Transplant Digest Issue 31 by St. Michael's Hospital

Transplant Transplant Digest

Digest

Fall 2021/Winter 2022 Issue No. 31

SPRING/SUMMER 2021 ISSUE NO. 30

Gout and the COVID-19 Vaccines and the KidneyTransplant

Canadian Landscape

Dr.Dr. Ramesh Prasad Jeff Zaltzman

At isthe time in ofkidney writing, approximately 50% Gout common transplant recipients, and of is related to high bloodat levels uricdose acidof (“hyperCanadians received leastofone a Health uricemia”). The main risk factors are3% cyclosporine Canada-approved vaccine, and received a and tacrolimus, diuretics, reduced kidney function, second dose. Product monographs for the two overweight, older age, and male sex. High acid mRNA vaccines, Pfizer-BioNTech, anduric Moderna, occurs in over 80% patients receiving recommend a second dose at 21cyclosporine and 28 days and 40% patients receiving tacrolimus. Gout oc-for respectively. The recommended second dose curs in 8 and 6% patients respectively. Gout reducthe virus vector vaccine by Astra Zeneca is between es 10-12 transplant patient by other 25%, approved mostly weeksand following thesurvival first. The through cardiovascular disease. virus vector vaccine by Johnson and Johnson requires only a single dose. What have we done in The symptoms of gout are similar to those in Canada with respect to vaccine rollouts?

non-transplant patients, but attacks can be more Owingand tosevere. world-wide demand and pain, supply frequent Symptoms include severe limitations, Canada hadand a slow and tumultuous redness, warmth, swelling, disability, starting procurement early on. None a of at vaccine night and becoming maximum in about day,the COVID-19 vaccines areand manufactured in over Canada, followed by skin peeling improvement a Continued page22 Continued onon page

In this issue...

In this issue... Gout andVaccines the Kidney •• COVID-19 and Transplant the Canadian • Landscape From the Editor’s Desk • Flash Glucose monitoring system: • Understanding if COVID-19 Vaccines Is it for me? are Effective • What is the Disability Tax Credit • Preparing (DTC)? for your Virtual Clinic Visit •• Your Lab Requisition Post-Transplant Chat: Most Com• Having a baby after a kidney mon Questions Asked in the Clinic • transplant Eating More Plant Based Proteins After Kidney Transplant • How much water should you drink • each Shingles Vaccine Post Kidney day? Transplant • Iron Deficiency after Transplant • COVID-19 vaccines: how safe and • My CPAP Journey effective are they in kidney trans• Post Transplant Chat : Knowing your plant recipients? • medication 10 year Anniversary: ABO Incom• Adjusting Transplant Program Research patible Transplant Pandemic • Participation Moving Backtoto In-Person Clinics • Limitations Welcome New Staff Test your Transplant Knowledge •• Writing to your donor family • Word Search TRANSPLANT DIGEST - PG 1

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From the Editor’s Desk Dr. Ramesh Prasad

Welcome to the Fall 2021/Winter 2022 issue of Transplant Digest. Our publication continues to run strong after 15 years, and we hope to continue conveying information that is both timely and relevant to anyone involved in kidney transplantation for years to come. Our family of transplant recipients, donors, and their health care providers continues to grow, and there will be a need to adapt as the times change. We strive to balance news, education, and some entertainment in a compact package, so please feel free to write us if there is anything you would like to see added or deleted, or just conveyed differently, as a letter to the editor. Please also take a moment to remember our many transplant patients who passed away from COVID, most of whom we lost before the vaccine became widely available. In this issue, we cover the ABO incompatible transplant program, disability tax credits, gout and the transplant kidney, shingles vaccine, flash glucose monitoring, plant-based dietary proteins, COVID vaccination, and moving back to in-person clinics. Our ever-popular post-transplant chat does not cover a single theme this time, but compiles answers to some of the most common questions asked in clinic. The word search and quiz should help you pass a bit of time while in the waiting room or when you are free. Until we meet again in the spring, have a safe and happy holiday season, and enjoy our wonderful Canadian winter.

Gout and the Kidney Transplant story continued from page 1

few weeks even without treatment. The overlying skin can become dark. Usually one joint is affected (80%), typically the big toe, which then looks like a sausage. Sometimes the knee, ankle, or wrist can be involved (20%). In the case of a first attack, diagnosis requires inserting a needle into the joint and taking out fluid, which shows urate crystals under polarized light. This can help distinguish gout from an infected joint, in which there is usually also fever. It is not necessary to take out fluid each time an attack occurs. However, with multiple attacks, a rheumatologist should be consulted. Early treatment can reduce pain and shorten attack duration. Icing of the affected joint and joint immobilization might help. Treatment needs to account for kidney transplant function, other medications, Continued on page 15

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Contact Information Dr. Ramesh Prasad – Editor Meriam Jayoma-Austria, RN, BScN, C.Neph.CNewsletter Coordinator Please send your comments or suggestions of topics for future publication to: meriam.jayoma@unityhealth.to St. Michael’s Hospital Kidney Transplant Program (across the hospital) 61 Queen Street East, 9th Floor Toronto, Ontario, M5C 2T2 Phone: 416-865-3665 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 health please contact your health care provider.

Flash Glucose monitoring system: Is it for me? Tess Montada-Atin, RN, NP

rises above the levels that are set as well as signal loss.

How does a flash glucose monitoring system work? The sensor is applied to the back of the upper arm and inserted below the skin. The sensor is about the size of a quarter. The sensor measures sugar levels in the interstitial fluid every minute and stores sugar results automatically every 15 minutes. A reader device or smartphone LibreLink app (iPhone 7 or greater) is held near the sensor when a sugar reading is needed at any time. The reader displays the current sugar level, a trend arrow showing the direction in which sugar levels are going and how quickly. It also displays a graph of sugar readings over the previous 8 hours.

What is a flash glucose monitoring system? A flash glucose monitoring system measures glucose (sugar) levels in the interstitial fluid through a wired enzyme glucose sensing technology (sensor). The interstitial fluid is the fluid that fills the spaces between cells. Whereas blood glucose meters take glucose readings from capillary blood with a finger prick. The Freestyle Libre and Freestyle Libre 2 are the flash glucose monitoring systems available in Canada.

Who can use the flash glucose monitoring system? The Freestyle Libre can be used by patients 18 years of age and older with type 1 or type 2 diabetes. The Freestyle libre 2 can be used by patients 4 years of age and older with type 1 or type 2 diabetes. The freestyle libre 2 is the next generation flash glucose monitoring system that is used with a smartphone and the LibreLink mobile app with optional glucose alarms to notify you when the sugar drops below or

Do you have to calibrate the flash glucose monitoring system with a blood sample? This technology is factory-calibrated, and therefore it is not necessary to calibrate with a blood sample glucose meter reading.

When does the sensor need to be changed? The sensor is changed every 14 days.

Can the flash glucose monitoring system be used for treatment decisions? The freestyle libre can be used for treatment decisions unless the sugar is rapidly changing shown by a straight trend arrow (↑ or ↓) OR sugar reading < 4.0, OR if symptoms do not match the reading. It is recommended to do a finger prick test in these situations. The freestyle libre 2 can also be used for treatment decisions unless symptoms do not match the reading, in which a finger prick test should be done.

Why sugar readings from a sensor don’t alContinued on page 13

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What is the Disability Tax Credit (DTC) ? Sharon Lee, MSW, RSW

November is Financial Literacy Month in Canada. Working to increase Canadians’ understanding of their personal finances is one of its many challenges. To that end, we are shedding some light on the DTC which has grown increasingly complex

Canadians with severe disabilities face a higher cost of living. The DTC helps individuals offset some of these costs through an annual tax credit

I have very low income or I don’t owe any taxes, is the DTC of any use to me ? The DTC is a non-refundable tax credit. It can only be used to reduce the amount of income tax you have to pay. With non-refundable tax credits, if the credit exceeds the amount of taxes owed, the excess is lost. This differs from refundable tax credits where credit that exceeds the amount of taxes owed is paid as a refund (See “Your Financial Tool Kit,” a govt resource to help you make sense of everyday financial questio ns)

Is the DTC transferable? If you cannot use part or all of the Disability Amount to reduce your tax payable to zero, you can transfer it to a qualifying family member. This person must provide you regular support for food, shelter or clothing

What other tax benefits & programs can I access with DTC status? The Registered Disability Savings Plan (RDSP) is a tax deferred savings plan. You can make contributions till age 59. The govt provides matching grants depending on your family income and contributions.

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It also provides bonds to low income individuals which are paid directly into the RDSP. No contributions have to be made to get the bond but grants/ bonds cease after age 49. Another program is the disability component of the Canada Workers Benefit (CWB). CWB is refundable tax credit to help individuals who are working and earning a low income.

For the 2021 tax year, what is the disability amount? $8,662. As the federal govt allows taxpayers to claim 15% of their non-refundable tax credits, your taxes may be reduced by $1,299 (see Part B of your T1 tax return)

I have been approved for DTC, how far back can I claim the credit ? This depends on the onset of the disability. You can

request your income tax returns be adjusted as far back as 10 years

What can I do if my application is denied? You can appeal or reapply with new information (see Disability Alliance BC Help Sheet for further details)

Any recent changes to the DTC program ? • • •

As of Oct 4, 2021: Updated application form T2201 E (21) As of Oct 4, 2021: Digital application for medical practitioners As of May 2021, a navigator role. Navigators act as a bridge between the applicant and disability program headquarters. They answer questions that call centre staff cannot. The goal is to help applicants with complex circumstances work through the application process

DTC status ? As of March 19, 2019 (Federal Budget Day), you are no longer required to close your RDSP but it will be subject to certain restrictions. Also under new rules, grants and bonds already in your RDSP retroactive to January 1, 2021 do not have to be returned as long as your RDSP remains open (2019 budget proposal received royal assent June 29, 2021)

I’ve had a transplant but now I am having problems with activities of daily living. Who can help me re-apply? In conversation with the DTC navigator, the patient was advised to approach the family doctor. The family doctor was likely to have the history and details of the patient’s restrictions, specifically, the effects of the impairment on her basic activities.

Frequently Asked Questions by post-transplant patients I qualified for the DTC under the life sustaining therapy criterion. My approval letter from CRA indicates I have permanent DTC status but I received a successful transplant this year. What are my rights and responsibilities ? According to CRA website “you must tell us if your medical condition improves and you no longer meet the criteria for the DTC.” Further communication with CRA confirms above, regardless of whether one has been granted temporary or permanent DTC status

I received my transplant June 2021. Does this mean I cannot claim the DTC when I go to file my 2021 taxes? You can claim the DTC for the year in which you received your transplant, irrespective of time of year

What happens to my RDSP when I lose

The above is general information only. You can speak to a tax expert about your situation. For further information you can contact the CRA designated call line 1800-959-8281. Each year the Kidney Foundation prepare tax tips for patients. Visit kidney.ca TRANSPLANT DIGEST - PG 5

Post-Transplant Chat: Most Common Questions Asked in the Clinic Ellenica Hicks, RN, Galo Meliton, RN, Rachel Tong, RN, Jennie Huckle, RN, Maureen Connelly, RN

1. When can I start having a bath again? When can I start swimming? You should not have any baths, enter hot tubs, or swim until the incision has completely healed and the ureteric stent is removed. If you still have your dialysis catheter, that needs to be removed and the entry site completely healed. Make sure that your blood pressure is under good control as well, and also have a checkup with your family doctor.

2. When can I get on an exercise bike? When can I lift weights? How much can I lift? You can get on an exercise bike once the stent has been removed and the incision is healed. Do not lift or push anything over 5kg/10lbs in the first 12 weeks after your transplant. You can go for long walks,

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gradually increasing your distance based on your tolerance. It is a good idea to have someone accompany you. After 3 months since the transplant, you can do any activity as tolerated, as long as the incision is fully healed. Be careful though, since you may have lost some muscle strength from the operation and will need to gradually build it up again.

3. As a man, when can I start having sex again? As a woman, when can I start having sex again? We get asked this a lot. A transplant usually quickly restores sex drive in both men and women. Men can typically start having sex again about 6 to 8 weeks after transplant, after the stent has been removed. Women desiring sex again can also do so 6 to 8 weeks post-transplant, but it is important to

avoid pregnancy (see below). Practicing safe sex is always recommended to avoid any sexually transmitted diseases that could potentially harm the transplant.

4. With the transplant drugs, do I need contraception? For women who are still fertile, contraception is advised to avoid pregnancy in the first year or unwanted pregnancy at any time. Please speak to your family doctor as soon as possible for contraception options. If you become pregnant please inform the transplant clinic at once, since certain transplant medications can harm the fetus. One year after the transplant, if you desire pregnancy, book an in-person visit at the Transplant Clinic to discuss your options.

5. What precautions should I take around pets? Pet waste can contain bacteria which can make you very sick. Use measures for safe and proper disposal of pet waste, use gloves and wash hands after disposal. Do not empty a litter box, if you can avoid this.

6. I am fond of the outdoors. Can I work in the garden? Can I go hiking? Wear gloves when handling soil in the garden. Soil can contain harmful bacteria. If you prick your finger, seek medical attention. Activities such as hiking can be pursued, but keep in mind your limitations. It is best to avoid caves due to the risk of fungal infection.

sitting for extended periods to avoid blood clots.

8. When can I start traveling again? Wait one full year after your transplant before travelling outside North America. The Transplant Clinic will provide a travel letter and it is recommended you see a Travel Medicine clinic for any vaccinations based on your destination, and to get advice about special precautions needed. Take enough medications with you to last beyond your return date.

9. Am I allowed to take part in sporting activity? You can definitely play sports once fully healed, but do not partake in contact sports unless cleared by the Transplant Clinic and your family doctor. Avoid large crowds, make sure your vaccines are up to date, maintain social distancing and always wear a mask.

10. What special hygiene measures should I take, e.g. hair, fingernails. Keep your hair clean, and avoid hair coloring if you are concerned about hair loss. With extra-long hair be careful to avoid food contamination. Keeping your hands clean is essential to preventing the spread of infection. Carry a hand-held disinfectant and use often. Wash your hands whenever you get the chance especially when you are in public. Long or artificial fingernails and chipped nail polish harbor dirt and germs and can contribute to the spread of infection, so keep your fingernails clean and trimmed.

7. Do I have to wear a seatbelt? Can I go for long distance drives? You can drive when your mood and judgment have returned to normal, after the prednisone dose has been reduced to a low level, if you can move freely to shoulder-check and operate the car safely and you are pain free and comfortable to wear a seatbelt across your incision. Seat belts are for your safety and by law you need to wear a seatbelt in a moving vehicle at all times. If you are a passenger, you can use a pillow over the incision for comfort. For long distance drives you will need to stop to stretch after TRANSPLANT DIGEST - PG 7

Eating More Plant Based Proteins After Kidney Transplant Nicole Luinenberg BASc. (Dietetic Student) and Karen Burleigh MSc. RD Plant-based diets, intermittent fasting, ketogenic diets, and juicing have received much attention in the media recently. You may have wondered if these diet trends are safe for kidney transplant recipients to reduce the risk of transplant failure and heart disease. If you are thinking about adding more plant-based sources of protein into your diet, or you already consume a vegetarian or vegan diet, it can be difficult to ensure you are consuming the right amount of protein you need. The vegetarian and vegan eating patterns reduce the amount of protein in the diet that comes from animal sources eg. meat, chicken, fish, eggs and dairy products. Although plant-based protein sources may seem limiting, it is possible to consume the right balance of foods, to get the right amount of protein that you need for good health after a transplant.

Why Choose Plant-Based Protein? Eating more protein from plants can benefit overall health for kidney transplant recipients, and may be safe for you. Plant-based sources of protein includes legumes, whole grains, nuts and seeds. These foods have less

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protein than obtained from animal sources, but this can be helpful to avoid eating too much protein. In general, a moderate protein diet can lead to lower blood pressure within the kidney, reduce kidney damage and stabilize kidney function1,2,3. Plantbased foods can also provide high amounts of fibre and other beneficial nutrients, and low amounts of saturated fat. That helps us to feel full for longer after meals, and benefits cardiovascular health1. Research shows that a meal pattern focusing on protein from low-fat dairy products and plant-proteins instead of red and processed meats, does protect kidney function, delay the need for dialysis, and improve overall health1,3.4,5,6. The Basics of Eating a Plant Based Diet: Protein from animal sources is considered “complete protein”, because it contains all the building blocks of protein (called “essential amino acids”) that your body cannot make on its own. Individual sources of plant protein may lack some of these essential building blocks. Luckily, plant-based protein sources are “complementary” to one another, which means one source can provide the building blocks that the other food is lacking. Therefore, eating a variety of plant sources of protein throughout the day is an easy way to ensure you are consuming all the building blocks your body needs to maintain or increase your muscle mass and overall health 6 eg. eating a legume with a grain or a seed (see diagram below). This can look as simple as pairing beans and rice; or hummus and tahini, where hummus is the legume (chickpeas), and tahini is the sesame seed; or eating a cereal that contains both grains and nuts/ seeds. Studies show that the quality of food is also important to maintain good kidney function: avoiding foods that are processed, or with a high fat or sugar content, is more important than just eliminating animal based protein1. Check Before You Start: Plant-based sources of protein can contain high amounts of potassium and phosphorus. So it is very important to first check with your transplant team that your blood work is acceptable and it’s safe for you to eat these high potassium foods. After a kidney transplant, includ e plant-based protein in your diet, when your kidney Continued on page 12

Shingles Vaccine Post Kidney Transplant Francine Kwee, Transplant Pharmacist Infection with the virus varicella zoster causes chickenpox. After chickenpox, the virus remains in the body in an inactive state and may reactive later in life causing shingles, also known as herpes zoster. Shingles symptoms happen in stages. At first you may have a headache or be sensitive to light. You may also feel like you have the flu. After a few days, it may look like a skin rash, often in a strip, with blisters. This may be followed by long-lasting pain after the rash has healed. Call your doctor right away if you think you may have shingles as it is best to get treatment early. Shingles can happen to anyone, but is more common in older adults and people who have a weakened immune system, such as those with a transplant. There are two types of shingles vaccines that may reduce the chance of someone getting shingles and prevent long term pain that can occur after shingles. It is very important to know the difference between these 2 vaccines.

• • •

•

Zostavax®II (Merck) is a “live vaccine” against

shingles that has been available for many years. • This vaccine should NOT be given to any patient after a transplant, or within 4 weeks before transplant. • This is given as a single dose for patients over 50 years of age. • If you are waiting for a transplant, check with your transplant doctor to find out if you should receive this vaccine.

Shingrix® (Glaxo Smith Kline) is a “killed or non-live vaccine’ that is a newer shingles vaccine since 2017. • Clinical trials in patients with weakened immune systems, such as transplant patients, is still ongoing. Check with your transplant doc-

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tor to find out if you should receive this vaccine. This vaccine can be given to patients 50 years of age or older. It is given as two doses, 2-6 months apart. It is recommended to wait 6 months after transplant to receive the vaccine so it will work better when your anti-rejection medications are more stable. If you are waiting for a transplant, this vaccine should be given at least 2 weeks before transplantation to maximize its effectiveness. The more common side effects may include injection site pain, fatigue, muscle pain, fever and headache.

Other Common Questions 1. Can I still receive the Shingrix ® vaccine if I have received Zostavax ®II in the past? Yes. Adults, who were previously vaccinated Zostavax ®II, can be re-vaccinated with Shingrix® at least 1 year after receiving Zostavax ®II continued on page 15

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COVID-19 vaccines: how safe and effective are they in kidney transplant recipients? By: Darren Yuen MD FRCPC Although the SARS-CoV2 virus (the cause of COVID-19 infection) often causes only a mild infection in the general population, data from around the world shows that kidney transplant recipients are at higher risk for becoming severely ill following infection. Indeed, studies have shown that organ transplant recipients who develop COVID-19 infection have roughly a 20% chance of dying. We think that transplant recipients are more likely to develop a severe COVID-19 infection because of the immune suppressant drugs they take to prevent rejection. These drugs work by making the immune system less active, so that it does not recognize the transplant kidney as being “foreign”. Unfortunately, when the immune system is suppressed by these drugs, it will also be less likely to recognize viruses like SARS-CoV2. As a result, the SARS-CoV2 virus is more likely to survive, and potentially cause an uncontrolled, severe infection.

How effective are COVID-19 vaccines in kidney transplant recipients?

The COVID-19 vaccines available in Ontario have been remarkably effective in reducing infections in the general population. Vaccines work by activating the immune system to fight off the virus, so that if you are later exposed to the virus, the immune system is ready to eliminate it quickly. If the immune system is suppressed by anti-rejection drugs, however, vaccines do not trigger as strong an immune response, and so we think that vaccines likely do not induce the same level of protection in transplant patients. Up until now, however, no one has known exactly how much protection COVID-19 vaccines provide for organ transplant recipients. To answer this question, we looked at the ~1800 patients who are being followed by the St. Michael’s Hospital Kidney Transplant Clinic. Based on our analysis, we

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estimate that COVID-19 vaccines reduce the risk of symptomatic infection by roughly 40%. In other words, 2 doses of a vaccine reduce your risk of getting a potentially life-threatening infection by nearly half. Although this protection is lower than the 70 – 95% reduction in risk seen in the general population, it still suggests that 2 doses of a COVID-19 vaccine are protective. It is important to note that the number of patients in our analysis was much smaller than the millions of people studied in the general population, and so our results are only an estimate. The other thing that we learned is that the most important risk factor for getting a COVID-19 infection was where you lived. If you lived in a “hot spot” with high community infection rates, your risk of getting COVID-19 was much higher. What this suggests to us is that the public health guidelines such as wearing a mask and staying physically distanced are critical, even if you are vaccinated. The St. Michael’s Hospital Kidney Transplant clinic staff are committed to helping you through this difficult time. We will always strive to provide you with information about COVID-19 as it becomes available. We are also participating in and leading a number of research studies on COVID-19 and other problems affecting kidney transplant patients. If you are interested in learning more, please email kidneyresearch@smh.ca or call the Research Office: Michelle Nash Research Program Manager 416-867-3692 Lindita Rapi Research Coordinator 416-867-7460 ext. 48024

10 year Anniversary: ABO Incompatible Transplant Program Galo Meliton, RN, C Neph (C) Chief Senior News Correspondent

The blood group incompatible direct kidney donation program at St. Michael’s Hospital celebrated its 10th - year anniversary in August of 2021. Blood group incompatibility is one of the major obstacles in direct kidney living donation. However, in 2011, St. Michael’s Hospital was able to circumvent this by using a special filter, called Glycosorb ® ABO Column which specifically absorbs the recipient blood group antibody directed against their identified kidney donor’s blood group. The columns are purchased from Sweden (Glycorex AB). The single-use columns are piggybacked to a plasmapheresis machine for several sessions (depending on the recipient’s baseline blood group titers) 4 hours each time. Another condition that has to be met in choosing this option is that there is a negative cross match between the potential kidney recipient and their identified kidney donor meaning, the potential recipient does not have any preformed antibodies against donor tissue.

One month prior to these treatments, the identified recipient is given an intravenous medication called Rituximab to prime their system in accepting the donor kidney. They are also given the standard triple immunosuppression they would normally be given post- kidney transplant one week prior to the pre-booked kidney transplant date. To date, 32 kidney recipients have undergone this procedure successfully. St. Michael’s Hospital remains to be the only center in North America that performs this immunoadsorption process in direct living kidney donation. This success is due to support from the Kidney Transplant Management team at the time that the columns were first introduced to our Program and continued support from the current Management Team, as well as dedicated nursing, pharmacy, and medical staff in both the Plasmapheresis and Kidney Transplant Programs here at St. Michael’s Hospital.

Moving Back to In-Person Clinics Since the outbreak of the COVID-19 pandemic, many patients were being virtually evaluated by telephone. Virtual visits are typically shorter, reduce infection spread, and are more convenient for your planning. As the outbreak is slowly being brought under control however, it is time to think about beginning to see patients in person again. At the present time, there are no major restrictions on patients visiting the Transplant Clinic in person, although the situation could always change. While we are still “seeing” most patients virtually, please request an in-person visit if you think it will be particularly helpful to your care. We may also ask you to come in-person if there is a health concern. It may also be a good idea to come in person if you had several visits done virtually, so that uncovered issues can be reviewed. TRANSPLANT DIGEST - PG 11

Welcome New Staff!

Emily Campbell Registered Dietitian

Germania “Gina” Martinez Clerical Staff

Mickail Lawrence Clerical Staff

continued from page 8

function has normalized. Vegetarian and vegan diets often do not provide enough iron or vitamin B12 to prevent anemia. Therefore, you may also need an iron and vitamin B12 supplement. A Registered Dietitian can guide you on adding more plant-based proteins into your diet, based on your lifestyle and transplant function to ensure you are meeting your nutritional needs for kidney and overall health. Grains:

rice, oats, barley, wheat, corn, teff quinoa, millet (breads & cereals)

Nuts & Seeds: sesame, sunflower, hemp, flax

Legumes: beans, chickpeas, lentils, peas, peanuts

Combining a variety of plant protein sources ensures we can obtain all the building blocks we need for protein production.

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References: 1. Cyrino, L. G., Galpern, J., Moore, L., Borgi, L., & Riella, L. V. A Narrative Review of Dietary Approaches for Kidney Transplantation. K i d n e y International Reports 2021; https://doi.org/10.1016/j. ekir.2021.04.009. 2. Clegg, D.J., Gallant, K.M.H. Plant-based diets in CKD. Clin. J.Am.Soc. Nephrol. 2019;14:141-143. 3. Kalantar-Zadeh, K., Fouque, D. Nutritional management of chronic kidney disease. N. Engl. J. Med. 2017;377:1765-1776. 4. Lew, Q.I.J., Jafar, T.H., Koh, H.W.L. et al. Red Meat intake and risk of ESRD. J. Am. Soc. Nephrol. 2017;28:304 – 312. 5. Haring, B., Selvin, E., Liang, M., et al. Dietary protein sources and risk for incident chronic kidney disease: results from the Athero sclerosis Risk in Communities (ARIC) study. J Ren Nutr. 2017; 27:233 – 242. 6. Berrazaga, I. et al. The Role of the Anabolic Properties of Plant- versus Animal-Based Protein Sources in Supporting Muscle Mass Maintenance: A Critical Review. Nutrients. 2019 Aug; 11(8): 1825.

Flash Glucose monitoring system continued from page 3

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ways match sugar readings from a finger prick? Sensor sugar readings come from the interstitial fluid, a thin layer of fluid that surrounds the cells of the tissues below your skin, not from your blood. There is a 5-to-10-minute delay in the interstitial fluid response to changes in blood sugar. When sugars levels remain constant (shown by →) the sugar readings from the sensor are similar to readings from a finger prick. When the sugar levels rise quickly (↑) the sensor readings maybe lower than the finger prick. When the sugar levels drop quickly (↓) the sensor readings maybe higher than the finger prick.

What are the advantages of using a flash glucose monitoring system? Requires no finger pricks • Painless, 1 second scan, and can be read through clothing • Can be checked anytime, anywhere • It is water resistant in up to 1 metre (3 feet) of water and can be worn while bathing, showering, and swimming. However, it should not be submerged longer than 30 minutes.

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The sensor automatically measures and continuously stores sugar readings; however, the sensor must be scanned every 8 hours otherwise store information will be lost. Information can be shared virtually with your health care provider

What can affect the sensor sugar readings? Taking ascorbic acid (Vitamin C) while wearing the sensor may falsely raise your sensor sugar readings. Taking salicylic acid (used in aspirin and some skin care products) may slightly lower your sugar readings. What is the cost of the meter and sensors? The freestyle libre reader is free. Both the freestyle libre sensors and free style libre 2 sensors are covered by Ontario drug benefits for people managing diabetes with insulin and by most private health insurance plans. The Freestyle libre 2 app is free. The cost of a sensor varies from pharmacy to pharmacy and range between $100-130. Ask your health care team if the flash glucose monitoring system is for you!

References Blum A. Freestyle Libre Glucose Monitoring System. Clin Dia-

Provides real time sugar readings • Shows how medication, activity and food affect sugar levels in real time

betes. 2018 Apr;36(2):203-204. doi: 10.2337/cd17-0130. PMID: 29686463; PMCID: PMC5898159. https://www.freestyle.abbott/ca-en/home.html#why-scan

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Test your Transplant Knowledge Choose the best answer for each question 1. What type of medication is prednisone? A

Calcineurin inhibitor

Corticosteroid

Non-steroid anti-inflammatory

D Antibiotic 2. This urine test will show how much protein you are losing from the kidney A ACR B BNP C CRP D culture 3. Average stay in hospital after a transplant is A 2 days B 4 days C 5-6 days D 2 weeks 4. The main reason to have a Foley catheter after transplant is A So you do not have to walk to the bathroom B To measure your urine production C To allow the connection of your new kidney to the bladder to heal D To give you IV fluids 5. This blood pressure medicine is usually not used early after a transplant A ACE inhibitor B calcium channel blocker C beta blocker D hydralazine

6. This blood test is often used to adjust the dose of your water pill A

ACR

BNP

CRP

D CBC 7. This blood test is often used to detect an underlying infection A

ACR

BNP

CRP

D chloride 8. After a transplant your staples are usually removed at A

4 days

1 week

10 days

D 3-4 weeks 9. This transplant medicine is not given orally (by mouth) A Prednisone B

mycophenolate

tacrolimus

D basiliximab 10. This vaccine should not be given to transplant patients A

Hepatitis B

Meningococcal

Measles

D Tetanus

Answers on page 15

PG 14 - TRANSPLANT DIGEST

Gout and the Kidney Transplant story continued from page 2

and other diseases present. Treatment includes prednisone, a medicine most patients are already taking, in a higher dose for a few days. The dose is then reduced slowly over a week. If two or more joints are involved at once, then injecting steroids directly into the joint may help. Steroid taper should then occur over three weeks rather than one. In all cases, the blood pressure and blood sugar should be monitored since steroids affect these. Colchicine is effective, but must be used very cautiously if there is also liver disease and transplant function is poor. Colchicine can be chosen over steroids if there is a simultaneous infection. Rarely, non-steroidal drugs (NSAIDs) like indomethacin are used, but these can hurt the kidney if used for a long period or repeatedly. Gout prevention medications like allopurinol and febuxostat already being taken should not be stopped, since restarting them later can precipitate another gout flare. They should not be started either during a gout attack because the gout can worsen as a result. Once the gout attack has resolved, focus should be on preventing future attacks. The serum uric acid level should be brought down to normal. The recommended level is less than 350 micromol/L, although this can be difficult to achieve. Drugs that raise uric acid, like diuretics, should be reviewed. Some blood pressure drugs like losartan may lower the uric acid. Weight loss, reducing alcohol and sweet drink intake, or switching from cyclosporine to tacrolimus may help in a small way. You may need to modify your diet. After a second attack, uric acid lowering medication should ideally be started. Xanthine oxidase inhibitors like allopurinol and febuxostat are commonly prescribed. These drugs are started at a low dose that is gradually increased, and should be taken indefinitely. It is critical to avoid these drugs in patients taking azathioprine, however, due to a strong drug interaction. Uric acid levels should be Answers for Knowledge Test on page 14:

rechecked in a month. Allopurinol sometimes has side effects too, so it is important to follow-up with the Transplant Clinic, your rheumatologist, and family doctor afterwards. Kidney function, liver and muscle enzymes and white blood cell counts are usually checked. Other drugs that increase uric acid excretion, like benzbromarone and probenecid, are sometimes used in kidney transplant patients if allopurinol or febuxostat is not enough to lower the serum uric acid. Since gout patients are at higher cardiovascular risk, these all need to be addressed as well. Be sure to inform the Transplant Clinic when you have a gout attack, so we can help with your care along with your other physicians. continued from page 9

2. If I have had shingles before, can I still receive the vaccine? Yes, however individuals with a previous episode of shingles should wait at least 1 year before getting the vaccine.

3. Can you get shingles from other people? The virus that causes shingles can only be spread from a person with a shingles rash in the blister phase to another person who has never had chickenpox. It is spread through direct contact with the fluid in the blisters. In such a case, the person exposed might develop chickenpox, but would not develop shingles. If the shingles rash has developed crusts, it is no longer contagious.

4. Is the cost of Shingrix® vaccine covered? Currently, it is publically funded in Ontario for adults between 65 to 70 years old. Seniors who have received the publically funded Zostavax® II vaccine, are not eligible for the publically funded 2-dose Shingrix® vaccine. If you have private insurance, it may be covered. Out of pocket cost is approximately $250 for the 2 doses. TRANSPLANT DIGEST - PG 15

1. B 2. A 3. C 6. B 7. C 8. D

4. C 9. D

5. A 10. C

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TRANSPLANT DIGEST - PG 16