
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I was told I have a G6PD deficiency. Can I take Sulfamethoxazole/Trimethoprim?
No. G6PD deficiency is an inherited condition in which the body does not have enough of the enzyme glucose-6-phosphate dehydrogenase, or G6PD, which helps red blood cells function normally. Without enough G6PD, red blood cells can more easily be damaged or destroyed. Certain medications, such as sulfamethoxazole/trimethoprim, can cause the breakdown of red blood cells if you have a G6PD deficiency. Always tell your doctor or pharmacist if you have this condition before starting any new medications to make sure it is safe.
What are the potential side effects that can happen with Sulfamethoxazole/Trimethoprim? • • • • • •
Stomach upset Nausea Diarrhea High potassium levels Low blood sugars Decreased blood cell counts
If you develop a rash, stop the medication immediately and contact the prescriber.
Are there any drug interactions?
Sulfamethoxazole/Trimethoprim has few drug interactions. If you are taking other medications that can also increase your potassium, you may be asked to have your blood work checked more regularly. If you have diabetes and are on medications to lower your blood sugar, monitor your blood sugars more regularly and watch for lows when starting Sulfamethoxazole/Trimethoprim.
Is it expensive?
Sulfamethoxazole/Trimethoprim is inexpensive and usually covered by all types of drug insurance plans.
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Post Transplant Chat - Dialysis after Transplant Sarah Mattok RN, Fernanda Shamy RN, Kevin Bradley RN, Jennie Huckle RN, Michelle Gabriel RN 1. Is it common to need dialysis after a transplant? The new kidney has gone through some stress before you received it. It can take a while for the kidney to recover and start working, so people sometimes need dialysis until it recovers. Poisons and extra water still need to be removed from the body before the new kidney is able to do so. This is called delayed graft function. Delayed graft function can happen about 25% of the time. 2. It’s been 1 or 2 weeks after transplant, and I’m still on dialysis. Why isn’t my kidney working yet? There is some time, sometimes many hours, between the removal of the kidney from the donor and its insertion into the recipient. The time the kidney is outside of a body can stun it. When blood flow is restored to the kidney, the accumulated poisons can affect the kidney. This is called “ischemia-reperfusion injury”. It can take several weeks for the kidney to recover from this shock. 3. How can you tell if my kidney is still alive? A biopsy from the kidney is usually taken before putting it in, and is read a day or two later. The biopsy can tell us how much damage there was to the kidney. Also, after the transplant, we do frequent ultrasound tests to make sure the blood is still flowing well through the kidney. Sometimes another biopsy is done. 4. How can I tell if my kidney is beginning to recover? As the kidney recovers, the creatinine level in your blood before your dialysis session will start to decrease. You may also notice that you are passing more urine. You may also start to feel better. Often, an increase in your amount of urine is the first sign of recovery. 5. I was on peritoneal dialysis before, but now I’m on hemodialysis. Why did this happen? In order for PD to work, the peritoneal membrane has to be intact. Sometimes during surgery, the peritoneal membrane is cut and the peritoneal cavity may be entered. This means that PD would no longer work for you, at least for the time being.
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6. I think my kidney is working now. How will you know when I can stop my dialysis? There is no need to stay in the hospital after the transplant just for dialysis. You can return to your home dialysis unit. We will ask the dialysis centres to do blood tests before you start your dialysis session. As we see the results improve, we will recommend when to stop dialysis. Of course, you will continue to come to the Transplant Clinic regularly during this time, and we can make the decision to stop dialysis when you come to the clinic. 7. I’m off dialysis now. Are there any precautions I need to take? You should continue with the same care of your dialysis access that you used to do before the transplant. We will arrange for dialysis lines or catheters to be removed when you no longer need dialysis. This can be done at our hospital or your own hospital if you wish. We usually recommend that you have your PD catheter removed at your home hospital. We do not usually remove fistulas or grafts. 8. Are there any long-term side effects from dialysis after a transplant? Side effects can be different for everybody, depending on the reason for needing dialysis after the transplant. Talk to your transplant doctor when you come to clinic about any side effect you experience. Avoid becoming too dry, i.e., keep yourself with a little extra fluid in your body at the end of dialysis, so that the chances of injury to the newly transplanted kidney from too little water can be reduced. 9. I think this transplant isn’t going to work. Can I get another one? Most kidneys will start to work within three months. If the transplant does not work, it is possible to receive another one, after a period of recovery. You will need to go through some additional testing to make sure you are safe and ready for a second transplant. You should discuss with your doctor the various wait listing options available for someone with a failed kidney. Sometimes the failed kidney will need to be removed, but often it can be kept and a second kidney would then be placed on the opposite side.
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Did You Know? What Happens to Your Dialysis Access After Kidney Transplantation? Galo Meliton, RN, C Neph (C), Senior News Correspondent Congratulations on receiving a kidney transplant. You probably have a number of questions in mind after this life changing event including: What happens to my dialysis access now that I have had a kidney transplant? If you had a hemodialysis line in your neck or shoulder as your dialysis access before the kidney transplant, the hope is that by the time you are ready to go home from Hospital after the transplant, provided your new kidney is working well, the team on 8C South (Nursing Ward) would have arranged for your line to be removed in the Diagnostic Imaging (x-ray) Department. If the kidney is not working all that well by the time you are ready to go home, the team may decide to have the post- transplant team decide when it would be appropriate for your line to be removed, either at your original home center or at St. Michael’s Hospital. Having the line removed when appropriate decreases another source of infection. If you were on Peritoneal Dialysis (PD) where you had a catheter in your abdomen (peritoneal cavity) for the purposes of dialysis, and if the kidney transplant is found to be very successful (usually from a living kidney donor), even as early as when you are on the operating table, the kidney transplant Surgeon may
decide to remove the PD catheter right there and then! There would be one less thing (procedure) to worry about down the road! On the other hand, if the new kidney is found to be not working as well as they have would have expected, the PD catheter removal would have to be arranged for with your original home center or at St. Michael’s Hospital once deemed appropriate. Having the catheter removed when appropriate removes another source of infection. Lastly, if you had an Arterio-Venous Fistula (AVF) as your hemodialysis access before the kidney transplant, you may find that the AVF may suddenly stop. The thrill (buzzing sensation) you would normally feel when the fistula is working would no longer be there. This is usually due to clotting in the fistula caused by a low blood pressure. Provided your new kidney is working well, there usually will not be a need to seek medical treatment for the fistula to be salvaged. As time goes on, and you feel much pain in the AVF, or it has gotten so big that you would want to have it clipped, our clinic can send you to one of our Vascular Surgeons who will discuss your options in this regard. That said, we would prefer that your dialysis access be intact in case you need it.
Scarring in the Kidney Dr. Darren Yuen
Scarring is a major cause of kidney failure, unfortunately affecting your native kidneys (the ones you are born with), as well as the transplant that you receive. Unfortunately, currently no safe and effective anti-scarring treatments exist. Work being done at St. Michael’s Hospital is leading the way in trying to figure out a way to prevent scarring from damaging your kidney. St. Michael’s Hospital researchers (Dr. Darren Yuen and Dr. Richard Gilbert) are growing scar-producing cells from kidney biopsies to learn why some kidneys scar a lot, whereas others do not scar at all. Our hope is that this “first in the world” study will provide us with new insights into how scarring is stimulated, and therefore will show us how to better target the scarring process. Stay tuned!
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Food is Medicine. Medicine Heals. Jenny Accetura, RD
The week of September 26th-30th, 2016 marked the second annual Canadian Malnutrition Week. The goal of malnutrition week is to raise awareness on the importance of food for recovery. What is malnutrition? Malnutrition is the lack of energy, protein and/ or nutrient intake that can be made worse by other diseases or infections. The lack of energy and or nutrients can affect body tissues, functional ability and overall health. The Canadian Malnutrition Task Force (CMTF) was developed to help reduce malnutrition through research and education initiatives and to inform the public about optimal nutrition care. Dietitians are committed to improving the detection, prevention and treatment of malnutrition in Canadian hospitals to make improvements in nutrition care. Research has shown that 1 out of 2 Canadians admitted to hospital are malnourished. Patients who are malnourished can stay 2-3 days longer in hospital and are two times more likely to get readmitted to hospital with an increased risk of developing pressures ulcers and other infections. In one study, older, malnourished hospitalized patients had more eating difficulties and reported dissatisfaction with food quality. This lead to reduced food intake, which increased length of hospital stay and worsened malnutrition. Many of the causes of patients not eating well in hospital are small problems. Some of the eating difficulties reported were; food not provided when meal tray missed, eating time interrupted by staff, poor position for eating, unable to reach meals and difficulty opening packages.
Although weight gain is very common after transplant, loss of appetite can also occur at various time points. Immediately following transplant surgery, it is possible to feel nauseous and have a lack of appetite. It is an adjustment period with changes in medications and managing multiple diseases and symptoms. This is a critical period, especially within the first 8 weeks after transplant. Energy and protein needs are higher to help with wound healing and recovery. In addition, there are times when you may be admitted to hospital or feel unwell, which may be caused by other diseases or infections and your appetite can decrease. It is important to make sure you nourish your body properly during these times to help you recover more quickly. Including protein rich sources at meals and snacks is essential to maintain lean body mass and prevent loss of muscle. Some examples include; greek yogurt, chicken, fish, turkey, eggs, soy protein, nuts and legumes. In addition to making sure you meet your protein needs, your energy needs are also important to prevent further weight loss. Including good sources of fat (unsaturated fat) like nuts or nut butter, avocado and a variety of oils can help you meet your needs. Overall, malnutrition is a widespread problem in Canadian hospitals that can affect the quality of life of transplant patients. If your appetite, food intake or weight is affected after your kidney transplant, it is your right to notify your team. We want you to eat your meals and we want you to get better. Food is medicine and medicine heals. 13
Congratulations... Dr. Ramesh Prasad is now the Director of the Kidney Transplant Program, St. Michael’s Hospital.
Jonathan Fetros, RN, MN, CHE is the new Director for Diabetes Comprehensive Care Program.
Dana Whitham, RD, MSc is the new manager for the Diabetes and Renal Transplant Program.
Lucy Chen is the new case manager for Diabetes and Kidney Transplant Program. She is currently on education leave to pursue her doctor in pharmacy.
All the Best to... Jill Campbell, previous director of Diabetes Comprehensive Care Program, has moved to the Centre for Addiction and Mental Health (CAMH) as Vice President, Clinical (Complex Care and Recovery), after 30 years of service at St. Michael’s Hospital.
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