Kidney Review - Issue 4 - Spring/Summer 2002
- Kidney-Pancreas Transplantation Delivers Cure for Diabetes
- Patient Profiles: Life After Kidney and Pancreas Transplantation
- Transitioning from Dialysis to Transplantation
- Answers to Patients' Frequently Asked Questions
- California Pacific Performs 151 Kidney Transplants in 2001
- Transplant Outreach Sites Benefit Patients In Northern California and Nevada
- High Success Rates Continue for Dual Kidney Transplants
Kidney-Pancreas Transplantation Delivers Cure for Diabetes
Research Shows Some Adult Onset Diabetics May be Kidney-Pancreas Transplant Candidates
by William Bry, M.D., Assad Hassoun, M.D. and Laura Miyashita 
As the incidence of diabetes continues to grow, more patients are seeking options to control its effects and avoid dialysis. A kidney-pancreas transplant offers the only curative treatment for diabetics with kidney failure and, thanks to recent surgical advances, more patients are receiving these combined transplants with success rates similar to those of kidney transplantation alone.
"Over the past five years, kidney-pancreas transplant success rates have significantly improved because of better immunosuppression and surgical techniques," says William Bry, M.D., surgical director of Kidney and Pancreas Transplant at California Pacific Medical Center, where kidney-pancreas transplants have been performed since 1989. "Recent developments such as the pancreas after kidney transplant option and research pointing to the potential benefit of kidney-pancreas transplantation for adult-onset diabetes have also increased interest in the surgery," he adds.
A pancreas transplant eliminates the daily burden of insulin shots and blood glucose monitoring, and can stop complications of diabetes including kidney failure, vision and nerve damage. According to Assad Hassoun, M.D., transplant surgeon, "Candidates for kidney-pancreas transplants are individuals with juvenile-onset diabetes and now, some with adult-onset diabetes, but any underlying heart disease must be treated before transplantation."
Options for patients seeking kidney-pancreas transplantation include:
- Simultaneous Kidney Pancreas Transplant (SPK): Performed for more than 25 years for the treatment of juvenile-onset diabetes, an SPK transplant involves one surgical procedure in which a cadaveric donor kidney and pancreas are transplanted together. The new kidney can filter toxins out of the body and the new pancreas makes insulin automatically, as your body needs it.
- Pancreas After Kidney Transplant (PAK): An option for people with a previous kidney transplant--either from a living or cadaveric donor--a PAK transplant treats diabetes through two surgical procedures. Patients first undergo a kidney transplant to get off dialysis and improve their quality of life. Then, once a cadaver pancreas becomes available, the recipient undergoes a second surgery to transplant the pancreas. Patients with a living kidney donor find this option particularly appealing.
In general, kidney-pancreas transplant surgery takes about six hours and patients are hospitalized for eight to 10 days if no complications develop. Complete recovery takes about eight weeks and patients must take anti-rejection medications for the rest of their life. "Even with the medication, though, patients point out they no longer worry about skipping a meal, doing too much exercise or having low or high blood sugar," says Bry. "It's really a new outlook on life."
Top of Page
Patient Profiles: Life After Kidney and Pancreas Transplantation Top of Page
Surgery Offers Benefits to Those With Juvenile Diabetes
By Laura Miyashita
Charlie Hopkins
Charlie Hopkins first learned of kidney-pancreas transplantation in 1998, after living with diabetes for over 30 years. "My nephrologist had me meet with Dr. Bry from California Pacific, and once I heard the transplant could get rid of my diabetes, I decided it was right up my alley," says Charlie, who lives in the Sacramento area.
Diagnosed with juvenile diabetes at age seven, Charlie was tired of taking insulin shots and checking his blood sugar throughout the day, as well as carefully watching his diet. The side effects of diabetes had also escalated, causing Charlie to undergo "more laser surgeries on my eyes than I could imagine," as well as sharp pains in his feet and high blood pressure.
In 1998, Charlie's name was added to the waiting list for a kidney-pancreas transplant and shortly after, dialysis became necessary. "I didn't have much energy or ambition being on dialysis," says Charlie. "I wasn't sleeping well and my skin was constantly grey."
Now, one year after his kidney-pancreas transplant, Charlie says he hasn't felt as good in over 10 years. "For me, I noticed the difference real quick after transplant," says Charlie. He left the hospital eight days after surgery and is now seen regularly in California Pacific's Roseville clinic. Although Charlie now takes anti-rejection medications daily, he says he has a much easier time taking his pills than carrying insulin. Tired of living off disability, Charlie has started taking classes and is considering a career in health care. He explains, "I now have the desire to do things. I'm up before my alarm and don't have to worry about my shots any longer." 
Tracey Renee Hunter
Since diabetes ran in Tracey Hunter's family, her dad noticed the signs right away when at age 15 her symptoms appeared. Within a year, Tracey began taking regular insulin shots and over the next two decades, her kidney function slowly declined. "I had back pain and was retaining so much fluid that my legs began leaking," says Tracey. She pursued a transplant evaluation after learning that her kidneys were only functioning at 20 percent and suffering three strokes within a year.
"I knew that transplant was an option for diabetic patients, so I came to evaluation with my family since they wanted to donate," Tracy explains. After her evaluation, Tracey's name was added to the waiting list and she began dialysis. Then, in December 2001 she received the call that a kidney and pancreas were available, so she chose that option.
"When I got the call, I dropped the phone and started screaming and crying," recalls Tracey. Her mom and stepfather took her to California Pacific in the middle of the night for her surgery.
While her transplant went smoothly, Tracy was readmitted to the hospital twice because of fluid accumulation around her pancreas.
Now, Tracey's diabetes is totally gone and she says she's "still in a state of shock trying to convince myself I don't have the disease." She advises other patients awaiting transplant to "be patient and keep their faith." "You have to be your own advocate and try to find living donors," says Tracey. "It's also important to not miss any dialysis treatments, to keep yourself stress free and make sure you stay healthy so you can get that transplant when the call comes."
Transitioning from Dialysis to Transplantation Top of Page
Knowing What to Expect After a Kidney Transplant Aids in Recovery
By Chris Becker, R.N., Marilyn Kaszpurenko, R.N. and Laura Miyashita
Last year, 151 patients make the transition from dialysis to kidney transplant at California Pacific Medical Center. Along with the new kidney come new responsibilities, and a lifestyle change in which dialysis is no longer an integral part of life.
"After a kidney transplant, patients must take an active role in their care--remembering to always take their medications and have lab work done, as well as coming to all clinic visits," says Marilyn Kaszpurenko, R.N., post-transplant coordinator at California Pacific. She adds, "Before, the dialysis clinic had assumed responsibility for much of this, but after transplant, it's the patient's responsibility."
"Our goal is to get kidney transplant patients healthy and active following surgery so they can have a better quality of life and return to their daily activities," says Chris Becker, R.N., another of California Pacific's post-transplant coordinators. "Typically, patients are able to go home five to seven days after transplant, so the amount of time to learn about caring for their kidney is brief."
Medications--the Key to a Healthy Transplant
The immunosuppressive medications needed to maintain a healthy transplant are a critical part of life post-transplant. Patients leave the hospital with a 30-day supply of medications provided by an insurance-approved retail pharmacy. After those 30 days, they are responsible for ordering all medications, either through a retail or mail-order pharmacy.
"When patients leave the hospital, they typically have 12 types of pills. With good insurance, that ends up costing the patient about $150 in co-payments a month," says Kaszpurenko. Medications are continuously monitored and adjusted, however, so after the first year, patients typically take between three to six kinds of pills.
Lab and Clinic Appointments--Monitoring Your Kidney's Function
After transplant, regular lab tests help show the transplanted kidney's function. Patients need to have their blood drawn twice a week, with the results sent to California Pacific for evaluation. At clinic visits, the team will review the results with the patient and make adjustments to medications if necessary. The frequency of lab tests will gradually decrease following transplant and ultimately, patients will have labs done once a month.
The first clinic visit following transplant will be at California Pacific in San Francisco. If the physicians feel the patient is stable, subsequent clinic visits can be scheduled at an outreach site in Modesto, Fresno, Roseville, Berkeley, San Jose or San Francisco.
Post-Transplant Activity
For three to six weeks following transplantation, patients are instructed to not drive or lift heavy objects because their incision is still healing. "You need to set up your life in advance, and have a family member or friend to help while you're recovering," says Kaszpurenko.
The transplant team encourages walking and light physical activity after patients leave the hospital, but Becker says, "Some people bounce back more quickly than others, so it is really important to listen to your body."
With an understanding of the steps involved inmaintaining a healthy kidney and taking responsibility for its care, patients will enjoy the improved quality of life that transplantation can bring.
To help prepare for and then maintain a healthy transplant, follow the checklists below:
Pre-Transplant Checklist
* Complete all tests ordered by your transplant doctor (the sooner, the better!)
* Identify an insurance-approved local lab in which you can have blood tests done (your dialysis unit will no longer do this)
* Register with your insurance's mail-order pharmacy or find a local pharmacy approved by your insurance
* Notify California Pacific with any changes in your:
-dialysis unit or physician
-insurance
-contact information (address, phone numbers)
-medical condition
* Identify your support system
* Identify your transportation system to/from San Francisco for your transplant and for 3-6 weeks following transplant when you are unable to drive
Post-Transplant Checklist
* Take medications every day and have lab tests done as instructed
* Use a mail order prescription service if possible and order a 90-day supply of medications to save money
* Bring the following to all your transplant clinic appointments:
-insurance card
-current medication list and
-list of tests done since last appt.
-name of your local physician
-names/doses of all medications including dietary supplements
* Continue regular visits to your local doctor for check-ups and health screenings
Wondering About Your Transplant or All Those Tests? Top of Page
Answers to Patients' Frequently Asked Questions
By Steven Katznelson, M.D. and Sharon Inokuchi, M.D.
During your wait for kidney transplantation, you will undergo regular blood tests and other exams to prepare you for surgery. Following is an overview of the waiting list process and reasons behind all those tests.
Q. After my evaluation, how long does it take to be placed on the waiting list?
A. Patients undergo blood tests to determine their blood and tissue type following evaluation. Typically, it takes three to four weeks to obtain these results. Once we have all blood test results, we determine if the patient is a transplant candidate and if so, add his or her name to the waiting list.
Q. What is the difference between being "active" versus "inactive" on the waiting list?
A. Once patients are determined to be transplant candidates and the initial lab tests are complete (see above), we add them to the transplant waiting list and mail a letter to their referring physician, usually requesting a number of tests. A patient's waiting list status is "inactive" until all tests are completed, meaning that they are accumulating waiting time but cannot yet receive a transplant.
Once California Pacific receives and evaluates all a patient's test results, the status is changed to "active," and that patient is eligible to receive a transplant. The goal is to get patients "active" as soon as possible. You can help by working with your physician to get all your tests completed quickly.
Q. How long will I have to wait for my transplant?
A. On the average, patients wait three to five years for a cadaveric kidney transplant, depending on their blood type. However, some patients may receive a transplant more quickly if they are candidates for dual kidney transplantation or if a perfectly matched kidney becomes available.
For living donor transplants, the wait can be as short as several months, depending on how quickly the recipient and donor's evaluations and tests are completed.
Q. Once I have a living donor who is a match, when can we undergo surgery?
A. Like the recipient, a living donor undergoes a complete medical and psychosocial evaluation. Once a living donor and the transplant recipient's medical work-ups are complete, we can schedule the transplant. The timing is only a matter of scheduling between the donor, recipient and transplant team.
Q. What happens with my monthly blood tests?
A. We must have blood samples for patients on the waiting list every month. The blood in the red-top tube is used for the following:
1. Antibody screening: An antibody screening determines the number of reactions between circulating proteins in the blood and human lymphocytes (a type of white blood cell). The result is called the "panel reactive antibody" or "PRA." Patients with a high PRA have a harder time finding compatible donors, as well as a greater chance for rejection after transplant.
2. Compatibility Test: The Kidney Team also freezes and stores blood samples to test for compatibility between the patient and kidney donors as they become available (also called "crossmatch testing").
Q. What events necessitate a call to my transplant team during my wait?
A. You should call your transplant team if any of the following events occur:
* You develop new medical problems or undergo any surgical procedures
* There are any changes to your:
-contact information (address or phone numbers)
-physician or dialysis unit
-insurance coverage
* You undergo a blood transfusion or become pregnant
* You identify any living donors who want to pursue evaluation
California Pacific Performs 151 Kidney Transplants in 2001 Top of Page
Medication Advances and Living Donor Transplants Improve Success Rates
By Laura Miyashita
Last year brought the "gift of life" to more than 150 kidney transplant recipients at California Pacific Medical Center. "Our transplant volume has steadily increased over the last few years and in 2001, we were able to transplant more patients, thanks in part to generous family members and friends who acted as living donors and gave their kidney to a loved one," says William Bry, M.D., surgical director of the Kidney and Pancreas Transplant Program. In addition to kidney transplants, eight patients received kidney-pancreas transplants at California Pacific in 2001.
The most common indication for patients receiving a kidney transplant is diabetes, followed by glomerulonephritis. The average waiting time is three to five years, or just months if a living donor is available. Following transplantation, California Pacific's one-year graft survival for patients with living-related donors is 96%; for patients with cadaveric kidney donors, the one-year graft survival is 90%.
If you are interested in further information about California Pacific's Kidney Transplant Program, please call us at (415) 600-1080.
Transplant Outreach Sites Benefit Patients in Northern California and Nevada Top of Page
New San Jose Location Offers Transplant Evaluation & Follow up
By Steven Katznelson, M.D. and Laura Miyashita
California Pacific's Kidney and Pancreas Transplant Program has further expanded its presence in Northern California with a new South Bay clinic in San Jose. "We want to make patients' transplant experience as easy as possible, and our outreach clinics enable us to deliver pre- and post-transplant care close to their home," says Steven Katznelson, M.D., medical director of outreach for the Kidney Transplant Program. He adds, "We continue seeing patients for routine post-op clinic visits at our outreach sites for the life of their transplant."
The Kidney Team visits outreach sites in Fresno, Roseville, Berkeley, Modesto and San Jose monthly to see pre- and post-transplant patients. Additionally, the team performs intermittent pre-transplant education and evaluation in Reno, Eureka, Fairfield, Redding and other sites. Last year, the team saw more than 1,600 patients at these outreach sites.
As a result of California Pacific's extensive outreach program, nearly all of the transplants we performed last year were from patients we see at our outreach sites. In 2001, we performed kidney transplants for:
* 40 patients (26%) from the Roseville Region (including Sacramento, Reno, Eureka and Redding)
* 35 patients (23%) from the Modesto Region (including Stockton and Merced)
* 28 patients (19%) from the East Bay Region (including Oakland, Berkeley and Fairfield)
* 21 patients (14%) from Fresno Region (including Clovis and Visalia)
Our local transplant nurse coordinators, who live and work in the outreach areas, are primarily responsible for the success of our outreach program. They provide both education and local transplant care. For information about outreach sites near you, please contact the transplant nurse coordinator nearest you with any questions. 
High Success Rates Continue for Dual Kidney Transplants Top of Page
By William Bry, M.D.
As reported one year ago in Kidney Review, California Pacific is the only hospital in Northern California offering dual kidney transplantation to help decrease waiting times for older patients. Dual kidney transplants use both kidneys from the same donor rather than just one, as with a typical transplant.
Most kidneys for the dual transplant procedure come from older donors, or donors with high blood pressure or other conditions that would normally exclude the use of their kidneys for transplantation. By using both kidneys, however, surgeons have been able to overcome any disadvantage the donor organs would have.
In the past year and a half, 14 patients have received dual kiney transplants at California Pacific, with a 93% success rate. No rejection has occurred for any patients, and their kidney function one-year following transplant is excellent, with an average creatinine level of 1.3. California Pacific is now expanding its dual kidney program and will offer any patient over age 50 this option if a dual kidney if it becomes available. By expanding this program, we expect to shorten the wait for a transplant without reducing its success.