Kidney Review - Issue 3- Fall 2001
Kidney Donation: How the Living Donor Process Works Top of Page
by Angela Bogetti-Dumlao, RN, Eileen Kelly, RN and Laura Miyashita
Knowing that the gift of one's kidney to a close friend or relative can help end dialysis treatments and enable the recipient to enjoy more freedom and energy prompts many to consider living kidney donation. In fact, in 1999, more than 4,000 individuals in the United States acted as “living donors,” accounting for 1/3 of all kidney transplants.
“We have been performing living donor transplants at California Pacific since 1969 and a recent survey of 57 living donors shows they felt their health, following kidney donation, had remained the same or was better than before they donated,” says Angela Bogetti-Dumlao, R.N., MSN, FNP, transplant nurse coordinator.
While cadaveric kidney transplants still outnumber living donor transplants, an increase in waiting times and surgical improvements have attributed to a steady rise in living donation. Last year, California Pacific performed 37 living donor transplants, with one-year recipient survival outcomes of 98.3%.
Who Can Donate?
Living donors are generally between ages 18 and 60 and in excellent health. They must be a relative of the recipient or have a close relationship to be considered for donation. If patients awaiting transplant have living donor candidates, the candidate first needs to call the transplant nurse coordinator at California Pacific (415) 600-1080. The nurse will discuss their general health, inquiring about conditions that may rule them out such as:
• Kidney disease
• High blood pressure (hypertension)
• Cancer (either current or previous cases)
• Heart disease
• Diabetes
Living Donor Evaluation
If the donor has none of the conditions listed above, he or she undergoes blood tests to check compatibility. The blood can be drawn locally and shipped to California Pacific for examination.
“We have worked with donors from all over the world, including Vietnam and Mexico-—as well as those throughout the U.S.,” says Eileen Kelly, R.N., transplant nurse coordinator. “Location isn't a factor, as long as they can come to California Pacific for the surgery.”
Following the blood tests, donor candidates receive a full medical work up at either California Pacific or a local transplant center if they don't live in California. This work up includes:
• Medical history, physical and psychosocial exam
• Blood tests
• Electrocardiogram and chest x-ray
• Urine test (24-hour collection done at home)
• Special X-ray study of the candidate's kidney (final study done after above work-up is medically cleared)
• Other tests if necessary
Once the Kidney Team receives all results, they are evaluated and a determination is made whether the candidate is appropriate for living donation. “We tell candidates that kidney donation is a gift given with no strings attached and no guarantees,” explains Kelly. She adds, “Once the kidney is in the recipient, the donor can't get it back.”
Transplant Surgery
Exams taken during the medical evaluation help doctors determine whether a donor is appropriate for laparoscopic nephrectomy, a less invasive procedure to remove the kidney. “We want to remove the kidney in the safest approach for both the donor and recipient,” says William Bry, M.D., surgical director of the Kidney and Pancreas Transplant Program. “Laparoscopic surgery is appropriate for most patients, unless they have very complicated anatomy.”
Following surgery, donors generally spend three to five days in the hospital and four to six weeks off work. While the decision to donate requires careful consideration, most donors say it was one of the most meaningful experiences in their lives. To read patient stories about living donation, visit the patient section .
Who Pays Living Donation Costs?
All medical expenses for the medical work-up and transplant surgery are covered by the recipient's insurance. In considering donation, candidates need to consider additional expenses such as:
• Travel to California Pacific in
San Francisco
• Parking, lodging or other incidentals
• Lost wages if they don't have sick time or short-term disability from work.
A Perfect Match Top of Page
Tracy Man Receives ‘Perfect' Kidney Just Hours Before Living Donor Transplant
by Laura Miyashita
After watching her younger brother's health decline as he battled with dialysis and diabetes, Shelley Knight of Napa decided that she'd try donating her kidney to give him a better life. “My brother and I share a strong bond and even though he'd never ask me to donate, I had to take action,” says Shelley.
At the time of Shelley's evaluation in January 2001, Chuck, a 38-year old father of two from Tracy, was bedridden and had undergone a dozen surgeries to try to get his shunt working for dialysis. “I tried to not let the dialysis get me down, but it takes so much time out of your life,” says Chuck. He was evaluated for a kidney transplant at California Pacific's Modesto Clinic, but was told it would likely be a few years before his name reached the top of the waiting list.
“We've been through so much together and were so close growing up that I had faith this would work,” says Shelley. Sure enough, a week after her evaluation, the transplant team said her kidney matched well enough to donate.
When their transplant date arrived, Chuck and Shelley had a final exam at the hospital and were given the green light for surgery the next morning. As they rested at their hotel, William Bry, M.D., surgical director of kidney transplant at California Pacific, contacted Chuck and Shelley to notify them that a kidney had become available from Ohio that was a perfect match. “The transplant team told us that we had basically won the Lotto because the perfect match moved Chuck up the waiting list as he was the only one in the nation who matched,” says Shelley.
“A perfect match can happen at anytime and is unrelated to a patient's waiting time,” explains Bry. “Because the success rates of these transplants are exceptionally high, a national sharing program notifies transplant centers if a perfect match becomes available and it automatically goes to that patient.” Approximately 5% of the cadaver transplants performed at California Pacific are perfect matches and already this year, 10 other perfect match transplants have been performed at the Medical Center.
“I believe in miracles and think Chuck does too after this experience,” says Shelley. Even though she was all set to donate her kidney, the perfect match kidney became available just hours before. “I felt better right after the transplant and left ICU in less than 12 hours,” says Chuck. Since his return home, Chuck says, “I've rebuilt our fence and am looking forward to going camping - things that were hard to do while on dialysis.”
Both Chuck and Shelley praise the staff at California Pacific for their encouragement and attention. “My experience at California Pacific was just wonderful,” says Chuck. “Everyone was so nice and informative-—they gave us their undivided attention.” Chuck and Shelley also thank the unknown individual whose life was cut short for the gift of his kidney. Shelly says, “Chuck's donor is the key to this miracle and we honor him for giving Chuck a new life.”
Top of Page
A Surgeon's Tale of Recovering Organs for Transplant
by William Bry, M.D., surgical director
While driving across the Golden Gate Bridge early one Sunday afternoon with my ten-year old son to buy a promised Gundam action figure (imagine a Pokemon on testosterone), Amy of the California Transplant Donor Network (CTDN) pages me with an offer of a kidney and pancreas for a patient on our waiting list. The donor specifics sound favorable, so I contact our on-call nurse coordinator, Joe, who has checked with the patient and her nephrologist to verify she is “ready to go.” By the time my son and I have successfully purchased a green Mobile Suit Leo action figure, I receive word that my patient is ready for the transplant and will be at California Pacific Medical Center that evening.
I get home and cancel our Saturday night plans (my wife is very understanding after 25 years of marriage) so that I can get to bed. I'll need my rest for the long night ahead of me. I am awoken by a page from the CTDN donor tech who is responsible for arranging the transportation and organ preservation logistics. She tells me when to arrive at California Pacific's Emergency Room for my van ride to the airport.
At the appointed time, I arrive at the San Francisco Airport and meet three surgeons from other transplant programs who have accepted organs for patients waiting at their hospitals. We board a chartered plane for a quick flight to Fresno, where we arrive for a 3:00 a.m. operating room appointment. By this time, the tissue typing has been completed (my patient is compatible!) and our recipient is at the Medical Center being seen by the transplant nephrologist and prepared for surgery.
In the Fresno operating room, the surgeons discuss the plan for the donation surgery so that we can all work together easily securing our respective organs. The surgery to remove the heart, lungs, liver, kidneys and pancreas takes about three hours to complete. The sun is just coming up as the thoracic teams head back to the airport with the heart and lungs which have to be transplanted quickly before they deteriorate.
Later that morning, the abdominal teams (who secure the liver, pancreas and kidney organs) have completed their work and we are heading back to the airport. We appreciate the Denny's breakfast provided in the van as we travel to our flight. A Life Flight priority landing at San Francisco Airport has us taxiing up to the terminal at 9:30 and we arrive at California Pacific's emergency room by 10:00 a.m. I greet my patient with the good news that the organ donation has gone smoothly and everything is in place for her transplant.
Maintaining a Healthy Transplant Top of Page
Healthcare Tips for Helping Ensure Your New Kidney's Survival
by Steve Katznelson, MD, transplant nephrologist
Over the past two decades, advances in immunosuppressive medications and surgical techniques have greatly improved the life span of kidney and pancreas transplants. The success of a transplant is to a great extent due to the recipient's underlying health. Therefore, patients awaiting transplantation should take all steps necessary to become as healthy as possible before surgery. Addressing the healthcare issues discussed below can improve the survival and well-being of both you and your kidney.
Recognizing Indicators of Heart Disease
Heart disease is the most prominent cause of medical problems following transplantation. If you have a history of heart disease, it should be addressed before receiving a transplant. The following medical problems may put you at risk for developing heart disease and should be discussed with your physician:
1. High cholesterol levels: High cholesterol can put patients at risk for heart disease and cause damage in the transplanted organ. If you have a high cholesterol level, discuss it with your doctor and ask if medical therapy is necessary. If you do not know your cholesterol level, ask to have it checked.
2. Hypertension: High blood pressure can cause heart disease and strokes as well as harm the transplanted organ. If you have hypertension that is not well controlled, discuss it with your doctors.
3. Smoking: Studies have shown that smoking greatly increases both the risk of heart attacks after transplant and transplant failure. Therefore, patients should try to stop smoking well before transplantation.
4. Uncontrolled Diabetes: If you have diabetes and your blood sugars are high, discuss better blood sugar control with your healthcare providers.
Bone Disease
Many patients with end-stage kidney disease have some degree of bone weakening. Bone disease can be caused by the kidney disease itself, overactive parathyroid glands and/or osteoporosis. Transplantation can further decrease bone strength, putting patients at risk for bone fractures. All of these problems can be diagnosed fairly easily and treatment options are now available for strengthening one's bones, even before transplantation.
Obesity
Obesity is defined as weighing more than 20% of your ideal body weight. Working with your healthcare providers to get at or close to your ideal body weight will make the transplant surgery easier and healing time shorter. Obesity is especially important to address before transplant as most transplant patients gain weight afterwards.
Routine Health Screenings
Women over 40 should have routine screening mammograms and PAP smears. Likewise, men over age 50 should have routine prostate screening (PSA, or prostate specific antigen testing). A sigmoidoscopy or colonoscopy is also recommended for men and women over 50.
Your transplant team encourages patients to be as healthy as possible prior to their surgery, and addressing these health issues can help improve the success of your transplant. If you have any questions, discuss these issues with your primary care doctor.
The following tips can help improve your transplant success. All of these issues can be discussed with your primary doctors.
1. Stop smoking.
2. If you are overweight, try to lose weight.
3. If you have heart disease, address this problem before transplantation.
4. Treat high cholesterol levels.
5. Treat high blood pressure.
6. Check for bone disease.
7. Have routine health screening tests completed before transplantation.
Financial Preparations for Kidney Transplant Top of Page
California Pacific's Financial Counselor Helps Patients through the Insurance Maze
By Rose-Ann Barca and Laura Miyashita
Paying for health care costs is a major concern for patients on dialysis or facing transplantation. To help guide patients with decisions and ease the process, California Pacific's Kidney Transplant Program has a financial counselor who works directly with patients and insurance companies to determine transplant benefits and other available funding.
“If patients have general questions about what type of funding is needed for a transplant or how their insurance benefits work, I meet with them and make necessary arrangements,” says Rose-Ann Barca, financial counselor at California Pacific.
She stresses that kidney transplant is a life-long expense with continuous medications needed to maintain the kidney's function.
Following is an overview of insurance types. If you have questions regarding your coverage, contact your health plan directly. For specific questions about kidney transplant coverage, you can also contact Rose-Ann Barca at (415) 600-1033; email barcar@sutterhealth.org.
Medicare
Medicare is a federal insurance program that helps with kidney transplant costs. Patients who qualify for Medicare receive benefits three months after starting hemodialysis or the same month they begin CAPD. If you are transplanted before dialysis, Medicare becomes effective the month you receive your kidney transplant. However, Medicare benefits are somewhat limited, with coverage for services at 80%. Only anti-rejection medications are covered, and again at only 80% for 44 months after transplant. If you don't have any coverage other than Medicare, you may pay $1,500 to $2,000 per month after transplant for medications alone.
HMO Plans
With HMO plans, you must access “in-network” facilities established by the HMO to receive benefits. Typically, inpatient services (hospital costs) are covered at 100%, with little to no co-payments. HMO plans have referral and pre-certification requirements that must be met, or again there may be no coverage.
Point of Service (POS) Plans
POS plans offer a tiered benefit structure in which you can use an “in-network” facility or one outside the plan's network. Because of this freedom, POS plans have higher premiums than HMOs. If you opt for an in-network facility, most of your care is covered at 100% with some type of co-payment. Alternately, if you access a facility outside the network, you will have a greater financial burden, with responsibility for deductibles and up to 50% medical costs depending on the plan structure.
Preferred Provider Organizations (PPO)
PPO plans offer the most freedom of all managed care plans, enabling patients to select from a greater number of providers with few pre-certification requirements. Generally, patients are responsible for an annual deductible. Most plans will pay 100% of costs after you meet this deductible, which can range from $500 to $10,000 depending upon the plan.
Medi-Cal
Medi-Cal is a state-funded program for those with little to no assets and/or disabilities. It covers all kidney transplant costs, including post-transplant medications. Some patients, due to their income, may be responsible for what is called a “share of cost” that they must meet each month medical services are provided before Medi-Cal will make any payments for their care.
Battling Rejection through Clinical Research Top of Page
By Sharon Inokuchi, MD, medical director
California Pacific's Kidney Transplant Program has an active clinical research program for studying new drug protocols that may benefit our kidney transplant patients.
Directed by Sharon Inokuchi, MD, PharmD, the goal of the Kidney Program's clinical research is to identify powerful drugs (immunosuppressive medications) that suppress the body's “immune response” and prevent rejection while minimizing side effects. The body's immune response is a natural defense system that protects against infections and cancer. While this response is vital to healthy life, it also makes organ transplantation challenging because the immune system views the transplant as being a foreign body.
The term “rejection” describes the immune response to transplant. Without proper medication, rejection can lead to a transplant's failure. To prevent rejection, immunosuppressive medications are given in various combinations. These medications can cause a number of side effects, including increases in blood pressure and cholesterol, fluid retention and infections.
To identify new drugs with fewer side effects, the Kidney Team offers patients numerous clinical trials. These trials enable some patients to try new immunosuppressive medications or combinations of medications that may improve their transplant success. We are currently enrolling patients in trials comparing:
1) Prograf and Prednisone with either CellCept or Rapamune (for new kidney transplant patients);
2) Cyclosporine and Prednisone with either Simulect or Thymoglobulin (for higher risk kidney transplant patients)
Qualified patients are invited to participate in ongoing studies and must sign an informed consent before the study begins.
Previous clinical research by the Kidney Program has contributed to U.S. Food and Drug Administration (FDA) approval of major new immunosuppressive medications now in clinical use including:
• Cyclosporine microemulsion (Neoral)
• Tacrolimus (Prograf)
• Basiliximab (Simulect)
• Sirolimus (Rapamune)
• Mycophenolate mofetil (CellCept)
For questions about our research program, contact Dr. Inokuchi or her Research Associate, Laura de Belen at (415) 600-1079.