Thursday, April 23, 2020

Pre-Emptive Kidney Transplants NKF Version

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Preemptive Kidney Transplants: Why Aren't They More Popular?

By Jim Myers, NKF Advocate and Kidney Advocacy Committee Regional Leader
A preemptive kidney transplant is a transplant that takes place for a kidney patient, before starting dialysis. It usually takes place before your kidney function deteriorates to the point where you need dialysis. In the U.S., only 2.5% of all kidney transplants are preemptive. Preemptive transplants are considered to be the preferred method of transplants when compared to post-dialysis transplants. The purpose of this article is to explore why they are not more popular. As we will see, the benefits of preemptive kidney transplants, by far, outweigh post-dialysis transplants as well as going on dialysis itself. 

What are the Benefits and Risks of a Preemptive Transplant?

  • Less risk of rejection Longer and improved quality of life
  • Avoids dialysis, including risks, health complications, lifestyle burdens and dietary restrictions
  • Lower costs in comparison to per person per year on dialysis
  • The risks of a preemptive transplant include:
  • Early exposure to the normal risks of surgery
  • Potentially wasting some native kidney function

What are the Risks of Dialysis?

  • bone disease
  • nerve damage
  • infection
  • cholesterol problems
  • poor nutrition
  • depression
  • decreased life span of a future transplanted kidney

So, What's the Hold Up?

There are both medical and economic advantages to preemptive transplants. Preemptive transplants lead to improved patient and graft survival. Cost savings are accomplished with preemptive transplants as well. Medicare spends over $89,000 per dialysis patient, per year whereas the annual cost per patient for a kidney transplant patient is $35,000.
There are 2 factors that are cited for the delay in preemptive transplants:
Did you know you don’t need a doctor to refer you to get a transplant evaluation?  You can contact any transplant center near you to start the process.  Click here to learn more about finding a transplant center in your area. Donor evaluations take a mean of 10.6 months to complete. There are a number of reasons why some living donor assessments may take longer than the average length of time. Sometimes these reasons are due to the transplant team/center and others it is due to the living donor. The clear downside to longer evaluations is that some recipient candidates end up on dialysis before they can be transplanted.
This delay may be caused by:
  • The self-referral by the potential recipient of her/himself to a transplant center opposed to a more organized physician referral
  • Donor candidates are subject to a ‘cooling off period’ and the opportunity to reconsider to avoid the transplant center’s appearance of coercing or pressuring the donor to donate
  • Donor needing to repeat lab work to ensure they’re healthy enough to donate
  • Donor’s ability to find appropriate time to complete testing/evaluation outside of their normal routine
  • Transplant center transplant volume and staff issues
The fix for some of these issues is to better educate patients on the true nature of preemptive transplants and donor candidates. This should lead to more timely referrals of recipient candidates and better knowledge of the options for transplants including a preemptive transplant. Steps should be taken to reduce the time donor evaluations take to complete and to be convenient for the potential donor. Most potential donors have made a personal and moral commitment to the potential recipient to donate. Delays, although unavoidable at times, can lead to donor frustration. Expedited referrals and proper education on the issue should lead to more frequent and healthy preemptive transplants. However, it is important to understand that any delay from the transplant center is almost always to ensure the safety and overall wellbeing of the donor.

The Bottom Line

Preemptive transplants are the best option for patients whose kidney disease is progressing to kidney failure. Discuss kidney transplantation with your doctor before your kidneys fail. The bottom line is this:  People who receive a kidney transplant preemptively have a greater chance of survival and a better quality of life than those who receive a transplant after starting dialysis.
 https://www.kidney.org/newsletter/preemptive-kidney-transplants
References:
Fishbane, S and  Nair, V. Opportunities for Increasing the Rate of Preemptive Kidney Transplantation CJASN August 2018, 13 (8) 1280-1282 https://cjasn.asnjournals.org/content/13/8/1280
Gourlay, Preemptive Kidney Transplant, What’s the Hold Up?, Transplantation; July 2018-Volume 102-Issue 7-p 1035-1036, https://journals.lww.com/transplantjournal/Fulltext/2018/07000/Preemptiv...(July 2018).
Prieto, Mikel, Pre-emptive kidney transplant, https://www.mayoclinic.org/tests-procedures/pre-emptive-kidney-transplan...(2019).
Jay, Colleen, J. Reassessing Preemptive Kidney Transplantation in the United States: Are We Making Progress? 100 Transplantation, Issue 5-p1120-1127, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4989865 (May 1, 2016).
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Monday, April 20, 2020

COVID-19 and Kidney Transplant Patients Unfinished

COVID-19 and Kidney Transplant Patients

Background

The Coronavirus usually causes the common cold. But not Cirus the Virus. COVID-19 or SARS-CoV-2 is a much severe disease, causing a world-wide pandemic that is rapidly affecting lives, especially those of us that have kidney disease. This blog is about exploring the affects that may have on kidney transplant patients. Currently, there are no antivirals or vaccines for the virus. Studies are ongoing.

COVID-19 SYMPTOMS

Symptoms include:
1. Fever
2. Cough
3. Shortness of Breath
4. Flu- like symptoms (muscle ache, fatigue)
5. Nausea, diarrhea, abdominal pain
6. Loss of sense of smell and/or taste
7. Possibly pneumonia

According to Dr William Goggins from Indiana University Health Kidney Transplant Center, Fever and Shortness of Breath are the main symptoms that should trigger a call to your transplant center doctor or transplant coordinator, for possible testing.

Lack of a Vaccine

Currently, as of the writing of this blog, there is no vaccine available for the Coronavirus.

Testing is Available But Limited

Currently, where I live in Lake County, Indiana testing is available, providing you have a doctor's order. It is limited as far as locations. The availability of testing is different by regions. Check with your health care department or nearby hospitals to find out about availability near you.

Transplant Recipients Maybe at a Higher Risk for the Virus

Currently, there is no scientific evidence that COVID-19 infections are more severe in kidney transplant recipients than healthy people. However, viruses in the past have cause a more severe version of the disease in people with kidney disease or people with low immune systems like kidney transplant recipients. Precautions need to be taken to prevent a higher rate of infection in these groups, including transplant recipients.

How is the Virus Transmitted?

Experts are certain that infect mostly occurs with direct contact with an infected person. However, recent theories have posited that the virus may be spread in the air by droplets. This is why there is a recent trend in the US of wearing masks and gloves when we go out and to maintain social distancing of at least six feet from others. Stay At Home Orders in certain states restrict travel only to essential travel, like going to the grocery or drug stores. Only essential services are open in those states.

It may also be possible to catch the virus from a surface touched by an infected person. If you touch a surface, washing your hands frequently and vigorously is recommended for 20 seconds before you touch your face, mouth or nose.

Also, people can be contagious when they have symptoms, but some people who appear non-symptimmatic may actually be carrying the virus. For this reason, many kidney transplant patients have shuttered themselves at home to avoid contact with others.

If the transplant patient is surrounded by persons who maybe infected, quarantine to a specific room maybe required to protect him.

Kidney Transplant Patients and Travel Restrictions

COVID-19 is a world-wide issue. A great place to check on the spread of the pandemic is the CDC website, https://www.cdc.gov/coronavirus/2019-ncov/index.html.

The American Society of Transplantation, https://www.myast.org/coronavirus-disease-2019-covid-19-frequently-asked-questions-transplant-candidates-and-recipients, makes the following recommendations on travel for kidney transplant patients:

• Follow public health recommendations for public distancing (at least 6 feet)
• Stay home as much as possible
• Avoid all unnecessary traveling, only leave home when it absolutely necessary
• The people who cohabit with kidney transplant patients, should also avoid all nonessential travel
• Avoid crowds
• Check travel restriction orders frequently as they may change. Reccommended places to check:
Centers for Disease Control and Prevention (CDC);

World Health Organization (WHO)


For example, in my home state of Indiana, there is a Stay At Home order in place, that is being more strenuously enforced. https://www.newsbreakapp.com/n/0Oj1zwa7?s=a1&pd=04frpavN.

• Patients and/or family members who have just returned from an area with high should avoid contact with family members & the public (quarantine) for 14 days after their return. If after 14 days, the individual remains healthy, he/she can resume contact. If he/she shows symptoms during that period, health care authorities should be contacted. If the transplant recipient shows symptoms, they should contact their transplant facility immediately.
• If avoiding contact is impossible, experts recommend
1. Frequently handwashing or hand sanitizer use
2. All householders avoid touching their face, eyes, nose and mouth
3. Limited contact with that family member as much as possible, maintaining social distancing
4. Cough and sneeze into your elbow or into a tissue, which is immediately disposed
• Transplant recipients should wear a mask or cloth covering in public, especially where social distancing is difficult to maintain. Better yet, to avoid public places to the extent possible. Cloth facemasks are recommended over surgical masks or N-95 respirators. The key is the mask should be tight fitting, so it serves to prevent you from touching your nose and mouth. Check out the CDC's Video on how to make your own facemask. https://youtu.be/KR-Zi7ZSnHM

Actions Transplant Recipients Should Take if They Are Running a Fever or Coughing and Sneezing

• Call your transplant center, you may need a doctor's order to obtain a test
• Put a mask on if you go out in public
• Avoid public places if possible
• Exercise good handwashing skills
• If you have flu-like symptoms or respiratory symptoms (fever, cough, shortness of breath, upset stomach ), call your transplant center immediately, avoid public places and put on a surgical mask. Even if you have mild symptoms, contact your transplant center first before going to a hospital or clinic.

Actions to be Taken if a Family Member , Co-Worker or other Close Contact is Diagnosed or Suspected of having COVID-19

• Call your transplant center immediately, make sure you tell your transplant coordinator that you had contact with some diagnosed or suspected of having COVID-19. Particularly if you have a fever, cough or shortness of breath
• Monitor yourself for symptoms
• Avoid any further contact with that person

How Do I Get Tested for COVID-19?
• Call your transplant center first, as you may need a doctor's order to be tested
• Follow their instructions

Should I keep my Hospital Appointments?
• All of my doctors have cancelled face to face appointments in favor of telemedicine appointments or rescheduling of appointments at a later date
•
• My kidney transplant doctor also pushed back my blood draws to every 4 months from every month
• Check with your transplant center for their instructions, particularly if you are newly transplanted, please remember that I am 4 years out from transplant. My instructions may be different than yours

What Can I Do To Prepare For An Outbreak of COVID-19 Where I Live?

• Check your local news for public health information
• Contact you local health department
• Always check with your transplant center
• Avoid crowded areas
• Avoid sick persons
• Frequently wash your hands, disinfect area that are frequently touched like door handles, counters, smartphones and tv remotes
• Make sure you have at least 2 weeks to 90 days worth of medicine and supplies on hand at all time. Avoid running out or rationing of your anti-rejection medication
• Have your medications mailed or delivered to your home, if that is not possible consider a pharmacy drive through or having a caregiver pick up your meds.



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