Tiffany Archibald 00:02
Let’s Talk About Kidneys takes a deep dive into the chronic kidney disease patient journey. We’re here to inspire meaningful conversations and to help people living with CKD gain a full understanding of their disease.
Bri Crow 00:15
Tune in today to learn what Dr. Muhammad Qureshi DNA transplant nephrologist has to say about the transplant pr ocess, testing, immunosuppressant medications, candidate requirements and their care plan. He also provides insight about the journey of the transplant patient, including kidney donation programs, types of donors, post transplant care, and the care team members involved with the patient’s care.
Tiffany Archibald 00:40
Welcome Dr. Qureshi today to our podcast. We are so excited to have you as our guest. How do you feel about being in our podcast studio?
Dr. Qureshi 00:49
Wonderful, a little bit nervous, but feeling great.
Tiffany Archibald 00:52
Oh, you are gonna do excellent and I think one of the things that it’s gonna be really interesting about this topic is that, you know, when patients are going through the chronic kidney disease process, they have to start thinking about their renal replacement therapy options. So today, as you know, we’re going to talk about transplantation. So with you being a transplant nephrologist, I think it’s a great fit. Are you ready?
Dr. Qureshi 01:18
Yes.
Tiffany Archibald 01:18
All right, let’s do it. Okay, why does a patient with chronic kidney disease need to consider getting a kidney transplant?
Dr. Qureshi 01:27
So definitely, there are both mortality and morbidity benefits for getting a kidney transplant. You know, that means you live longer, and you live better by getting a kidney transplant versus staying on dialysis. You know, if you look at the studies, 50% of the patients do not make it to five years after starting dialysis, unfortunately. And compare that to 80% of patients who live a healthy life at five year mark with a kidney transplant versus continuing on dialysis. So there’s a huge benefit in living longer with a kidney transplant. And not only living longer, you live better too. You know, because now you don’t have to do dialysis, you do not have to follow all the dietary restrictions that comes with with doing dialysis, right. And, and so there are all those benefits. You pretty much live as close to you would have lived with before having a kidney failure – on transplant versus continuing on dialysis.
Tiffany Archibald 02:22
Okay, so that’s good information. So I’m sure that people listening want to know who even qualifies to be a candidate for transplantation.
Dr. Qureshi 02:31
Excellent. So anyone who has kidney function less than 20 percent, or someone who has already started dialysis on a chronic basis, can potentially qualify for a kidney transplant. And once the patient gets referred to the transplant center based on those criteria, then it’s up to the transplant center to make sure that they are healthy enough to undergo that transplant surgery, healthy enough to tolerate all the immunosuppressive medications that they have to be on after receiving a kidney transplant. So there’s a thorough evaluation by the transplant center that undertakes once the patient meets the minimum criteria to be referred.
Tiffany Archibald 03:09
Okay. And so can you give us an idea of the type of testing that is done during the pre-transplant evaluation, because you just kind of talked about, the patient has to be healthy enough, they have to have a you know EGFR of a certain level, but what are the details of the pre transplantation?
Dr. Qureshi 03:28
So once the patient makes it to the transplant center to see if they are a good candidate for transplantation, there are two considerations in our mind. Once a patient you know, once I see the patient in that in that pre-transplant clinic, I see them make sure make sure that their heart is healthy enough to tolerate the actual transplant operation because, as you know, the transplant operation itself entails you know, you have to have a healthy enough heart to tolerate at the surgery and the anesthesia. So a lot of times that’s done by doing a stress test, or sometimes even a cardiac catheterization with the help of our cardiology colleagues. And the second consideration for all the testing is to make sure that whether they can tolerate the immunosuppressive medications or not. As you know, once a patient receives a kidney transplant then they have to be on these immunosuppressive medications pretty much lifelong to make sure that the organ stays in a body does not reject the organ. So those immunosuppressive medications comes with certain risks and the main risk is the risk of infection and the risk of cancers. So before anyone gets a kidney transplant, we make sure they do not have any infections that they already have, any pre existing infections. And typically that’s done by doing some blood tests, some serologies, you know, to rule out HIV hepatitis, you know, any latent TB or you know, depending on where you live in certain areas, there are certain endemic infection making sure you rule those out.
Tiffany Archibald 04:51
Okay. So let me let me pause you there. So when you talk about the different infections and the immunosuppressive medications, can you give us an idea again, like an example?
Dr. Qureshi 05:04
So we’ll talk more about those immunosuppressive medications, but that but there are, you know, immunosuppressive medications and the medications that a patient has to take after the kidney transplant. To make sure that the body does not reject the kidney, right? And those medications, just like any other medications, comes with risks. And the main risks with those medications is that they can make you more prone for infections and certain cancers, right. I mean, those medications are great because they prevent the rejection and make sure that the kidney stays in the body functioning. But so as I said, it comes with the risks, so we mitigate those risks by, you know, before someone get a kidney transplant, making sure they do not have any pre existing infections that are undiagnosed. And the same thing goes for the cancers, before someone gets a kidney transplant, we make sure they do not have any undiagnosed cancer. So we do age appropriate cancer screening, right. So for example, for women, you know, all the women pretty much get Pap smear, you know, a mammogram. Men get prostate cancer screening, and if you’re more than 45 years of age, then you get colon cancer screening in the form of colonoscopy. And then, you know, everyone gets some kind of an imaging, some chest imaging in the form of a chest x-ray, and, you know, some kind of an abdominal imaging mostly in the form of abdominal sonogram, but some patients also need a CT scan, depending on their on the risks.
Tiffany Archibald 06:27
Okay, so everything that you’re describing, kind of entails the patient journey to transplantation. So you’re discussing the pre-evaluations, the different tests, what are some other things that are considered as the patient goes through their pre transplant journey?
Dr. Qureshi 06:47
So it’s not only the transplant nephrologist to evaluate the patient, it’s actually the transplant surgeon, there’s a dietitian, there’s a social worker who will evaluate the patient in that pre-transplant process. You know, the surgeons make sure that the patients because as you know, the kidney transplant happens in the lower part of the body, of the abdomen, so the surgeons make sure that you know, starting off, you’re not obese, you know, your BMI is in a decent range. So that, you know, after you get that kidney transplant, that wound healing is not a problem. Then the social worker, make sure that you have adequate coverage for your medications. As I said, those medications, the immunosuppressive medications, have to be taken lifelong. So you know, the social worker, the case manager, make sure you have adequate coverage from your insurance for those medications.
Tiffany Archibald 07:32
So what are some other things that the social worker considers? I know medication and being able to cover those, what are some other aspects that the social worker covers?
Dr. Qureshi 07:43
So there is something called a care plan. So every patient who who gets a kidney transplant, we want to make sure that they have adequate care plan. That means that they have someone who will be able to at least help them out for the few months after the kidney transplant, because you know, they have a fresh surgery. We want to make sure that there’s someone who at least is with the patient to take them to the appointments that they have to go after the kidney transplant process. They have some kind of a social support someone to drive them back and forth for the appointments. Not a lot. But at least, you know, we had the social worker identifies a few people who who are willing to help out the patient once they have a kidney, especially in the immediate post transplant period.
Tiffany Archibald 08:20
Okay, can you touch just quickly on the dietitian role and the pre transplant evaluation?
Dr. Qureshi 08:26
Excellent. So as I said, you know, a patient has to be at a good BMI. Typically, we consider a good BMI, which is body mass index, which tells how much weight a patient has. A good BMI would be ideally under 30, or a BMI at least less than 35. So the dietitian once they once they evaluate the patient, they make sure that the patient is not obese, and you know, if they can lose some weight, they help the patient getting to the weight, which will be an ideal weight for patient to undergo transplant surgery. And also check for the frailty you know, if the patient is very frail, you know, they, you know, you don’t want to have a patient who is very frail to begin with, because after the surgery, you know,
Tiffany Archibald 09:09
Their is weight loss, yes.
Dr. Qureshi 09:10
Exactly. There is weight loss, you know. You’re in bed for a few days, at least. So you want to start off at a good point where you’re not too frail. The dietitian evaluates the patient from that standpoint as well. And if they need some physical therapy, they refer the patient for that as well.
Tiffany Archibald 09:25
Okay. And then your a transplant nephrologist. So can you talk about the role of the transplant nephrologist during the pre-evaluation process?
Dr. Qureshi 09:35
Yes. So once the patient goes through all all the pre-transplant screening and tests, then they get put on a transplant list. Right. And that transplant list, just to kind of briefly, kind of do that before we go the inpatient role, is, you know, there’s a there’s a organization called UNOS which which, which uses a centralized computer system to match the transplant programs and the OPOs, which is the organ procurement organizations. They have a centralized computer system which uses algorithms to match the right recipient with the right donor. And once that match happens, then then the patient gets a call for a kidney transplant. And as you were asking, you know, once the patient moves up the list, and then they get called for a kidney transplant to the transplant center, then as a transplant nephrologist, you know, that’s, that’s when we check the patient one more time. You know, let’s say patient comes in, you know, and they have received an organ offer, then the first person that they typically see is a transplant nephrologist who will make sure one more time that the patient is, nothing has changed from the last time they had all the evaluation and they are still a good transplant candidate. Typically, that entails you know, making sure that they don’t have any active infections, they don’t have any active wounds, they get some blood work done just before the transplant surgery as well to make sure that they are a good match, you know that, you know, there’s a cross match that happens making sure that you know, the kidney is compatible. And then, you know, some some these days, we have to do COVID screening and other tools, some of those other tests to make sure just before the transplant surgery, everything is still right. And and then the patient undergoes a transplant surgery. And as a transplant nephrologist, you know, we kind of pretty much follow the patient throughout the course, not only in the pre-transplant course, right before the transplant and then right after the transplant when they are still in the hospital, making sure that they they get started on those immunosuppressive medications that we just talked about. Again, you know, there are different type of immunosuppressive medications that we have to use for the patient at the time of surgery, which we call an induction immunosuppressive medication. And then subsequently, the lifelong immunosuppressive medications, which are called maintenance immunosuppressive medications.
Tiffany Archibald 11:59
right, right. I remember the, the gigantic pill box. The pill box of eternity. Sometimes it’s what 50 pills a day. And you know, as you start to recover during that transplant recovery process, some of those medications, I remember them dropping off, because, you know, the first transplant that I had that was very overwhelming, like, Oh, my God, I’m gonna have to take 50 pills a day. But you know, that’s essentially cut in half. So what kind of care is needed once the transplant happens and the patient is discharged? We know that when they’re in the hospital, they’re getting that round the clock care. They’re seeing the nephrologist. They’re seeing the surgeons. They have the nurse practitioners. Everyone’s kind of, you know, making sure that each day, each hour, they’re having that care. So can you talk about the care that’s needed once patients are discharged?
Dr. Qureshi 12:58
Yes, so once the patient gets discharged from the hospital, your transplant nephrology team still follows you rather closely in that post transplant post hospital phase as well. You know, just to give you an idea, you know, we as transplant nephrologists see our patient very frequently, especially in the initial post transplant phase. We get to see our patient three times a week for the first two weeks. And then, you know, after that, you know, twice a week for another two weeks, and then after one month, typically once a week, for another month. So you get an idea that how frequent we see the patient, realizing that they are on all those new medications, which they are not familiar with, right? So so those immunosuppressive medications, you know, need some adjustments, some tweaking as well, especially in the initial phases. So the patient gets followed very frequently. And during those times, you know, the transplant nephrology team, your your dietitian, your social worker, your pharmacist still keep involved in the patient care to make sure that nothing falls apart and the patient is comfortable with the with the new medications, right. So, as you know that in the post-transplant phase, there can be there can be certain complications, right. So, so we have to, we have to follow the patient very closely for that. For example, if if the new new wound that you know the surgery where the patient has a surgery, there can be some surgical complications, you know, you can have a wound infection. In that case, we refer the patient back to the transplant surgeon make sure that they provide adequate care. Sometimes to develop some infections that we were talking about earlier. So that screening happens in the post-transplant phase as well and sometimes we need help with the infection disease colleagues to make sure that they help with the infection management. And you know, more long term you know, for subsequent months and years, the risk of cancers can go up so, so patient, get some screening, even post-transplant for years as well. Make sure that they have not developed any new cancers or or any chronic infections for that. add her as well. So the journey is pretty much, you know, lifelong once…
Tiffany Archibald 15:04
It’s a lifelong journey for sure, for sure.
Dr. Qureshi 15:07
Yeah. And then, you know, your your transplant team, your transplant nephrology team is there to help you, you know. I could, I could tell you in our transplant clinic, we follow the patients, you know, we have patients who have had kidney transplant more than 25 years ago. And we, you know, obviously, we don’t see them very frequently, but we still see them, you know, on a fairly regular intervals. So it is it is, as you know, it’s a lifelong journey. And, and then we, we are there to help help our patients navigate through all of that.
Tiffany Archibald 15:37
And in talking about the lifelong journey, I know that if there are patients out there that are looking to have a transplant or have had a transplant, you know, I can speak from, you know, experience in saying that, keeping those appointments, even if it’s, you know, going in for your labs, even if you feel everything is, you know, functioning and working properly, because you know, anything can happen if you aren’t, you know, in the consistent care of your nephrologist and your your care team. So I would definitely second that notion and support that. So now let’s talk about the different transplant options that are out there. We talked about the deceased donor versus the living donor, in your opinion, or is there an opinion, even standard, on which is better for each patient?
Dr. Qureshi 16:27
I think that’s an excellent question. So transplant at any given day, whether living or deceased, is definitely superior when compared to continuing on dialysis. So that’s as I showed you those numbers earlier. So that’s that’s a given. But between the two between, the two different types of transplant, living versus disease, living transplant is superior for various reasons. Number one, you know, the living transplant happens in a much controlled setting, you know, you already have a date as to when you’re going to have a kidney transplant, it is coming from a living person, right. So the kidney in the deceased donor scenario sits on a pump or on ice for a certain period of time before it gets implanted or put in in the in the in the recipient. Versus in the living living donor, you know, the two surgeries happens pretty much side to side, you know, in one OR there’s a living donor and in the other OR there’s a person who wants to kidney. So there’s, there’s what we call an ischemia time. There is very limited minimal ischemia time. So what that really entails is that a kidney pretty much works right away, in in case of the living donation, living donor compared to the deceased donor, where there can be sometimes what we call a DGW, or delayed graft function, because that kidney is sitting on ice. So the living donor is definitely superior because you get a better quality kidney, it’s a much controlled fashion surgery. And then I think the most important thing is that when someone gets a living, living kidney, they get it in a much more timely manner, too, right? Because when you are on a deceased donor list, then you have to be on the list for, depending on how long you’ve been on dialysis, you know, you can be on the list, it can take several years before you get an offer for a kidney transplant. Compared to a living kidney donation when you know, where you do not have to wait as soon as you have a living donor available, which is a good match for you, you can pretty much have the kidney transplant surgery within a matter of weeks. So from that standpoint, you know, the living donor kidney transplant is definitely superior compared to the deceased donor.
Tiffany Archibald 18:36
Okay, so we’re talking about the living kidney donor. We’re talking about the deceased donor. How do the relationship even happen? How do those relationships even happen with a living donor?
Dr. Qureshi 18:49
Very good question. So so as you know, that, you know, someone is willing, someone who’s wants to give the kidney, right. So they and their intended recipient is not a good medical match, right. And there are several options out there, you know, through the universe, or through other organizations, which, which can help you swap the kidneys. That means your donor kidney goes to, to the other recipient…
Tiffany Archibald 19:11
So let’s explain that. So someone has a donor that went through the testing process. They got tested, however, that person wasn’t a match for the person that they tested for. So then now you can talk about the paired process.
Dr. Qureshi 19:30
But that’s exactly what it is called. It’s called paired exchange. Right? So that’s, that’s a swapping, you know, that means your donor kidney goes to the, to the other recipient, where where there was a match, and then the other person’s who’s, you know, other person’s donor goes to the other recipient. So it’s basically one to one swap, or it can actually be in the form of chains, you know, where multiple peers are involved instead of, you know, two peers. So, UNOS is one of the organizations that can help do that. There are other organizations kidney registry which, which also helped with that process. So I always tell my patients that, you know, if you have a living living donor who wants to give the kidney, you don’t really have to worry about knowing their blood type, knowing whether they are a good donor, whether they are going to be a good match or not, because now you have all these programs, you know, which can help you find the right match for you. So I think it can be very overwhelming, but you tell our patient, you know, look for a donor, then they kind of get into this thing, you know, whether it should be a match, I don’t know if my donor is the right blood type, I don’t know if my donor has this medical problem or that, so we kind of try to try to ease that for our, for our dialysis patient. Telling them and as long as there’s someone who wants to give them the kidney, you know, their job is to just encourage them and help them turn in the application. And what happens from there on, you know, is up to the transplant program. If they’re a good match, by all means, you know, that donor kidney goes to the intended recipient. But if they are not a good match, then there all the swapping programs that are out there, peer donor exchange programs out there, which really help find the right match for the for the recipient.
Tiffany Archibald 19:37
Okay, and I think one of the final questions kind of wraps up just everything we’ve discussed today. Where do patients even find the assistance and applying for transplantation? I know, that’s something that, you know, we probably could have talked about earlier, but I think it’s, it’s a good wrap up question.
Dr. Qureshi 21:31
Right. So, you know, as you know, all the typically, there is a nephrologist involved by the time a patient needs a kidney transplant, right. As you said the kidney function has to be below a certain percentage or the patient is already on dialysis. So the nephrologist, you know, your dialysis nephrologist, or your or your general nephrologist, they help you refer to the transplant program. So they have in the CKD clinic, you have the navigator help available. In the dialysis unit, there are social workers who help help the patient turn in the transplant applications. So when you’re in your in your in your nephrologist office or in the dialysis unit, you already have those resources available, and then your nephrologist can help refer you to a particular transplant program of, of their liking or depending on where the patient lives, on or the program that they’re worked with in the past.
Tiffany Archibald 22:24
Okay. And so if you had to leave us with one key point from this interview today, which was a wealth of information on transplantation, and, you know, we’re hoping that the listeners out there, whether they are personally being considered for a renal replacement therapy option as a transplant, or if they know someone, I’m hoping that is passed along. So if you can give us one key point, what would that be?
Dr. Qureshi 22:55
Well, I would say, as we started our talk with you know, that transplant has a huge benefit in mortality and morbidity benefit. That means you live longer and you live better. So if you’re if you have less than 20% kidney function, you’re on dialysis already. Make sure you you talk to your nephrologist, make sure you get referred to the transplant program. You know, whether you qualify, whether it happens or not is a different thing. But at least you should know that that’s an option out there for you. And that’s a great option. Because, you know, as we said, it has all those benefits and, you know, you can live pretty much a normal life as you would have before the kidney failure. So don’t let this option, you know, you know, you have to consider this option. You know, as I said, you know, make sure your nephrologist refers you and and have the word out and you know, for our general listeners who are not CKD patients, you know, you know, I think kidney donation is still a little bit of a taboo. So we have to make sure people out there realize that, you know, there are so many patients who need the kidney transplant and kidney donation is a great option. And you know, it does not compromise the donor. The donor has to go through a very thorough evaluation. So we have to try to educate the masses as well, so that we can help our patients with kidney disease get out of dialysis situation and you know, live a healthy life.
Tiffany Archibald 24:14
Alright, so I will say I will end this with share your spare. You have two kidneys. You can live with one. And transplantation save so many lives and, you know, just gives individuals that longevity and that quality of life that they can’t have on dialysis. So, thank you again, Dr. Qureshi for being our guest today. And we know that you provided us with a wealth of information so we hope that the listeners learned a lot and can share and if they can share the information or share their pair. I think that would be a great outcome.
Dr. Qureshi 24:49
Thank you. Thanks for inviting
Bri Crow 24:51
Thanks for tuning in today. Learn more about Dallas Nephrology Associates www.dneph.com. And if you found the information valuable, be sure to share with those who are impacted by chronic kidney disease.