Kidney Review - Issue 2- Spring 2001
- New Kidney Transplant Option Helps Shorten Waiting Time
- Dual Kidney Transplants Transform Lives
- What to Expect After Kidney Transplantation
- The Transplant Evaluation Process
- Sun Sense - How to Protect Yourself from Sun Exposure
- On the Road Again--Traveling After Transplantation
- Healthy Diet Critical to Transplant Success
New Kidney Transplant Option Helps Shorten Waiting Time Top of Page
By William Bry, MD, surgical director and Laura Miyashita
California Pacific Medical Center Introduces Dual Kidney Transplantation
With waiting times for kidney transplantation averaging between three to five years, transplant physicians continually seek new options for treating kidney failure. One alternative, introduced at California Pacific Medical Center last year, is a dual kidney transplant. This technique involves the transplantation of two kidneys from an older or “marginal” cadaveric donor rather than one kidney from a younger donor.
“We have performed eight dual kidney transplants in the past year and have had excellent transplant function and success,” says William Bry, MD, surgical director of California Pacific's Kidney and Pancreas Transplant Program. “Because these transplants have been as successful as single transplants, we are expanding the program.”
Dual Transplants Help Return Patients to a Normal Life
Currently, more than 30 transplant programs around the nation perform dual kidney transplants. Their results, in addition to published research, support dual kidney transplantation because of its success in returning patients with kidney failure to a normal life. Joe Galante, a 68-year old patient who received a dual kidney transplant last November at California Pacific says, “There are no words to explain how good I feel since my transplant. I want to cry from happiness, the gift of life is so great!”
“The main advantage of dual transplantation is a shorter waiting time,” says Bry. “Because this option is still relatively new for patients in Northern California, there are fewer patients on the dual transplant list and waiting times are reduced in half.”
Donor Sources
The kidneys used in dual kidney transplantation come from cadaver donors who are usually older than 55 years and/or have a history of high blood pressure or other medical problems. Because of the age and medical problems associated with these donors, the single kidneys are not used for standard kidney transplantation. However, by using two kidneys from a marginal donor, excellent transplant function and survival results are obtained.
“Kidneys used for dual kidney transplantation have to meet minimum standards of function and structure to be accepted,” says Bry. “The disadvantage of dual kidney transplantation is a longer surgical procedure but no increase in the risk of rejection has been observed.”
Dual Transplant Surgery
The surgical procedure for dual kidney transplantation is similar to that of a single transplant, but because of the additional organ involved, lasts longer. During the transplant, the surgeon places the donor kidneys to the left and right of the bladder. The diseased kidneys remain in place, located above the transplanted organs. The entire procedure takes about four hours.
After surgery, patients recover in the hospital for about a week and begin taking the immunosuppressive medications needed to prevent rejection. Within six to eight weeks, transplant patients can usually resume normal activities.
Dual Kidney Transplants Transform Lives Top of Page
By Laura Miyashita
The decision to have a dual kidney transplant came easily for Joe Galante and Ramona Melgoza, dialysis patients who were on the kidney waiting list for over three years. Among the first patients at California Pacific Medical Center to receive two transplanted kidneys in place of one, Joe and Ramona are eager to share their experience, encouraging others to consider a dual kidney transplant.
Joe Galante
“I feel like a new man and when I think of my two new kidneys, I thank God for the miracle,” says Joe Galante, a 68-year old Modesto area patient who underwent a dual kidney transplant in November 2000. Prior to his transplant, Joe's glomerulonephritis caused him to go on peritoneal dialysis for one and a half years, leaving him feeling weak and depressed because dialysis treatments took up so much time.
“The doctors at California Pacific gave me the option of being on both the single and dual kidney transplant waiting lists, so I agreed,” explains Joe. In November, he received a call from the hospital saying two kidneys were available, so Joe immediately came for the transplant. “Once I woke up after surgery, I just had sore muscles. There wasn't enough pain for me to even ask for painkillers,” he says. After eight days recovering in the hospital, Joe returned home, feeling like a new person.
“After getting a transplant, you feel normal again, not weak like on dialysis,” says Joe. Although he was hoping to avoid dialysis altogether by getting listed for a transplant early on, Joe's kidney failure changed his plans. “Looking back, I appreciate transplant so much more having gone through dialysis,” he explains. “And I am so grateful for the good people who donated organs and were willing to help others.”
Ramona Melgoza
During her wait for a kidney transplant, Ramona Melgoza had her share of ups and downs. When she started dialysis, Ramona, a 58-year old kidney failure patient from Merced, thought her daughter could give her a kidney, but when that didn't work out, her transplant team suggested other options to shorten the wait. After hearing about a dual kidney transplant in which she would receive two kidneys from a marginal donor, Ramona agreed.
“Last October at 1:00 a.m., the nurse at California Pacific phoned to tell me that two kidneys had become available,” Ramona explains. “I got so excited, I blacked out and don't remember much about the ride to San Francisco or getting ready for the transplant.”
Following the four-hour transplant surgery, though, Ramona's memories are vivid. “I woke up and felt a beautiful sensation. It was as if someone had given me life again.” Her new kidneys, which she learned came from a 27-year old diabetic man with good kidney function, are working perfectly and Ramona has been returning to her dialysis unit to promote transplantation. “I'd recommend kidney transplant to anyone, it's been great for me,” she says.
What to Expect After Kidney Transplantation Top of Page
By Transplant Nephrologists Lawrence Bohannon, MD, Sharon Inokuchi, MD, Steven Katznelson, MD and Barry Levin, MD
Q. How long will my new kidney last?
A. This is a difficult question to answer because not all transplant patients and transplanted kidneys are alike. In general, in the United States, an average cadaveric kidney lasts about nine to 10 years and an average living donor kidney lasts about 15 to 16 years. The kidneys that last the longest are those from perfectly matched siblings. On average, these can last well over twenty years. Some transplants will probably last forever and our goal is to try to make yours such a success.
Q. Will the kidney disease I currently have damage my new kidney?
A. Most diseases that cause kidney failure can recur in a transplanted kidney. Approximately 20-30% of transplanted kidneys develop recurrent disease and between 5-10% of the time this leads to failure of the transplanted kidney (graft loss). Among the diseases that most often cause graft loss are diabetes and several types of glomerulonephritis, including focal and segmental glomerulosclerosis (FSGS), Ig-A nephropathy and Type 2 membranoproliferative disease. Diseases of the kidney attributed to genetic causes, developmental defects or drugs do not recur in the transplanted kidney. Hypertension can damage your native kidneys or your transplant and it is critical to control your blood pressure.
Q. What will my life be like after my transplant? Will my activities be restricted?
A. Following transplantation, patients are on a variety of drugs, some of which may alter their general level of alertness. These medicines, particularly the pain killers, are usually necessary for one to three weeks following kidney transplantation. Patients should refrain from driving during this time.
General activity may begin once patients leave the hospital. Typically, you may initiate gradual progressive activity such as walking 10-20 minutes once or twice daily. Patients should avoid vigorous exercise such as swimming, weight lifting and high impact aerobics until the surgical wound has sufficiently healed—usually about four to six weeks. The Kidney Team generally recommends that patients refrain from significant physical activity for at least two to three months. After this time, patients can begin a routine exercise program three to four times a week.
A large majority of patients who feel extremely well following transplant will engage in activities such as skiing, swimming, golfing, tennis and even professional basketball, or will return to work. Patients appear to be limited only by their imaginations and areas of interest.
Q. Can I have children after transplant?
A. Some post-transplant patients may wish to start families or add to their present one. The Kidney Team typically suggests they hold off for a year or two to ensure that kidney function is stable and immunosuppressive medications have been tapered to lower doses. Most couples will have completely normal and healthy babies, although the risk of miscarriage may be higher than in non-transplant pairings. Expectant mothers on immunosuppressives should be followed closely by their obstetricians as well as their transplant team.
Q. Will my physical appearance change?
A. Most kidney transplant patients find they look somewhat different after surgery. They no longer have a pale, dry complexion, dialysis catheters or swelling between dialysis treatments. As early as the day after surgery, their cheeks turn pink and eyes brighten. Rough skin may soften and scars become lighter.
Some unwelcome changes caused by anti-rejection medications may also occur. These include weight gain, thinning or overgrowth of hair and a variety of skin problems. The transplant team works with each patient to adjust medications and keep unwanted changes to a minimum while protecting the kidney. A healthy kidney means a better chance for a healthy appearance.
The Transplant Evaluation Process Top of Page
Steven Katznelson, MD, transplant nephrologist
A Guide for Patients Considering Kidney Transplantation
Considering kidney transplantation is one of the most important decisions of many peoples' lives. Last year, California Pacific Medical Center's Kidney Program evaluated more than 500 patients who made this decision.
The process that leads to kidney transplantation involves three main steps:
1) Referral to the transplant program
2) Evaluation
3) Placement on the organ waiting list
Throughout these steps, California Pacific's Kidney Transplant Team is available to help you, providing individual attention and an opportunity to learn all about kidney transplantation.
The Referral Process
In general, any adult with end-stage renal disease can be referred to California Pacific for a transplant evaluation. We encourage transplant referral before patients begin dialysis, but many patients who undergo evaluation have already started dialysis.
Depending on your insurance type, you or one of your health care providers can make the referral. The Kidney Team prefers a referral letter from your kidney doctor with background medical information. Once a patient is referred, our financial specialist will screen his or her insurance to make sure the evaluation is covered.
Evaluation
Once California Pacific's financial specialist obtains insurance clearance or “authorization,” the Kidney Transplant Team schedules an office visit for transplant evaluation. Evaluations are offered at California Pacific in San Francisco and outreach sites throughout Northern California and Nevada.
During evaluation, patients meet with a transplant physician, nurse coordinator and social worker. The visit begins with a slide show about the transplant process and includes a question and answer session. Transplant candidates are encouraged to bring loved ones to this visit. Patients then meet separately with all the transplant team members. After these meetings, the medical work-up needed for each transplant candidate is discussed. The transplant nurse then arranges pre-transplant blood tests (ABO blood typing and tissue typing).
After the “evaluation day,” the Kidney Team writes a letter to your kidney doctor summarizing the meeting and describing any tests that need to be done. To make it convenient for you, these additional tests can be performed close to home by your local doctor. Test results are then forwarded to California Pacific. If patients have potential living donors, they will receive instructions about getting them involved in evaluation.
Placement on the Organ Waiting List
Placement on the United Network for Organ Sharing (UNOS) waiting list occurs once patients have been seen in the pre-transplant evaluation clinic, identified as potential transplant candidates and undergone the pre-transplant blood tests. Once your name is on the waiting list, you will need to be prepared and ready to respond should a suitable donor kidney be found. While waiting for transplantation, patients are urged to contact California Pacific Medical Center with any changes in their medical or insurance status.
Sun Sense - How to Protect Yourself from Sun Exposure Top of Page
Steve Katznelson, MD, transplant nephrologist
With summer approaching, many transplant patients will plan summer vacations and engage in outdoor activities. While you should take advantage of these activities, you need to protect yourself against the sun, since it can be the enemy of transplant patients.
In general, everyone (both transplant patients and non-transplant patients) should limit their sun exposure. Sun not only increases the risk of skin diseases including skin cancer, the most common type of cancer in transplant patients. In transplant patients, the risk of developing skin cancer is much higher than in people who have not received a transplant because all anti-rejection medications increase the risk of skin cancer.
To decrease your risk of developing skin cancer after receiving your transplant, follow these precautions:
* Limit your amount of direct sun exposure;
* Wear sun block (SPF 25 or greater) on all exposed skin surfaces;
* Wear a brimmed hat to protect areas that receive the most sun exposure, such as the forehead, nose, cheeks and back of the neck.
* Whenever possible, wear light clothing to cover sun-exposed areas.
* Visit a dermatologist routinely to look for any suspicious skin growths.
On the Road Again - Traveling After Transplantation Top of Page
William Bry, MD, surgical director
One of the joys of having a kidney transplant is the freedom to travel without worrying about dialysis. In fact, a question that patients frequently ask is “How soon can I travel after my transplant?”
Your freedom to travel is determined by how closely the transplant center needs to follow you. When you first leave the hospital, your labs will be checked each Monday and Thursday near your home, making it difficult to travel very far. The chart below shows the frequency of laboratory studies following your transplant. As shown, the greater the time after transplant, the less often you need to have your labs checked or visit the transplant clinic. If you travel, it is important to let your transplant nurse coordinator know how to contact you. This may be a contact number where you are staying or an agreement that you will check your home messages while away.
When traveling, remember to take an adequate supply of medications with you, including extra in case your return home is delayed. Be sure medications are properly labeled so customs will not detain them if traveling overseas. Additionally, keep your medications with you in your carry-on bag when you fly. This way, you won't run out of medication if your bags are lost or delayed.
You can have your blood work done at a lab where you are traveling as long as you remember to carry your lab orders with you, notify the lab where to send the results and notify your transplant coordinator in advance. By following these safeguards, you'll see how easy it is to travel after your kidney transplant. Bon voyage!
Healthy Diet Critical to Transplant Success
By Laura Miyashita and Mary Pasquali, RD, MS
Prior to transplantation, end-stage renal disease patients need to be in the best health possible. In addition to following a regular dialysis schedule, receiving vaccinations and avoiding contact with those who are sick, a healthy diet is critical to a successful transplant outcome. While patients on hemodialysis face more restricted dietary guidelines, those on peritoneal dialysis must also watch their food intake to maintain good health.
Hemodialysis Diet
Typically hemodialysis patients follow a renal diet that limits consumption of potassium, phosphorus, sodium, fluids and proteins. Restricting intake of these nutrients and fluids helps prevent the dangerous build up of toxins and wastes in the bloodstream. In people without kidney failure, the body processes the nutrients it needs and the kidneys eliminate the remaining nutrients. In patients with kidney damage, however, the kidneys can't eliminate excess fluids and nutrients, so intake is limited to prevent an electrolyte imbalance.
Peritoneal Dialysis Diet
Because peritoneal dialysis sessions occur more frequently than hemodialysis, dietary restrictions are less strict. Even so, patients should consult with their physician or dialysis dietitian because protein loss is common. To increase protein levels, eat foods such as meat, poultry, fish, dairy, eggs and tofu.
Post-Transplant Diet Restrictions
In general, the strict diet limitations patients may face pre-transplant do not apply post-transplant. Patients need to start eating phosphorus-containing foods (dairy products and others) and can usually begin eating potassium-containing foods as well.
Following transplantation, patients should limit the amount of fat and cholesterol in their diet because anti-rejection medications and a liberalized diet can cause elevated cholesterol and fat levels. Patients also need to be careful of weight gain that may occur from anti-rejection medications.
To help extend the life of a transplanted kidney, follow these guidelines:
* Limit your sodium, saturated fat and cholesterol intake
* Monitor your weight and eat a well-balanced diet with selections from all food groups
* Take 1,000 to 1,500 mg of calcium daily to keep your bones healthy
Additionally, regular exercise (30 minutes at least three times a week) will help control your weight.