Kidney Review - Issue 5 - Fall/Winter 2002

Transplanting Older Patients: Age Need Not Matter

Kidney Transplantation Enables Otherwise Healthy Individuals to Get Off Dialysis

by Steven Katznelson, M.D., transplant nephrologist, and Laura Miyashita

As the average age of dialysis patients steadily climbs, the question, "Am I too old for a kidney transplant?" is increasingly asked by prospective kidney transplant recipients. The answer to that question is: "No patient is too old for kidney transplantation as long as they are healthy, other than having kidney disease."

Currently, nearly half of all dialysis patients are over age 65 and the older dialysis population is expected to continue growing. As a result, an increasing number of older patients are becoming interested in kidney transplantation. In 1990, only about 4% of patients on the cadaveric kidney transplant waiting list in the United States were 65 years old or older; by 2000, 11% of patients awaiting transplantation were age 65+. Living donor transplants performed for patients over 65 jumped from 1% to 6% in the same decade, resulting in 1,200 kidney transplants (living donor and cadaveric) among the 65+ population in 2000.



Careful Screening Essential to Successful Transplantation
"In the early days of transplantation, many programs would not transplant patients over age 60 because of concerns that their success would be limited," explains Steven Katznelson, M.D., transplant nephrologist at California Pacific Medical Center. He adds, "Many new scientific studies now show that the transplant success rates for older recipients can be as good as those of younger patients if the transplant team screens them very carefully prior to transplant."

Because underlying cardiovascular disease is more common among older patients, rigorous screening tests to identify possible problems before transplant are necessary. Often, cardiovascular problems can be fixed, making a subsequent kidney transplant possible.

Older patients may have an advantage with respect to rejection. As Katznelson explains, "Older immune systems tend to respond with less vigor to the transplanted kidney than their younger counterparts, resulting in fewer rejections." In part because of this decreased risk of rejection, older patients as a group can experience some of the best long-term transplant successes, as long as they stay healthy from a cardiovascular standpoint. Additionally, new data also shows that for healthy older transplant candidates, a kidney transplant may extend one's life compared to dialysis.

Transplant Recommendations for Adults 65+
Katznelson points out several recommendations for transplanting older patients:

No age restrictions: There should be no absolute upper age limit for patients whose overall health and life situation suggests that transplantation will be beneficial.

Cardiovascular screening: Older patients pursuing kidney transplantation should receive a thorough medical screening for cardiovascular disease and cancer prior to transplantation.

Periodic re-evaluations: Older patients awaiting a cadaveric kidney transplant should receive periodic re-evaluations while on the waiting list.

"There is no patient who is too old for transplant as long as the pre-transplant evaluation finds the patient healthy," says Katznelson. The oldest person to have received a kidney transplant in the U.S. was 84 at the time of transplant (in 1995) and both the patient and kidney continue to do well.

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Transplanted at Age 78, Fresno Man Feels Fortunate for Gift of Life

by Laura Miyashita

At age 77, Barr Andreasian and his family decided he still had many good years ahead of him and pursued kidney transplantation to overcome his kidney disease. "I didn't even know I had kidney disease until I was going in for surgery to get my knee replaced and my blood pressure went sky high," says Barr. After consultation with his Fresno nephrologist, Joseph Duflot, M.D., Barr learned his kidney failure was due to a medication he had taken for knee pain.

Dr. Duflot put Barr on a strict diet and closely monitored his kidney failure, but in early 1999 at age 77, Barr had to start peritoneal dialysis. "Dialysis saved his life prior to the kidney transplant," says Janice Andreasian, Barr's wife. While he was on dialysis, Dr. Duflot pursued the idea of kidney transplantation with him and his family, as well as the Kidney Team at California Pacific. After his pre-transplant tests came back and showed Barr was in good health other than his kidney disease, the California Pacific team decided to move forward with the transplant process.

"My daughter Laura offered to donate her kidney, but at first I said no," explains Barr. "She finally won the argument and the tests showed that she was a great match," he adds. In May 2000, Barr and his daughter had their kidney transplant surgery and her kidney started working immediately in him. "The surgeon told me I had blood vessels of a 30-year old and that the surgery went wonderfully," says Barr. His wife Janice added, "California Pacific's team was great and we were very happy with our experience. I just can't say enough good things about everyone at the hospital!"

Both Janice and Barr feel very fortunate with the results of the transplant and, other than general aches and pains, Barr says he feels great. "It was difficult at the beginning to learn all the medications and probably took me a little longer to recover than others, but we're grateful for the outcome and my health," he says.

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Becoming "Active" on the Waiting List

Active Status Enables Patients to Receive Kidney Transplant

by Steven Katznelson, M.D., transplant nephrologist

Because of the lengthy waiting list for kidney transplantation, California Pacific uses a two-step process so patients can accumulate waiting time while completing final tests necessary for their transplant. Because only patients who are "active" on the list can receive a transplant, it is important to get all pre-transplant testing completed as soon as possible. This also enables you the chance of being offered a perfect match transplant, which can happen at any time once your waiting list status is "active."

Step One: Pre-Transplant Evaluation and Waiting List Placement
The first step to get on the waiting list is having pre-transplant labs drawn, which usually occurs the day of a California Pacific evaluation clinic. The labs include blood group typing (ABO typing) and tissue typing (to identify the six antigens for matching purposes). About three weeks following the completion of these tests, a transplant candidate is placed on the waiting list.

Patients will receive a list of additional tests that need to be completed from the transplant team at the time of their evaluation visit. These tests may include anything from an x-ray to a sophisticated heart test. A similar list also goes to your dialysis unit and primary doctor.

Step Two: Complete Requested Tests and Become Active
The second step is to complete your tests. To do so, your primary care doctor or, perhaps, part of your dialysis staff, can order them. Our experience has shown that if you ask your health care providers to order these tests and follow up, the process will get completed more quickly and you will be closer to your transplant! Until all tests are complete, a patient is on the waiting list but considered "inactive." This means that you are gaining waiting time but cannot yet receive a transplant. Once all requested tests are completed and reviewed by California Pacific's team, you are "activated." This means you are ready for transplant.

Even though most patients wait on the list for several years, some "active" patients receive a perfectly matched kidney well before their average waiting time passes. About 16% of transplants in the United States last year were perfect matches. Whether a patient has been waiting for five days or five years, federal law states that the perfect matched kidney must be offered to him or her.

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The Road to Recovery: When to Resume Activities After Transplant

by Steven Katznelson, M.D., transplant nephrologist

Anxious to resume activities following transplant, many patients inquire about the timeline for their recovery. The following list describes different activities and recommendations about how and when to start:

Exercise -- California Pacific's Kidney Team recommends that patients begin light exercise immediately after transplant. This involves walking -- and lots of it. Although patients may not be in the best physical shape because of previous kidney failure, they need to push themselves, even if the exercise is tiring. After several weeks, riding a stationary bike offers another good source of exercise. By six weeks post-transplant, patients can start virtually any activity within reason. However, any new activity should be started slowly.

Driving -- Most patients can resume driving about three to four weeks post-transplant. Before driving, ensure that your wound is healing well, that you are alert and not fatigued, no longer experiencing significant pain or taking medications that can cause drowsiness. The Kidney Team recommends that another adult driver accompany you on your first drive post-transplant.

Work —- Transplant patients can consider returning to work after about six weeks, although this timeline varies by individual. Some patients actually do some work earlier (if it involves low stress and little physical activity), while some need more time.

Sexual Activity -— Patients can usually resume sexual activity four to six weeks after transplantation. You should follow the same rules as in the "Exercise" section regarding level of activity. Patients may be more likely to conceive children after transplant and should be careful to use birth control.

Sun Exposure -- Because transplant recipients are more likely to develop skin cancer, we recommend that all patients guard their skin from the sun. This involves always wearing clothing that protects the skin from sun exposure (including a brimmed hat) and sun block on all exposed areas.

Being In Crowds -- Because transplant patients are taking medications that suppress their immune systems, the concern about catching colds and other infections is real. However, we want our patients to enjoy their new lives. The Kidney Team does not recommend avoiding all crowds. Common sense works well here. If someone close to you is sick, keep your distance and wash your hands frequently if there has been contact. If you have prolonged exposure to a sick person, consider wearing an anti-microbial mask. Take a mask to movies or other events where you are unavoidably exposed to someone coughing or sneezing.

These are general words of advice. If you have further questions regarding your specific needs, please ask your transplant team or primary care doctor.

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Your Call for the Kidney Transplant Has Come. Now What?

What to Expect During Your Transplant Hospitalization

by Chris Becker, R.N. and Laura Miyashita

Receiving the phone call for your kidney transplant is an exciting and anxious time. To help you prepare for this event, you should plan in advance who will take you to and from the hospital, and understand what will happen during your hospital stay.

Preparing Yourself for the Hospital Trip
California Pacific's transplant team will contact you at any time of the day once a kidney becomes available. If you have obtained a pager to notify you of a donor kidney, make sure it's always on. Because you will need to leave home within an hour of receiving the transplant call, you should have a transportation plan arranged in advance.

"Upon arrival at California Pacific, the transplant team will perform a pre-operative evaluation to ensure that you are healthy enough to undergo surgery," explains Chris Becker, R.N., post-transplant coordinator. "This evaluation, which takes a few hours, involves a review of your medical history, a physical, chest x-ray, EKG and, if needed, dialysis," she adds.

The Transplant Surgery
After being brought to the operating room, patients receive a general anesthetic and undergo their kidney transplantation. The surgery typically takes between three to four hours.

Following surgery, patients are moved to the Intensive Care Unit (ICU) for close monitoring. The anesthesia will wear off about four hours after transplant. You will receive pain medication and the team will monitor your urine output. The next day, you will be transferred to the hospital's transplant floor for further recovery. You will begin to learn about your anti-rejection medications and will eat and walk as soon as possible.

Returning Home Following Transplant
Most kidney transplant recipients leave the hospital five to seven days following surgery. You will be eating solid food at this point and will be going to the bathroom on your own. Typically, patients are discharged in the late afternoon, once the team completes all transplant teaching and finalizes medication doses.

"Patients are sent home with one month's supply of seven to 10 medications and will have a clinic appointment in San Francisco one week after discharge," says Becker. Subsequent visits may be scheduled at outreach sites close to home. In addition to taking medications throughout the day, transplant recipients are required to have lab work done twice a week. Later, the amount of lab work required will decrease.

For additional information on resuming activities post-transplant, see the article above.

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UNOS and CTDN: Not Just Initials, But a Key to Your Transplant


By William Bry, M.D., surgical director, Kidney & Pancreas Transplant Program

As a transplant surgeon, each call I receive about a possible donor means that many committed individuals have done hours of behind the scenes work to help ensure the gift of life lives on. Not only has a family made the decision to donate their loved one's organs, but nurses, doctors, secretaries and coordinators also work together to get these organs to a grateful recipient. These staff don't receive much of the limelight but are integral parts of the process. Just who are the agencies that oversee the local transplant process? Read on…

United Network for Organ Sharing
The United Network for Organ Sharing (UNOS) is a nonprofit organization based in Richmond, Virginia, that maintains the nation's organ transplant waiting list under contract with the U.S. Department of Health and Human Services. Through the UNOS organ center, organ donors are matched to waiting recipients 24 hours a day, 365 days a year.

Created in the late 1980s, UNOS has organ distribution policies that help ensure all patients have a fair chance of receiving the transplant they need. Prior to this time, there was competition among transplant programs as each coordinated organ recovery efforts for their own institution.

California Transplant Donor Network
Responsible for donor organ and tissue recovery in 40 Northern California and Nevada counties, the California Transplant Donor Network (CTDN) is one of 59 Organ Procurement Organizations (OPO) that carries out UNOS policies on a local level. CTDN acts as a liaison between organ donors and 7,000 local patients on the waiting lists at:

* California Pacific Medical Center
* Stanford University Medical Center
* University of California, San Francisco

This year, CTDN has already recovered 260 kidneys and 44 pancreata, and their organ recovery rates are currently among the highest in the country. Phyllis Weber, director of CTDN, explains, "CTDN is always striving to improve organ and tissue donation and our donation rate is at an all-time high. More patients on our waiting list are being transplanted in 2002 than in any prior year in the organization's history."

In addition to coordinating organ and tissue recovery and distribution for the 7,000 individuals currently waiting for transplants in our region, CTDN educates health care professionals and the general public about organ and tissue donation. CTDN is staffed by a variety of health care professionals who are specially trained to work with families, hospitals and the public, and to promote organ and tissue donation.

For more information about organ donation and transplant, visit www.unos.org or www.ctdn.org.

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Success and High Number of Transplants Define California Pacific's Kidney Program

By Laura Miyashita

Since the inception of our Kidney Transplant Program in 1969, more than 3,100 kidney transplants have been performed at California Pacific, an average of about 150 annually. It is this volume -- and the high success rates that accompany these transplants -- that give our team the experience and commitment necessary for success.

As of August 1, 33 living donor transplants have been performed this year at California Pacific. One donor, Lowell Brinson III of Sacramento, says of his experience: "You've got a winning and more importantly, rewarding team of experts and professionals. I must commend everyone involved in our transplant journey." In addition to living donor transplants, California Pacific's Kidney Team also performs kidney-pancreas transplants (including pancreas after kidney transplants), dual kidney and cadaveric kidney transplantation.

With clinics throughout Northern California, California Pacific makes it convenient for our patients to receive a kidney transplant evaluation and follow-up treatment. Other than coming to San Francisco for the transplant surgery and one follow-up appointment, patients can receive all care close to home at our clinics in San Jose, Modesto, Roseville, Berkeley or Fresno.

For further information or a kidney transplant evaluation, contact us at (415) 600-1080.

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Talking About Transplant
Events Offer Dialysis Patients Insight into Kidney Transplantation

By Laura Miyashita

Have you thought about transplantation but unsure if it's for you? Or are you waiting for a transplant at California Pacific and want to know your current status? Our nurse coordinators are conducting educational events at dialysis units throughout Northern California called "Talking About Transplant" to help answer your questions.

These events feature discussions about kidney transplantation and the evaluation process as well as educational materials and handouts on kidney pancreas transplantation. Issues such as living donor transplant, dual kidney transplant (an option for patients over age 50) and kidney pancreas transplant are addressed.

"By hosting 'Talking About Transplant' events at local dialysis units, we are hoping to provide an outlet for patients' questions about transplantation, from whether one is medically suitable to what transplant involves," says Sharon Deane, R.N., transplant nurse coordinator for the Sierra Foothills region. "We also work with patients already listed for transplant to determine if their testing is all complete and where they stand on the waiting list," she adds.

To request a Talking About Transplant event at your dialysis unit, ask your social worker or call the coordinator below who is closest to your city.

Transplant Nurse Coordinators
East Bay - (510) 448-4865 - Clarissa Golden, R.N.
Fresno - (559) 322-0194 - LaVon Hughes, R.N.
Modesto - (209) 832-0725 - Angela Bogetti-Dumlao, R.N., MSN
Roseville - (916) 697-4755 - Sharon Deane, R.N.
South Bay - (408) 832-5495 - Gay McLaughlin (or) (925) 389-1214 - Sharron Marcos, R.N.