Transplant Digest, Issue No. 32 (Spring/Summer 2022)

Transplant Digest

Spring/Summer 2022 Issue No. 32

International Travel In The Age of COVID The COVID-19 pandemic brought international travel to a halt in 2020. Since then, travel has slowly and cautiously resumed. Kidney transplant patients are also anxious to start traveling again, but what is the travel situation like and what extra precautions are necessary?

First, make sure you are fully vaccinated and more than a year post-transplant. When including the booster shots, the total number of doses that kidney transplant patients received exceeds the minimum required for travel to most countries. Keep your vaccine documentation with you at all times. Keep paper copies of everything. Second, obtain a travel letter from the Transplant Clinic. Third, make sure you have enough anti-rejection and your other medications with you at all times, in your handbag, for your whole trip and then some more. There is Continued on page 2

In this issue...

• • • • • • • • • • • • • • •

Front cover Editor’s Desk Contact Information New Advanced Kidney Care Clinics Update on Highly Sensitized Program Staff Updates Evusheld FAQ HIV and Kidney Transplantation Test Your Knowledge Transplant Chat Making Health A Priority Kidney Foundation Awardee The Pulse on Pulses Donor Kidney Ultrasound Study Word Search

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From the Editor’s Desk Dr. Ramesh Prasad

Welcome to the Spring/Summer 2022 Issue of Transplant Digest. There seems to be cheer with both the warmer weather and the feeling that the COVID pandemic is finally being brought under control with the vaccines. St. Michael’s remains at the forefront of the fight against COVID, with both vaccine and non-vaccine strategies being employed in the Transplant Clinic. We remain aware that transplant patients have other health care needs too, and review these at each clinic visit. Education remains an important part of transplant care, and that is where Transplant Digest contributes.

In this issue, we cover varied topics including pulses in the diet, Evusheld® to prevent COVID infection, international travel, the highly sensitized patient (HSP) program, HIV in kidney transplantation, vital signs, and an interview with a transplant patient on making health a priority. We also have a transplant quiz and word search. Chief News Correspondent Galo Meliton interviews our dietitian Emily Campbell on receiving the Kidney Foundation Impact Award. Many patients have asked about dialysis related topics, such as dialysis around a transplant, managing failing and failed kidney transplants, transplant-related testing around dialysis schedules, anticoagulation, and so on. I must apologize for this void. Requests to our dialysis specialists over the last 16 years result in vague unfulfilled promises and polite refusals. I commit to continue working on this deficiency. See you again in the Fall.

International Travel in the Age of COVID story continued from page 1

little we can do to help you once you are out of the country. Fourth, test yourself for COVID before you leave even if it is not mandatory, and take some test kits with you as well. Ensure you have travel insurance that covers COVID! Follow all commonsense precautions against COVID when it comes to masking, touching, socializing, eating, etc… Fifth, have a plan in advance for the unfortunate situation that you do get COVID. Make sure that the place to which you are going has adequate testing and treatment facilities for both kidney transplant patients and for COVID, since you might be stuck there for a while. Inform us if you can. Finally, inform us for sure after you come back to Canada, and we can book a clinic appointment if necessary.

Travel procedures are largely the same as before the pandemic, but much more involved and longer, even more so if you have prescription medicines with you.

Have fun but be safe!

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Contact Information Dr. Ramesh Prasad – Editor Meriam Jayoma-Austria, RN, BScN, C.Neph.C Newsletter Coordinator Please send your comments or suggestions of topics for future publication to: meriam.jayoma@unityhealth.to St. Michael’s Hospital Kidney Transplant Program (across the hospital) 61 Queen Street East, 9th Floor Toronto, Ontario, M5C 2T2 Phone: 416-865-3665, option 2 Disclaimer Note: Views presented in this newsletter are those of the writers and do not necessarily reflect those of St. Michael’s Hospital or the University of Toronto. Subject matter should not be construed as specific medical advice and may not be relevant. For all questions related to your health please contact your health care provider.

Coming soon – our new Advanced Kidney Care Clinics

Artistic rendering of St. Michael’s Hospital’s Advanced Kidney Care Clinics

After years of planning and fundraising, St. Michael’s Hospital’s new Advanced Kidney Care Clinics is almost ready for us to move in! St. Michael’s is one of the largest kidney centres in Canada. Our new bigger, state-of-the-art facility will help us to accommodate the surging demand for kidney transplants and kidney care. When it’s completed, the new centre will have the latest exam rooms and procedure areas, spaces for personalized education, and bright comfortable waiting areas.

We’ve renovated an entire floor at 61 Queen Street. We will have all of our team on one floor – nurses, social workers, dietitians, clerical assistants – so your care can be even more seamless. We are scheduled to move in late fall of 2022, and we will let you know more details closer to the time.

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Update on the Highly Sensitized Program (HSP) Dr. Jeff Zaltzman

For many patients awaiting kidney transplantation, the wait can be quite long. The length of time someone waits depends on age, blood type and whether it is difficult to find an acceptably matched kidney. At the time of accepting a kidney, the transplant nephrologist in conjunction with Trillium Gift of Life in Ontario (TGLN) need to ensure that the intended recipient does not have any Donor Specific Antibodies (DSA). What is DSA? Some people develop antibodies which are part of the immune system against other humans. These are known as HLA or alloimmune antibodies. The antibodies can develop in people who have received blood transfusions, have had a previous transplant, or have had prior pregnancies. The antibody levels are measured on every potential transplant recipient, and for those on dialysis they are measured every 3 months. The antibody level can range from 0- 100% and this is called PRA. The higher the PRA (antibody level), the harder

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it is to find an acceptable matched kidney. The reason for this is that the more antibodies one has, the more likely is that they will have one or more HLA antibodies-against any given donor kidney. These antibodies are called Donor Specific Antibodies (DSA). We cannot transplant a donor kidney to which the recipient has one or more DSA’s as this often leads to an accelerated rejection of the kidney and loss of the transplanted kidney.

In Canada, we typically do not share kidneys between provinces. However, one exception is for potential recipients across the country who have high PRA (95-100%). Why is this done?

Essentially, the larger the donor pool, the more likely to find a kidney for a difficult to match person. Since 2013, under the stewardship of Canadian Blood Services (CBS), all patients on a provincial kidney wait list with a PRA of 95% or greater, have access to donors from anywhere in Canada. This is known as the Highly

sensitized Program (HSP). HSP donor kidneys are allocated as are non-HSP kidneys in any jurisdiction, using computer matching. The HLA antigens (proteins) of the donor are identified, and the HLA antibodies of all recipients are known. The first criteria to allocate a kidney is to ensure that the recipient does not have any DSA. A given transplant recipient will have their PRA calculated, in addition to identification of the anti-HLA antibody specificities.

As an example, in a small province such as Manitoba with only 1 million people, there may be only 15-20 deceased donors annually. It would be almost impossible to find a suitable donor for someone with a PRA of 100% (many, many HLA antibodies). However, if the donor pool now includes all of Canada with a population of 37 million, there are now approximately 600 potential deceased donors. The higher the donor number, the greater the likelihood of finding a match for a difficult to match recipient.

Now our Manitoba recipient has increased their chances of finding a suitable kidney by 30 fold. Although Ontario, the largest province has many more deceased donors, even hard to match Ontario residents have benefited from the HSP system. To date the National HSP program has resulted in more than 800 kidney transplants, many of which would not have happened were it not for this program.

However, unfortunately, there remain many on the transplant wait-list with so many HLA antibodies, that regardless of the National HSP system, they may never get a kidney. Therefore, the next iteration of the HSP program will be to identify antibodies in such patients that may be acceptable to cross. Based on data, clinical history, and understanding of the makeup (HLA proteins) of a prior kidney transplant, clinicians in conjunction with the HLA lab directors will try to identify antibodies that are not as dangerous as others. As an example, if someone has 35 different HLA antibodies, perhaps only

25 are “bad” or dangerous, and the remaining 10 can be ok if the recipient receives a transplanted donor kidney that expresses some of these 10 HLA antigens (proteins). This will allow for more opportunity for the very hard to match recipients. At the time of this writing, this work has just begun, and those of us in the transplant community look forward to this becoming a reality.

Staff Updates Maureen Connelly spent many years as a nurse with the living donor team, but has now joined us in post-transplant clinic.

Victoria Lane is our social worker for the living donor program while Nicole Pacheco was on leave. We are pleased to welcome Nicole back, but are sad to see Victoria go. We’d like to thank her for all her hard work, and wish her best of luck.

Mickail Lawrence is a clerical assistant who has moved to the 9th floor to be the new face of our reception desk.

Edyta Tworek is a nurse who has joined our team to enhance our process for pre-transplant referrals.

Shinelle Villafana is a clerical assistant working with the pre-transplant team and also helping at the 9th floor reception desk.

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Evusheld FAQ

Dr. Darren Yuen and Dr. Caitriona McEvoy

Frequently Asked Questions by post-transplant patients

Who is currently eligible for Evusheld?

Tier 1 • Recent transplant in last 6 months • Transplant patient who received Rituximab in last 6 months • Transplant patient who received ATG (Thymoglobulin) or plasmapheresis in last 3 months Tier 2 • All transplant patients 60 years of age and above Tier 3 • All transplant patients less than 60 years of age

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Why is Evusheld limited to certain groups?

There is a limited supply of Evusheld and current criteria focus on patients who are most likely to benefit from COVID-19 prevention.

How does Evusheld work?

EVUSHELD consists of two medications called tixagevimab and cilgavimab. Tixagevimab and cilgavimab are types of protein called ‘monoclonal antibodies’. Evusheld work specifically against the COVID-19 virus by preventing the virus from infecting healthy cells in your body. This can help prevent you from getting COVID-19 illness.

What are the potential side effects of Evusheld?

•

hypersensitivity reaction (rash or hives - an

itchy red rash or raised bumps) injection site reaction (pain, redness, itching, swelling where the injection was given) injection related reaction (examples of these include headache, chills and redness, discomfort or soreness near where the injection was given)

Does vaccination not work in transplant patients?

In the PROVENT study, the patients who received Evusheld, compared to those that did not, had more cardiac adverse events. It is not known if these were related to Evusheld or their underlying medical condition.

Can you still acquire a COVID-19 infection even after being fully vaccinated and receiving Evusheld?

• •

Symptoms of cardiac events to monitor for include pain, pressure, or discomfort in the chest, arms, neck, back, stomach or jaw, as well as shortness of breath, feeling tired or weak (fatigue), feeling sick (nausea), or have swelling in their ankles or lower legs.

Patients with a previous cardiac event may be at a higher risk of cardiac adverse events following Evusheld and should discuss the risks and benefits of Evusheld with their doctor.

Will Evusheld interact with my other medications?

It is not expected to interact with other medications. However if you have recently been vaccinated for COVID-19, it is recommended to wait 14 days before receiving Evusheld.

How is Evusheld administered?

It is given by intramuscular injection on each side of the upper (gluteals) buttocks.

How effective is Evusheld?

Compared to placebo, Evusheld reduced the risk of developing symptomatic COVID-19 by 77% at the 3-month analysis.

At the 6-month extended analysis, there was an 83% relative risk reduction with Evusheld.

No, there still continues to be value in receiving all COVID-19 vaccines that you are eligible for.

Evusheld is used as an additive layer of protection in those that may have a partial response to vaccination.

Yes, it is still possible.

Can you still receive COVID-19 vaccine after Evusheld?

There are no data available about providing the COVID-19 vaccine after Evusheld. The American Society of Transplantation suggests that you can get your next COVID vaccine dose when it is scheduled.

If a patient is eligible for both a vaccine dose and Evusheld, which one should be given first?

If you are currently eligible for a COVID-19 vaccine dose, we recommend that you get it first, and wait 14 days before receiving Evusheld.

Should I still get Evusheld if I have had COVID-19 infection in the past?

Yes. It is still possible to be reinfected with COVID-19, but it is unlikely to happen within 2 months of a previous infection. We recommend that you get Evusheld, when all your symptoms are completely resolved.

Why are there 2 injections?

Evusheld is a combination of two antibody medications. Each antibody requires a separate injection in a separate syringe.

Will Evusheld help treat a COVID infection?

No, it is used as a preventative COVID-19 medication. You should not receive it if you have an active COVID-19 infection.

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Is there any monitoring involved after I receive Evusheld?

You will be monitored for at least 15 minutes after you receive Evusheld.

I may have been exposed to COVID-19 recently, can I still receive Evusheld?

It is recommended to wait at least 8 days after confirmed or probable exposure before receiving Evusheld to ensure you do not have a current COVID-19 infection before receiving Evusheld.

Will there be Evusheld “boosters”?

Evusheld is thought to provide protection for at least 6 months. It is unclear at this time if repeat doses are beneficial/recommended.

I am pregnant or thinking of becoming pregnant soon. Is it safe to receive Evusheld?

Evusheld was not studied in pregnant or breastfeeding patients. At this time, we would recommend against receiving Evusheld.

Resources: Evusheld consumer information (Health Canada) https://covid-vaccine.canada.ca/info/evusheld-en.html Ontario Health Evusheld patient handout: information about the safe and effective use of Evusheld for patients and caregivers

HIV and Kidney Transplantation Dr. Ramesh Prasad Human Immunodeficiency Virus (HIV) infection has been around now for more than 40 years.

HIV treatment has greatly improved over this time, and so patients are largely able to live normal lives. Some patients will also develop kidney failure, undergo dialysis, and eventually be referred for a kidney transplant. Their kidney failure may or may not be directly related to HIV. The understandable concern in this situation is: will anti-rejection drugs for the transplant, which weaken the immune system, also make the HIV infection worse? Will the transplant be infected with HIV, and will it work properly?

Kidney transplantation in HIV can actually be quite successful. Patients can live normal lives and enjoy their transplant just like everyone else. However, certain conditions must be fulfilled. First, the HIV infection should be adequately treated. This means using a combination of three drugs, typically a combination of two drugs called “NNRT” or NNRTI” drugs, and one drug called an “INSTI” drug. These doses have to be stable for 6 months. It is preferable to avoid “protease inhibitor” drugs because these can interact with the calcineurin inhibitor (CNI) drugs used for the transplant. Second, the HIV infection has to be under control.

HIV viral loads should be undetectable, and the CD4 cells (the cells which fight infection) should be sufficient, over 200 cells/microL. Third, the HIV positive patient should be as healthy as any other patient undergoing a transplant, and go through the same screening process. There should be no history of serious opportunistic infections or HIV-related cancer.

After the transplant, there must be ongoing monitoring by an HIV specialist. The HIV vi-

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ral load should be monitored monthly initially, and then at least once every three months. If there is co-infection with hepatitis B or C, then a hepatologist (liver specialist) needs to be involved as well, with liver ultrasounds performed periodically. Monitoring CNI drug levels is extremely important. Septra® protection against PJP is needed. Data indicates that tacrolimus is preferable over cyclosporine, steroids must always be used, and thymoglobulin may be preferable to basiliximab for induction therapy.

The one-year transplant success rate is around 90%, 3-year success rate 75%, and about 90% patients are still alive at 3 years. Opportunistic infections do not increase. Acute rejection rates can be higher though, between 20 and 60%, but these can be treated with increased steroids.

In South Africa for over 20 years, and in the United States under the HOPE act of 2013, kidneys from HIV positive donors are being offered to HIV positive recipients. The initial results seem to be very promising. HIV positive living donors are also being studied in the United States, and so far donation appear to be safe. While we have not been doing HIV positive-to-positive transplantation in Canada, this may become a possible option for the future.

We have been performing kidney transplants at St. Michael’s for many years now, although our total numbers are still small. We look forward to serving more HIV positive individuals in the years to come.

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Test your Transplant Knowledge Choose the best answer for each question 1. Which of the following diseases in NOT caused by a virus?

6. Which substance in the urine is monitored closely as a routine?

A

A B C D

monkeypox BK CMV diphtheria

2. Which of the following drugs is NOT routinely used in kidney transplantation?

B C D

7. Which of the following is a routinely used antibiotic?

A

A B C D

cyclophosphamide cyclosporine tacrolimus prednisone

3. Which organ CANNOT be successfully transplanted yet?

A B C D

brain small intestine liver lung

4. Which animal is most likely to provide organs to humans for transplant?

A B C D

horse cow pig sheep

5. What is the average lifespan of a living donor kidney transplant?

A B C D

5 years 10 years 20 years 50 years

creatinine potassium calcium albumin

B C D

vancomycin trimethoprim-sulfamethoxazole ertapenem fosfomycin

8. What organ is transplanted along with the kidney in type 1 diabetes?

A B C D

pancreas liver small intestine lung

9. What test can be used to readily distinguish urine from other body fluids?

A B C D

albumin creatinine BK virus sodium

10. How many urine filters are there in an average kidney?

A B C D

10,000 100,000 1,000,000 10,000,000 Answers on page 15

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Post-Transplant Chat Vital Signs Galo Meliton, RN, Ellenica Hicks, RN, Maureen Connelly, RN

1. What are the vital signs you look for in patients?

We check blood pressure (BP), temperature, heart rate (pulse per minute), and respirations (breaths per minute). We also check for oxygen saturation (SaO2) if deemed necessary. Unlike what most people think, this is NOT the amount of oxygen in your blood, but rather, the “ability” of your red blood cells to “hug” or “embrace“ oxygen and therefore carry it to our vital organs like the heart and the kidneys.

2. Why are these called “vital” signs? Is one more important than the other?

They are called “vital” signs because they are important signals to let us know if something is wrong with any of our body systems

to keep us healthy. They are things that can be measured. They are all equally important.

Symptoms, on the other hand, are those things we feel, report, and complain about that there is something that’s not right like a cough or swelling.

3. Do I need to measure my vital signs often?

Should I keep a log?

It is a good idea to measure your vital signs and have a log so we can review them to see if they fall within normal parameters and compare them with your previous readings.

Doing them every second day after your kidney transplant should be enough. Check your blood pressure at different times of the day so we would have an idea what it is like throughout the day. Do not hesitate to contact your family doctor or the transTRANSPLANT DIGEST - PG 11

plant clinic if you are concerned about any of your readings. Our phone number is (416) 867- 3665 Option 2, and our email address is posttransplant@smh.ca.

4. Do the vital signs correlate with each other?

Most definitely. Just like all our systems in our bodies are all interrelated. They may all be high, for example, due to a fever.

5. You guys seem really concerned about my weight, but not my other clinics. Why? Increased weight indicate fluid retention, which may mean the kidney is not working as it should. It could also be harmful to your general well- being, including your cardiovascular health. A lot of patients succumb from this and not the kidney itself. On the other hand, unplanned weight loss may mean you are not absorbing important nutrients to maintain a healthy weight. This would need investigation by your Family Doctor to start, and by other specialists, if necessary. You can also contact Emily Campbell, RD if you have any concerns about your weight.

6. How should I measure my blood pressure?

How should I measure my pulse rate?

You should be sitting down for a few minutes, well rested for approximately 15 to 20 minutes with no distractions while you are checking your pulse and blood pressure. If you have been moving around chances are your BP may be elevated. The BP cuff should be at heart level. Ideally, you would have taken your blood pressure medications at least one hour before checking them. It is not ideal to check the BP over clothing. Remember not to check the BP using the arm with a working fistula. To check your pulse, feel the inside edge of your wrist and count the pulse

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for 15 seconds and multiply it by four. If the pulse is not regularly beating, count it for a full minute. Please remember to report your pulse during your phone clinic visits with us as this is, as mentioned here, part of your “vital” signs.

7. My home blood pressure doesn’t agree with your clinic’s blood pressure. What does that mean?

Your BP machine may be defective. Please bring it in or to your Family Doctor’s office for comparison. Other factors that may affect your blood pressure may include the time of day when you take your medicines and the stress of being in the clinic.

8. Do I need to check my temperature all the time? Also, I can’t measure my own breathing.

What should I do?

You should take your temperature if you are unwell. A temperature of more than 37.5 C is considered a fever. Our team would advise you to monitor your temperature if you have a fever. You can take Tylenol if you do not have an allergy to this medication. Make sure to drink more fluids to prevent dehydration and seek medical attention if your fever persists.

You can ask a family member or a friend/ partner to count how many times you breathe in a minute. If you find you are short of breath at rest or find it difficult to breathe, you should seek medical attention.

continued on page 15

Making Health A Priority

By Emily Campbell and David Giles (patient) Approximately 30% of post-transplant patients will experience excessive weight gain, around 6-10 kg after transplant. The reason why many patients gain weight is multifaceted. Some experience weight gain, because of an improved appetite post-transplant or eating a more liberalized diet and variety of foods and calories. But, the immunosuppression and anti-rejection medications which can also contribute to weight gain. While some weight gain may be needed, especially in those who were underweight before transplant, but, excessive weight gain can lead to health conditions like diabetes, gout, high cholesterol, high blood pressure.

Finding your reason why to start a health journey (like eating better or losing weigh) is important; perhaps your new kidney may be some inspiration for you to life your healthiest life possible. One post-transplant patient David Giles felt this way. I caught up with him to learn about his health changes and recent weight loss, read our interview below.

Emily: “David, congratulations on your recent health changes. I would love to know a bit more about your journey and what inspired you to put your health first.”

David: “When I started dialysis in 2017 my weight was 97-98 kg. The doctors told me that I should try to lose weight but with the ups and downs of dialysis I just didn’t do it. On December 8, 2020, I received my kidney transplant and went through the weeks of recovery, getting used to the medicine and enjoying food again.

By May 15, 2021, I was up to 103.5 kg and my clothes were too tight, I was out of breath and not enjoying life. I was given this great gift of a kidney transplant from a stranger and knew

Year 1 I needed to fix this. That was when I decided I had to do something! I knew that the medicine I was taking for anti-rejection and immunosuppression wasn’t going anywhere, and I had to figure out some lifestyle changes that could be made to help my health and determine my reason or my “why” for wanting to make changes.

My ultimate reason was “I was given a gift and I was going to do everything possible to keep it!”.”

Emily: “Wow that is wonderful. I completely agree, getting a new kidney is a gift and it is inspiring to see how you want to take care of it.

Tell me about how you took your why and made it into an action plan?”

David: “The two things I knew I wasn’t doing was eating properly and exercising. I knew that was obvious as I’m putting on weight but had to must admit it to myself. I started with looking at why and what I was eating. Once I knew why I was eating I was more aware and would try to stop the munching because of boredom or stress and try to find other things instead of eating to get through. If I was hungry, I would TRANSPLANT DIGEST - PG 13

eat. I still had to look at what I ate, so I wrote it down. I realized there wasn’t really a whole lot of fruit and vegetables in my diet and the portions were way too big. I started slowly by replacing chips and cookies with fruit and vegetables. I had more of them on my plate and proper portions of the rest. I still ate what I wanted, I just watched how much. I also read that if you crave something, then you should have it. If you don’t you will constantly crave it and eventually you will give in and eat it, and a lot of it. So have that little piece of cake or cookie to satisfy the craving. Just not the whole thing or package! I also started to meal plan and prepare my lunches for the week and dinners for the family. This way I knew what my lunch would be and didn’t have to think or decide while at work and end up going to a fastfood place and being mad at myself. It was hard to begin with but after a while it became easier and it’s now my Sunday routine. I still go out for dinners and with family and friends, I just plan those outings with my food choices during that day or the next day to make up for enjoying myself. The other big change I did was drinking water instead of pop and juices. I still have the occasional one, but I constantly have water with me.

Emily: “Using your plate as a strategy is something that we can use in any situation. Aiming for half your plate in vegetables, quarter in carbohydrates or starches, and quarter plate in protein at meals can help to keep our portions appropriate and keep us full. What about exercising?”

David: “I knew I had to start doing something, so I started walking. I set a goal to do 300 steps the first day and each day after I added 300 steps as I worked my way up to 10,000/ day. When I started I was slow and didn’t really think it was doing anything, but I kept at it and looking at my ultimate reason (my why) and did it one day at a time. As I kept going, I was up

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to an hour every day and the distance I could go became longer and longer. The walking also kept me busy, so I wasn’t thinking about eating. I still do at least an hour a day and now enjoy and look forward to it. The next thing I will be doing is adding workouts a couple times a week.”

Emily: “These goals are quite SMART (specific, measurable, achievable, realistic, and timebound) which can help set us up for success when we are making lifestyle changes. When we reach our goals, celebrating and setting new goals is a great strategy as well. What were some of your other markers of success during this transition?”

David: “As I kept going with both the exercise and eating better, I did start to lose weight.

Which was great but when that slowed, plateaued, or increased I would get down. But I knew this was a long journey and tried not to beat myself up. I also looked at other things that showed success like more energy, better sleep, walking longer and faster, needing new clothes but this time because they were too big. All these things I enjoyed and celebrated as I accomplished them. When I did this, it also helped me get back on track and continue.”

Emily: “What are some strategies you used to stay motivated and on track?”

David: “I wrote my why on my phone lock and home screen, so I saw it every time I looked at my phone and had it by my bed, so it was the first and last thing in the day.” My wife also was amazing with encouragement and compliments to keep me going.

Emily: “Where are you now?”

David: “I am now at 76.5 kg and have maintained this weight for three months. I still will continue to get myself in better shape and

know that there will be ups and downs along this path. As I said the medicine isn’t going anywhere and it’s up to me to do my best.

David: “It’s not easy! It’s actually hard work but take one day at a time, one step at a time and one goal at a time (no snack, smaller portions, moving easier, lose one pound) and you can do it! Just don’t beat yourself up or give up if you have a bad day or put back on weight. Stick to it and you will have success. Remember you have gone through a tougher battle than this getting to the transplant, I know I did. You can do this!”

Thank you so much to David for sharing his health changes. If you have nutrition questions or are looking to make lifestyle changes our transplant dietitian Emily can be reached at 416-867-7460 extension 48043 or ask to see her in clinic.

continued from Post Transplant Chat on page 12

9. My blood pressure seems unusually high today. What should I do? Sometimes it’s very low as well. What does that mean?

A high BP reading is more than 140 systolic (the top number) and a low BP reading is less than 100 systolic. If you find your BP readings are consistently high or low and you feel symptoms such as a headache or dizziness, please contact your family doctor or call the transplant clinic. Sometimes, your body’s ability to regulate BP in a consistent range may be affected by different conditions, especially posture.

10. I’m feeling a thumping in my chest. Sometimes I sweat or am short of breath as well. Is this serious?

Yes this can be serious. These symptoms may be the early signs of a Myocardial Infarction (MI) better known as a heart attack. Our transplant team would advise you to seek urgent medical attention. It’s a good idea to have someone check your vital signs if possible.

Answers for Knowledge Test on page 10: 1. D 2 . A 3. A . 4 C 5 . C 6 . D 7. B 8. A 9. B 10. C

Emily: “Congratulations David. This is wonderful. What is your biggest take away for those living post-kidney transplant and may want to start making some health changes?”

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Our New Clinical Dietitian receives Kidney Foundation Impact Award

chronic kidney disease and will be presenting in Sep-

Galo Meliton, RN, C Neph (C) Chief News Correspondent

wellbeing.

Emily Campbell, RD, dietitian extraordinaire,

The Kidney Foundation of Canada

who joined our team very recently, received the 2022 Impact Award from the Kidney Foundation of Canada. In the short time that Emily has been with our team, she has definitely made an impact in our patients’ lives. Let us get to know her a little bit more: Q: Tell us a little bit about yourself and where have you worked before and what was your role?

I am a registered dietitian and certified diabetes educator. I grew up in Sarnia and moved to London, Ontario to complete 2 undergraduate and a master’s degree at Western University. I moved to Toronto when I was completing my internship rotations.

I spent two rotations at St Joseph’s Health Centre and fell in love with nephrology as well as the organization. After graduation, I worked in long-term care for one year, then returned to St Joseph’s Health Centre and have worked in dialysis, general medicine and oncology. In my current role at St Michael’s I work with patients in the post-kidney transplant clinic, kidney stone prevention clinic, and lipid clinic.

Q: Tell us about the recent award you received from The Kidney Foundation of Canada.

I recently had the honour of being nominated and chosen to be one of the recipients of the 2022 Impact Award from the Kidney Foundation. I volunteer with the foundation in a few different capacities: as a dietitian replying to patient inquiries through The Kidney Community Kitchen, I am a recipe and blog author for the website, and I have also presented at various peer support group meetings for nutrition for

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tember to the post-kidney transplant support group.

I was selected for this award based on the roles I have played in patients’ lives in helping them make nutrition changes to support their overall health and

Link: Kidney Foundation https://bit.ly/3IMfoer Q: Tell us about the 2 books you have written.

To me nutrition is important in managing not just kidney disease, but also as a preventative medicine and to help manage conditions associated with kidney disease like diabetes, high blood pressure, and high cholesterol. There is more and more research suggesting that nutrition can help preserve kidney function and manage these conditions but also just as much information out there about past renal diet recommendations. Recently, I have published two cookbooks for those following a renal diet: The Complete Renal Diet Cookbook and the Renal Diet Cookbook for Caregivers. These books take a newer approach to nutrition and teach those living with kidney disease how to include nutritious and delicious foods into their diet.

Q: Tell us something about yourself no one else knows.

I am a certified scuba diver!

Q: What do you enjoy doing in your spare time?

I am always getting myself into something new. I quite enjoy physical activity so you will often find me out on my bike, for a run or out for a walk. I also enjoy trying all the ice cream flavours at the Kawartha Dairy near my cottage in Minden.

Thank you Emily, for your time and graciously allowing us to interview you and get to know you better

The Pulse on Pulses Emily Campbell, RD

Looking for a new recipe to try? Try this chickpea and arugula salad included here.

If you have nutrition questions our transplant dietitian

After kidney transplant, nutrition plays an important

Emily can be reached at 416-867-7460 extension 48043

role in helping to keep you healthy and to prevent con-

or ask to see her in clinic.

ditions after transplant like high cholesterol or diabetes from developing. Making nutrition changes can help to

Chickpea and Arugula Salad:

decrease your risk. Following a heart healthy diet that is

Serves 1

low in saturated and trans fats, cholesterol and sodium is a good place to start.

Ingredients •

2 cups of arugula

When we think about a heart heathy diet, it starts with

•

½ cup (125 mL) of chickpeas

aiming for half of our plate in vegetables at each meal,

•

¼ cup cucumbers, chopped

choosing plant-based proteins more often, and limiting

•

¼ cup large yellow bell pepper, chopped

sugar and fat.

•

1 tbsp (15 mL) of lemon juice

A heart healthy diet is often high in soluble fibre which

•

1 tbsp (15 mL) of olive oil

helps to keep us full as well as control cholesterol and

•

1 tsp (5 mL) of white vinegar

blood glucose levels, and that is why it is important after

•

⅛ tsp of black pepper

transplant.

•

1 slice sourdough bread, medium slice

Plant-based proteins, like legumes such as beans or puls-

Steps

es, are a good source of soluble fibre and are lower in

1.

In a large bowl, add 2 cups of washed arugula.

saturated fat compared to animal proteins like chick-

2.

Drain and rinse canned chickpeas in a colander

en, beef, or pork. These foods are often recommended

until the water runs clear. Add ½ cup of chickpeas

to avoid when we are on dialysis, but, after your kidney

to the large bowl. Store extra chickpeas in an air-

transplant they can provide you with important nutrients

tight container and place in the refrigerator for

and are something to consider including in your diet three

later use. Refrigerated canned chickpeas can last

times per week. Some examples of beans and pulses in-

for 3-4 days.

clude: chickpeas, lentils, and black beans. Choose canned

3.

Add cucumber and bell pepper to the large bowl.

no added salt for lower sodium and potassium options.

4.

In a small bowl, add lemon juice, olive oil, vinegar and black pepper (for dressing).

Here are some ways to include more pulses into your diet after transplant: • •

5.

Add dressing to the large bowl, toss together and serve with 1 slice of sourdough bread.

Add chickpeas or lentils to a salad with cucumber, onion, and bell peppers

Per serving: 49 g NET carbohydrates, 14 g protein,

Incorporate black beans into a hamburger by

467 mg potassium, 176 mg phosphorus, 404 mg sodium

mixing ground beef and black beans together when forming the patties •

Add lentils to a vegetable soup

Recipe by Emily Malfara, dietetic student.

•

Snack on a low sodium hummus made of chick-

Written by Emily Campbell, registered dietitian

peas

post-transplant clinic.

TRANSPLANT DIGEST - PG 17

Donor Kidney Ultrasound Study

Michelle Nash, Kidney Research Program Manager

BRIEF STUDY SUMMARY

Scar tissue forms when tissues are injured.

Scar tissue can also be referred to as fibrosis.

Injuries to blood vessels in kidneys can lead to scarring or fibrosis. Scar tissue or fibrotic tissue does not work as well as healthy tissue.

Dr. Darren Yuen is leading a research study at St. Michael’s Hospital to see if a type of ultrasound, called photo acoustic ultrasound, can help to assess how much scarring is present at the time of kidney donation. This study will also try to learn about what scarring means in terms of how well and how long a donated kidney will work.

Photo-acoustic ultrasound involves shining light using a laser into the kidney. We will use light that is specifically absorbed either by collagen (the main building block of scar tissue) or hemoglobin (the main component of blood).

When either collagen or hemoglobin absorb these specific wavelengths of light, they produce an ultrasound signal that can be detected by an ultrasound machine. We will use this to map the amount of scarring and blood vessel damage in the transplant kidney.

The study will collect information to see whether we could have predicted how well a donated kidney would function over 5 years based on the amount of scarring present at the time of donation.

PG 18 - TRANSPLANT DIGEST

The photoacoustic ultrasound is similar to the routine ultrasounds that are done in the operating room and does not cause any significant delay in the surgery.

Dr. Eno Hysi, Dr. Alex Koven and the Kidney Research Program Team (Michelle Nash, Lindita Rapi, Weiqiu Yuan, Niki Dacouris, Debra Fogelman) will all be working with Dr. Yuen on this exciting first of its kind study. Dr. Ramesh Prasad and Dr. Jeff Zaltzman are also supporting this study.

As with all research involving patients, this study has been approved by the Research Ethics Board at Unity Health Toronto.

INITIAL PA ULTRASOUND

All donor kidneys have been approved to be scanned while the kidney is stored on ice. All scans will be done by someone trained to do the specialized ultrasounds.

For consenting participants: OPTIONAL OPERATING ROOM PA ULTRASOUND

After the donor kidney has been implanted but while the kidney is still exposed, the transplanted kidney will be scanned a second time and the bladder will be scanned. Participants may also choose to have some additional bladder assessments completed as well.

CHART REVIEW

For consenting participants, information will be collected from their medical charts to see how well the donated kidney works over the next 5 years.

If you have any questions about this study or research, please feel free to contact the Kidney Research Program Team.

INTRODUCTION to some of the DONOR ULTRASOUND TEAM and the Photoacoustic Ultrasound Equipment

Dr. Darren Yuen Staff Nephrologist, Clinical Scientist and the Primary Investigator for this study.

Dr. Eno Hysi Nephrology Post-Doc Fellow has developed the PA US technique and will be providing technical support in OR.

Dr. Alexander Koven Urology Fellow will be completing the renal and bladder scans as appropriate.

Image of the VisualSonics’ Vevo LAZR-X high frequency ultrasound system.

Adapted from www.visualsonics.com.

Kidney Research Team will be available for consenting participants, study coordination and study support.

Michelle Nash –Research Manager 416-867-3692 Lindita Rapi –Research Coordinator 416-867-7460 ext 48024 Weiqiu Yuan –Research Assistant 416-867-7460 ext 48409

TRANSPLANT DIGEST - PG 19

Word Search

Find the words in the grid below, then use the remaining letters to uncover your SECRET MESSAGE! U

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WORD LIST AUSTRALIA

CHINA

IRAN

MEXICO

SAUDI ARABIA

TAIWAN

ARGENTINA

CZECHIA

IRAQ

NETHERLANDS

SINGAPORE

TANZANIA

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KENYA

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SPAIN

UNITED KINGDOM

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INDIA

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PHILIPPINES

SWEDEN

UNITED STATES

CHILE

INDONESIA

MALAYSIA

ROMANIA

SWITZERLAND

YEMEN

This newsletter is sponsored through an unrestricted educational grant from Astellas Canada.

TRANSPLANT DIGEST - PG 20