Transplant Digest, Issue 15

Transplant Digest Fall 2013/Winter 2014, Issue No. 15

In this issue ...

Traveling Road Show in Timmins, Ontario, a Huge Success

Traveling Road Show in Timmins, Ontario, a Huge Success

Galo Meliton, RN C Neph (C), Senior News Correspondent Dubbed as the Mother of all Road Shows, four members of the Renal Transplant team, headed by Dr. Ramesh Prasad, Maureen Connelly, RN, Living Donor Coordinator, Galo Meliton, RN, Recipient with Living Donor Coordinator, and Mari Vella, Social Worker in the Recipient Program went to Timmins, Ontario on September 17, 2013 and met with several members of the Nephrology Program at the Timmins and District Hospital and did a Road Show for their pre-transplant patients, families and friends.

Penny Onlock, RN, who organized this event along with Galo Meliton, warmly greeted the team from St. Michael’s Hospital and gave a tour of their newly refurbished unit.

Dr. Prasad commented how impressed he was seeing the changes that have been made to their unit since he was there last about 6 years ago as a visiting doctor.

We were then met by the rest of their team, headed by Dr. Malvinder Parmar, their Primary Nephrologist. After both teams discussed individual patient cases in work up as well as process issues, Dr. Prasad presented “Assessment of Patients for Renal Transplantation” at their Education Rounds.

The Road Show then proceeded, led by Dr. Prasad who gave a talk entitled: “An Introduction to Renal Transplantation”. Maureen Connelly spoke about the Living Donor process, and the Paired Exchange Program. She also spoke about the process of getting on to the Deceased Donor list. Mari Vella then spoke about insurance coverage and travel issues, both topics very relevant to a patient population that is so far away from our Transplant Center. Galo Meliton then spoke about the blood group incompatible direct kidney donation using Glycosorb Columns as an option for those pairs in whom the Paired Exchange Program does not work out.

From the Editor’s Desk Contact Information St. Michael’s Renal Transplant Symposium 2014 What You Can Do (or not do) To Help Us in the Transplant Clinic Post Transplant Chat: Cancer after a Kidney Transplant Repeating Laboratory Tests Facebook Posting: “I need a kidney, can you help?

Vaccinations and Transplantation Invitation for Healthy Volunteers to participate in a Living Kidney Donor Research Study Delayed Graft Function The Long Term Effects of Becoming a Living Kidney Donor Research Study What is plasmapheresis?

Letter to the Editor

This event was a huge success, and it would have not been possible without the kind sponsorship from Novartis Pharmaceuticals represented by Jennifer Cardella, Specialty Sales Representative in Transplant. We would like to thank Lorna Green, Program Manager to the ICU/ER/Nephrology and Pharmacy, and Dr. Parmar for their very warm reception and hospitality. A big thank you also goes to Jonathan Fetros, our Clinical Leader Manager who was very supportive throughout this entire process.

TRANSPLANT DIGEST FALL2013/WINTER 2014, Issue No.15

From the Editor’s Desk

Welcome to our new Fall 2013 issue of Transplant Digest. As always, we have a wide variety of topics for your perusal, which we hope will suit every interest. The transplant process is rarely easy for the donor or recipient, and it is inevitable that most patients will experience some bumps along the way. Knowledge is empowerment. It is our hope that through publications like Transplant Digest we can disseminate as much information as possible so that at least some of this anxiety can be alleviated. I truly do not believe that there are any professional “secrets” that cannot be shared, so if you would like to know more about a particular issue, please let us know so that it can be considered for a future issue.

In this information-packed issue we tackle some of the more difficult issues in clinical transplantation. Delayed graft function is an anxiety-provoking, common event after a transplant. Cancer is discussed in some depth in Post-Transplant Chat. We have information on vaccinations after transplantation, repeating blood tests, organ solicitation, plasmapheresis, and kidney donor studies. We are also very active on the road, not just in the clinic, as one of our features points out. Please take home a copy of Transplant Digest, and ask us for another one too if you wish to share it with someone close.

Dr. Ramesh Prasad Editor

Contact Information

St. Michael’s Hospital

Dr. Ramesh Prasad – Editor Meriam Jayoma-Austria, RN, CNeph(C) – Newsletter Coordinator

Renal Transplant Program (across the hospital) 61 Queen Street 9th Floor Toronto, Ontario, M5C 2T2 Phone: (416) 867-3665

Please send your comments or suggestions of topics for future publication to: jayomam@smh.ca 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 to individual patient circumstances. For all questions related to your own health please contact your health care provider.

RN’s and Allied Health Professionals

MARK YOUR CALENDARS The St. Michael’s Hospital Renal Transplant Program Presents

Renal Transplant Symposium 2014 State of the Art in Renal Transplantation: Update 2014

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Friday, May 23, 2014 (0700-1600) The Li Ka Shing Knowledge Institute 209 Victoria Street, Toronto, Ontario

Cost: $100 (Includes Buffet Breakfast and Lunch) Registration details to Follow

What You Can Do (or Not Do) to Help Us in the Transplant Clinic As you know, the Transplant Clinic is a busy place. This can cause stress for some patients and their caregivers, over and above the anxiety of preparing to come to the clinic. You may have had a recent illness, and this can make the visit particularly challenging. However, there are some things that patients and their accompanying persons may find useful to remember in order to make the clinic visit a pleasant one for all.

We often see over 30 patients in a clinic. This often means the clinic gets extended beyond usual clinic hours. We do not send anyone who has an appointment away, but please do not expect to be seen as a walk-in. Please be patient when there is a delay, particularly with the staff at the front desk.

Some patients need to be seen especially quickly. The staff is doing their best to serve you.

In keeping your best interest in mind, please do your scheduled blood work ahead of your clinic visit. If you come less frequently, such as once in 6-12 months, it is very helpful to do your blood work a few days prior to the visit so that the visit is more productive. It is your responsibility to ensure that we have the information we need. This will help us provide you with a better care.

Bring the list of all your medications and the list of any other doctors treating you. This makes managing your care and communicating with other health professionals much easier. If you have doubts about the importance of a particular piece of paper you have, just bring it.

If understanding English is an issue for you, please bring someone who can help.

Make sure you bring your prescription to the pharmacy. We no longer fax or call the pharmacy for refill of your prescription.

We do not prescribe narcotics in this clinic.

There are occasional other issues that come up.

We regularly see over 30 patients in each clinic. At times, the clinic gets extended beyond the regular clinic hours. We will see all patients who have an appointment. However, we cannot accommodate patients who walk in to the clinic without a scheduled appointment. We ask for your patience when there is a delay, particularly when you are in the reception/waiting area.

Some patients may need to be seen more urgently, but know that we are doing our best to serve you in timely manner Due to the high volume of patients and activities in the clinic, we do not recommend that you bring small children to your clinic appointment; please only do so if there are no other alternatives.

Insurance, employment or other paperwork will not be filled out during the clinic visit. They will be done only outside of clinic hours, usually within a week or two.

Thank you.

The Transplant Clinic Staff 3

Post Transplant Chat Cancer after a Kidney Transplant Fernanda Shamy, RN; Jennie Huckle, RN; Thelma Carino RN; Sarah Mattok, RN; Imelda Lo, RN.

1. Is it true that I can get cancer after a transplant?

Yes, transplant patients have a 5 – 10% higher risk of developing certain types of cancer than nontransplant patients. For some patients it might be higher than this.

2. How do I know if I am at a higher risk for cancer?

The immunosuppressive medication you are taking places you in a higher risk category for cancer development than the general population. Your doctor will have advised you about this before getting the transplant. In general, a previous history of cancer in you, a strong family history of any cancer can increase your risk, your lifestyle choices such as smoking and frequent sun exposure, poor diet, and sedentary lifestyle can all contribute in some way. Some patients who are “EBV negative” are at higher risk for some kinds of cancers.

3. Are there some kinds of cancers I should be more worried about?

Skin cancer and lymphomas are most common, but we have seen virtually all kinds of cancer. If you have previously had a cancer there is a risk that it will come back after the transplant.

4. Do you screen for cancer after transplant?

Early detection is very important; you have to be very proactive in your care. Regular follow-up and yearly check-ups from your family doctor are strongly recommended. We do not do regular cancer screening after the transplant. Women should perform monthly breast examination. Men should do a testicular examination. Become a mole watcher. Examine your skin regularly and with the help of a partner to look at areas you can’t see.

5. H ow often should I be screened for cancer after I get my transplant?

What type of screening tests should I be undertaking?

You need to take care of your whole body. Again, an annual health examination that includes a skin examination from your family doctor is very important. Women require a yearly gynecological check-up and routine Pap smear, breast examination and mammogram. Men should be checked regularly for enlargement of the prostate gland and testicles. Colorectal cancer screening every 2 years (or what your gastroenterologist suggests) after 50 years old for both sexes is also recommended.

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6. What can I do on my own to prevent cancer?

Early detection of cancer can be helped by monthly breast, testicular and skin self examination and routine medical check-ups for the tests outlined above are a must. Other general measures should also be undertaken. These include: reduce sun exposure, stop smoking if you are a smoker, follow a balanced diet plan and get enough exercise.

7. I’ve heard that some transplant drugs are better than others to prevent cancer. Is this true?

If so, why I am I not being prescribed them?

Not always. Patients react to medications differently and so everyone’s prescription can be a little different. You are given the medication that is best for you. For the most part cancer prevention is not considered when prescribing anti-rejection drugs. Research is still going on to see if cancer prevention is worth any of the risks of using anti-cancer transplant drugs routinely.

8. Nurse, I think I’ve got cancer! What should I do?

Please call your Family Doctor immediately for a follow-up, or seek medical attention as soon as possible. If the diagnosis is confirmed please call us as soon as possible. We can schedule an appointment to discuss how this will impact your transplant care, including any suggested changes to your anti-rejection drugs.

9. D oes the Transplant Clinic treat my cancer? Will the Transplant Clinic continue to follow me if I am transferred to a cancer specialist?

No, the Transplant Clinic does not treat your cancer. We can however refer you to a specialist best suited to your own case, if you wish. We will continue to follow-up on your kidney transplant care and will collaborate with your specialist to give you the best possible care. Please make an appointment to see us soon after any test or procedure is done.

10. Does getting cancer prevent me from getting another transplant if I need one?

No, getting cancer does not prevent you from getting another transplant. However, you need to be medically cleared by your cancer specialist and transplant specialist first before getting another transplant. Typically this will involve a waiting period, at the end of which you must be cancerfree.

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Repeating Laboratory Tests Dr. Ramesh Prasad Almost every post-transplant patient has been asked at some time or another to “repeat” their laboratory tests. These tests could be blood tests, urine tests, or even an ultrasound or chest x-ray. Obviously this can be both frustrating and expensive for patients to do, so it would be helpful to know why this is asked of patients from time to time.

One of the most important things about monitoring test results is “trends”. For example, consider two patients each with a serum creatinine value of 200 micromol/l, and both transplanted about 5 years ago. Patient A has had a value of 200 each time for the past 5 years. Patient B on the other hand, has a value of 200 this time, but three months ago the value was 150. Patient A is fine but something needs to be done about patient B. Further tests might include an ultrasound and a kidney biopsy. But before doing this, a quick repeat blood test could very well show that the creatinine is “back down” to 150 again, and there is no need to worry! The “rise’ from 150 to 200 may have been due to temporary volume depletion from a diarrhea, a cold, or even a lab error (yes, this can happen theoretically). So repeating blood tests can be a good way to prevent having to do more complicated tests. It would be better to do this right away rather than wait another three months for the next routine blood tests, since if something needs to be done it can be done more quickly, if for example the “repeat” creatinine in patient B was again 200 or higher.

Some other reasons for repeating tests include: 1. Doing additional types of tests that need to be done as a result of the abnormal first test result, to put together a more complete picture of what is going on.

2. It was asked by the lab or the radiologist (in case of an ultrasound or chest x-ray) to follow-up on an abnormal finding.

3. A recent hospitalization and more frequent testing needed because of delicate health.

4. Patient clearly unwell but the diagnosis is not yet established e.g. blood cultures for intermittent fever.

5. Possible risk to the kidney from medical procedures (like IV dye or contrast exposure).

6. Transplant medication type or dose, or drugs that interact with transplant medications were recently changed and so drug levels need to be checked.

7. A new non-transplant medication was started e.g. some blood pressure medications can affect the serum electrolytes (such as potassium) and the creatinine.

8. Poor history provided by the patient or sparse documentation for transplants done outside Canada.

Rest assured, we will not ask for more frequent tests than are needed to take care of you. If you have any questions or concerns, please contact the Transplant Clinic.

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Facebook Posting: “I need a kidney, can you help?

Maureen Connelly, RN BScN Live Donor Coordinator Public solicitation for an organ donor has taken on variety of different forms. Public websites such as MatchingDonors.Com charge a fee for prospective transplant candidates to post their profile with a picture and story about their need for a kidney transplant. This is done with the hope that an altruistic individual will pick them as a recipient of their organ. While soliciting the public for an organ donor is not illegal, it does present some challenges. Many health professionals have argued that such websites are fraught with ethical issues.

It challenges the just allocation of a scare resource and may put vulnerable individuals in need of a kidney at risk of exploitation. The person who makes a public appeal “jumps” the line and may receive a kidney ahead of an individual at the top of the transplant waiting list.

When anonymous donors from public websites contact the live donor office they are educated about the options available to them: a) Donate to the person who makes the public appeal. b) Meet the individual who made the public appeal or remain anonymous. c) Donate instead to the person at the top of the transplant waiting list who has waited the longest d) Consider donating through the Canadian Blood Services national paired exchange program. This creates a domino effect and the anonymous donation may result in more transplants occurring.

Another form of public solicitation is social media websites such as Facebook. The Living Donor Team is seeing an increased use of personal web pages such as Facebook with people posting their need for a kidney donor. Oftentimes people feel uncomfortable to do a face to face “ask” to friends or family to consider being a donor for them, or are hoping to find as many prospective donors as possible to expedite getting a transplant. This presents some challenges as well. It does provide a means to get the word out that you need a kidney and raises general awareness of the need for organ donors.

A donor may come forward for you whom you do not know, but who is a Facebook friend from your contact list. This person may or may not wish to meet you or make their offer known to you.

Acquaintances may offer a kidney but never follow through with contacting the Live Donor Nurse but tell you they have and “ have not heard back” Multiple individuals may offer to donate to you but the old adage that there is “safety in numbers” holds true and oftentimes people back out when they know several other offers are on the table.

All donors who contact the Live Donor RN have a preliminary health screening done. Potential donors with no obvious contraindications to donation are sent an information package, health forms to complete and a lab requisition to get their blood type done. Prospective donors are then triaged by the donor team to begin donor testing on the most likely suitable donor. It is not possible or efficient to work up multiple donors simultaneously.

There is a separate team who look after donors including the nurse coordinator, social worker, doctors called kidney specialists (nephrologists), surgeons called urologists and a psychiatrist.

They are not involved in the care of the transplant candidate. The donor’s information is kept confidential and they are advised that they may withdraw their offer to donate at any time.

We do not speak to anyone about their evaluation without their permission. Donors with no prior relationship with the recipient they have come forward to donate to may choose to meet the recipient or remain anonymous.

We encourage all potential kidney donors to discuss the idea of kidney donation with their significant family members or friends who may help with their decision.

Kidney donation is not right for everyone, but the majority of donors who do so, even anonymously are grateful for the opportunity to help another individual regain their health.

For further information on living kidney donation, contact: Maureen Connelly, Live Donor RN @416-867-3676

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Vaccinations and Transplantation Dr. Jeff Zaltzman

Vaccination for the prevention of infectious diseases has been an integral part of medicine ever since the pioneering work of Edward Jenner in 1796, who vaccinated himself against “cowpox” a form of smallpox, and Louis Pasteur who developed a rabies vaccine in 1885. Few measures in preventive medicine are of such proven value as standard vaccinations, and in the developed, developing and third world nations, vaccinations have played a major role in eradicating or reducing the incidence of many transmissible infections. In Canada both children and adults are immunized against a variety of infections, the entire list of which can be found at this site: www.phac-aspc.gc.ca/ publicat/cig-gci/index-eng.php.

Transplant Recipients Since all solid organ transplant recipients require life-long immunosuppressive medications, they are at higher risk for infection-related complications including communicable diseases, which can be prevented or ameliorated by vaccination. It is hoped and expected that the majority of

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vaccinations would have occurred long before the need for transplantation, but this is not always the case.

In addition there is an ongoing need for regular vaccination for some diseases following transplantation. Importantly, some vaccines are derived from live viruses and are not safe for patients who are taking immunosuppressive medications, because of the risk of vaccinederived infection. One such important example is the “Shingles” or Herpes Zoster vaccine (Varicella, live attenuated “Zostavax”).

Unfortunately shingles is a very common and painful infection that often afflicts transplant recipients. It is a secondary infection of the chicken pox virus that lives in one’s spinal cord forever. In some people, particularly those taking immunosuppressive medications, the virus can reactivate, leading to a linear painful vesicular skin rash that can persist for a long time. The Zostavax vaccine is currently recommended for adults over age 50, but because it is a live vaccine, it is not safe for transplant patients. However, clinical trials are in process looking at the safety and efficacy of using the shingles vaccine for kidney transplant recipients.

The most important “adult” vaccinations that transplant patients should receive include: Hepatitis A and B, the annual influenza vaccination, S.pneumoniae, tetanus.

The Health Canada recommendations for pre and post-transplant recipients are summarized and adapted below. Of note, live vaccines are not safe for post-transplant recipients.

Vaccination of solid organ transplant candidates and recipients Vaccine

Cholera and travellers’ diarrhea (inactivated) Diphtheria

Post-transplant Pre-transplant (If not vaccinated pretransplant) Inactivated vaccines

Comments

Use if indicated

Use if indicated

Routine use

Routine use

Haemophilusinfluenzae type b (Hib)

Individuals 5 years Individuals 5 years of of age and older: 1 age and older: 1 dose dose recommended recommended

Hepatitis A

Use if indicated

Use if indicated

Recommended

Hepatitis B

Routine use

Routine use

Higher dosage recommended for posttransplant

HPV

Routine use

Routine use

3 doses

Influenza (inactivated) Japanese encephalitis

Recommended annually

Recommended annually

Use if indicated

Use if indicated

Meningococcal conjugate

Pertussis Pneumococcal conjugate 13-valent Pneumococcal polysaccharide Polio (inactivated) Rabies Tetanus Typhoid (inactivated)

Children and adolescents: routine use Adults: use quadrivalent meningococcal conjugate vaccine if indicated by risk factors for invasive meningococcal disease Routine use

Children and adolescents: routine use Beginning 6 Adults: use quadrivalent months postconjugate meningococcal transplant vaccine if indicated by risk factors for invasive meningococcal disease

Routine use

Recommended

Once every 5 years

Recommended

Recommended

One life-time re-immunization recommended

Routine use

Routine use

Use if indicated Routine use

Use if indicated Routine use

Use if indicated

Use if indicated

Recommended

Live vaccines Measles-mumps- Recommended rubella Varicella Recommended Rotavirus Routine use Influenza (live)

Use if indicated

Herpes zoster Yellow fever

Routine use Use if indicated

Typhoid (live)

Use if indicated

BCG Smallpox

Use if indicated Contraindicated

Invitation for Healthy Volunteers to participate in a Living Kidney Donor research study The Transplant Research Office at St. Michael’s Hospital is looking for Healthy Volunteers to act as control participants for a 5 year study, known as the Living Kidney Donor Study.

This study looks at the long term health effects of living kidney donors and compares the medical results between a kidney donor and somebody who has not donated a kidney (non donor). You do not have to be a kidney donor to participate.

If you consent, the following will occur once a year for 5 years: • Short interview with a Research Coordinator (can be done over the phone) • Fill out questionnaires (mailed to you) • Blood pressure monitoring (mailed to you) • Provide blood and urine samples (can be provided at a lab close to home or work) No compensation is provided for those participating in the study, however as a thank you token, participants will receive a $10 coffee card upon completion of the first visit.

For more details, please contact Lindita Rapi at 416-867-7460 ext 8024 or rapil@smh.ca.

Not recommended Not recommended Not recommended Not recommended; use inactivated vaccine Not recommended Contraindicated Contraindicated; if indicated, use inactivated vaccine Contraindicated Contraindicated

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Delayed Graft Function Dr. Ramesh Prasad Once the kidney transplant is done we would all like it to work right away. This means making lots of urine, the serum creatinine coming down, the patient feeling better, and no more dialysis. While this usually happens, sometimes it does not. A patient may need dialysis soon after the transplant either as an emergency for high serum potassium, for example, or in a more controlled way to remove fluid and kidney toxins. Obviously, this is depressing for everyone involved. One wonders if the kidney will work at all. Here is some information that may be helpful.

Delayed graft function (DGF for short) is defined as the need for dialysis within the first week after a transplant.

Its cousin, slow graft function (SGF for short) means that although dialysis is not needed, the creatinine is not coming down by at least 10% per day. It actually happens about 25% of the time in the case of deceased donor transplants, but much less often with living donor transplants. There may be injury to the kidney causing “shock” to it when it is being retrieved from the donor, when it is stored on ice for a long time, or when it is being implanted in the recipient. The process of dying in the donor itself can cause the release of chemicals that inure the kidney. If the recipient has low blood pressure, poor blood vessels, or has for example a heart attack during the operation, then DGF is more likely to occur.

The long term effects of becoming a living kidney donor research study: The St. Michael’s Hospital recruitment experience Lindita Rapi, Michelle Nash Background Dr. Amit Garg, a nephrologist and director of Kidney Clinical Research Unit (KCRU) in London, Ontario is actively researching many different aspects of living kidney donation including investigating the long term outcomes after the kidney donation surgery. “The Long-term Effects of Becoming a Living Kidney Donor” is one of the largest prospective research studies on living donors in Canada.

The study looks at important outcomes such as the changes in blood pressure, kidney function, and cardiovascular disease. Other information including the effects of kidney donation on pregnancy, psychosocial health and the financial burden of the donation process are also examined in this study. The hope is that the results of the study will help to improve the living kidney donor experience and to help to create and guide better government and hospital policies in this area.

The study follows living kidney donors for five years after donation and matches them with controls (non donors). All donors who consent to the study are asked to find a control person. The purpose of the control participant is to help us understand what changes in the donor are related to general aging or are related to the donation process.

A control participant can be a healthy person who has not donated a kidney and does not plan to donate a kidney for the duration of the study. Control participants cannot have high blood pressure, diabetes, kidney disease or heart disease or be on medication to control these medical issues. The Research Team will discuss these issues with anyone who is interested in joining the research study to help determine if they are eligible for the study.

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What can be done to prevent DGF? Nowadays in Ontario more kidneys are being “pumped”, which means delivering nutrients to the “sleeping” kidney as a kidney in a living person receives them. Transplanting the kidney as soon as possible helps, and research is being done on adjusting the composition of the preservation fluid, and using medications to allow the kidney to adapt better when it is being severely stressed, which it is when it is outside the body.

What is done once DGF happens? Dialysis is continued as long as needed. Dialysis as such does not damage the kidney but only does the work for the kidney when it is unable to do so. An ultrasound of the kidney looks for blood flow into and urine drainage out of

the kidney, and to assess blood flow inside the kidney.

Transplant medications are sometimes adjusted. The urine output and bloodwork is checked closely to look for improvement. Sometimes dialysis is continued after discharge, waiting for recovery in the transplant clinic. If DGF persists, a kidney biopsy may be done to assess the extent of kidney damage, and to look for rejection which can sometimes start and require different treatment. The kidney more than likely will recover so dialysis will no longer be needed. By keeping yourself as fit as possible in the meantime with diet, medication, and exercise as prescribed, you will recover more fully once the kidney itself recovers.

Purpose In Canada, 13 Transplant Centres are involved in the study including the Transplant Program at St. Michael’s Hospital. 96 living kidney transplants were performed at our hospital from May 2010 to Dec 2012. The study target was to enroll 75-100% of living kidney donors in the study with a donor/control ratio less than 2 (1 control for every 2 donors). Our actual enrollment rate is 50% (48 donors) and donor/control ratio 4 (1 control for every 4 donors). Consequently, we have less control participants than anticipated. As part of this review, we examined our experience over 2.5 years of recruitment and analyzed specific reasons contributing to lower than expected enrollment rates of both donors and controls.

Results 28 donors did not show interest in participating (29.1%); 12 donors (12.5%) live or work out of country; 8 donors did not speak English (8.3%).

Of the 48 donors who consented to the study, only 15 were able to find a control participant. The main reason given by the donors was not having close family or friends who they felt comfortable asking about participation in the study. Of the 15 controls participants referred, 4 control participants did not meet the eligibility criteria and 11 are still active in the study.

Conclusions Recruitment to donor studies in a Toronto population is difficult. The reasons for poor recruitment are varied. Recruitment of controls is especially challenging. Efforts to increase public awareness regarding the importance of studying long term donor outcomes should be made.

Next Steps We are advertising the study in this issue of the Transplant Digest to help improve our enrolment of control (non-donor) participants. Please see our advertisement in this issue. The control population is critically important to the success of the study and we hope that if you’re interested or know anyone that might be, please have them contact someone from the Transplant Research Team to obtain more information.

We would be happy to take the time to explain the study to anyone that is interested. The study has been designed to make the research visits as convenient as possible.

Transplant Research Team Lindita Rapi Michelle Nash Weiqiu Yuan

Research Coordinator Research Manager Research Assistant

416-867-7460 ext. 8024 416-867-3692 416-867-7460 ext. 8409 11

What is plasmapheresis?

Dr. Katerina Pavenski

Plasmapheresis (also called therapeutic plasma exchange or apheresis) is a treatment that is sometimes used to prepare a patient for a transplant or to treat one type of transplant rejection. The treatment uses a machine (which looks a lot like a dialysis machine) to remove patient plasma, a clear part of blood that contains antibodies as well as other blood proteins. The plasma is simultaneously replaced either with donor plasma or, more commonly, human albumin solution derived from donor plasma. The goal of plasmapheresis is to reduce the amount of unwanted antibodies in patient’s body with hope to prevent or treat disease caused by them. For example, plasmapheresis may be used prior to a transplant to remove antibodies directed against a donor kidney from the recipient’s blood to reduce the risk of rejection.

If after a transplant patient develops rejection due to donor antibodies (called antibody mediated rejection), plasmapheresis may be used to remove these antibodies and thus halt the immune attack on the graft. In addition to its role in transplantation, plasmapheresis has many other

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uses in medicine; for example, a number of diseases caused by auto-antibodies (example, myasthenia gravis, Goodpasture syndrome and others) can be treated with plasmapheresis.

To perform plasmapheresis, a nurse will use the patient’s dialysis line or a fistula. The treatment is safe and generally well tolerated.

Possible side effects may include numbness and muscle cramps (caused by the blood thinner citrate used during the procedure) and lightheadedness.

These side effects may be reduced by giving calcium during the treatment and holding blood pressure medications prior to the treatment, respectively.

Plasmapheresis machine cannot tell apart good antibodies (those that help you fight infections) from bad antibodies (those that cause disease) and will remove both. As well, some clotting proteins may be removed as well. Therefore, treatment may result in a weakened immune system and a tendency to bleed. These changes are temporary and will resolve with time as patient’s body replenishes what was removed. The number and frequency of treatments depends on a patient’s condition and will be determined by his/her doctor. Each treatment takes about 1-2 hours to complete and can be done during a hospital admission or as an outpatient. For more information, please contact your transplant doctor.

Letter to the Editor Jim & Isabella Voden

Hope all is well. We wanted to make sure that you all know how grateful we both are for what you all did. Because we don’t have everyone’s contact information, could you please take the time to share the following with everyone mentioned. We would really appreciate it.

We, Isabella and myself, would like to take the time to thank all those directly and indirectly involved in our transplant operation with a BIG THANK YOU!! We know its been now over 6 months since the transplant, but we sure wanted to make sure you know how grateful we feel everyday. Although we honestly feel words are not enough, this will have to do.

From the first day of communication with Maureen, to ongoing preparations with Galo, it has been a truly remarkable and wonderful experience.

To all the doctors involved, specifically Dr. Zaltzman, Dr. Schrieber, Dr, Prasad, Dr. Pace, Dr. McFarlane and Dr. Honey, thank you for a job well done. We fully expect that down the road there may be few hurdles to tackle, but we couldn’t imagine doing it without you fine people. You all treated us with the utmost care, not only physically, but you really cared how we felt.

The support staff, nurses and dieticians on the 9th floor at 61 Queen St., must receive our continued thanks. We actually look forward to interacting with them on each of our continued visits.

Although they are all extremely busy, they always have something to say to put smiles on our faces and always guide us with any of our concerns.

The nurses and supporting staff in Renal Unit on the 8th floor at St. Mikes could not be a more compassionate and caring group. From the time we arrived pre- transplant, and since after our operations, they all show such commitment to their challenges and work. To all of you, thank Jim and Isabella Voden you.

There were a lot caring people involved in preparing us for the transplant. We never felt more secure in our decision moving forward because of them also. To all those people, from the Cat Scan department, Cardio department, Imaging department and to the people that poked and installed a variety of specific tubes for Isabella pre operation, we both want to thank you.

Like on every good team, there has to be a great quarterback. We certainly had one on each of our teams. Galo Meliton and Maureen Connelly, thank you from the bottom of our hearts. Without either one of you, none of this experience would have occurred. You both were our “go to people”.

Whatever the question, it was always answered honestly and compassionately. You held our hands all the way, from blood tests to after operation visits.

We share our wonderful experience with our family. Like we do, please share the this letter with all involved.

Always our heart felt thanks,

Jim & Isabella Voden

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Funding for this publication provided by Hoffmann-La Roche Limited