Transplant Digest - Issue 23 by St. Michael's Hospital

Transplant Digest Fall 2017/Winter 2018, Issue No. 23

Shipping Kidneys for Transplant By Lucy Chen, Case Manager

Sometimes, a living kidney donor is a not a match to their friend or family member. The national Kidney Paired Donation (KPD) program makes it possible for transplant to still happen. The program uses a sophisticated computer program to match donor-recipient pairs who are not a match to each other with other donors and recipients to whom they are compatible. The program is Canada wide so that patients and their donors can access a large pool of other donor-recipient pairs to find a match. This means that sometimes the donor or the recipient has to travel very far to a different transplant center for surgery. Having surgery and going through the recovery process in a strange city far from your family and friends can be very stressful. There is also the extra cost of airfare, hotels, and other travel expenses. KPD participants can choose not to travel but this means limiting the pool of potential matches.

In This Issue... Shipping Kidneys for Transplant From the Editor’s Desk Contact Information Creatinine: What is it and What Does it mean? Diabetes Medications and Your Kidney Transplant Kidney Stone and Transplantation Post-Transplant Chat: Wound Care after Kidney Transplantation St. Michael’s Transplant Program Retreat: A Report Transplant Ambassador Program Another Successful Year for High School Outreach Initiative Updates on Research Checkout our new website! Kudos! Save the Date

This summer, we made it possible for a kidney donor to donate to a patient in Vancouver through the KPD program without having to travel all the way there. Our kidney donor had surgery at St. Michael’s which allowed this donor to recover close to home in Toronto. Instead, we sent the kidney on a flight to Vancouver with Air Canada’s Medical Program to reach its new home. Making sure the entire process went without a hitch took months of preparation. The St. Michael’s living donor team worked with our surgeons, operation room nurses, nephrologists, and managers to develop clear step-by-step procedures to ensure the kidney got to its destination safely and as quickly as possible. We also had a lot of help from Trillium Gift of Life, Toronto General Hospital transplant program, Air Canada, and BC Transplant to lend equipment, expertise, and guidance along the way. A special organ cooler must be used to make sure the kidney stays at 0 to 10 degrees Celsius at all times. When transporting an organ for transplant, time is of utmost importance. The shorter the time the kidney spends on ice, the better. A Toronto Police officer was on hand to take the kidney from downtown Toronto to Pearson airport in a record 18 minutes, using sirens to bypass any traffic jams. On the plane, the kidney was safeguarded at all times by the flight captain. Once in Vancouver, an ambulance with sirens sped the kidney to St. Paul’s Hospital to be transplanted into its new home. Continued on page 2

Transplant Digest 1 Fall 2017 / Winter 2018, Issue No. 23

In April of this year, Dr. Gill and his group published research showing that transplants from shipped kidneys last just as long as regular non-shipped kidneys (1). We hope our success thus far means more patients will be able to donate or receive kidney transplants without needing to travel far from home in the future. Next, we plan to develop step-by-step procedures for receiving a kidney from the airport for transplant at St. Michael’s. Stay tuned for that story in another issue! (1) Gill J, Rose C, Joffres Y et al. Cold ischemia time up to 16 hours has little impact on living donor kidney transplant outcomes in the era of kidney paired donation. Kidney Int. 2017 Apr 19. pii: S0085-2538(17)30105-9.

From the Editor’s Desk Welcome to the Fall 2017/Winter 2018 issue of Transplant Digest. Over the past ten years, we have covered almost every topic of interest to patients, their caregivers, and health care providers. Topics are not necessarily the most popular every time, since if we emphasized popularity then some topics would be repeated too often and others ignored entirely. Past issues are available online through the St. Michael’s website. We also have an updated Transplant Program website, which we hope you will find to be both user-friendly and informative. Although I cannot (nor anyone else I suspect) predict what the next ten years will hold for us in the medical field, it is my hope that Transplant Digest will continue to be an important part of your health care needs when it comes to information sharing. In this issue, we have topics on what creatinine is all about, kidney stones, diabetes medications, wound care, and research studies. News items include information about the new website, the high school research initiative, our transplant retreat, and the Transplant Ambassadors program. We always welcome suggestions for topics and articles from patients and our health care partners in the community. Please do not hesitate to bring up for discussion or clarification anything you read in Transplant Digest (present or past issues) at your next clinic visit. Dr. Ramesh Prasad, Editor

St. Michael’s Hospital

Contact Information

(across the hospital) 61 Queen Street 9th Floor Toronto, Ontario, M5C 2T2 Phone: (416) 867-3665

Renal Transplant Program

Dr. Ramesh Prasad – Editor Meriam Jayoma-Austria, RN, BScN, CNeph(C) – Newsletter Coordinator LEVEL B

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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. For all questions related to your own health please contact your health care provider.

Creatinine: What is it and What Does it mean? Dr. Ramesh Prasad Among all the blood tests that patients with a kidney transplant are asked to provide, the single most important test when it comes to knowing how well the kidney is working is called the “serum creatinine”. Almost every patient with kidney disease is familiar with the name of this test. But what exactly is creatinine all about and what exactly does “creatinine level” mean? “Creatine” is a chemical derived from amino acids that is made in the liver. It travels to the muscle, where it forms phosphocreatinine, which is a high energy chemical in muscle, and creatinine is formed in the process. Creatinine is excreted by the kidneys into the urine, and very little creatinine leaves the body through other routes. Once excreted, it doesn’t get reabsorbed either. The urine is full of creatinine. The “normal” creatinine level in the blood is different for everybody, but is usually higher in men. The level is higher in larger people Bigstockphoto.com with more muscle, and in young adults compared to older adults, because it depends on how much muscle mass one has. Creatinine is produced at a constant rate in the body. This is a very useful property of creatinine, because it can be used to help assess the completeness of 24-hour urine collections, for example. Most labs now measure the serum creatinine level in the same way, so that the serum creatinine can be roughly translated by an equation into a “percentage” of kidney function that you have (actually, it is the rate at which your kidneys are filtering the liquid part of your blood, but that’s another topic). When the kidneys are diseased, the level of creatinine in the serum rises (serum is the liquid part of the blood that remains after your blood is allowed to clot in a tube). This is often how kidney disease is detected, and then followed over time. Therefore, apart from some exceptions like muscle wasting or kidneys that are working too hard from uncontrolled diabetes, a low serum creatinine level is typically a good thing. In dialysis patients the creatinine level is very high. After a successful transplant, it comes down almost to, but not quite into the normal range because it is after all only one kidney that has been transplanted, not two! There is really no “normal” creatinine value for a kidney transplant patient; it is different for everybody, more different than it can be in the general population. “Normal” is not the same as “ideal”. Normal in this case means “usual”. What is more important is that the creatinine level remains stable over time. If the kidney transplant gets into trouble, the creatinine begins to rise again. It is important to detect a creatinine rise early, so that something can be done about it. That’s why regular blood testing is so important! A rise in creatinine might mean rejection of the kidney, volume depletion, drug toxicity, infection, urine obstruction, and so on. Further tests will be ordered to try to determine why the creatinine has risen. It will be very helpful for YOU to know what your creatinine level is. If you don’t know what it is, please ask in the clinic. That way, if you ever have to see a doctor or go to a hospital and they find a high creatinine level, you will be able to discuss with them what the usual creatinine value is for you, and this will help them to take care of your transplanted kidney.

Diabetes Medications and Your Kidney Transplant Tess Montada-Atin, NP Which diabetes medications are safe to take with a kidney transplant? Most diabetes medications are broken down or cleared by the kidney. When the kidneys aren’t working as well, less medication may be needed. There are 5 stages of chronic kidney disease (CKD).

Stage 1 2 3 4 5

Description Some kidney damage with normal filtration Mild decrease in kidney function Moderate decrease in kidney function Severe decrease in kidney function Kidney failure

Kidney Function (GFR mL/min/1.732) > 90 60-89 30-59 15-29 <15

Most of the diabetes medications are safe to take in kidney transplant patients, including metformin. Metformin is usually the first choice of medication given for the treatment of diabetes. In CKD stages 1-2 the regular dose of metformin can be taken. In CKD stage 3 metformin can still be taken safely, but at a lower dose. Although metformin does not cause kidney damage, it can build up in the blood when the kidneys aren’t working well and cause a serious condition called lactic acidosis. Therefore, metformin should not be taken in CKD stage 4 and 5. See chart below which diabetes medications can be taken at what stage of CKD (indicated by a ✓.) Some of these medications should be taken at lower doses especially in stage 3 or higher (indicated by an *)

Diabetes Medication All insulins gliclazide(Diamicron ® ) repaglinide(Gluconorm ®) glimepiride (Amaryl ®) glyburide (Diabeta ®) linagliptin (Trajenta ®) saxagliptin (Onglyza ®) sinagliptin (Januvia ®) alogliptin (Nesina ®) liraglutide(Victoza ®) exenatide (Byetta ®) abiglutide(Tanzeum ®) canagliflozin(Invokana ®) dapagliflozin(Forxiga ®) empagliflozin(Jardiance ®) pioglitazone (Actos ®) rosiglitazone (Avandia ®) acarbose (Glucobay ®)

Stage 1 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Stage 2 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Stage 3 ✓ ✓ ✓ ✓ ✓* ✓ ✓* ✓* ✓*

✓ ✓ ✓ ✓

Stage 4 Stage 5 ✓* ✓* ✓* ✓ ✓ ✓* ✓

✓*

✓* ✓*

✓* ✓* ✓*

✓*

✓ ✓ ✓ ✓

✓* ✓*

Although there are many options for diabetes medications for kidney transplant patients, treatment choice should be individualized to the patient’s situation.

Kidney Stones and Transplantation Dr. Ramesh Prasad Among all the diseases of the kidney that can affect people, the topic of kidney stones interests most people. Almost everyone knows someone who has had a kidney stone at some point in the past. However, the link between kidney stones and kidney transplantation is rather remote. Kidney stones do not typically cause kidney failure, which is the reason for kidney transplantation. Yet sometimes the issue of kidney stones comes up in the Transplant Clinic. Here is some information about kidney stones in the context of transplantation worth knowing about. Eighty percent of patients with kidney stones form calcium-containing stones, usually calcium oxalate or rarely calcium phosphate. Other stones include uric acid, struvite (magnesium ammonium phosphate), and cysteine, but sometimes stones are mixed, such as containing both calcium oxalate and uric acid. The composition of a stone can be determined when a stone is passed in the urine and captured, to be sent to the lab for analysis. Many people have smaller stones without knowing about them, and these are picked up when an ultrasound of the kidney is performed for other reasons. A CT scan of the kidneys might be ordered to confirm the diagnosis. Trace amounts of blood can be detected in the urine if patients pass smaller stones or â&#x20AC;&#x153;gravelâ&#x20AC;?. Pain and blood in the urine are the most common symptoms when the stone grows large enough to pass into the ureter. The pain from passing a kidney stone can be quite severe, with the patient typically rolling around in bed trying to find a comfortable position.

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Transplant patients have ultrasounds performed for a variety of reasons, and stones in the kidney transplant are often picked up this way. These stones usually belong to the donor, but now the recipient has to deal with these stones. Living donors are excluded if they have a history of kidney stones, but not deceased donors when their kidney function is otherwise very good. Not every deceased donor will have a pre-donation ultrasound or CT scan either. Small stones are usually managed conservatively, meaning they are just watched for further growth by an ultrasound over time, along with dietary advice since your diet can affect stone formation immensely. The transplant drugs themselves do not cause kidney stones, and it is rare for kidney transplants to fail because of kidney stones. There is always a concern, however, that a stone will grow and cause obstruction, leading to hydronephrosis, with greater impact on kidney function since there is only one working kidney. If the stones are large and/or multiple, then a referral may be made to a urologist for considering options like lithotripsy or stone removal through laparoscopy. Some form of treatment is typically needed when stone size exceeds 10 mm. You may also be referred to a Stone Prevention Clinic, to receive specific advice about preventing kidney stone formation in the future. Generally speaking, a high fluid intake and low sodium (salt) intake are very helpful for patients with kidney stones. Limiting your sugar intake may also help. A 24-hour urine collection when you are not having an acute stone episode will help guide further management.

Wound Care after Kidney Transplantation By Sarah Mattok RN, Fernanda Shamy RN, Galo Meliton RN, Jennie Huckle RN, Kevin Bradley RN

Why are there so many staples on my wound? Why is the skin red around the staples? The staples are there to hold the sides of the wound closed until it heals. The surgeon decides how many staples are necessary when you are in the operating room. The skin can be red around the staples because it is inflamed by the metal staples. This redness will go away once the staples are removed. If the redness is spreading or the skin is sore, let the transplant clinic know. This can be a sign of infection.

I’m noticing some watery liquid coming out of the wound. Is this something to worry about? It is common to have a bit of clear, pink or light yellow liquid coming out of the wound. This is fluid that accumulates under the skin and is finding the easiest path out of the body.

I’m noticing some yellow or green liquid coming out of the wound. What should I do? This could be a sign of infection. Check if it is red around the wound, and check your temperature. Call the transplant clinic for advice, or go to the emergency room if you have a fever or feel unwell.

My wound is starting to hurt when I move into certain positions. What should I do? You should limit your exercise and movement until you are assessed in the transplant clinic. Keep moving your body parts that don’t hurt, and do your best to find a comfortable position to rest and to sleep. Tylenol® in limited quantities might help, but try to avoid narcotics because they can constipate you and worsen the pain. If the pain is severe, seek medical advice.

Is it OK not to wear seatbelt because of my wound? You must always wear a seatbelt, and you must follow the law! If it is uncomfortable, you could put a small pillow over your wound and underneath the seatbelt.

Is it OK to drive, exercise and swim? You can drive when you feel it is safe for you. Please note, the decision to start driving is your responsibility and no one else’s. Keep in mind that the anti-rejection medicines can impair your judgment.

continued from previous page The discomfort from the surgery can also make it hard for you to make quick movements such as checking over your shoulder or looking in the mirrors. You can do light exercise for the first three months. Walking is one of the best exercises during this time. Avoid lifting more than 5-10 pounds at a time initially, and gradually increase this load as tolerated. Ask the transplant clinic when you can start swimming. This time is usually after your wound has completely healed, your staples are all out, and your stent has been removed.

My wound has started to hurt all of the time. What does that mean? This is not normal and could be a sign of a complication, such as an infection. Make sure you tell the transplant clinic about this pain. You may need to have an ultrasound or extra lab tests to determine the cause.

Do I need to take an antibiotic to prevent wound infection? How else can I prevent a wound infection? Wound infections are not common. If you get an infection, you will probably require an antibiotic to treat it. Keep the wound clean and dry. Wash the area with soap and water and pat it dry. This is usually enough to prevent infections. You did receive an antibiotic at the time of surgery to prevent wound infections.

When and where will the staples come out? We will remove the staples at your post-transplant clinic visits. We usually take out half the staples at about 3 weeks after the surgery, and the remaining staples a week later, as long as the wound is healing well. For some people, staple removal may have to wait longer.

10) Iâ&#x20AC;&#x2122;m noticing that the wound has started to gape. How do you make the wound close again? If the wound starts to open, call the transplant clinic or go to the emergency room as soon as possible. Wounds that open up usually need to have special dressings and packing to help them heal from the inside out. Wounds cannot be stapled up again.

St. Michael’s Transplant Program Retreat: A Report Dana Whitham, Program Manager

A retreat. It’s a word that usually means to withdraw or move back, but in this case it meant an open space to think. A space where all ideas are welcome. A place to plan a move forward and not back. In January and again in September, our transplant team went on a retreat. As the manager of this team, I couldn’t be more proud. We already have an amazing program. We already provide exemplary care. But this team wanted to be better. We generated more than fifty ideas, in the first day alone. The suggestions revolved around efficiency, innovation and improving collaboration and communication. In day two of our retreat, the team spent some time identifying the core characteristics of the ideal professional. We feel we each need to be knowledgeable, respectful, empathetic, professional and collaborative. We also feel that these core characteristics will ground us in providing the best experience for our patients along their transplant journey. Our goal is to be viewed as “People Transplanting People”. With respect to our vision, we determined that we want to provide a journey through transplant that represents quality care in all angles. Care that is safe, efficient, effective, evidence based, innovative and patient centered. As a result, the new vision of our Kidney Transplant Program is “Best options, best experience, best outcomes”. In the upcoming months, we will be continuing to move forward with many of the ideas that were generated at the retreat. That means continuing to empower our patients and the transplant professional community through education. It also means collaborating with our network of transplant partners and finally, it means continuing to develop into being the best team that we can be, through laughing and learning and growing together.

Are you a Transplant Recipient or Living Donor? Become a Transplant Ambassador Written by: Lawrence Geller Edited by: Sharon Lee RSW What is the Transplant Ambassador Program (TAP) ? TAP is a patient led initiative, supported by the Canadian Disease Network, in partnership with the Ontario Renal Network. The goal of the program is to connect individuals who are considering a transplant or donating, with a Transplant Ambassador. All Transplant Ambassadors are either past donors or recipients. The program is being launched in 13 renal programs across the province with St. Michael’s Hospital being one of them. What do Transplant Ambassadors do? As a Transplant Ambassador you will meet with patients who are considering a kidney transplant or donating a kidney. You will be sharing your experience as either a recipient or donor so that you can support patients living with chronic kidney disease and their family members in learning more about transplantation and living donation. During my transplant journey, I wished there was someone I could have spoken to who had “walked in my shoes.” I remember all the things that came along with my transplant such as the testing, the waiting that ensued, the healing process after surgery and so much more. Hearing from someone who has benefitted from either giving or receiving can go a long way to help those considering transplant feel comforted and supported. Join the St. Michael’s TAP team! If you are a successful kidney recipient or donor interested in becoming a Transplant Ambassador at St. Michael’s Hospital, please visit www. transplantambassadors.ca or email lawrence.geller@transplantambassadors.ca or jason.kroft@transplantambassadors.ca

Updates on Research Michelle Nash, MSc Thank You Volunteers! We would like to sincerely thank all of the patients who have helped us to explore new ideas and approaches to chronic kidney disease and kidney transplant over the years. We are constantly working to improve outcomes and the experience for patients with kidney disease. Research Program Update We are currently involved in many different research studies focusing on chronic kidney disease and kidney transplant. The Kidney Transplant Study Doctors, also known as Study Investigators, include Dr. Ramesh Prasad, Dr. Darren Yuen and Dr. Jeffrey Zaltzman. We have an exciting group of studies that we have been working on this past year. Below, we have provided a basic introduction to some of the current types of studies in the Transplant Program. The studies are identified by their simple or short title. MRI STUDIES DGF MRI STUDY, DWI MRI STUDY, RTF MRI STUDY

• The goal of these studies is to use information obtained by MRI (magnetic resonance imaging) to help us understand kidney damage related to scarring or fibrosis. Bigstockphoto.com

LABORATORY STUDIES CROSS-SECTIONAL STUDIES: AMINODAT STUDY, ANEMIAT STUDY

• The goal of these studies is to look for unique laboratory biomarkers at a single study visit that may help us to better understand diabetes and anemia after kidney transplantation. PROSPECTIVE STUDIES: UHN QFT CMV STUDY

• The goal of this study is to see if a specific lab test that is drawn at different study visits can help guide medical decisions related to CMV prophylaxis medications after kidney transplant. Cytomegalovirus or CMV is a common cause of infection in kidney transplant patients.

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QUESTIONNAIRE STUDIES UHN LDKT STUDY

• The goal of this study is to help learn more about potential barriers to living donation using questionnaires completed at different points in time in the transplant work-up process.

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CLINICAL TRIALS REGIFT STUDY, ZOSTER 041 STUDY, FKC014 STUDY, BK KIDNI STUDY

• Clinical trials use formal, organized research methods to learn more about a topic. Clinical trials allow conclusions to be made about a topic by comparing different groups in a controlled way. The goal of clinical trials includes testing new medications in development to see how well they work and to see if they are safe. 10

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continued from previous page Research Contact List We have recently started a Research Contact List in our program. If you would like to receive information directly from the Research Team about upcoming studies, please either let any of the clinical program staff know or feel free to contact the Kidney Research Team directly at the numbers listed below. Signing up for the Research Contact List does not mean that you are agreeing to participate in any studies - it just means that you agree to receive information about research directly from the Research Team. This is entirely voluntary and you can remove your name from the Research Contact List at any time. If your name is not on the Research Contact List, you would hear about research opportunities from your clinical team, ads in the waiting room, patient publications (ie newsletter), etc. Research Manager Research Coordinator Research Unit Coordinator Research Assistant

Michelle Nash Lindita Rapi Niki Dacouris Weiqiu Yuan

416-867-3692 416-867-7460 ext 8024 416-864-6060 ext 3225 416-867-7460 ext 8409 St Michael’s Hospital Kidney Research Team Patient Orientated Research We are working to find ways to involve patients more in the research process and to get information that has been learned from research back to the kidney transplant patient community. We would also like to get feedback on what we are doing well and what we could improve within the research program.

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We are in the process of improving the Kidney Transplant Research page on the St. Michael’s Hospital website. We’re planning to post information about studies that are currently active as well as to post links to articles that have been published by our team.

If you have any ideas for research, for the website, any suggestions for general improvement or would be interested in being contacted for your feedback on different initiatives as they are developed, please contact Michelle Nash at 416-867-3692 or by email at nashm@smh.ca. If you are interested in finding out more about Canada’s Strategy for Patient Oriented Research (SPOR), please have a look at the following website: http://www.cihr-irsc.gc.ca/e/41204.html Next Issue Watch for more information on current studies and updates on recent publications. 11

Check out our new website! By Lucy Chen, Case Manager

www.stmichaelshospital.com/transplant We are very excited to announce the launch of our brand new website with updated content and a new easy-to-use interface. Here are some of features you will find on our site: - Transplant health information library. The information you find here is specifically written for St. Michael’s kidney transplant patients. All of the content has been reviewed by your doctors, nurses and other health care team members. You can also easily print out any of the pamphlets at home. - Upcoming events. Check back frequently so you don’t miss any of our events, like our biannual Connect & Learn forum for post-transplant patients and their support persons. - Meet the Team. You can “meet” all the members of our team virtually and learn about how each person can support you in your transplant journey. - A portal for Health Care Providers. Share our website with your family doctor, dentist and other specialists. We have posted tips and resources about caring for kidney transplant patients, like medications, vaccines, and more.

Another Successful Year for High School Outreach Initiative Galo Meliton, RN C Neph (C) Senior News Correspondent The High School Outreach Initiative (HSOI) had another successful year (2016/2017). The HSOI is designed to convey the importance of organ and tissue donation and transplantation to youth (aged 1619) in the GTA, predominantly in the Toronto District School Board (TDSB) and the Toronto Catholic District School Board (TCDSB). The overarching goal it to create a culture of organ and tissue donation and increase registration rates in this age group through education and by encouraging the students to speak with their families. Highlights of the successful school year included 56 presentations in 33 different high schools across the GTA. The number had greatly increased by 33% from the previous year due to early contacts with existing teachers and the addition of a volunteer to help aide the process to reach put to the multitude of schools/ teachers. There were a total of 13 new schools this year along with the 20 already existing schools. Of the 56 presentations, 12 were assembly presentations, consisting of between 50- 1000 students. Thank you to all the patient volunteers who co-presented with all the volunteer Health Care Professionals as well as the Hospital leads from St. Michael’s Hospital (Galo Meliton, RN) , Toronto General Hospital (Anna Cocco, Education Coordinator), and The Sick Children’s Hospital (Stephanie So, Physiotherapist). This initiative is in collaboration with the Trillium Gift of Life Network (TGLN). Thank you as well to the HCP volunteers from St. Michael’s Hospital who did presentations this past year: Dr. Jeffrey Zaltzman, Galo Meliton, RN, Suela Cela, Social Worker, Meriam Jayoma, RN, and Ronald Merko, RN. If you are interested in volunteering as a patient or HCP volunteer, please contact Galo in the PostTransplant Clinic at (416) 867- 3665 Option 2.

Kudos! Congratulations to Galo Meliton for getting the best abstract award from the International Transplant Nurses Society (ITNS) Conference held in Buena Vista, FL. in June of 2017. The abstract is entitled “ABO-incompatible kidney transplantation using ABO Immunoadsorption Columns: A single center experience”

Congratulations to Dr. Ramesh Prasad for completing his Doctor in Philosophy at the University of Waterloo.

Welcome to the Kidney Transplant Team....Kathryn Salvatore, RN 13

Save the Date Monday, June 18, 2018 Li Ka Shing Knowledge Institute 220 Victoria Street, Toronto ON The St. Michael’s Hospital Kidney Transplant Program is pleased to invite all nursing and allied health professionals to the

7th Biennial Kidney Transplant Symposium “Moving Forward with Best Outcomes” We are excited to share with you the latest updates regarding transplant evaluation, cancer screening, metabolic syndrome, immunosuppression, and much more! Watch for registration details to follow

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30 Bond Street, Toronto, ON M5B 1W8 Canada 416.864.6060 stmichaelshospital.com