Transplant Digest, Issue No. 33

Transplant Digest

Fall 2022/Winter 2023 Issue No. 33

New Nephrology Ambulatory Clinic Dr. Jeff Zaltzman I am so very pleased to share with you, our transplant recipients some very exciting news. As of the new year, we will officially be welcoming our transplant patients to our brand new transplant clinic at 61 queen St east 8th floor. This has been a long time coming as we have long outgrown our current space.

Presently, our transplant staff are located on the 2nd floor, the 7th floor, and the 9th floor at 61 queen St east. With the new space, the entire transplant team including the pre- transplant coordinators, the living donor team, and the post-transplant nursing and administrative staff will be moving to the new transplant area. This will be a state-of-the-art clin-

In this issue...

• • • • • • • • • • • • • •

New Nephrology Ambulatory Clinic 50 Year Transplant Anniversary From the Editor’s Desk First Decade of Transplants at St. Michael’s Hospital How can I be a Kidney Donor?

A Tale of Two Transplants Emily Campbell and Tess Montada-Atin Win a Research Grant Nuts for Phosphorus Transplant Quiz An update on COVID-19 for kidney transplant recipients Potassium binders after transplant Post-Transplant Chat The Most Common Questions Kudos & Welcome, Thank you & Farewell Kidney Transplant Clinic Changes its BK PCR Bloodwork Routine

Continued on page 2

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From the Editor’s Desk Dr. Ramesh Prasad

Welcome to the Fall 2022/Winter 2023 edition of Transplant Digest. As the days become shorter and the nights longer, your mood might feel lower and you may be wondering how to cope with life. Remember that our transplant program is part of your extended family, and we are only a phone call away. We can try to help connect you with the appropriate resources. Be sure to take extra care with following medical advice during stressful periods, including taking your medications on time, getting your lab tests done, and seeking medical advice if you have any health-related concerns.

In this issue of Transplant Digest, we have exciting news about our new clinic space. We also have a COVID-19 update, advice about common early post-transplant concerns, how to be a kidney donor, BK virus, a transplant quiz, potassium binders, and dietary phosphorus. Our senior RN Maureen Connelly reports on two of our most senior transplant recipients, one who has had his kidney transplant for more than 50 years and another who had two transplants more than 30 years apart! As always, please feel free to seek clarification on anything written, and contribute yourself.

...continued from page 1

ical facility with an expansive, 7,200 square-feet of space in the new centre, meaning bigger exam rooms to accommodate patients in wheelchairs, beds and stretchers, a generous sized bright waiting room, and computer facilities for our patients.

In addition to our transplant program, our multidisciplinary kidney care team will also be moving to this clinic. This new clinic is the result of years of planning and supported by the generosity of many donors through the St. Michael’s Hospital foundation. When the kidney transplant program was relocated to 61 queen St E 9th floor in 1988, our transplant program was following less than 300 prevalent patients. We were doing approximately 30 to 40 transplants per year. Currently we care for almost 2000 patients who have been transplanted and have over 400 new referrals per year. We are one of Canada’s largest kidney transplant programs, performing between 130-150 transplants annually. The transplant program at St. Michael’s is actively involved in education, clinical and basic scientific research. The transplant research team will be relocated to the second floor at 61 Queen Street east, but they will have a presence in the new space to meet with patients to enable discussion and ongoing management of transplant patients involved in clinical research studies.

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Contact Information Dr. Ramesh Prasad – Editor Meriam Jayoma-Austria, RN, BScN, C.Neph.CNewsletter 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 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.

How can I Be a Kidney Donor?

We receive each case and assess their current and past health. Tests include blood work, chest x-ray, cardiac testing, kidney function tests, an abdominal ultrasound and CT scan.

Kevin Bradley RN Living Donor Coordinator

The donor team consists of donor nurses, a social worker, transplant nephrologists and transplant surgeons. This team will ultimately help facilitate and guide you through the donor process and also see if it is safe for you to proceed.

It can be a big decision when you choose to be a living donor and come forward for the testing.

This is why we assess each person individually to make sure donating is safe for you. In order to be considered safe, the potential donor must come forward voluntarily and be in good health. At St. Michael’s you must be at least 18 years old and we are happy to say that we no longer have an upper age limit for donors. We have had many donors come forward who are in their 50’s, 60’s and 70’s.

We also accept donors who live out of province or in another country. If the donor resides in another province we help facilitate the bulk of tests by liaising with your family doctor and providing the protocol needed to assess your general health. This cuts down on the number of visits to make to Toronto.

First Decade of Transplants at St. Michael’s Hospital YEAR

Living Donor Transplants

Deceased Donor Transplants

1969

1

1970

2

1971

4

1972

5

2

1973

1

15

1974

2

16

1975

1

15

1976

2

24

1977

5

25

1978

7

17

1979

3

21

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Former Athlete Achieves a New Record: 50 year Transplant Anniversary Maureen Connelly, RN Toronto in 1972 was an exciting time. Team Canada was celebrating its triumphant return from Russia after having won the Canada/ Russia hockey series. Paul Henderson scored the winning goal in overtime. The Eaton Centre and the CN tower were under construction. A new rising star named Elton John was playing at Maple Leaf Gardens and Second City was in full swing. John Candy, Martin Short, Catherine O’Hara, Eugene Levy and Gilda Radnor were the stars.

1972 also marks the year when Louis Lacroix received his kidney transplant. His transplant was the 9th one performed at St. Michael’s Hospital after the program started in 1969.

Fast forward to 2022 and we are celebrating with Louis this incredible 50-year milestone. Louis kindly agreed to share his memories with us of this remarkable story.

On April 21, 1972 Louis was just shy of his 19th birthday when he received his transplant.

Maureen: Louis, please tell us what you remember as being a teenager with kidney disease. How and when were you diagnosed?

Louis: I did not realize the extent of my kidney disease as a teenager until I ended up in hospital. I considered myself a healthy teen playing basketball and track and field. In my early teens I wasn’t sick, but I had a feeling that things were not right. The first changes began with my nipples becoming enlarged and painful. When I went to the doctor I was told I would grow out of it. Nothing really changed over the next couple of years. When I turned 17, I began to have a lot of indigestion and was told it was probably an ulcer. Before long my stomach began to become distended and I started to experience a loss of appetite and was constantly throwing up.

From there things began to move very quickly once I was admitted to the Penetang General Hospital.

The next thing I knew I was put in an ambulance and sent to emergency at St Mike’s. This would be my first contact was Dr. Goldstein. Until then I had no concept of how sick I was and that I had kidney failure. The doctors told me they were amazed I was not in a coma with my extremely abnormal lab results.

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Pictured above: Louis Lacroix

Maureen: How long were you on dialysis before you received a transplant?

Louis: After the initial diagnosis, dialysis began almost immediately, I don’t remember the number of sessions I had per week as it was all a blur but it might have been two times per week. I remember taking the Greyhound bus from Midland to the old bus terminal in Toronto.

My time on dialysis was thankfully short lived, about 17 weeks. When I was down for my dialysis session, I remember Dr. Ferris coming and telling me that there was a kidney available for me. Looking back now, it may seem like it was a no brainer, but I was pretty much alone making the biggest decision of my teenage life. I had great nurses on my side who helped me to feel so not alone, I still remember a dialysis nurse named Maureen who was especially kind. With their support, I agreed to proceed with the transplant surgery. There are some things in your life that stand out. I always remember with such clarity the moment when Dr Ferris was taking blood as he was smoking his pipe and asked if I was afraid. I replied, “I sure am!” In those early years of dialysis, the unit was pretty small but the upside was I could have my favourite meal of eggs and bacon!

gan. I received a commendation for community involvement as a member of the OPP running club, doing triathlons-sprint level 800 meter swim/ 30 k, bike/5 k runs I still keep active at the local gym and play tennis.

I have worked a full time job as a Nutritional Manager in Long Term Care for over 30 years until my retirement at 60. My wife Gail and I moved up to our cottage in Muskoka on Skeleton Lake and in the fall, we go to Florida for the winters. It’s a little different this year as we have moved into the town of Bracebridge hope to be going south this winter.

Thank you Louis for sharing your memories with us and congratulations on your 50 transplant anniversary, a record for St. Mike’s and possibly a world record!

Maureen: How long were you in hospital after the transplant?

Louis: I was at St. Mikes which seemed forever but was about 6-8 weeks (Maureen- note- patients were actually in isolation after transplant for 6-8 weeks! Now patients are in hospital on average 5-7 days!)

Maureen: What things do you think you did to keep your kidney lasting for so long?

Louis: I listened to the doctors, took my meds religiously, kept active and believed in a higher power.

Maureen: What were you able to accomplish with having a functioning kidney and good health?

Louis: I was always very athletic and involved in sports. I played basketball in High school and on a college varsity basketball team where I was named team captain and MVP, I also played in the Simcoe County Basketball League.

In addition to basketball I began long distance running and completed 2 marathons, countless 1⁄2 marathons and 10k races. I was a community runner on the OPP racing team and raced just about every weekend all across Ontario and into MichiTRANSPLANT DIGEST - PG 5

A Tale of Two Transplants: An Inspiring Story of Two Living Donor Transplants Maureen Connelly, RN Oct. 17th is a day John Allen will always remember as a cause for celebration. He received both his living donor transplants on this day 31 years apart.

Oct. 17, 1991: When his father Sam was 74 years old he gave him his 1st kidney. His father lived on for many years after kidney donation and recently passed away after a life well lived at age 105!

John: My journey to renal failure started when I was six with a minor urinary tract operation that resulted in a serious infection which eventually led to the removal of a kidney at the age of eighteen. My Dad was keenly aware of my renal issues over the years, but it was my renal failure and subsequent dialysis in spring 1991, that started the search for the best treatment for renal failure. The nephrology team at St. Michaels recommended a living donor transplant as the best option. All family members were tested and Dad was the best match. On October 17, 1991 my 74-year-old father donated a kidney to his 45-year-old son.

Maureen: We know the kidney from your father lasted for an incredible 30 years. What happened next?

Pictured above & right: John Allen and his dad

Oct. 17, 2022: His sister in law Gay Taraby gave him his second living donor kidney. Gay lives in Montreal and is a managing partner at Frylow Quebec.

Maureen: John, my colleagues and I extend our sympathy to you and your family on the loss of your father. Please tell us about your father.

John: My Dad was born on a small farm in Northern Ireland and emigrated to Canada (Montreal) in 1938 at the age of 21. His eldest sister worked for a garment manufacturer who offered to train my Dad in the clothing business. Thirty years later, Dad bought the business after the passing of the owner.

John: Fast-forward 30 years and I was experiencing renal failure once again. I commenced dialysis in June of 2021 and once again a transplant from a living donor was presented as the best option. My sister-in-law is very close to my wife and me and she became aware that our quality of life would improve dramatically with a kidney transplant. After extensive consultations with her husband and Living Donor Coordinator RN Kevin Bradley, she volunteered to give the greatest gift one person can give to another. On October 17th, thirty-one years to the day after my first transplant, I received another transplant and from a non-blood relative.

Maureen: Tell us about your sister in law who was your 2nd donor.

Pictured left: Gay (sister in law)

Maureen: Please tell our readers how and when you were diagnosed with kidney problems.

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John: She’s the youngest of 4 children, two sisters and a brother. She had a very successful career in the swimwear, restaurant supply and golf industries. This is where her passion for golf developed and takes every opportunity to be on the golf course.

She loves being around family; as a great aunt she often takes out her nephews and niece on picnics in the summer and skiing in the winter. She’s also a wonderful sister who decided on her own, to become a donor.

that John’s Dad lived to 105 with only 1 kidney, I felt very comfortable proceeding as a potential donor.

I genuinely feel grateful that I was able to help John and am overjoyed knowing how he feels today and how he and Terry are now able to plan their future with excitement!

Maureen: Gay, thank you so much for sharing your kidney donation journey with us. John, thank you for a personal glimpse into your experience of having not one but two living donors who impacted your quality of life in such a positive way.

Maureen: After a successful teaching career, how is life for you now post retirement?

John: Post-transplant life is so much more enjoyable. I have much more energy and time and food tastes so much better. Soon we’ll be able to visit my sister-in-law in Montreal and spend time with the rest of the family.

Dialysis is a life-saving treatment but a kidney transplant represents a new life with a future. Finding a living a compatible living donor can take some time and effort but the results can be life altering.

Maureen: Gay ; Please share with our readers how you arrived at your decision to be a kidney donation?

Gay: When I knew that Terry and John were “putting their affairs in order”, I was heartbroken.

I spoke to my husband Mike about offering myself as a possible donor to John, knowing that our blood types were a match. We did some research including speaking with two friends who were kidney recipients. We asked them about the process and impact on not only their lives but also their donors.

There weren’t any negatives – it all lead to positive outcomes for everyone.

Emily Campbell and Tess Montada-Atin Win a Research Grant!

Kidney transplant recipients are at increased risk of developing diabetes after their kidney transplant because of anti-rejection medications and steroid use. Glucagon like peptide-1 receptor agonists (GLP-1RA) are a specific type of diabetes medications (e.g. Liraglutide, Semaglutide, etc.) that helps with diabetes control and weight loss but kidney transplant recipients have sometimes been excluded from large clinical trials. As a result, Emily Campbell, registered dietitian and Tess Montada-Atin, nurse practitioner have been awarded an Interprofessional Based Practice Research grant looking at GLP-1RA medications in kidney transplant patients. Emily and Tess will be working with Dr’s Darren Yuen, Ron Wald and Kevin Yau to support the study over the next two years.

I worried about John’s quality of life and in turn, how it affected my sister. Once Mike and I realized that my quality of life would be unchanged and knowing TRANSPLANT DIGEST - PG 7

Nuts for Phosphorus Written by: Julia D’Amico, Dietetic Student Edited by: Emily Campbell, RD CDE MScFN

Phosphorus is the second most abundant mineral in the body. This mineral is an important nutrient that occurs naturally in many foods, and has several vital functions. Phosphorus is needed for the production, growth, maintenance, and repair of all tissues, cells, DNA and RNA. Your kidneys remove excess phosphorus from your blood, and this is much more effective with your new kidney after a transplant. Phosphorus also helps the body use and store energy, as well as works closely with other vitamins and minerals. Phosphorus works very closely with vitamin D, calcium and magnesium to aid in bone strength - about 85% of the body’s Phosphorus is in bones and teeth1.

After a kidney transplant, it is common to experience low levels of phosphorus, affecting up to 90% of patients after surgery2. Some symptoms of low phosphorus, also called hypophosphatemia, include: loss of appetite, anxiety, bone pain, fatigue, irregular breathing, numbness, weakness, weight loss. It is important to speak with your transplant team if you experience any of these symptoms.

Phosphorus is found in many foods. A great source of phosphorus is nuts and seeds. This includes pecans, macadamia nuts, walnuts, peanuts, pumpkin seeds. These may have been foods that you needed to limit before your transplant, but remember your nutrition needs may change with your new kidney and you may be asked to include some of these now. While nuts and seeds are a great source of phosphorus, after a kidney transplant you may be instructed to limit your potassium intake - some phosphorus-rich foods, like nuts and seeds are also rich in potassium, which you

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may need to limit depending on your bloodwork, speaking with the dietitian can help to determine your needs. Some lower potassium nuts include: pecans, walnuts and macadamia nuts.

If your phosphorus is low, here are some tips to incorporate more phosphorus-rich foods in your day: • Sprinkle pumpkin seeds onto a salad or steel cut oatmeal • Bread your favourite meat in crushed walnuts mixed with breadcrumbs • Have peanut butter and whole grain crackers as a snack in between meals • Add pecans to your Greek yogurt

Another excellent and delicious way to get more phosphorus is by making a trail mix. This is a great low sodium snack that you can enjoy at home or on the go. Try making a trail mix like the one below at home.

Trail Mix Recipe Serves 1

Ingredients • 2 Tbsp roasted unsalted pecans • 2 Tbsp roasted unsalted Macadamia nuts • ¼ cup Rice Chex cereal • ½ cup unsalted popcorn • 1 Tbsp unsweetened, dried cranberries Steps: 1. Mix all ingredients together in a bowl.

Want to make extra? For multiple servings, multiply each ingredient by two or more as necessary.

Per serving: 10.6g NET carbohydrates, 3.5g protein, 93.3mg phosphorus, 153.1mg potassium, 63.9mg sodium References: 1: Phosphorus Information. Available form: https://www.mountsinai. org/health-library/supplement/phosphorus 2: Recovery of Hyperphosphatoninism and Renal Phosphorus Wasting One Year after Successful Renal Transplantation. Pieter Evenepoel, Bjorn K.I. Meijers, Hylke de Jonge, Maarten Naesens, Bert Bammens, Kathleen Claes, Dirk Kuypers, Yves Vanrenterghem.

Kidney Transplant Clinic Changes its BK PCR Bloodwork Routine Galo E. Meliton, RN, C Neph (C) Chief Senior News Correspondent

We always try to improve our process in the kidney transplant clinic at St. Michael’s Hospital in order to improve patient care. To this end, the kidney transplant clinic at St. Michael’s Hospital is changing its BK PCR bloodwork routine to yearly past the five year anniversary of the kidney transplant. The old process tested yearly only up to 5 years after the kidney transplant’s second anniversary. The reason for this change is to ensure that monitoring our patient population‘s condition and status are complete throughout the life span of their kidney transplant.

BK is a virus that most of us have been exposed to as children. It was discovered in 1971 in Sudan, Africa in a kidney transplant recipient whose initials were BK, hence the name. It typically has no symptoms.

It does not affect healthy people but is relevant to kidney transplant recipients as it “lives” in the urinary tract and can potentially damage the kidney transplant. If you have it, it will always be in you, and it may be “asleep” until you are immunocompromised as in being on anti - rejection or immunosuppressive medications after a kidney transplant.

Unfortunately, a number of kidney transplants were lost globally prior to this virus being discovered as kidney transplant programs worldwide unknowingly gave kidney transplant recipients more anti- rejec-

tion or immunosuppressive medications to counter a suspected kidney rejection when the blood creatinine was elevated from their usual baseline readings.

Moving forward, this bloodwork is done monthly for the first three months post – transplant, then every three months up to two years (as per the previous routine), then yearly for as long as the kidney is working; it may also be done at any other time as deemed necessary (due to increased creatinine, for example).

You may continue to have this bloodwork drawn at St. Mike’s or at the outside lab you normally go to. Regardless, it is processed at the St. Michael’s Hospital Microbiology laboratory. With good team work, the Kidney Transplant Program at St. Michael’s Hospital has yet once again come up with a strategy in order to improve patient care.

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An update on COVID-19 for kidney transplant recipients Darren Yuen MD FRCPC

It is hard to believe that we are reaching the 3 year mark of the COVID-19 pandemic. Since December 2019, the medical community has made some remarkable advances in our understanding of this virus, and how we can prevent and treat it. Since so many changes have happened over these 3 years, we thought we would review some important points.

The bad news: COVID-19 is probably here to stay Despite massive efforts to contain the virus, most experts have come to the conclusion that COVID-19 is here to stay in Canada for the foreseeable future.

It is likely that SARS-CoV2, the virus that causes COVID-19, will be mostly a seasonal infection, with the fall and winter months seeing an increase in infections. In the spring and summer, COVID-19 will still be around, but probably at lower levels as we all spend more time outdoors.

The good news: We have new ways to prevent and treat COVID-19

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In the first wave of the pandemic, the number of COVID-19 infections in our kidney transplant community, and in the province at large, were actually quite low compared to the numbers of infections we are seeing in 2022. However, transplant patients who got COVID-19 in 2020 were often getting quite sick, needing hospital and even ICU admission. During that scary time, more than half of our transplant patients who contracted COVID-19 needed to be admitted to the hospital, and roughly 1 in 5 patients died.

Now let’s fast forward to 2022. The number of infections we are seeing every day is much higher than in 2020, but transplant patients who get COVID-19 are rarely sick enough to be admitted to the hospital, and very few people are dying.

The game changer: vaccines What happened in between 2020 and 2022 that has made things so much safer for our transplant patients? The main advance has been vaccines.

Roughly 80% of St. Michael’s Kidney Transplant patients have received 3 COVID-19 vaccine doses,

with at least 50% having 4 doses. We have learned that these vaccines, while not perfect at preventing COVID-19 infections, are very good at protecting against severe infection. What does this mean?

It means that getting vaccinated protects against needing to be hospitalized, going to the ICU, and dying with COVID-19. This is the key lesson we have learned: the more vaccine doses you have, the more likely you, as a transplant patient, are protected against getting very sick with COVID-19. While vaccination might not provide a lot of protection against COVID-19 infection in general, what matters the most is that it will protect you against severe infection.

Are vaccines safe?

The simple answer to this question is yes. COVID-19 vaccines have been tested in a huge number of

against COVID-19 infection. Evusheld is not a vaccine, but rather is made up of protective antibodies that fight off the SARS-CoV2 virus. It is given as two injections, one injection in each buttock. Basically, doctors and scientists realized that transplant patients produce fewer antibodies in response to vaccines, and so they decided to give transplant patients a “top-up” of antibodies made in the lab. This is what Evusheld is. Evusheld was designed against the original SARS-Cov2 virus, and so it might lose some of its protective capabilities with the newer Omicron subvariants that are arising. We will keep you updated on whether Evusheld will still be effective, but for now we (and Ontario Health) are recommending getting Evusheld every 6 months.

What should I do if I test positive for COVID-19?

The key is to get a rapid antigen test as soon as you develop possible symptoms of COVID-19. The most common symptoms include: fever, chills, sweats, cough, runny nose, sore throat, diarrhea, and low energy. If you test positive, call the Kidney Transplant clinic as soon as possible, as there are new COVID-19 treatments, but they must be started within 7 days of symptom onset. If it is a weeknight, you can call us the next day. If it is a weekend, go to your local Emergency Room. Of course, if you develop shortness of breath or are feeling very ill, always go to your local hospital’s ER.

Summary

Are there other advances we should know about?

In addition to vaccines, a new drug called Evusheld has been released that was shown to protect

Answers to Transplant Quiz on page 16 1. A 2. B 3. C 4. D 5. D 6. B 7. A 8. C 9. B 10. A

people (including transplant patients) around the world, and their safety has been shown time and time again. When one weighs the risk of severe COVID-19 infection in people who are undervaccinated, there is no question that getting vaccinated is the safer option.

The bottom line is that we have learned a great deal about COVID-19, and have developed effective ways of preventing severe COVID-19 infection, and treating infections when they happen. Although COVID-19 is here to stay, we are much better prepared now to protect you against this virus. Stay tuned for more updates!

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Potassium binders after transplant Elena Nazvitch, Clinical Pharmacist Potassium is an important mineral in your body that makes your muscles and nerves function. The kidneys help regulate the amount of potassium in your body. In patients with kidney disease, the kidneys are not working well in regulating the potassium level. A high level of potassium is dangerous and can cause the heart to not function well or stop.

Even after transplant, some patients may still have elevated potassium. Medications that are used after kidney transplant and are required either for the safety of your kidney, to prevent an infection or to control your blood pressure, can also elevate the potassium in your body. This is why the clinic keeps a close eye on your potassium levels after transplant, and if changes in diet alone are not working to reduce the potassium, your doctor may prescribe a medication to help lower the level.

There are several medications that are currently available for treatment of high potassium that may be prescribed to you. These include Calcium Polystyrene sulfonate and Sodium Polystyrene Sulfonate; they are usually given multiple times per day depending on the potassium level. A few years ago, two new medications for lowering potassium, Patiromer sorbitex calcium and sodium zirconium cyclo-

silicate, have also become available and are usually given once daily to control potassium levels.

Please see below for a quick review on the newer potassium binders that you may see prescribed by our clinic:

Sodium zirconium cyclosilicate (Lokelma®) powder for suspension How does it work?

Sodium zirconium cyclosilicate binds to potassium in the gastrointestinal tract in exchange for hydrogen and sodium, making less potassium available to be absorbed into your body and therefore, lowering the amount of potassium in your blood.

How do I take this medication?

This medication comes in 5 grams and 10 grams sachets. Your doctor will let you know what specific dose you will be taking.

•

•

empty the contents of the entire sachet into a drinking glass containing approximately 45 ml of water, still well and drink immediately while the powder is suspended. The powder will not dissolve in the water and will appear like a cloudy liquid. if the powder settles, stir it again and drink the entire dose.

How do I store it?

Lokelma® should be stored at 15-30°C and taken immediately after reconstitution.

Are there any drug interactions?

There are medications that interact with sodium zirconium cyclosilicate. Please speak to your pharmacist about your specific medications. In general, we recommend taking this medication at least 2 hours before or after your other oral medications.

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Patiromer (Veltassa®) powder for suspension How does it work?

How do I store it?

Patiromer is a calcium-sorbitol complex that binds to potassium in the gastrointestinal tract, making less potassium available to be absorbed into your body and therefore, lowering the amount of potassium in your blood.

The patiromer powder should be stored refrigerated at 2-8°C. If stored in room temperature (1525°C), it needs to be used within 6 months.

The reconstituted suspension should be kept in room temperature and used within 1 hour.

How do I take this medication?

Are there any drug interactions?

Patiromer comes in 8.4 grams, 16.8 grams and 25.2 grams packet. Your doctor will let you know what specific dose you will be taking.

• empty the contents of the entire packet into approximately 40 ml of water and stir • another approximately 40 ml of water should be added to the mixture as needed • drink the mixture immediately after stirring. If any powder remains in the glass after drinking, add more water, stir and drink until you take the entire dose • the mixture should be used within 1 hour • you can use apple or cranberry juice instead of water if you prefer. Do not use other liquids. Do not use hot liquids

There are medications that interact with patiromer.

Please speak to your pharmacist about your specific medications. In general, we recommend taking this medication at least 3 hours before or after your other oral medications.

Other important information about potassium binders Like other medications, potassium binders have side effects, which may not make them suitable for every patient. Your transplant team will decide if they are right for you based on your history and your other medical conditions.

The new potassium binders are also costly. You can speak to your transplant pharmacist about options for coverage.

April is BeADonor Month in Ontario. Our goal during BeADonor Month is to inspire those who have not yet registered consent for organ and tissue donation to join the more than four million Ontarians who have already registered. Registering gives hope to the almost 1,400 Ontarians currently waiting for a lifesaving transplant and takes less than two minutes at beadonor.ca.

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Post-Transplant Chat The Most Common Questions Galo Meliton, RN, Ellenica Hicks RN, Jaspreet Sidhu RN, Maureen Connelly RN, Jennie Huckle RN

1. What should I do or not do in the first few days after I get home from the hospital?

Rest when you are tired but keep active within your limitations- walking short distances, leg and arm movements while sitting, climbing stairs at home.

Make sure you are passing urine regularly. Check your blood pressure and keep a log to bring to the clinic. Use only a sponge bath to clean your body and incision area. If you require dialysis, be sure to keep your appointments.

2. When can I resume a normal diet? Are there any restrictions? Can I eat out?

We encourage a healthy diet. Generally speaking, there are no restrictions until your bloodwork determines that you need to limit certain foods such as potassium, phosphorus or salt in your diet. We will notify you if dietary restrictions are needed. Don’t eat out of you an avoid it for the first few days.

3. Can I play with my pet? Can I do gardening?

Don’t do either until the staples have been removed and your incision is fully healed. After this, as long as you are comfortable with moving, you can gradually increase either of these activities. Do not clean your cat’s litterbox because of the risk of getting parasites. Ensure you wear a mask when dealing with bird excrement. When the time comes, make sure you wear gloves when gardening to avoid thorn pricks and contact with manure.

4. What is the best way to get to clinic?

Ask a family member, partner or friend drive you or use taxi, Uber or Wheel Trans for the early clinic visits until you are able to drive (see below) or take transit independently.

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5. Can I go for doctor or dentist checkups, grocery shopping, banking, etc..?

Early in transplant you can go to your doctor if needed. Dental checkups, grocery shopping, banking, etc… can be done once you are fully recovered and are comfortable ambulating and lifting (especially with groceries). You may need to ask for help from family and friends. Now is the time to pull all your resources together!

6. When can I start driving? Do I have to wear a seatbelt?

We recommend you can start driving when your prednisone dose down to 10mg daily, when you are comfortable wearing a seat belt resting across your incision and when you are pain free. You must always wear a seatbelt and follow all traffic laws.

It’s best to wait to start driving until your stent has been removed.

7. When can I start having sex? What special precautions should I take during sex?

You can start having sex when you feel ready, whether you are a woman or man. Always practice safe sex. For female patients, remember that a transplant can quickly restore fertility, so you must follow contraceptive practices. If you plan to become pregnant, you should wait for a year after the transplant and let the clinic know since we may need to make some changes to your medications.

8. When can I have my central line or peritoneal dialysis catheter taken out?

Once we know your transplanted kidney is working well, we will instruct you to contact your home dialysis centre to arrange for your peritoneal dialysis catheter removal. If you have a central venous catheter, this can be taken out by the radiologist at our hospital or your dialysis hospital.

9. What kind of exercise is permitted and when? How much weight can I lift?

Always exercise within your limitations, with no heavy lifting more than 10 pounds for the first 3 months after the transplant. Walking and light jogging are always good. You can get on a treadmill when you feel ready, and use an exercise bike once the stent has been taken out, provided your incision is fully healed.

10. When can I travel?

We recommend to wait one year after your transplant before travelling outside North America, and 6 months within North America as long as the kidney transplant is working well. Don’t forget to get your travel letter beforehand, arrange a supply of medications, and have contact information for a local transplant centre if you are planning an extended stay abroad.

Kudos and Welcome!!!

Dana Whitham Senior Clinical Program Director Kidney and Metabolism Program

Michelle Gabriel Gabriel “Gaby” Busque Clinical Leader Manager Clinical Pharmacist in Kidney Transplant Program the post transplant clinic & Transplant-Nephrology-Urology Unit

Jaspreet Sidhu Post-Transplant Nurse

Sarah Crittenden Living Donor Social Worker

Thank you and Farewell!

Ornella Colacelli – Project Coordinator Nicole Pacheco – Living Donor Social Worker TRANSPLANT DIGEST - PG 15

Transplant Quiz Answers found on page 11

1. Which of the following tests is NOT a blood test?

A

albumin to creatinine ratio

B

NT-proBNP

6. Which of these transplants across blood groups is almost always possible?

A A to O

C CRP

B O to A

D hemoglobin

C AB to B

2. Which of the following drugs is NOT available as a tablet or pill?

D B to A 7. Which of these diseases does NOT recur in the transplant?

A

azathioprine

A polycystic kidney

B

basiliximab

B FSGS

C

tacrolimus

C diabetes

D cyclosporine 3. After a transplant you can never eat the following fruit.

A banana

D vasculitis 8. When can you usually travel overseas after a transplant?

A one month B six months

B apple

C one year

C grapefruit

D three years

D grapes 4. Which of the following does NOT create blood antibodies against your transplant?

9. How often should you do blood tests between the first and second year after transplant?

A

pregnancy

A weekly

B

blood transfusion

B monthly

C previous transplant

C once every three months

D kissing

D once a year

5. Which of the following is NOT an anticoagulant?

10. Where are the transplant surgical staples removed?

A

heparin

A transplant clinic

B

warfarin

B home

C rivaroxaban

C operating room

D aspirin

D ward

is sponsored through an unrestricted educational grant from Astellas Canada TRANSPLANT DIGEST - PG 16 PG This 16 newsletter - TRANSPLANT DIGEST