Kidney Review - Issue 1 - Fall 2000
- Kidney Transplantation Between Spouses and Close Friends Gains Popularity
- A Life-Changing Gift
- Questions and Answers About Living Kidney Donation
- New Anti-Rejection Medications Improve Transplant Results
- Vaccinations Critical for Pre- and Post-Transplant Patients
- Keeping Your Transplant Team Within View
- California Pacific's Kidney and Pancreas Transplant Program
Kidney Transplantation Between Spouses and Close Friends Gains Popularity Top of Page
With the nation's kidney waiting list growing longer each year, an increasing number of patients are turning to family and friends for donation in hopes of saving or restoring their quality of life.
"We have seen a dramatic rise in the number of spouses and close friends coming forward to donate one of their kidneys," says William Bry, MD, surgical director of California Pacific Medical Center's Kidney-Pancreas Transplant Program. "Many donors say it's one of the most meaningful experiences in their lives."
Kidney transplants between husbands and wives have been performed since the late 1980s, following improvements with immunosuppressive medications. At the time, it was assumed that the success rate would be about the same as cadaver donor transplants due to the lack of a genetic relationship between donor and recipient. To everyone's surprise, however, "spousal" transplants proved to be more successful than cadaver donor transplants.
Based on the success of transplants performed between husband and wife, "living-unrelated" transplants expanded in the 1990s to include kidney donation between close friends who are not married. The volume of living-unrelated kidney transplants continues to rise, with several hundred procedures performed each year. Most programs, including California Pacific's, require a long-term emotional relationship between the donor and recipient.
Advantages of Living-Unrelated Transplantation
Benefits of transplantation with a living donor include:
Greater Chance of Success.
Living donor transplantation is the most successful kidney transplant procedure. Part of this success is due to the short time between donor and recipient surgeries (kidney preservation period). Cadaver transplants, by comparison, have a long preservation period (20 hours on average) because the organ must be transported and the patient called in. Due in part to this unavoidable delay, cadaver donor kidneys may not always function immediately.
Better preparedness. Living donors undergo an extensive evaluation of their general health and kidney function to help ensure a successful transplant. In comparison, when a cadaver donor becomes available, doctors have only hours to decide whether to accept or turn down the organ. Additionally, cadaveric donor kidney recipients are "on call" for their transplant whereas the surgery for living donor transplants is scheduled in advance.
Less waiting. Living donation recipients do not need to wait on the regional kidney transplant waiting list, which can last several years in California. The surgery can be scheduled at a time that is convenient for all parties. In some cases, attempts can be made to arrange the transplant before the need for dialysis. Additionally, when patients have a living donor kidney available, it frees up a cadaver donor kidney for someone who is not fortunate enough to have a living donor.
All living donors go through a medical and social evaluation where they learn more about these benefits as well as risks of donating a kidney.
Positive Transplant Outcomes Boost Interest
The one-year graft and patient survival rate for living-unrelated kidney transplants at California Pacific Medical Center is 96%. This outcome, as well as three- and five-year results, are similar to those of living-related kidney transplantation and compare favorably with national data.
More than 25% of the living donor kidney transplants performed at California Pacific Medical Center involve a spouse or friend acting as the donor. With all the advantages of living-unrelated transplantation-—and continued development of new anti-rejection medications—-this number is expected to rise, offering patients with kidney failure an important option for restoring their health.
A Life-Changing Gift Top of Page
Organ donation is a selfless act that saves and improves the lives of thousands of individuals each year. The following story describes the experience of two friends who underwent a living donor kidney transplant, and the bonds they now share.
Angela and Jim
After seeing his friend's kidney disease progress during the course of their six-year friendship, Jim Thomas offered Angela Lee the gift of life—his kidney. Angela, a 49-year old mother of two from Danville, had been suffering from glomerulo nephritis for half of her life and was on dialysis for more than three years while awaiting a kidney transplant. Her husband wanted to donate, but high blood pressure and a family history of diabetes prohibited it. And Angela felt her kids were too young to undergo the surgery. So Jim, a church friend of the Lees, stepped in.
“Once I found that I could live quite normally with only one kidney and that our different racial backgrounds were irrelevant to donation, it was a no-brainer,” says Jim, a 51-year old East Bay resident. “I had been friends with Angela and her family for several years and knew that her life was pretty miserable—she never had a medically ‘normal' day, even on dialysis.”
After a thorough evaluation at California Pacific Medical Center, Jim was declared a match and a transplant date was set. On January 19, 2000, Jim and Angela underwent the living donor transplant surgery. “The day after my surgery, I got out of bed,” says Jim. “By the next morning, I was racing up and down the hospital halls, IV pole and monitors in tow.”
Angela's recovery took a bit longer, but by day three, she was walking around. “I went to see Jim down the hall and we talked about all that had happened,” she explains. “Every day, I started feeling better and better—and neither of us felt any pain around the incision.” Jim added, “The surgery went beautifully. The transplant staff at California Pacific were just wonderful—they prepared us well, administered to us beautifully and were compassionate throughout.”
Three days after the kidney transplant, Jim was discharged. Angela returned home to her family shortly thereafter. Now, off dialysis for nearly eight months, Angela is enjoying her freedom and the new life her kidney has given her. “I can eat and drink whatever I want—and the independence is wonderful,” she says. “I feel blessed that Jim came to my aid and for his generosity. I continue to visit my friends at the dialysis clinic who are waiting for a transplant and remind them to stay healthy and take care of themselves so they can enjoy the same freedom that I have.”
Questions and Answers About Living Kidney Donation Top of Page
Q. How do I approach the subject of donation with family or close friends?
A. To discuss this topic, it's best to bring up the subject of kidney transplant in a general, non-demanding way. For example, you can say, “My doctor recently told me that I need to have a kidney transplant. The waiting list is three to five years for a cadaveric organ, but if I have a living donor it could happen within a few months.”
Interested parties will usually ask follow-up questions about the procedure. (e.g. “Do you have a donor? Does the donor have to be a relative? What kind of surgery is it?”) The recipient should then refer the person to their transplant social worker or coordinator for more information. Recipients should be prepared to leave the topic alone if their close friends say nothing or if they seem resistant.
Q. Who covers a donor's medical costs?
A. A donor's transplant-related medical costs are covered by the recipient's insurance. Donors are responsible, however, for related expenses such as transportation, lodging, meals for family, long-distance phone calls and other incidentals. A social worker can help determine the costs of such items and possible funding sources if necessary.
Q. What is the recovery time for a living donor?
A. Typically, donors are fully recovered four to six weeks after an open nephrectomy (kidney removal through open surgery) or three to five weeks after a laparoscopic nephrectomy (a minimally invasive kidney removal procedure). Donors are automatically signed off for six weeks disability, with more time available if needed.
Q. What evaluation does a living donor undergo?
A. In addition to a thorough physical examination and lab work in which kidney function and anatomy are analyzed, all donors are interviewed by a social worker. The social worker speaks with prospective donors to ensure that the procedure will not be detrimental to them emotionally, psychologically, financially, spiritually or socially. Donors are also assessed to determine if they are under pressure or coercion to donate.
Q. Do kidney donors and recipients have to have the same ethnic background?
A. No. Donors do not have to have the same ethnic or cultural background as the kidney transplant recipient. California Pacific Medical Center simply requires that they have an “emotionally close relationship that has withstood the test of time.”
New Anti-Rejection Medications Improve Transplant Results Top of Page
Kidney and pancreas transplant patients are enjoying better outcomes than ever, due in part to the development of new medications that help prevent rejection of transplanted organs. Introduced during the past several years, the advanced anti-rejection medications (immunosuppressives) alter a transplant recipient's immune system so that it doesn't “fight” against the tissue of a new kidney or pancreas.
As a result, kidney transplant recipients have a 90% or better one-year transplant survival rate. This outcome is significantly higher than the 60% to 80% graft survival reported in the mid-1980s.
Some of the recently introduced immunosuppressives that are contributing to increased kidney and pancreas transplant outcomes include:
Prograf® (FK506 or tacrolimus)
Prograf is a relatively new immunosuppressive medication originally used in liver transplant patients. Research has shown it is highly effective for kidney transplant recipients in place of cyclosporine. In fact, recent studies suggest that Prograf may be the drug of choice for some groups of transplant recipients, including pancreas transplant recipients and patients who undergo re-transplantation.
CellCept® (mycophenolate mofetil)
CellCept has replaced Imuran in most immunosuppressive drug regimens because it decreases rejection episodes more effectively.
CellCept is usually used in conjunction with Prednisone and either cyclosporine or Prograf. New data suggests that CellCept may actually help lengthen transplant survival.
Rapamycin® (sirolimus)
Rapamycin is a new immunosuppressive medication recently approved by the
U.S. Food and Drug Administration (FDA) for use by transplant patients. When used in conjunction with cyclosporine and Prednisone, it has shown to be an excellent medication for preventing rejection episodes. Rapamycin may also have fewer side effects than some other immunosuppressive medications.
New Cyclosporine Preparations
In the mid-1990s, Neoral®, a cyclosporine formulation with certain properties that are beneficial to kidney transplant recipients, was released and virtually replaced the use of Sandimmune for new transplant recipients. Now, generic formulations of cyclosporine are available. Gengraf®, the newest formulary, is equivalent to Neoral in its effectiveness and will be used for some transplant recipients.
Immunosuppressive Medication Combinations
Like many transplant programs, California Pacific Medical Center uses a combination of CellCept with prednisone and either Prograf or cyclosporine for most transplant recipients. Other new medications are used in transplant patients depending on their individual circumstances.
Our Kidney-Pancreas Transplant Program is performing clinical research to investigate new immunosuppressive medications, with several trials currently in progress. This research allows us to continuously search for even better drugs and drug combinations that will further improve transplant survival and patient response.
Vaccinations Critical for Pre- and Post-Transplant Patients Top of Page
Proper immunization for patients who are awaiting or recovering from a transplant is an important factor in preventing serious infections. For adult patients awaiting transplantation, routine immunizations plus vaccinations against pneumonia, hepatitis B and the flu are critical
Following transplant surgery, patients have a high risk of infection because of a weakened immune system. The anti-rejection medications taken to prevent rejection of a new organ weaken the body's ability to make antibodies and may cause a decreased response to vaccines. Therefore, transplant recipients may need larger or increased doses of some vaccines to ensure their effectiveness. A health care provider or transplant physician can assess the response to a vaccine and adjust the dosage accordingly.
Transplant patients should avoid “live virus” vaccines such as those for measles, mumps and rubella (MMR) because the live virus may in fact cause these illnesses. Instead, ask for “killed” or “inactivated” vaccines, both of which are safe for transplant patients.
Pneumococcal pneumonia, hepatitis B, and influenza A and B vaccinations are advised for all transplant patients. Revaccinations for pneumococcal pneumonia—both for pre- and post-transplant patients—should occur every five to six years. If patients have not completed the hepatitis B vaccine series (a cycle of three injections) before transplant surgery, they should continue the series following transplantation. Annual influenza A and B vaccinations are also important and should be administered to transplant patients each fall.
Although the varicella vaccine for the prevention of chicken pox is approved for use in healthy children, the vaccine is not yet available for use by transplant or dialysis patients. Researchers are investigating such a treatment. Additionally, researchers are developing vaccines to prevent infections due to cytomegalovirus (CMV) and Ebstein-Barr virus—two viruses that can cause serious illnesses in transplant recipients.
Important Vaccinations for Transplant Patients
* Inluenza A/B - yearly in the fall
* Hepatitis B - with monitoring to show effectiveness
* Pneumococccal Pneumonia - with booster every 5-6 years
Keeping Your Transplant Team Within View Top of Page
Even though she's nearly 200 miles from her transplant team in San Francisco, Bernice Woods can see her doctors in person after a short drive through Fresno. Bernice, a kidney transplant recipient who lives in Fresno, Calif., is one of the hundreds of patients seen each year at California Pacific Medical Center's kidney outreach clinics. Since her transplant in February 2000, Bernice has received all of her follow up care locally at the Fresno outreach clinic and through a new telemedicine program.
Outreach Clinics
California Pacific's Kidney-Pancreas Transplant Program operates outreach clinics staffed by a full-time nurse coordinator in the following communities:
* Berkeley/East Bay Area
* Fresno
* Modesto
* Peninsula/South Bay Area
* Roseville/Sacramento
Our nephrologists visit these clinics every month, as well as sites in Eureka, Redding, Reno and Fairfield to stay in touch with transplant patients.
At the outreach clinics, patients can undergo parts of the pre-transplant evaluation and keep in touch with their team to monitor any health problems prior to transplantation. After surgery, patients meet with their transplant nephrologist at the clinics for post-operative follow up visits.
Telemedicine
While telemedicine is already used in medical fields from psychiatry to trauma assessment, California Pacific is the first program to offer this technology for transplant patients.
“I can talk to my doctor in San Francisco about post-transplant symptoms and my overall health through the television,” says Bernice. “I've had two telemedicine sessions and it's just like talking to the doctor in person. There is an outreach coordinator in the room in Fresno who sets up the connection and can intervene if the doctor has any follow up necessary.”
While telemedicine will not replace outreach clinic physician visits, it offers an additional means of communication for transplant patients.
California Pacific's Kidney and Pancreas Transplant Program Top of Page
California Pacific Medical Center offers one of the leading adult kidney-pancreas transplant programs with outcomes ranked near the top nationwide. In 1969, we performed our first kidney transplant and more than 2,800 have been performed since. Presently, more than 110 patients annually receive kidney or kidney-pancreas transplants at California Pacific.
Through our five outreach clinics in Northern California, a telemedicine program and site visits to Pacific Rim countries, we bring our specialists to local communities. Our comprehensive patient care is supported by the latest advances and research—including new surgical techniques and ongoing clinical research. We evaluate nearly 700 patients each year who are interested in kidney or kidney-pancreas transplantation, and continue to grow as a result of our excellent results and patient friendly services.
To learn more about our kidney or pancreas transplant services, give us a call at (415) 600-1080.