Transplant Digest Spring/Summer 2020 by St. Michael's Hospital

Transplant Digest SPRING/SUMMER 2020 ISSUE NO. 28

COVID-19 and the Kidney Dr. Jeff Zaltzman The novel SARS2 corona virus or COVID-19 has been the largest viral pandemic seen in more than a century. At the time of this writing over 100,000 Canadians have been known to be infected with close to 9000 dying as a result. This discussion will focus on the impact of COVID-19 and patients with kidney disease including: patients with chronic renal failure, those on dialysis, and kidney transplant recipients. In addition, we will examine the potential effect on the kidneys of critically ill patients. As is presently understood, anybody has the same risk for getting infected with this virus. However the majority of deaths have occurred in the elderly population (75% of Canadian deaths in long-term care facilities). Despite these statistics, persons of any age can become quite ill and even succumb to COVID-19. Fortunately, most infected patients have mild symptoms or are completely asymptomatic. In addition to the mortality risk associated with age, other known risk factors include people with hypertension or type 2 diabetes and those who are immunocompromised. It thus Continued on page 2

In this issue... •

COVID-19 and the Kidney

•

Impact of COVID on the National Kidney Paired Donation Program

•

How to Deal with Stress During These Difficult Times

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Working at the COVID Assessment Centre

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Post-Transplant Chat: COVID-19

•

HealthCare in a Pandemic: Where We Are and Where We are Headed

•

Measuring Heart Function with BNP

•

Seasonal Allergic Rhinitis

•

2020 is Year of the Nurse

•

Vaginal Yeast Infection

•

News of Note

•

Peer Support Program

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From the Editor’s Desk

St. Michael’s Hospital Renal Transplant Program

Dr. Ramesh Prasad How much the world can change in a short period of time! The novel coronavirus, COVID-19, has come to occupy a central place in our news headlines, thoughts, and daily lives. COVID-19 has certainly affected work lives as well, and in the health care professions, fighting COVID-19 has become a main focus. Some of our transplant staff was redeployed to help out with COVID-related efforts. However, COVID or no COVID, as a transplant program our main job will always be taking care of over 1700 kidney transplant recipients in all their needs related to their transplants, as well as helping over 300 patients with kidney failure towards their goal of getting a transplant soon. COVID-19 still dominates this issue of Transplant Digest. We have articles on how the virus affects the kidney, life in the assessment centre, the virus’s effect on how we provide health care, and answers to commonly asked questions in Post-Transplant Chat. For those sick of hearing about COVID, we have articles on heart function, vaginal infections, and seasonal allergies. The pandemic will end, and we will ultimately emerge stronger and healthier from the experience. Until we meet again, please take all necessary precautions and stay safe.

(across the hospital) 61 Queen Street 9th Floor Toronto, Ontario, M5C 2T2 Phone: (416) 867-3665 Please send your comments or suggestions of topics for future publication to: Meriam.Jayoma@unityhealth.to 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.

COVID-19 and the Kidney story continued from page 1 becomes clear why those with kidney disease may be at increased risk. Many people with chronic kidney disease have hypertension (high blood pressure) and/or diabetes. In any dialysis unit in Canada approximately 50-60% of the patients have diabetes as the cause of their kidney failure. In addition to diabetes and hypertension, the dialysis population tends to be older adults. To date approximately 175 dialysis patients in Ontario known to be infected with COVID-19. This represents less than 2% of the dialysis population, however of these, 36 (22%) died as a result. The data for patients with chronic kidney disease (CKD) has not been as robustly collected so likely the numbers of COVID-19 infected CKD patients are much higher than what is reported. Regardless, the Ontario Renal Network reports that of 47 CKD patients with documented COVID-19, 16 (34%) have died. Most of us believe that the number of infected CKD patients is much higher, which would translate to a much lower case fatality rate. Kidney transplant patients have additional risk namely taking anti-rejection medications to maintain the health of their kidney. These medications suppress the immune system making it more difficult to fight off the virus if infected. There are mixed reports as to whether COVID-19 infected transplant recipients have a higher mortality compared to the general population. Canadian kidney PG 2 - TRANSPLANT DIGEST

transplant patients so far appeared to have fared quite well, perhaps owing to precautionary measures such as social distancing. Between the 2 adult kidney transplant programs in Toronto, thus far we are aware of 18 patients who were infected. Some patients required hospitalization. One patient died as a result of COVID-19. The current strategy in dealing with infected transplant patients is to cautiously reduce the immunosuppressive medication. Lastly, there is emerging evidence that COVID-19 can directly and indirectly affect the kidneys. The virus binds to a particular receptor on cells and blood vessels known as ACE2. The kidneys contain a high amount of ACE2. Studies have shown that the virus can be detected in kidneys of some patients who have died of COVID-19 with newonset kidney failure. The sickest patients with COVID-19 require intensive care (ICU) many of whom develop kidney failure and require dialysis. The mechanism of kidney injury is varied and includes severe infection with low blood pressure, blood clots within the kidney and perhaps direct virus kidney damage. At this time there are no proven therapies for COVID-19 and the world anxiously awaits successful vaccine development. In the interim, kidney patients, dialysis and transplant patients need to maintain a higher degree of vigilance to stay safe.

Impact of COVID on the National Kidney Paired Donation Program Maureen Connelly, RN

COVID-19 was declared a pandemic by the World Health Organization on March 11, 2020. Health care delivery as we knew it will certainly change moving forward. Many of our kidney donors and transplant candidates had their scheduled surgeries canceled. They are anxiously waiting for news of when their surgery can be rescheduled. St. Michael’s and other hospitals will receive guidance directives from Ontario Health on the requirements that need to be met before surgeries can resume. Ontario Health published a document available on line entitled: “A Measured Approach to Planning for Surgeries and Procedures during the COVID-19 Pandemic” . This has also had an impact on the Kidney Paired Donation Program. Paired exchange is when two separate but willing donors are each unable to donate to their intended recipients due to blood group ( ABO) incompatibility or because of incompatibility of cross match blood testing. In this program the willing donors are matched with the other’s respective recipient so that each recipient can receive a kidney with a compatible living donor. The paired exchange program is offered through Canada’s transplant programs in co-operation with Canadian Blood Services. CBS is managing the waiting list computerized registry that matches suitable donors and recipients. A run cycle of the computer algorithm is performed three times a year in February, June and October. This allows transplant programs time to enter as many donor and recipient pairs into the registry to improve the odds of matching. Once matched in the registry, the kidney donation surgery

takes place on the same day as their recipient or within 3-5 days of each other’s surgery. This option involves travel for the donor to the transplant center where they are matched to a transplant recipient. Due to current travel restrictions the June run cycle was canceled on the advice of the CBS medical advisors. The plan moving forward is to run monthly cycles with transplant programs that are currently ready to resume surgery. The computer will match only donors who live within close proximity to the transplant center that they are matched to. Once all transplant programs are able to resume surgeries, CBS will revert to the quarterly run cycles. Moving forward, there will still be efforts to have donor travel limited, either with local matching when possible or by shipping kidneys. The protocols for sending and receiving kidneys are being shared amongst transplant programs. In future this could be the preferred option for paired exchange donor/ recipient transplants. The impact and transmission between living donors and transplant recipients is unknown at this time. The screening and management of potential living donors is based on current expert recommendations, and these procedures will be subject to change as the local and global situation changes. At the top of the list will be screening donors for COVID and restricting travel for 14 days prior to surgery. If you wish more information on kidney donation please contact the live donor team at livedonorteam@smh.ca or by phone at 416-867-3676.

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How to Deal with Stress During These Difficult Times Galo Meliton, RN C Neph (C), Sharon Lee, RSW There is no doubt that COVID- 19 has changed our lives. We hear the fear in your collective voices and how you have and continue to endure more stress than ever imagined. When situations are unpredictable, this can naturally lead us to worry and feel anxious. There are things you can do individually and collectively to cope and support one another.

Know the facts Using reliable sources of information ensures what you do learn is fact, not fear-based. Use this knowledge to develop personal plans of action for a range of possible scenarios that could affect you both socially and financially. This will improve your ability to make difficult decisions and take action when necessary.

Improve your sense of control Has there been another time in your life when you felt things were out of control? Increase positive coping behaviors that have worked for you in the past. Be mindful of what has and has NOT worked. Be receptive to new coping behaviors (i.e. meditation, deep breathing, exercise etc). Find the self-care practice that works for you. Remember building resiliency in times of uncertainty is learned.

Improve your ability to endure

Are you frustrated and exhausted trying to change something you are not in control of? Worry can be both helpful and unhelpful. Rather than imagining the worst case scenario, also known as “catastrophising,” look at problems that need your attention right now. Focus on what you can accomplish and change. In life altering times, our frame of reference shifts. What you may have described as a “good day” a couple of months ago will change to meet the reality of your current situation. Most importantly, practice self-compassion by looking for ways to be kind and patient to yourself, and to those around you.

Stay Connected In addition to finding activities that give you a sense of achievement and that you can do just for pleasure, we need closeness/connection with others. Stay connected with family and friends via phone, email, text messaging, video call and even snail mail. More than ever before having someone you can share thoughts, feelings and problem solve with becomes necessary. Seek support from those who are in similar circumstances. The Kidney Foundation continues to hold support group meetings for patients and family members. Groups are being held via-telephone until physical meetings can be resumed. Call the transplant social worker for details (416-864-6060) ext 44173.

Seek help The psychological weight of living in unprecedented times may become overwhelming. The transplant team is also here to help provide support, community resource information and referral.

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St. Michael's Transplant Program Working at the COVID Assessment Centre Sarah Mattok, RN I had been following the news reports about this new coronavirus since the beginning of the year, and was worried about its spread, but I never thought it would be anything like this. I couldn’t have imagined people being told to stay at home, our streets emptied of people and cars, and seeing empty shelves in grocery stores. Nobody knew how badly Toronto would be hit, but in March we were seeing news reports of the devastation in China, Italy, and closer to home, New York City. Our hospital shut down its non-essential services, including almost all of our transplant activity. The hospital asked for people to volunteer to be redeployed to other units that would need help. I began working at the COVID Assessment Centre on March 16, the first day it opened. It was amazing to see how well-organized and put together it was. They had transformed a lobby and meeting room into a wellbuilt centre with full precautions to keep everyone, both patients and staff, as safe as possible. All the staff there wear masks, face shields, gowns, and gloves – I have never felt unsafe there. The process in the centre is designed to prevent contamination as much as possible. Greeters at the door make sure that we don’t have too many people inside at once, and that everyone puts on a mask. Patients are escorted through the centre to make sure nobody gets

too close or gets lost. Anyone who performs procedures on patients is assigned a helper who takes notes and handles the paperwork. In the beginning, we were mainly concerned about people who had travelled out of the country, but that started to change as the virus started to spread within the community and most flights were cancelled. The work at the centre has evolved as the needs of the community and Unity Health have changed. We started going out in teams to do testing at places like the hemodialysis unit and long-term care. Our Assessment Centre team also started going out to do testing at local homeless shelters. The Sherbourne Health Centre loaned us their bus to use as a base at the shelters. We wear space suits (not really, but they feel like it!) and set up tents outside. The suits have hoods and are waterproof, so we’re protected from the rain. We do the swabs on site, which gives the shelter residents a chance to get tested without having to travel to the Assessment Centre. Despite the stress and sadness over the past couple of months, it’s been wonderful to see how our community has pulled together to flatten the curve, and also to show their support to front line workers. I’m honoured to have had the opportunity to work with people from all over our hospital in the fight against COVID, and I look forward to brighter days ahead.

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Post-Transplant Chat: COVID-19 Kathryn Salvatore, RN, Galo Meliton, RN, Rachel Tong, RN, Jennie Huckle, RN, Kevin Bradley, RN 1. What is COVID-19? What symptoms should I look for? Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. Most common symptoms: • fever • dry cough • tiredness Less common symptoms: • aches and pains • sore throat • diarrhea • pink eye • headache • loss of taste or smell • a rash on skin, or discoloration of fingers or toes Serious symptoms: • difficulty breathing or shortness of breath • chest pain or pressure • loss of speech or movement *If you develop serious symptoms call 911 immediately

2. As a transplant recipient, do I have to worry about getting COVID-19 at home or in the community? All people should take the recommended precautions to avoid getting COVID regardless of whether or not you are a kidney transplant recipient

3. What precautions should I take to prevent getting COVID-19? • Wash your hands regularly with soap and water, or clean them with alcohol-based hand rub • Avoid touching your face • Cover your mouth and nose when coughing or sneezing • Stay home if you feel unwell • Practice physical distancing by avoiding unnecessary travel and staying away from large groups of people • When leaving the house wear a mask and stay at least 2 metres away from others

4. Is it safe to come for my clinic visit? Yes. Every person coming into the clinic will be screened for COVID at the building entrance and are provided with a mask and hand sanitizer. Both the clinic and the lab have implemented precautions to ensure everyone’s safety. Until PG 6 - TRANSPLANT DIGEST

further notice you will not be able to bring anyone with you to your visit. The hospital has a no visitor policy in place.

5. Are there any special travel precautions I should take? When leaving your house travel by car, bike or walk where possible. If you need to take public transit try to travel during non-peak hours and take shorter trips. Always keep hand sanitizer with you, and use it often.

6. Are there any risks to the kidney transplant from COVID-19? As with any virus or infection, there is a potential risk of adverse effects on the kidney, but this is rare.

7. Am I allowed to take time off work or work from home if there is a risk of getting COVID-19? Yes. If you feel as though you are at risk of getting COVID-19 at your work place we can provide you with a letter to support working from home.

8. Should I get the COVID-19 vaccine when it becomes available? This will depend on the type of vaccine that is developed. Inactivated (killed) vaccines are considered safe for transplant recipients, but attenuated (live) vaccines are not. Please check with us before you receive a vaccine.

9. I know someone waiting for a kidney transplant. Will the COVID-19 pandemic affect their chances of getting a transplant? No. Despite the pandemic kidney transplants continue to be performed, although they may have to wait longer. Potential transplant recipients are checked for COVID-19 when they come to the hospital, and will receive the transplant only if the test comes back negative.

10. I have been diagnosed with COVID-19. What should I do? COVID-19 affects different people in different ways. Most infected people will develop mild to moderate illness and recover without hospitalization. Anyone who tests positive will receive directives from the medical team and will be cared for appropriately.

HealthCare in a Pandemic: Where We Are and Where We are Headed Michelle Gabriel, RN, Interim Clinical Leader Manager The week of March 16 changed our world from anything we knew before. We were asked to stay home; schools & businesses closed, and parks and public places were no longer open. The Ministry of Health asked health care centers to reduced planned hospital activity such as elective surgeries, ambulatory appointments & testing such as ultrasounds, x-rays and CT’s , in order to make room for people unwell from COVID-19. That also meant putting a stop to most deceased donor kidney transplants and all living kidney transplants. The kidney transplant clinic was only available to patients who recently received their transplant just prior to the pandemic. Ontario was trying to prevent what cities like New York or Madrid had experienced – a health care system overwhelmed, unable to treat its most vulnerable. Though the last several weeks have been difficult and uncomfortable at times, all the hard work has paid off. Numbers of COVID-19 patients, both in hospital and in the community, have reduced steadily over the last few weeks. Hospitals and Health Care Centers, such as Unity Health St. Michael’s Hospital, are now planning what ambulatory & hospital care will look like moving forward. Similar to the provincial plans for reopening businesses

Measuring Heart Function with BNP Dr. Ramesh Prasad

BNP

You may have noticed a new blood test on your lab requisition when doing routine blood testing at St. Michael’s. This test is called NT-proBNP, or BNP for short (there is a subtle difference between the two that is not important clinically). BNP stands for B-type natriuretic peptide (BNP). BNP is a hormone produced by your heart. BNP is released into your bloodstream in response to

and public places, health care will take a staged approach to increasing activity. All transplant centers in Ontario have started doing deceased donor transplants with hopes of starting living donor surgeries in the near future. In the last 8 weeks, we have all been forced to think in a different way about how best to meet the needs of our patients and our program. Virtual care such as telephone visits & video conferencing have been available for a number of years. In the past we always preferred to see our patients in person, convinced that this was the best way to deliver care. In many circumstances this is still the case, but we have learned that we can sometimes also provide good patient-centered care by telephone. Patients have been receptive to completing blood work at a community lab ahead of their virtual visit, and being prepared with their medication list and record of weight and blood pressures. As we implement a phased approach to face-to-face care, virtual care will remain an important tool to connecting with our patients.

changes in pressure inside the heart. These changes can be related to heart failure and other cardiac problems. The blood level of BNP rises when heart failure develops or gets worse, and levels goes down when heart failure improves. In most cases, BNP is higher in patients with heart failure than in those with normal heart function. Therefore, if you develop shortness of breath and have too much salt and water in your body, the BNP level will be higher. The BNP can be used to guide the use of diuretics to help remove the excess salt and water. Other conditions like pneumonia that also cause shortness of breath do not cause as much of a rise in BNP, and diuretics do not help that situation. Monitoring the BNP level along with the creatinine will allow your team to help keep both the heart and the kidney happy, because this heart-kidney balance can be difficult to achieve especially early post-transplant. Importantly, the BNP test is not covered by outside labs. If you have any questions about getting a BNP test done or understanding your BNP result, please contact the Transplant Clinic. TRANSPLANT DIGEST - PG 7

Seasonal Allergic Rhinitis Vivian Tsoi, PharmD, RPh

With the advent of warmer weather, individuals with allergic rhinitis may have noticed flares in their symptoms. Broadly, rhinitis refers to inflammation of the nasal mucosa, where the inflammatory response is mediated by immunoglobulin E. Patients often present with sneezing, runny and/or itchy nose, nasal congestion, and post-nasal drip. They can also experience ocular symptoms, including red, itchy and watery eyes. Common seasonal triggers of allergic rhinitis are grasses/ weeds (e.g. thistle, orchard, sweet vernal) and tree pollens (e.g. oak, elm, maple) in the spring and summer months, and ragweed during the fall. Some patients suffer from perennial or year-round rhinitis, secondary to dust, mould or animal dander. Based on a Health Quality Ontario assessment from 2016, the Canadian prevalence of allergic rhinitis was estimated to be between 20-25%, with numbers increasing. If inadequately managed, rhinitis can cause significant impairments in quality of life, sleep and work performance. The first step to managing allergic rhinitis is allergen avoidance, if the allergens are known. Non-pharmacologic strategies include keeping house and car windows closed, limiting time outdoors when pollen counts are high, and changing clothes after working or playing outside. Intranasal saline (e.g. Salinex©, hydraSense©) is also

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useful, as it removes the inhaled allergen via irrigation of the nasal cavity. If allergen avoidance is not possible or is unsuccessful in controlling symptoms, there are many therapeutic options available. One or several of the following may be helpful for patients. It should be noted that certain over-the-counter and prescription products may contain a combination of medication classes (e.g. antihistamine with a decongestant). Oral antihistamines are one of the first line therapies for allergic rhinitis. Some antihistamines work by competitive antagonism of histamine binding at histamine-1 receptors, while others work as inverse agonists at histamine-1 receptors. Second and third generation antihistamines (e.g. cetirizine (Reactine©), loratadine (Claritin©), desloratadine (Aerius©), fexofenadine (Allegra©)) are preferred over first generation antihistamines (e.g. diphenhydramine (Benadryl©), hydroxyzine (Atarax©)), as they do not cross the blood-brain barrier as easily. Thus, the former are less sedating and less anticholinergic. Dose adjustments of antihistamines are required in renal and/or hepatic impairment. Some antihistamines (e.g. rupatadine (Rupall©), bilastine (Bilaxten©)) can also prolong the QTc interval; routine monitoring should be Continued on page 9

2020 is Year of the Nurse By Maureen Connelly RN The World Health Organization (WHO) had declared 2020 as the Year of the Nurse. This was to coincide with the bicentenary of Florence Nightingale’s birthday. During the current pandemic it’s hard not to see some irony in this declaration. So it seems fitting to reflect on the contributions to health care that Florence Nightingale established. • • • • •

On the request of the British government- took a team of nurses to the Crimean war Pioneer of evidenced based health care- she used statistics and data collection to advance and support her ideas on Nursing and Health promotion. Campaigned for universal access to healthcare regardless of ability to pay Advocated a holistic approach to health and healing. Founded the first School of Nursing at St. Thomas Hospital, London UK in 1860

“Every nurse ought to be careful to wash her hands very frequently during the day.” Florence Nightingale

place for patients with risk factors for QTc prolongation, such as taking concomitant QTc prolonging drugs, female gender, and electrolyte abnormalities.

watery discharge via its antimuscarinic effects. Similarly to other intranasal therapies, monitoring for nose bleeds, nasal dryness, headache, and throat irritation should be done.

Another mainstay treatment is the use of intranasal corticosteroids (e.g. beclomethasone (Beclo Aq©), ciclesonide (Omnaris©), fluticasone (Flonase©), mometasone (Nasonex©)). They provide a local antiinflammatory effect to relieve nasal congestion and ocular symptoms. When using the nasal spray, patients should be educated to point the applicator tip away from the middle of the nose and back towards the nasal cavity to minimize the risk of septal perforation. Patients should also monitor for nose bleeds, nasal dryness, headache, and throat irritation.

In patients who suffer from ocular symptoms, there are various eye preparations available (e.g. olopatadine (Pataday©), sodium cromoglycate (Cromolyn©), oxymetazoline (Visine Red Eye©)). As with topical decongestants, vasoconstricting eye drops should be used short term to reduce the risk of rebound vasodilation. For all eye products, stinging, widened pupils, and blurred vision may occur.

Other common treatments for allergic rhinitis include oral and intranasal decongestants (e.g. pseudoephedrine (Sudafed©), oxymetazoline (Drixoral©), xylometazoline (Otrivin©)). By stimulating alpha-adrenergic receptors within the nasal mucosa, blood vessels are constricted and mucosal edema is reduced. Decongestants should not be used in those with hypertension, hyperthyroidism, and ischemic heart disease due to their stimulant side effects and potential to increase blood pressure and heart rate. Intranasal products should only be used for 3-7 days to avoid rebound congestion. For those with significant nasal discharge, intranasal ipratropium (Atrovent© Nasal) can reduce volumes of

When patients fail oral antihistamines due to toxicity or lack of efficacy, intranasal corticosteroids, and/or corticosteroid/antihistamine nasal sprays, a leukotriene receptor antagonist may be trialed. Montelukast (Singulair©), a frequently used medication for asthma, is also indicated for allergic rhinitis. It has been shown to decrease both nasal airway resistance and obstruction, and has anti-inflammatory properties. In severe cases where symptoms cannot be controlled by various medications and nonpharmacological strategies, confirmation of allergens via skin testing and immunotherapy should be considered. TRANSPLANT DIGEST - PG 9

Vaginal Yeast Infections Vivian Tsoi, PharmD, RPh A vaginal yeast infection (also known as vulvovaginal candidiasis) is caused by Candida species, a group of fungi that commonly live on the skin and inside the vagina. There are a number of reasons that cause Candida to overgrow and cause infection, including pregnancy, diabetes, antibiotic use and a moist vaginal environment. Other immunocompromising conditions, such as transplantation and the use of immunosuppressant medications, can predispose women to vaginal yeast infections. • • • • •

What are the signs and symptoms of a yeast infection? Itching and burning around the vagina and vulva White, cottage cheese-like vaginal discharge Pain during sexual intercourse Swelling of the vulva

When should patients seek medical attention? Any patient who has never had yeast infections before, has a weakened immune system, is pregnant or is unsure if she has a yeast infection, should consult a health care provider for assessment.

What are some non-pharmacologic strategies to manage a yeast infection? • • • •

Maintain good vaginal hygiene Avoid vaginal douching Avoid scented cleansing products that can cause irritation Wear breathable underwear made from natural fabrics

Is it safe for patients to use probiotics to prevent yeast infections? At the Transplant Clinic, Pharmacy is often asked about the use of probiotics to reduce the incidence of yeast infections. Given the immunocompromised state of transplant patients, we dissuade individuals from taking probiotics, due to the potential for bacterial overgrowth and pathological infection. Yogurts that contain <1 billion CFU of probiotics are considered a safe alternative (e.g. Activia©).

What is the treatment for a yeast infection? Once diagnosed with a yeast infection, many anti-fungal treatments are available over-the-counter without a prescription. These include vaginal suppositories, internal

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or external creams and oral anti-fungals. The choice of product depends on a number of factors, such as patient preference, formulation (vaginal suppositories and oral capsules are less messy to use than vaginal creams), convenience (1 day vs. 3, 6 or 7 day treatments) and cost. All intra-vaginal products have similar efficacy and may cause local hypersensitivity. They should be administered before bedtime to improve contact time and to minimize leakage of the product. Patients choosing to take oral fluconazole should be warned about headache, dizziness, abdominal pain and stomach upset. Anti-fungals carry the risk of significantly interacting with calcineurin inhibitors (CNIs), namely tacrolimus (Advagraf©, Prograf©) and cyclosporine (Neoral©). While the product monographs warn patients of potential interactions with CNIs, minimal amounts of miconazole (Monistat©) and clotrimazole (Canesten©) are actually detectable in the serum when used intra-vaginally. As per studies by the manufacturers, only 1-1.5% of a topical dose of miconazole is measurable in the blood; in comparison, the amount of topical clotrimazole absorbed is less than 1/200 of that absorbed after an oral dose that is 15 times greater. Fluconazole (Diflucan©) is a common oral medication used to treat yeast infections. As a moderate CYP3A4 inhibitor, fluconazole prevents the metabolism of CNIs, which are CYP3A4 substrates. This can lead to supratherapeutic CNI levels and the risk of CNI toxicity. When fluconazole is prescribed at doses of ≥200 mg/ day or for prolonged durations, doses of CNIs should be reduced and therapeutic drug monitoring closely followed. A baseline review of the patient’s QTc interval and liver function tests are also warranted in the latter scenarios. In patients where little to no improvement is seen after the initial anti-fungal course, prompt re-assessment by a health care professional is encouraged.

News of Note •

Due to the rapidly evolving COVID-19 situation, new evidence and information is being created and shared at a record pace around the globe. In response to the need for up to date information a number of medical journals have provided open access to support and increase access to medical information, and have created new resources to enhance transparency and find ability of COVID-19 information. The Health Science Library at St. Michael’s is helping health professionals stay abreast of newly published research in real time.

•

The current pandemic has highlights the need to improve how the world tracks disease outbreaks as noted in the Globe and Mail( May 26, 2020). Dr. Kamran Khan- infectious disease specialist at St. Michael’s created pandemic predicting software called BlueDot. Dr. Khan and his team of about 50 experts use big data and artificial intelligence to warn about potentially serious outbreaks. This data provides information about diseases around the world in real time allowing for faster responses to prevent new outbreaks from happening.

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Dr. Nav Persaud Family Health Physician at St. Michael’s and Canada Research Chair in Health Justice at the University of Toronto contributed to a Globe and Mail article “COVID -19 has intensified our need for national pharmacare.” ( May 26, 2020)

Transplant Word Search T

Transplant Digest - Contact Information Dr. Ramesh Prasad – Editor Meriam Jayoma-Austria, RN, BScN, CNeph(C) Newsletter Coordinator

WORDS

Breath Distance Recover Travel Cold Fever Sanitize WHO Cough

Mask SARS Corona Pandemic Spread Covid Quarantine Swab

Transplant Digest SPRING/SUMMER 2020 ISSUE NO. 28

Kidney Transplant Program

KIDNEY CONNECT SUPPORT GROUP KIDNEY CONNECT SUPPORT GROUP KIDNEY CONNECT SUPPORT GROUP This support is an opportunity fortalk youwith to talk withwho others who This support group is group an opportunity for you to others have “been there” too. have “been there” too. Kidney Connect Peer Support Groups will be held via telephone. Kidney Connect Peer Support Groups will be held via telephone.

Register through e-mail Ontario.programs@kidney.ca or phone 1-866-390-7337. Register through e-mail Ontario.programs@kidney.ca or phone 1-866-390-7337. Call in details will be provided. Call in details will be provided.

USMONTH! EACH MONTH! JOIN USJOIN EACH PM to 3:00 PM3:00 to 4:30 PM4:30 PM THURSDAY, THURSDAY, SEPTMEBER THURSDAY, MAY 25,MAY 202025, 2020THURSDAY, SEPTMEBER 24, 202024, 2020 THURSDAY, JUNE THURSDAY, OCTOBER THURSDAY, JUNE 25, 202025, 2020 THURSDAY, OCTOBER 29, 202029, 2020

THURSDAY, THURSDAY, NOVEMBER THURSDAY, JULY 30,JULY 202030, 2020THURSDAY, NOVEMBER 26, 202026, 2020 THURSDAY, THURSDAY, DECEMBER THURSDAY, AUGUSTAUGUST 27, 202027, 2020 THURSDAY, DECEMBER 17, 202017, 2020 The Kidney Foundation of Canada remains committed to providing telephone information and The Kidney Foundation of Canada remains committed to providing telephone information and referral support as well as peer support for patients, family members, caregivers, transplant referral support as well as peer support for patients, family members, caregivers, transplant recipients and living donors affected by kidney disease. recipients and living donors affected by kidney disease.

more information: For moreFor information: Phone: 1.866.390.7337 Email: ontario.programs@kidney.ca Phone: 1.866.390.7337 Email: ontario.programs@kidney.ca Web: www.kidney.ca Web: www.kidney.ca

This newsletter is sponsored through an unrestricted educational grant from Astellas Canada.