Transplant Digest Issue 29 (Fall 2020/Winter 2021) by St. Michael's Hospital

Transplant Digest

FALL 2020/WINTER 2021 ISSUE NO. 29

2 Mts

COVID-19 and return to work and school Darren Yuen, MD

With the re-opening of workplaces and schools, transplant patients around the province face difficult choices regarding what to do, to keep themselves and their families safe. Although we are still learning about this virus, emerging evidence suggests that transplant patients are probably more likely to contract COVID-19, and if they are infected, may have a more severe course. Thankfully, the vast majority of our patients have not reported a COVID-19 infection. Those who have contracted COVID-19 have also generally done well with a monitored reduction of their anti-rejection medications. Although things are changing on an almost daily basis, currently some guidelines have been released to help transplant patients as they decide Continued on page 2

In this issue... • COVID-19 and return to work and school • Recurrent Disease after Kidney Transplantation • Understanding how scarring develops in transplanted kidneys • The Flu and You: Answers to Common Questions for the 2020-2021 Influenza Season • Sodium Glucose co-Transporter 2 inhibitors (SGLT2i) in Diabetes and Kidney Transplant… • Post Transplant Chart: Transplantation in the COVID Era • Farewell • Congratulations • Welcome and Thank You

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From the Editor’s Desk Dr. Ramesh Prasad

The new COVID-19 world affected the transplant world just like everywhere else. Although we had to suspend performing new transplants for a while, we were soon able to adapt and start up the deceased donor, then living donor transplant programs again. The hospital remains as safe as possible to come in for your transplant-related care. We can provide some post-transplant care virtually, but this naturally means patients and families will have to share some of the work of monitoring. Please ask the Transplant Clinic if you have questions about what you and your family should and should not be doing, when you need to call us, and when you need to come in to the clinic or the hospital. In this issue of Transplant Digest, we have articles on new medications for diabetes after transplantation, recurrent disease, the influenza season, transplant scarring, and return to work and school. Our popular Post-Transplant Chat covers everything you may want to know about COVID-19. Our expanded word search and transplant quiz will hopefully provide you with some entertaining learning. We celebrate the retirement of Maureen Connelly, our senior nurse. Transplant Digest is primarily about information sharing. If you have any questions about any of these features or anything else for that matter, or would like to contribute an article, please do not hesitate to contact us. Until next time, please stay safe.

and educational organizations are offering the option of on-line learning, which can help reduce how and when to go back to work and school. the risk. Whatever option you choose, we would Generally, it is recommended that transplant encourage you and your family members to patients speak to their employers to see if they practice the safe practices promoted by Public can minimize their risk of contracting COVID-19. Health Ontario, including social distancing, Each person’s situation is unique, and so there is washing your hands, and staying home when no “one-size-fits-all” answer. Generally, though, if feeling ill. your work involves daily interaction with others, it is recommended to either work remotely Below, please find a helpful website from BC from home or adopt flexible hours to minimize Transplant, the transplant organization for interactions with others. If these are not possible, British Columbia, that provides some additional a leave from work may be necessary, or at the guidance. very least, provision of the necessary PPE to http://www.transplant.bc.ca/about/newssafely perform your job. We are happy to discuss stories/news/novel-coronavirus-(covid-19)this with you should you have questions. information-for-solid-organ-transplantWith respect to return to school, the same recipients COVID-19 and return to work story continued from page 1

considerations apply. The relative risk of COVID-19 infection is highly dependent on the local infection rates in your neighbourhood, and these can also change with time. Most school boards PG 2 - TRANSPLANT DIGEST

We recognize that this is a very difficult time. Rest assured that we are always here to answer your questions, and will continue to work with and support you as the COVID-19 pandemic evolves.

Recurrent Disease after Kidney Transplantation Dr. Ramesh Prasad

We often think of kidney transplantation as the end of kidney failure. While that may be true, living with a kidney transplant is really only the next phase in your kidney history. Some old enemies that continue to be around after a transplant are conditions like high blood pressure, diabetes, and heart disease. If these conditions are not addressed properly, the new transplant will be affected. Unfortunately, in a few patients the original cause of kidney failure also begins to affect the kidney transplant. While uncommon, it is important to be aware when “recurrent disease” happens so that hopefully it can be treated sooner and more effectively, allowing the kidney transplant to last longer. Here are four kidney diseases that can recur in the kidney transplant. IgA Nephropathy: The most common kidneyspecific disease worldwide, it usually recurs more than 3 years after the transplant, about 25% of the time. It will often be present on a kidney biopsy done for other reasons, in which case it may not cause harm. Protein in the urine is common, but visible blood is rare. It recurs more in young men in whom the original disease was especially aggressive, and when steroids (like prednisone) are avoided after transplant. Treatment for recurrent IgA nephropathy might include tonsillectomy, or drugs like cyclophosphamide and rituximab. Focal Segmental Glomerulosclerosis (FSGS): FSGS is actually a group of diseases, among which “primary” FSGS is more likely to recur up to 40% of the time, sometimes immediately after the transplant, but usually within the first year. Clinical suspicion based on protein in the urine may sometimes be enough to start treatment. Risk factors include younger age, Caucasian race, aggressive course in the native kidney, a family history of FSGS, or in the case of children, a living-related donor. Treatment includes plasma exchange and rituximab.

Membranous Nephropathy: This usually recurs either in the first year, or after five years posttransplant. It mainly manifests as protein in the urine. In recent years, a test called PLA2R has been used to distinguish primary from secondary membranous nephropathy, and to diagnose recurrence. Strangely, membranous nephropathy can occur for the first time in a kidney transplant. The recurrence rate is about 20%. Rituximab is an important treatment. Membranoproliferative glomerulonephritis (MPGN): Several types of MPGN have been distinguished from each other in recent years, and the recurrence rate based on subtype is 30-90%. Unlike the other conditions above, clinical course in the native kidneys does not predict the risk of recurrence after transplant. Therapy remains experimental, but might include rituximab, eculizumab, and plasmapheresis. There are other conditions besides these four that can also recur. The possibility of disease recurrence in the kidney transplant is one important reason why you must provide regular blood and urine testing. You can then be offered a kidney biopsy sooner rather than later to diagnose these and other conditions, or even be started on treatment sooner so that the kidney transplant can last longer. TRANSPLANT DIGEST - PG 3

Understanding how scarring develops in transplanted kidneys Dr. Caitriona McEvoy

All roads lead to scarring…but what if we could retrace our steps?

Scarring

People can develop kidney disease for a variety of different reasons, and a kidney biopsy is an important test we often perform to help us determine the exact underlying cause. A kidney biopsy involves taking one or more tiny pieces of your kidney to examine under powerful microscopes. This gives us important information, not only about the specific condition causing injury to the kidney, but also, about the presence and extent of any associated scarring of the kidney tissue. Interestingly, irrespective of the underlying cause of the kidney disease or injury, the associated scarring is what leads to kidney failure. This holds true for both native and transplanted kidneys. We do not fully understand all of the signals, sequences, and steps that happen in the cells of the kidney which result in that transition from injury to progressive scarring. When we see extensive scarring on a biopsy, much damage has already been done.

But what if we could “retrace our steps”, and characterize the signals and steps happening in the kidney as scarring initiates and then progresses? A new project being undertaken at St. Michael’s hospital by Dr. Caitriona McEvoy and Dr. Darren Yuen hopes to do just that. We plan to look at stored kidney transplant biopsies at various timepoints along the road from normal/healthy (at the time of transplant) to injured kidney and finally, kidneys with established fibrosis. We want to build a detailed ‘roadmap’ of all of the genes being activated or inactivated as the fibrosis initiates, and to better understand the exact cell types in the kidney being most affected. With this information, we hope to identify turning points, where it might be possible to stop scarring from developing. If we know what genes are actively promoting scarring, and at what point in the process they get ‘turned on’ we have vital information that may help us to develop new treatments to stop scarring in its tracks! It’s important to acknowledge the generous funding from the Papantony research fund that allows this research to proceed, and most importantly of all, the invaluable contributions from all of our patients, who selflessly agree to participate in research projects like this. PG 4 - TRANSPLANT DIGEST

The Flu and You: Answers to Common Questions for the 2020-2021 Influenza Season Vivian Tsoi, PharmD, RPh

What is the flu?

How can you catch the flu?

Influenza (the “flu”) is a respiratory infection caused by influenza A and B viruses. Flu activity typically begins to rise in the fall and peaks in the winter months. The flu can cause mild to severe illness, which may lead to hospitalization or death. Each year in Canada, it is estimated that 12,200 hospitalizations and 3,500 deaths are related to the flu.

The flu is mainly transmitted by droplets spread through coughing or sneezing, or by contact with respiratory secretions. The virus can incubate in your body for 1-4 days before symptoms appear. In adults, the flu can be spread to other people 1 day before symptom onset, and up to 5 days after.

What are common symptoms of the flu? How do they compare to symptoms of the Coronavirus? Symptoms

Flu

Coronavirus

Fatigue

Common

Fever

Common

Cough

Common

Diarrhea

Sometimes

Usually in children

Muscle aches/pains

Common

Sometimes

Shortness of breath

Common

Sneezing

Sore throat

Sometimes

Who is at highest risk for getting the flu? 1. People at high risk of flu-related complications and hospitalization: • Pregnant individuals • Indigenous peoples • People ≥65 years old • Children 6-59 months old • People who live at long term care facilities/nursing homes/retirement homes • Those with chronic health conditions, such as heart/brain/lung/ kidney disorders, diabetes, cancer, a weakened immune system (such as kidney transplant recipients), morbid obesity 2. People at risk of transmitting the flu to those listed above: • Child care providers • Health care workers • Household contacts of those at high risk of flu-related complications 3. People who provide essential community services TRANSPLANT DIGEST - PG 5

How do I protect myself from the flu?

What is the difference between a “trivalent” The best way to protect yourself from the flu is to and a “quadrivalent” flu vaccine? get vaccinated. The National Advisory Committee on Immunization (NACI) recommends that the flu vaccine be offered to anyone ≥6 months of age, who do not have contraindications to receiving the vaccine. Other healthy practices include proper hand hygiene, regularly disinfecting commonly touched surfaces, staying home if you are sick, wearing a mask, and physical distancing.

Does the flu vaccine really work? Clinical trials have shown that the flu vaccine is effective in protecting people against the flu. However, the effectiveness of the vaccine can vary from one flu season to the next. It depends on how well this year’s vaccines match the circulating flu viruses, as well as the health status of the person receiving the vaccine. Even if the match is poor, vaccinated individuals are more likely to be somewhat protected than those who are unvaccinated. Protection against the flu is expected by day 14 post-vaccination.

Can I get the flu from the flu vaccine? No. Inactivated flu vaccines do not contain live virus. The live flu vaccine contains attenuated or “weakened” virus that does not cause illness.

Which type of flu vaccine is safe for someone with a kidney transplant?

Quadrivalent vaccines provide slightly broader protection than trivalent vaccines. Trivalent vaccines contain 2 influenza A viruses and 1 influenza B virus, for a total of 3 flu strains. Quadrivalent vaccines contain the same viruses as in the trivalent vaccine, with 1 additional influenza B virus, for a total of 4 flu strains.

Should I be getting the “high-dose” flu vaccine? The “high-dose” flu vaccine contains 4 times the amount of hemagglutinin antigen (60 ug per strain) than the standard-dose quadrivalent vaccine (15 ug per strain). Hemagglutinin antigens are proteins found on flu viruses that trigger the production of an antibody response in the body. For those ≥65 years old, the trivalent, high-dose vaccine is recommended by NACI. Although the vaccine contains 1 less influenza B strain than the quadrivalent vaccine, it provides better protection against the influenza A virus, which occurs more often and carries a higher burden of disease in older individuals. If the trivalent, high-dose vaccine is not available, the quadrivalent vaccine can still be administered to those ≥65 years old to avoid delays in vaccination.

For kidney transplant recipients, only inactivated vaccines should be administered. Live vaccines (e.g. FluMist®) are not safe post-transplant and should be avoided. Age Group

Recommended Type of Vaccine

<65 years old

Preferred: Quadrivalent, inactivated vaccine (Standard-Dose) Alternative: Trivalent, inactivated vaccine (Standard-Dose)*

≥65 years old

Preferred: Trivalent, inactivated vaccine (High-Dose) Alternative: Quadrivalent, inactivated vaccine (Standard-Dose)

*Note: The trivalent, inactivated, standard-dose vaccine is not publicly funded for the 2020-2021 influenza season

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What are possible side effects of the flu vaccine? • Common (mild, temporary): Injection site reactions (redness, tenderness/pain) • Uncommon: Allergic reactions, oculorespiratory syndrome • Rare: Guillain-Barré syndrome

Is the flu vaccine covered? Yes. Under the Universal Influenza Immunization Program (UIIP), a number of flu vaccines are available at no cost to eligible Ontarians ≥5 years old with a valid health card. Flu vaccines are available at medical offices or at participating community pharmacies.

Which vaccines are offered under UIIP for 2020-2021? Flu Vaccine

Type of Vaccine

Dose/Route of Administration

FluLaval Tetra

Quadrivalent, inactivated

0.5 mL, intramuscular

Fluzone®

Quadrivalent, inactivated

0.5 mL, intramuscular

Flucelvax®

Quadrivalent, inactivated

0.5 mL, intramuscular

Fluzone® High-Dose

Trivalent, inactivated

0.5 mL, intramuscular

Unfortunately, I ended up getting the flu- are there any treatments? Most people recover from the flu in 7-10 days, generally with remedies for symptom relief (e.g. acetaminophen for pain/fever, adequate hydration). Medications like Tamiflu® may be offered to those at higher risk of flu-related complications and hospitalization. If you have the flu and feel extremely unwell, please seek medical attention from your family doctor or the nearest emergency department. As always, please check with the Transplant Clinic before starting any new medications, herbals, or over the counter products to combat the flu. These treatments may interact with your medications and could affect your kidney function. References: 1.

Public Health Agency of Canada. Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2020-2021. September 22, 2020. (Accessible at: https://www.canada.ca/en/public-health/services/publications/vaccines-immunization/ canadian-immunization-guide-statement-seasonal-influenza-vaccine-2020-2021.html)

Centers for Disease Control and Prevention. Similarities and Differences between Flu and COVID-19. October 6, 2020. (Accessible at: https://www.cdc.gov/flu/symptoms/flu-vs-covid19.htm)

World Health Organization. Q&A: Influenza and COVID-19- Similarities and Differences. March 17, 2020. (Accessible at: https://www. who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-similarities-and-differences-covid-19and-influenza?gclid=Cj0KCQjw2or8BRCNARIsAC_ppya2VQHCKEwlKUOXKJKl7RarabfMrcV3hzA51GihI1WjoajSfUlGFUEaAjkrEALw_wcB)

Ontario Agency for Health Protection and Promotion (Public Health Ontario). Fact Sheet: Influenza Vaccines for the 2020–2021 Influenza Season. Toronto, ON: Queen’s Printer for Ontario. 2020. (Accessible at: https://www.publichealthontario.ca/-/media/ documents/f/2020/fact-sheet-influenza-vaccine-2020-2021.pdf?la=en)

Ontario Ministry of Health. Executive Officer Notice: Pharmacist administration of publicly funded influenza vaccines. October 2, 2020. (Accessible at: http://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/exec_office_20201002.pdf)

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Sodium Glucose co-Transporter 2 inhibitors (SGLT2i) in Diabetes and Kidney Transplant…Is this the right medication for me? Tess Montada-Atin, NP Diabetes mellitus is common in kidney transplant recipients. It is the leading cause of end stage renal disease (ESRD) requiring dialysis or transplant. New onset diabetes after transplant (NODAT) occurs in up to 20% of patients. Sodium glucose co-transporter 2 inhibitors (SGLT2i) are the newest class of medications available to treat type 2 diabetes. Research has shown that SGLT2i not only improves blood sugar control but also protects the heart and kidneys.

How do SGLT2is lower blood sugar? • It lowers blood sugar levels in your body by increasing the amount of sugar you pass in your urine.

What are the benefits of taking a SGLT2i? • Slows progression of chronic kidney disease and decline in kidney function • Reduces the risk of heart, stroke and hospitalization for heart failure

What are the side effects of SGLT2i?

• Reduces the risk of death

• SGLT2i may cause yeast infections and urinary tract infections. If you have a history of frequent yeast or urinary tract infections, an SGLT2i may not be the right medication for you. Speak to your nurse practitioner or doctor.

What do I do if I am sick?

• A positive side effect in some people is, it may cause up to a 3kg weight loss as well as lower blood pressure.

• You can start taking the SGLT2i once you feel better or your symptoms have gone away

happen when an SGLT2i is taken with other diabetes medications.

• Research done thus far shows that SGLT2i use in kidney transplant patients with diabetes or NODAT is well tolerated, safe and effective in lowering blood sugar however there is ongoing research being done

• You should not take this medication when you are sick with diarrhea or vomiting or are unable to drink fluids to keep hydrated as this can worsen your kidney function

Is an SGLT2i safe to take with a kidney • Low blood sugar (less than 4) is rare but can transplant?

• In rare cases it can cause diabetic ketoacidosis, which is acid build up in the blood. • It may also increase cholesterol.

What are the names of the available SGLT2i and how do I take them? • Canagliflozin (Invokana),Dapagliflozin (Forxiga), Empagliflozin (Jardiance), Ertugliflozin (Steglatro) • These medications are pills taken once a day

• Our transplant team is doing a study to understand the safety and effectiveness of SGLT2i use and its effects on kidney function in patients with diabetes and a kidney transplant • Speak to one of the transplant team members to discuss if this medication is for you

References 1.

Zinman, B. Wanner, C. Lachin, JM, et al. Empagliflozin, cardiovascular outcomes and mortality in type 2 diabetes. N Engl J Med 2015; 373:2117-28

Neal B., Perkowvic, V., Mahaffey, KW., et al. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med 2017; 377:644-57

Wiviott SD, Raz, I., Bonaca MO., et al. Dapagliflozin and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2018 *published on line

Mahling, M., Schork, A., Nadalin, S., Fritsche, A., Heyne, N., & Guthoff, M. Sodium-Glucose Cotransporter 2 (SGLT2) Inhibition in Kidney Transplant Recipients with Diabetes Mellitus. Kidney Blood pressure research. 2019;44:984–992

Strøm Halden, TA., Kvitne, KE., Midtvedt, K., Rajakumar, L., Robertsen, I., Brox, j. et al. Efficacy and Safety of Empagliflozin in Renal Transplant Recipients With Posttransplant Diabetes Mellitus. Diabetes Care 2019 Mar; dc190093. https://doi.org/10.2337/dc19-0093

Rajasekeran, H., Kim, J., Cardella, CJ., Schiff, J., Cattral, M., Cherney, D., and Singh, S. Use of Canagliflozin in Kidney Transplant Recipients for the Treatment of Type 2 Diabetes: A Case Series. 2017. Diabetes Care. DOI: https://doi.org/10.2337/dc17-0237

Perkovic, V., Jardine, M., Neal, B. Bompoint, S., Heerspink, H., Charytan, D. et al. for the CREDENCE Trial Investigators. Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy. N Engl J Med 2019; 380:2295-2306.

Heerspink, H. Stefánsson, BV., Correa-Rotter, R., Chertow, G., Greene, T., Hou, F. et al. for the DAPA-CKD Trial Committees and Investigators* Dapagliflozin in Patients with Chronic Kidney Disease. N Engl J Med 2020; 383:1436-1446. DOI: 10.1056/NEJMoa2024816

Transplant Quiz (Answers on page 15) 1. The first successful kidney transplant was performed in

2. This transplant drug is given in a modified form through the veins at the time of transplant

(a) tacrolimus (b) mycophenolate (c) prednisone (d) sirolimus

3. This device has to be taken out a few weeks after the transplant surgery

(a) abdominal drain (b) stent (c) feeding tube (d) support belt

4. This blood test indicates how well your kidney transplant is working

(a) creatinine (b) BNP (c) tacrolimus level (d) PTH

5. This blood test indicates that you may have an infection or rejection

(a) urea (b) calcium (c) urine albumin-to-creatinine ratio (d) CRP

6. This test indicates whether or not the donor and recipient form a good pair or not

(a) kidney ultrasound (b) platelet count (c) urine culture (d) cross-match

7. This medication is often stopped one year after the transplant

(a) Septra® (b) tacrolimus (c) cyclosporine (d) erythropoetin

8. Valganciclovir (Valcyte®) is a medicine used to treat or prevent this type of infection

(a) BK virus (b) herpes zoster (c) cytomegalovirus (d) candidiasis

9. This condition needs proper control for the kidney transplant to last longer

(a) diabetes (b) high blood pressure (c) excess weight (d) all of these

10. This option cannot be considered if you are not a good pair with your donor

(a) buying a kidney (b) paired exchange (c) desensitization (d) joining the waitlist TRANSPLANT DIGEST - PG 9

Post-Transplant Chat Transplantation in the COVID Era Rachel Tong, RN, Ellenica Hicks, RN, Galo Meliton, RN, Jennie Huckle, RN, Kevin Bradley, RN, Kathryn Salvatore, RN

1. Are new transplants being performed

since COVID started? Are patients still being listed?

Although we did stop doing kidney transplants for a short period of time back in March and April 2020, our program resumed doing transplants early in May. We continue to transplant patients, as well as adding new patients to the wait list. We constantly communicate with other transplant programs to make sure our policies are similar. As of now, there is no plan to cut back on transplants in the event of a second COVID wave.

2. Is it safe to come to the hospital for a transplant? Yes, the hospital has strict precautions in place to ensure everyone’s safety. Some precautions include entrance screening, and mandatory mask wearing for both staff and visitors. Very few COVID patients are being hospitalized, and every effort is made to ensure that there are no COVID patients on the transplant ward.

3. Will I be screened for COVID before the transplant? PG 10 - TRANSPLANT DIGEST

Yes. When you are called and admitted for a transplant, you will receive a rapid COVID test. The results will take 2-4 hours to come back, and you will be offered the kidney only if you are COVD negative.

4. I am COVID positive. Can I still receive a transplant? If you are COVID positive you will need to be placed on hold from the waitlist for about 3 months. At the end of the 3 month period, we will require a negative COVID test before you can be considered for reactivation on the waitlist. Your overall health at that time will also be taken into account. 5. What are the restrictions on family

visits to the hospital at the time of transplant?

Each patient or their Substitute Decision Maker may identify 1 designated Essential Care Partner (ECP) from within the patient’s social circle who remains constant for the duration of patient’s admission. The patient may have a visit every other day by the identified ECP for a maximum of three hours. (Level 2, subject to change).

Source: https://covid.unityhealth.to/wpcontent/uploads/2020/10/Essential-CarePartner-Visitation-Levels-Guidelines.pdf

6. Am I at greater risk to get COVID after the transplant? Will COVID affect the kidney? The risk of contracting COVID after receiving a transplant is not significantly different from the general population. However, there is a risk of one getting sicker if you have a transplant. Like any infection, COVID can affect the kidney. You can discuss this risk with your transplant doctor.

7. Should I take extra time off work after the transplant? We recommend approximately six weeks to three months off work for all transplant patients depending on individual health status and the type of work. The COVID pandemic has not changed this recommendation.

You should go to the emergency department if: • You have severe difficulty breathing • Severe chest pain • Feeling confused or unsure of where you are • Losing consciousness Source: https://covid-19.ontario.ca/covid-19test-and-testing-location-information

10. I’ve recovered from COVID. What happens next? Congratulations! Notify the transplant team right away since we may need to adjust your transplant medications again, especially if they were adjusted during your COVID infection. Continue to follow the safety guidelines from the Ministry of Health since you are not necessarily immune from getting COVID again.

8. The transplant clinic always seems crowded. Is it safe to come for a posttransplant visit? For the time being, we have been moving a majority of our clinic appointments to virtual care in the form of phone conversation to reduce the volume in the waiting room. We see patients in-person if transplanted recently, or if they have items to address requiring in-person attention, such as a physical examination. Everyone in the hospital is required to wear a mask, and we abide by strict physical distancing in the waiting area. Visitors accompanying patients are not allowed unless essential

9. What if I get COVID after the transplant? If you get COVID after the transplant, you must self-isolate. Inform the transplant team as soon as possible as we may need to adjust your transplant medications.

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Farewell and

Dear Patients and Colleagues

I am writing to say good bye as I retire from what has been an amazing, rewarding nursing career for the past for 46 years. I look forward to spending more time with my friends and family including the 5 most precious grandchildren this Granny Mo could ever wish for! Since graduating from the last class of St. Michael’s School of Nursing in 1974 and then Ryerson University in 2009, I have had the opportunity to work in many specialized areas including all the critical care areas- such as coronary care, neurosurgery, cardiovascular ICU and emergency trauma to transplantation. The transplant program celebrated its 50th year last year and I’m proud to have been part of that history for 31 years. It would be safe to say that being part of such an amazing program is where I found my niche in nursing.

Maureen Connelly, RN

of the high rejection rates, many transplant recipients went on to live for many years with a functioning transplant.

When I started with the transplant program, we followed 250 post transplant patients whereas today we have nearly 2000 patients Our Transplant Digest editor, Dr. Prasad asked being followed in the clinic. Living donor me to reflect back on my years as a transplant transplants were less common compared to nurse coordinator and take you down memory the 40-50 living donor transplants per year lane from what the program was like when I today. started to where we are today. They say it takes a village to raise a child. The I will share one early memory that stands out. same holds true for coordinating a living kidney I worked in the Acute Care Unit in the late donor transplant or preparing patients to be 1970’s when transplantation was still relatively placed on the deceased donor waiting list. new. Patients were in isolation for six weeks My hardworking colleagues have all played compared to 5-7 days in hospital now! The an integral role it preparing and successfully anti-rejection medications were in the very supporting our donors and recipients on their early stages with only high dose Imuran and transplant journey. Prednisone available to prevent rejection. The Imuran could not be administered until the white blood cell results came back late in the afternoon. If the white blood cell count was too low, the Imuran dose was held. Too many of those transplants were lost to rejection as a result. Those patients were our early courageous pioneers who bravely chose transplant as a treatment option and paved the way for future transplant recipients. However, in spite PG 12 - TRANSPLANT DIGEST

The hospital administration has to support transplant activity. We have that support in spades from Dr. Tom Parker, VP, Jonathan Fetros Senior Program Manager and Dana Whitham Clinical Leader Manager. The organizational culture of an organization is from the top down and we are fortunate to have these leaders inspiring us to be compassionate stewards of excellent evidenced based health care delivery.

My colleagues, the nurses, clerical support staff, and allied health professionals all work collaboratively to make the transplant and donor experience successful. The team works hard and still manage to share laughter with each other every day. Thank you for your collegiality and wisdom. You’ve made it a joy to come to work every day. Our kidney specialists (nephrologists) and surgeons (urologists) are a team of wonderful caring brilliant physicians who make every moment a teachable moment. Thank you to all of you for sharing your wisdom with me. Of all my colleagues, I do want to give a special acknowledgement and thank you to Dr. Jeff Zaltzman with whom I have worked for 31 years. He is a shining example of a wonderful compassionate physician, colleague, leader and patient advocate. His kindness to me for so many years has been exceptional and so very much appreciated. Thank you to our community partners in dialysis centres and kidney care clinics in collaborating with us to promote transplantation and living kidney donation. Your expertise in preparing and referring your patients to us is greatly appreciated. A big thank you goes out to our heroes – all the living kidney donors who have improved the lives of loved ones and in some cases, total strangers by stepping forward to selflessly donate a kidney. I have learned so much from each and every one of you about kindness and generosity. A special thank you to the families of deceased donors who gave consent for organ donation under such difficult circumstances. Your generosity has made such a profound difference in improving the lives of organ recipients. To our transplant recipients, thank you for being such wonderful examples of strength and resilience through some challenging times. Your courage while managing a chronic illness has been truly inspirational to me. To our generous financial donors, thank you for your generosity in helping to get us closer to our shared vision of a Transplant Centre of Excellence. Anyone who wishes to contribute to this worthy cause can do so by contacting the St. Michael’s Hospital Foundation Office.

Maureen's early nursing days

Once again I wish to express my gratitude for being a vital part of St. Michael’s Hospital and our transplant program. I feel truly blessed.

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Welcome and

Dana Whitham, Clinical Leader Manager

Andreea Gavrus, RN

Transplant Coordinator for Recipients with Living Donors

Andreea obtained her Bachelor of Science in Nursing degree at the University of Toronto in 2014. She began her career working at The Scarborough Hospital, caring for elderly patients requiring acute medical care, and at Providence Healthcare in rehabilitation. Since 2016, she has been working at St. Michael’s Hospital in the Kidney Transplant, Nephrology & Urology inpatient unit, where she has been caring for pre-op and post-op kidney donors and recipients. We are excited to have Andreea serve the kidney transplant population as coordinator for recipients with living donors. Andreea joined the Transplant team on October 26th 2020.

Shaniel Des Vignes, RN

Transplant Coordinator for Deceased Donors Shaniel graduated from Ryerson University in 2007 with her Bachelor of Science in Nursing. She started her nursing career at St. Michael’s Hospital in 2007 in the Hemodialysis unit where she worked for 4 years. On a mission to broaden her nursing portfolio, Shaniel spent 18 months working in the trauma neurosurgical ICU and ward. According to Shaniel, “although the trauma neuro ward experience helped me to develop a variety of invaluable nursing skills, it also allowed me to realize that my true passion lies in the nephrology community”. In 2013 Shaniel began working in the home dialysis program where she has spent the last 7 years helping those manage dialysis at home and prepare for transplant. Shaniel joinsed our program on November 9th as part of our transplant team to manage our patients listed for deceased donor transplant. Shaniel also works twice a week in our post-transplant clinic. Our team wishes Maureen Connelly, RN all the best in her retirement. We have been fortunate to have Maureen as part of our team for more than half of our successful 50 years. Maureen’s work with our live donor program has been recognized both locally and nationally and the transplant community has certainly benefited from her expertise and wisdom. We are thankful to Maureen for all of her contributions and encourage you all to read her reflection of her career in this edition of Transplant Digest. Maureen’s last day with us was on November 26th 2020. Our team also bids a kind farewell to Michelle Engson, RN. Michelle’s clinical skills and knowledge in transplantation were of great value to our team and we are grateful for her time with us. Michelle initially joined us in May 2019 to assist in coverage within posttransplant and then provided coverage within the recipient side of the Live Donor Program. Michelle saw our patients through the challenges of changes in staffing, OR closures and other COVID-related concerns. We owe her a debt of gratitude for helping us through these difficult times. We wish Michelle all the best in her future. Michelle’s last day with our team was on November 26th 2020.

Word Search Find all the words listed at the bottom. After you have found all the words, spell out the remaining letters to discover your SECRET MESSAGE! H

Adrenal

Cornea

Head

Lips

Pineal

Tendon

Aorta

Digit

Heart

Liver

Pituitary

Testis

Bladder

Ears

Hip

Lung

Platelet

Ureter

Brain

Face

Ileum

Medulla

Pons

Uterus

Cell

Fallopian Tube

Jejunum

Neck

Retina

Vertebra

Cerebellum

Forearm

Kidney

Nose

Skin

Cerebrum

Hair

Leukocyte

Ovary

Spinal Cord

Colon

Hand

Ligament

Pancreas

Spleen

Transplant Quiz answers 1. b

2. c

3. b 4. a 5. d

6. d

7. a

8. c

9. d

10. a TRANSPLANT DIGEST - PG 15

Congratulations to the 2020 Winners

Keenan Covid-19 Research Award - Lung Life after COVID-19

Dr. Darren Yuen Scientist, Keenan Research Centre for Biomedical Science, and Nephrologist, St. Michael's Hospital Dr. Kieran McIntyre Respirologist, St. Michael's Hospital THE CHALLENGE: COVID-19 survivors, even those who've had only a mild case, may develop permanent lung scarring that leads to long-term breathing complications. THE SOLUTION: Rapidly diagnose lung scarring in COVID-19 survivors using a new, bedside ultrasound tool. At the same time, test a new drug to treat COVID-19-induced lung damage.

St. Michael’s Hospital Kidney Transplant Program (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.

Transplant Digest

FALL 2020/WINTER 2021 ISSUE NO. 29