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Kidney and Pancreas Transplant Program

Welcome!

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What causes kidney disease?

• High blood pressure• Diabetes• Chronic infection• Inherited disease• Unknown causes

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What do your kidneys do in your body?

• Filter waste from the body• Eliminate extra fluid by urination• Analyze and balance special chemicals

in the body• Make special hormones

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What happens when the kidneys don’t work?

• Waste stays in the body• Excess fluid stays in the body• Body chemicals are not in balance• High blood pressure• Anemia

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Can dialysis takethe kidneys’ place?

• Dialysis can:• Remove some of the waste and fluid• Balance some of the chemicals• Help control blood pressure

• Good dialysis depends on:• eating and drinking foods and fluid allowed• taking medication correctly• attendance at treatments and M.D. visits

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Remember:

• A normal kidney works to clean the blood 24 hours a day for a total of 168 hours each week.

• Hemodialysis works to clean the blood 3-4 hours per day, 3 times per week, for a total of 9-12 hours per week.

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What is a kidney transplant?

• An operation to place a kidney from a donor into the body of a person whose own kidneys have failed. • Kidney can come from a deceased donor

• most common -- least successful • Kidney can come from a living donor

• less common -- best success rate

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A well-functioning transplant kidney will:

• Remove the waste from the body• Remove the extra fluid from the body• Stabilize the chemicals• Make special hormones to make blood,

and control blood pressure

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Deceased Donor

• Donor has been declared brain dead• Testing has been performed and the patient’s

condition is permanent• Brain death-not a coma or vegetative state

• patient cannot breathe without a machine• basic brain reflexes and blood flow are absent

• Brain death is death

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Deceased Donors

• Donor may have a signed donor card • Donor’s closest relative must still give

permission for organ donation• Donor’s past medical and social history

is reviewed prior to organ donation

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Transplant Facts

• There are 78,209 patients waiting for a kidney in the United States as of January 2, 2009.

• There were almost 14,000 kidney transplants done in the United States in 2008.• Over 8,800 were from deceased donors• Over 4,900 were from a living donor

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Living Donor Transplant Advantages

• Better success rates• Less chance of rejection episodes• Waiting time - only the time for the

recipient and donor evaluation• Transplant can be scheduled at the

convenience of the donor & recipient

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Success Rates

• Living donor kidney transplants last an average of 22 years.

• Deceased donor kidney transplants last an average of 14 years.

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Disadvantages to receiving a living donor transplant• You must discuss the need with family

and friends• A NKF Living Donor brochure is enclosed

in the Transplant Orientation Packet• Donors must have a major surgery• Donor’s recovery requires

approximately 4-6 weeks

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Who can be a living donor?

• A donor must be at least 18 years old• A donor must not have any disease that

could be passed onto the recipient or made worse by donation

• A donor must not have any evidence of kidney disease

• A donor must be emotionally mature and competent to make decisions

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Who can be tested as a living donor?• Family members-parents, children,

brothers, sisters, aunts, uncles, nieces, nephews, cousins, grandparents

• Emotionally related - husband or wife, in-laws, friend

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How is the donor tested?• A complete history and physical exam• Blood tests to evaluate the donor’s

health and compatibility with the recipient

• Chest and abdominal x-ray, CT angiogram of the kidneys, EKG

• Consult with kidney specialist and surgeon that performs the donor’s surgery

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What are the risks to the living donor?• Surgical risks are bleeding, infections,

anesthesia complication, and circulation problems causing blood clots.

• The risk of death from the donation surgery is extremely low. It is estimated as 1 in 3000, which is less than the risk of death from an appendectomy, hernia repair, or gall bladder removal.

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Donor Questions

• How long are they hospitalized? 2-4 days• When can they return to work? 4-6 weeks• Can military personnel donate? Yes• Is future fertility affected? No• Do donors have to take medicine after they

donate a kidney? No• Can a person sell a kidney? No

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How is the donor kidney removed?• Open nephrectomy• Laparoscopic nephrectomy

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Who pays for the donor’s evaluation and surgery?• Usually, the recipient’s insurance,

Medicare or Medicaid will pay for the hospital and physician expense of donation

• You will be notified by a financial coordinator if your insurance does not cover living donation

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Assistance Programs for Living Donors• These programs may assist with travel,

housing, and other financial burdens associated with donation.

• Details regarding these programs will be discussed with the donors during the evaluation process.Georgia Transplant FoundationNational Living Donor Assistance ProgramOther local resources

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Can donors develop kidney disease after they donate?• Yes, but they do not develop kidney

disease any more frequently than non-donors.

• Kidney donation does not protect a person from developing kidney disease and it does not cause a person to develop kidney disease.

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Does the donor have to have special care after donation?• Donors are seen by their surgeon for

post-operative care • Donors are encouraged to have yearly

physical examination by their personal physician. This examination should include blood pressure measurement, and lab work to measure blood sugar and kidney function.

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How is a donor matched to a recipient?• There are three parts to matching a

donor to a recipient. • ABO (red blood cell typing)• Antibodies (compatibility testing)• Antigens (white blood cell typing)

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ABO - Blood Types

• There are four major blood types• O 45% of the population• A 40% of the population• B 11% of the population• AB 4% of the population

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Type O Blood

• A person with type O blood can only receive a kidney from a type O donor.

• The donor may be O positive, or O negative

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Type A Blood

• A patient with type A blood can receive a donor kidney with type A blood or type O blood.

• The donor may have A positive, A negative, O positive, and O negative

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Type B Blood

• A patient with type B blood may receive a kidney from a donor with type B blood, type O blood, or is some cases, Type A blood.

• The donor may have B positive, B negative, O positive, and O negative, or in some cases, A positive or A negative.

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Type AB Blood

• A person with type AB blood may receive a kidney from a donor with AB, B, A, and O blood.

• The donor may have AB positive, AB negative, B positive, B negative, A positive, A negative, O positive and O negative

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The rH Factor

• The rH factor is a very important factor in blood transfusions, and pregnancy.

• The rH factor is not a factor in kidney transplantation because the factor is not present on a kidney, therefore it does not have to be considered for matching.

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Antibodies form after exposure to the tissue of another person.• Antibodies can form from a blood

transfusion. • Antibodies can form in a mother from a

pregnancy. (The baby has the father’s antigens.)

• Antibodies can form from a previous transplant

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How is the blood checked for antibodies?• A blood sample is drawn from you and

placed in a panel representing the tissue typing of a 100 different people.

• The blood sample is analyzed to see how many of the 100 people your blood kills.

• This sample is called a PRA, which stands for Panel Reactive Antibody.

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What does the PRA mean?

• 100% PRA Difficult to find a compatible kidney

• 50% PRA You are not compatible with 50% of the population

• 0% PRA You do not react to any of the other tissue types on the panel. You will be easy to transplant.

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What is a crossmatch?

• A crossmatch is another test that determines whether you have antibodies to your potential donor.

• A crossmatch is done prior to a living donor transplant, and prior to a deceased donor transplant.

• The crossmatch must show compatibility or the transplant cannot be done.

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Antigens

• The antigens that are important in transplantation are present on the kidney, and other tissues of the body including the white blood cells.

• A patient’s antigens can be determined by testing the white blood cells.

• Laboratories at transplant centers are able to determine the patient’s antigens.

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How are antigens inherited?

• Mothers have six antigens, but when the mother creates a child, she can only pass three of her numbers to her child.

• Fathers have six antigens, but when the father creates a child, he can only pass three of his numbers to his child.

• The child then has six antigens.

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Family Tissue Typing

• Mother’s typing (1,2,3,)(4,5,6,) half• Father’s typing (7,8,9,)(10,11,12) half• Anne (patient) (1,2,3)(7,8,9,)• Bob (1,2,3)(10,11,12) half• Carol (4,5,6,)(7,8,9) half• David (4,5,6)(10,11,12) none• Elizabeth (1,2,3)(7,8,9) perfect

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Family matching

• Parents will be a half antigen match• Children will be a half antigen match• Brothers or sister match:

• 25% will be a perfect match• 50% will be a half match• 25% will be a zero match

• Remember: red cell match & compatibility still has to be considered

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Paired Donation

• You have a donor that cannot donate to you due to an incompatibility of blood type or crossmatch.

• Another donor and recipient pair exists in the same situation.

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Paired Donation

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On average, a living donor kidney will

always have a better outcome than a deceased donor

kidney.

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The Transplant Process

• MCG Orientation Class• Financial counseling for the surgery and for

post transplant medications. • Transplant Evaluation• Transplant Conference

• Approval for transplant - living donor / placement on the waiting list

• More testing to perform to determine suitability• Not approved – you, your nephrologist and your

dialysis center will be notified – and we’ll tell you why.

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The Transplant Process

• Our goal is to make transplantation available to all who will benefit

• For some of you, transplantation may not be the right answer

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Financial Clearance• The MCG Financial Counselor will contact

your insurance company and determine coverage for the surgery and for post transplant medications.

• A letter will be mailed to you explaining your insurance benefits for transplant surgery and medications. Please verify that all of your correct insurance information is listed in the letter.

• A medication plan is necessary prior to your being considered for a transplant evaluation.

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Financial Responsibility

• It is your responsibility to understand how your insurance covers transplant surgery and transplant medications.

• Notify our office if you have any insurance changes. Any change in insurance will affect your out-of-pocket costs.

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Who pays for medical care after a transplant?

• Private insurance• Medicare - for 36 months• Medicaid - for as long as the patient is

eligible• Patient expense

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Insurance and Medication Plans

• Medicare + Private Insurance with drug coverage

• Medicare + Medicaid with drug coverage• Medicare only – a financial plan is

necessary to cover what Medicare does not pay – Fundraising Coordinator works with patient to develop a financial plan, usually goal attained by fund-raising

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Insurance and Medication Plans

• Georgia Medicaid Only - with drug coverage

• South Carolina Medicaid with drug coverage and Medicare or eligible for Medicare at time of transplant

• South Carolina Medicaid only and not eligible for Medicare benefits- is not in MCG’s network of providers. Cannot be transplanted at MCG.

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Insurance and Medication Plans

• Medicare Advantage Plans are not recommended for transplant. It is best to remain enrolled in traditional Medicare when considering transplant.

• Please inform a MCG Financial Counselor if you have Veterans Administration (VA) benefits or a Cobra plan. There are exceptions to how these benefits cover transplant expenses.

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Medication Costs

• Immunosuppression medication cost ranges from $1400 to $1800 per month.

• Medicare Part B will pay 80% of this amount for 3 years.

• Patients without private insurance or Medicaid medication coverage will have the responsibility of the 20% copayment each month. This is approximately $360/month or $4400.00/year.

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Is there any exception to the 36 month coverage of Medicare?• Patients who are disabled for another

cause other than kidney disease are not limited to the 36 month coverage rule. Coverage is continued due to the disability.

• Patients who are 65 years old or turn 65 within the three years after a transplant, have continued coverage due to age.

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Medicare Part D Prescription PlanBenefits for 2009

• Tier 1-Standard deductible $295, beneficiary pays 25% of covered cost until total prescription costs reach $2700

• Tier 2-“Donut Hole” or “Coverage Gap”beneficiary pays 100% of prescription costs or $4350 out-of-pocket

• Tier 3-Catastrophic Coverage benefit- generic drugs $2.40, other drugs $6.00

• If you qualify for “extra help” or low-income subsidy your prescription drug costs will be between $1.10 and $6.00 with no coverage gap.

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Will you have to take other medications after transplant?• Yes, you will need to continue to take

the medication for any other conditions that you may have, such as:• hypertension or heart disease• diabetes• cholesterol• reflux• gout

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Georgia Transplant Foundation• A charitable foundation that helps meet

the needs of organ transplant candidates, recipients and their families.

• Programs include Financial Assistance, JumpStart, Scholarships, Access to Care, Wellness Conference, Dental Work Assistance, Living Donor Assistance

• Call 770-457-3796 or 1-866-428-9411

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Georgia Transplant Foundation Transplant Savings Accounts • The Georgia Transplant Foundation offers a

savings program called Access to Care that will match your savings dollar-per-dollar up to $10,000, however you must be a Georgia resident to be eligible for matching funds.

• South Carolina residents may enroll in an unmatched savings account with the Georgia Transplant Foundation

• MCG’s Fundraising Coordinator can help you apply for these accounts.

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Are there reasons why a person cannot have a transplant?• Active infection• Cancer• Active substance abuse• Severe heart, lung, liver, or vascular

disease• Obesity (Body Mass Index over 38)• Current pattern of noncompliance

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Nutrition• We encourage all patients to follow proper

nutritional guidelines. • If your BMI is over 38: Please discuss a

weight loss plan with your dietician or physician.

• BMI of 30 or greater or less than 20: We encourage you to seek out nutritional counseling at your dialysis center or with your physician.

• Please contact your transplant coordinator if you are unsure of your BMI.

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Immunizations

• We encourage all patients to be immunized against the following:

• Hepatitis B• Varicella Zoster• Meningococcal infection• Pneumococcal infection• Influenza

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Transplant Evaluation

• One day out-patient evaluation at MCG• Testing includes:

• Blood tests & tissue typing• Chest & abdominal x-ray, EKG• Complete medical history & physical• Consultation with transplant social worker and

transplant surgeon• In your packet you have a consent form that

describes this process. We ask that you bring it back with you on evaluation day.

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Patient Satisfaction Surveys

• Will be sent to recipients within 3 months of their outpatient medical evaluation.

• Will be sent to living donors within 6 months after donation.

• Your comments and suggestions matter a great deal to us and are very much appreciated!

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Transplant Coordinators

• Christina Wiggins, RN• Bill Wolff, PA• Amanda Wright, RN• Lynn Joyner, RN• Tonia Ryll, RN• Pam Grubbs, RN (living donors)• Dee Hawkins, RN (post transplant)• Belinda Boedy, RN (post transplant)

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Transplant Approval

• The transplant coordinator will receive any special testing that is required on you.

• The transplant coordinator will review these tests with the transplant surgeon. Upon approval, you will be activated on the transplant list or prepared for a living donor transplant.

• Living donors will be tested.

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How does a patient know if they are on the list?• A letter of activation will be sent to:

• Your home• Your dialysis center• Your referring nephrologist

• You will not be on the waiting list until you receive an activation letter.

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How long is the waiting time for a kidney transplant?• The national average waiting time for

patients placed on the list in 2002• Blood group O 1827 days 5.0 years• Blood group A 1140 days 3.1 years• Blood group B 1955 days 5.3 years• Blood group AB 732 days 2.0 years

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In Georgia, the average wait time is between 2 ½ and 3 ½ years.

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Why will some of you wait longer than others?• Patients with blood group O have a long

wait because there are so many patients on the list with that blood group.

• Patients with blood group B have a long wait because there are not many donors with group B blood group.

• Patients with high antibody (PRA) levels wait longer than those with low levels.

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What should you do during the waiting time?• Try to maintain your state of health by

compliance with dialysis & medications.• Notify your transplant coordinator of health

changes, address and telephone changes. • Make sure that your dialysis center is sending

monthly blood samples. “PRA’S”• Notify the transplant office if you will be out of

town or away from your telephone.

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Who will notify you of a kidney offer?

• The MCG transplant coordinator will call you by telephone.

• You must have a working telephone in your home or a cell phone. Please make sure that everyone in the home is aware that MCG could be calling for a possible kidney transplant offer. Please do not screen by caller ID.

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How much time will we have to find you?• The coordinator will have only one hour to

find you and then accept the organ. • The coordinator will have your telephone

numbers, contact numbers, beeper or cell phone numbers, and dialysis center numbers.

• Coordinators are almost always successful in finding you in this time.

• Please let us know of any travel plans you have.

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How much time will you have to get to MCG?• You will be given time to drive to MCG

at a safe rate of speed. • You will be required to have a reliable

transportation plan for the transplant and for post transplant clinic visits.

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What happens after your arrival to MCG?• You will be admitted to 4 south, the

MCG Transplant floor. • Blood will be drawn for the crossmatch

and other preoperative tests. You will have x-rays, EKG, and physical exam.

• You will go to the operating room if the crossmatch is compatible and all of the testing is approved by the surgeon.

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How long does the surgery take and will you be in ICU?• Surgery lasts for approximately 4-5

hours• You will go to the recovery room for

approximately one hour.• You do not usually go to the intensive

care unit, normally return to 4 south, the transplant floor, and an experienced transplant RN will care for you.

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Do your old kidneys need to be removed?

No. The removal of your old kidneys is usually not necessary. If you have extremely large kidneys because of polycystic kidney disease, or if the kidneys are chronically infected, they may need to be removed.

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How long is it before your kidney starts working?• Some kidneys start producing urine and

cleaning the blood immediately, others take several days or weeks before they begin to function.

• Living donor kidney transplants usually work sooner than deceased donor transplants.

• Dialysis may be necessary until your kidney begins to function.

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What is rejection?

• Rejection is when the body’s immune system has recognized the kidney as something foreign to the body and tries to attack and destroy it.

• Rejection is diagnosed by laboratory tests that monitor kidney function.

• A biopsy of the transplant may be necessary to evaluate the rejection.

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Rejection Treatment

• Rejection episodes are treated by changing the dosages of anti-rejection medications or adding a new one temporarily.

• Kidney rejection does not necessarily mean kidney failure.

• Most episodes of rejection can be reversed with anti-rejection medications if they are diagnosed early enough.

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Signs of Rejection

• Pain or tenderness over the transplant• Fatigue/weakness/fever• Less urine output than usual• Swelling of hands or feet/weight gain• Elevated blood pressure• You may not have any symptoms, but

kidney function tests may be abnormal

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What are immunosuppressants?• The body’s natural response to anything

foreign is to reject it by way of the immune system.

• Immunosuppressants are supposed to signal your body not to attack the new kidney.

• Immunosuppressants must be taken as long as you want your kidney to function.

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Immunosuppression

• Immunosuppressant medication protect your transplanted kidney by inhibiting the immune system from recognizing the kidney as something foreign

• There are several immunosuppressant medications and your transplant nephrologist will prescribe the combination that is correct for you.

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Immunosuppression

• Side effects of immunosuppression can include toxicity to the kidneys, tremors, headaches, elevated blood pressure, nausea, diarrhea, susceptibility to infections/viruses.

• Your transplant nephrologist will alter your medications to avoid side effects and still provide protection for your kidney

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Immunosuppression

• The most important thing you need to do to stay healthy is to take every dose of your medications, every day.

• By doing this you can protect you new kidney from rejection and keep it strong.

• It is important to take your medicine even when you are feeling well—so you can keep feeling well.

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Transplant patients risk of cancer• The use of immunosuppressive

medication can increase the risk of some, but not all types of cancer.

• Colon, breast, prostate, and lung cancer does not seem to be increased in transplant patients.

• The most common type of cancer in a transplant patient is a skin cancer.

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Prevention and Treatment of Skin Cancer• Skin cancer occurs 20 times more often in a

post transplant patient than in the general population.

• Early detection and aggressive management should be the treatment of skin cancers.

• Sun exposure should be avoided.• You should have complete skin evaluations

as part of your post transplant care.

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Does the disease that caused your kidney to fail attack the transplanted kidney?• It is rare for the original disease to

return and cause damage to the kidney.• It is important that blood pressure and

blood glucose be controlled post transplant.

• The possibility of recurrence of disease will be discussed with you during your evaluation.

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Can you return to work after a transplant or are you disabled?• If you have normal kidney function and

no other health problems that would make you disabled- you can return to work.

• Some of you may return to work within 6-8 weeks. Some require a longer time.

• If you have complicated medical problems, you may not be able to return to work.

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Does the post transplant patient have to stay on a special diet?• After transplantation, you can eat a

regular diet, but it is recommended to avoid high salt, high fat, and high sugar foods.

• Fluids including milk and juices are not restricted.

• Other dairy products are not restricted –like cheese and ice cream.

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Can transplant patients exercise?• Post transplant patients are encouraged

to participate in daily exercise. Exercise increases the health of the transplant patient and helps prevent weight gain.

• Pre-transplant patients are also encouraged to exercise. Patients should consult their physician prior to starting an exercise program.

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Can I have children after transplantation?• Men with normal sexual function can

father children after his recovery from surgery.

• Women should avoid becoming pregnant for at least one year, but preferable two years after transplant.

• You should discuss any intention of conception with their MD to ensure the safe use of transplant medications.

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Post Transplant Care

• It is important that transplanted patients have frequent clinic visits after hospital discharge.

• Your kidney function will be monitored• You will be observed for side effects

from the medications

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Estimated Clinic Schedule

• Week 1 In hospital• Weeks 2,3, &4 2 visits per week• Weeks 5,6, &7 1 visit per week• Around week 6 Stent removal • After 8 weeks the visit frequency will be

determined by your condition. • Your appointments can be alternated

with your home nephrologist.

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Stent Removal

• A stent is placed inside you to help urine flow freely after transplant.

• This stent will need to be removed around 6 weeks after your transplant.

• An appointment will be made for you and you will be notified when and where to go for the stent removal.

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Are there any rehabilitation programs for transplant patients?

• Transplant patients can be referred to their state vocational rehabilitation department for assistance in obtaining work.

• Georgia patients can be referred to the Georgia Transplant Foundation’s program called JumpStart.

• JumpStart offers career testing and development and job readiness training.

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More Information

• If you have further questions, please contact the MCG Transplant Office.

• Call 706-721-2888 to speak to one of the Transplant Administrative Secretaries. They will assist you, or connect you with a transplant coordinator, social worker or financial counselor.

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Kidney and Pancreas Transplant Program