Post Transplant Watch: Bone Disease

Bone disease is something that kidney disease often brings with it. The reason for this is that our kidneys play a major role in building our bones and keeping them strong.

One other issue is steroids. Most kidney transplant centers have used steroids as part of their immunosuppression protocols. Over the years, great strides in the post kidney transplant medication management have allowed doctors to minimize the doses of steroids we have to take in order to keep our transplants. In fact, there a already a number of transplant centers that have moved to a steroid-free immunosuppression protocol with great success rates.

But for most of us, whose transplant centers regimens include steroids, and for those who require steroids otherwise experience rejection, the consequences of steroids is something we have to deal with.

Here are some steps that doctors will monitor closely in order to minimize the problems caused by steroids with respect to bone disease.

RISK FOR OSTEOPEROSIS

Osteopenia and osteoperosis are two situations that everyone looks to avoid. They are signs that our bones are weaker that should be and in many cases more brittle and thinner also. Having weaker bones makes us more susceptible to fractures and other bone injuries as well as unwanted changes in our stature that make it more difficult to function normally.

For patients at risk of osteoperosis, the following guidelines will help in preventing it from happening and keep a close watch so that more aggressive treatment can be made when there are possible signs of moving towards it.

Being in any of following situations may put you in greater risk of osteoperosis

• Women
• Menopause or above 45 years
• Personal or family history of low-trauma fractures
• Amenorrhoea (absence of menstrual bleeding)
• Slender build (BMI <>

STEP 1: Weight bearing exercises

I learned that weight bearing exercises are very important in keeping our bones strong. They also help build bone density. The logic sounds contrary to what we'd normally think. Common thinking would be, by not pushing or handling weight, we preserve our bones. But ironically, forcing our bones against heavier objects and making them 'work', actually improves their health, similar to how our muscles react to exercise. While being sedentary makes our bones deteriorate faster.

Not all exercises, however, are created equal. Some help in increasing bone mass and strength, while others don't. For example, exercises like lifting weights, brisk walking, climbing stairs strengthen bones, while swimming, rowing, cycling have been shown not to be as effective.

Also, different exercises affect different bones. Activities like climbing stairs, jumping and brisk walking help increase bone density in the hips and spine, whereas push-ups, for example, strengthen the bones in with wrist, arms and shoulders.

STEP 2: If you smoke, stop

Studies have shown that smoking is detrimental to bone health and bone healing.

The reason? Cigarettes and tobacco contain nicotine, which constricts blood vessels of their normal diameter. Because of the constriction of the vessels, the amount of nutrients that are supplied to the bones are less than they should be.

STEP 3:Calcium carbonate

Taking calcium carbonate is often needed in order to make sure that you get sufficient calcium that may otherwise be lacking from diet.

STEP 4:Vitamin D if or other activated forms of Vitamin D

Along with calcium, vitamin D is needed in order to build bones. With lessened function, the kidney isn't able to produce the same amount of vitamin D that it used to. Thus, supplementation with vitamin D is often required.

Depending on how well kidney function is, however, the type of vitamin D matters. If kidney function is good, meaning a GFR of 50ml/min or higher, then the vitamin D3 supplements are often given.

But in cases where there is decreased kidney function, like when creatinine is above 200 μmol/L or 2.3 mg/dL, your doctor may prescribe an activated form of vitamin D formulation like, alfacalcidol.

In doing this, it effectively side steps the need for the kidney to work in order to convert the vitamin D that comes in oral form or sunlight into the activated form which is what the body can use.

STEP 5: DEXA scan

A DEXA scan can be compared to other imaging machines like x-rays, and MRI machines. What they do is to scan through our bones and provide us an indication of how strong our bones are, in terms of bone mass density.

This is something that isn't always done by physicians but something I've learned to be quite important in gauging how well our bones have done over time (if they are improving or weakening) and if the current treatments being prescribed are working.

It is a good idea to get one before transplantation and yearly thereafter for comparison.

In an upcoming post, we will take a look at how the steps may differ when a diagnosis of osteopenia or osteoperosis has been determined.

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Kindess From A Stranger

When we look at the world we live in, we often see a lot of harsh and sad events that lead us to look at the world we live in with a negative perspective. The thing is, often enough, just when we're ready to give up on believing that man is still capable of great kindness and compassions, it never fails to pull out a surprise.

Here's a great inspirational story that reminds us of the wonders and generosity we are all capable of. In this instance, a cab driver offers to donate his kidney to a passenger whom he knows needs it.

PHOENIX — Rita Van Loenen had no idea that a trip in Thomas Chappell's taxi cab could end up being the ride that saves her life.

"There are better odds of getting struck by lightning," Van Loenen said. "A random taxi driver offering to give me his kidney and all these pieces match. There has to be something behind this. How can this be?"

Chappell, who has been driving Van Loenen to dialysis appointments, shocked the Gilbert, Ariz. woman a month ago by offering to donate his kidney. But even more shocking to her was that doctors found they had the same blood type, that they were compatible.

"He calls me all excited. If we were a closer match, we would've been siblings. I was ready to fall off the floor," Van Loenen said.

The Phoenix taxi driver said he was a man of faith and that a higher power wanted him to step in.

"By then, me and the good Lord already had a talk. He said 'Tom, you go give her one. It will work," Chappell said.

Last year, Van Loenen, an instructor in special education methods, began feeling ill and experiencing water retention in her legs. She went to see a doctor and was diagnosed with kidney disease. With kidney failure setting in, friends and family were tested but there was no match.

In February, she received her cousin's kidney but that transplant failed. One day, Van Loenen, 63, found herself telling Chappell, 56, about how her son was now going to get tested. Chappell decided to add his name to the list.

"I said 'Rita, your son's a whole lot younger than me. He's got a lot more years. I'm gonna go down and go through the process and see if it will work.' I don't think she really believed I was going to."

The gesture evoked tears of gratitude from Loenen but she was still skeptical.

"A little bit in my heart I didn't believe it. He said 'give me the number' and I have transplant number at Mayo (Clinic in Scottsdale) memorized."

The two first met more than three months ago. It wasn't an auspicious beginning.

Chappell was half an hour late picking Van Loenen up for a dialysis appointment.

"When I got there she was not happy," Chappell said. "And I can understand it now. She's sick and all these things she goes through ... The next day, it just so happens I got her again."

Since then he has — and he insists it is by happenstance — been her taxi driver three to four times a month. For the last month, Chappell has started undergoing the arduous process of donor screening, undergoing numerous tests and exams. But none of it has brought second thoughts.

"This has put a whole new kind of lift in my boots. I never knew what it felt like to give somebody life and that's what I'm doing," Chappell said.

Van Loenen said Chappell never asked for any compensation. She still can't quite believe his level of commitment.

"I've never known anybody so enthusiastic to get a body part removed," Van Loenen said.

After the transplant, which hasn't been scheduled yet, Chappell will need to tread carefully. He will have to rest between four and six weeks but his work has promised to cover his lost wages.

"I've had drivers do some pretty incredibly amazing things for no charge. But this is just over the top," said Jim Hickey, national sales and marketing director for the company that owns VIP Taxi. "We're just so proud of him."

Van Loenen said that, thanks to Chappell, she can actually make plans for the future.

"Whenever I tell my friends or my family, they just find it so incredible," Van Loenen said. "They do call him an angel. My friend says there's angels everywhere. That's the right way to capture it."

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Night Hemodialysis Just as Effective as Kidney Transplant

In the first study of its kind, it has been shown that night time home hemodialysis, which is done for 6 to 8 hours nightly, up to 7 days a week, is as effective as receiving a transplant. The long term study focused on comparing the survival rates and how this particular type of dialysis compares with both cadaver and living donor transplantation.

For the first time, it has been shown that patients who receive night home hemodialysis live just as long as those who receive kidney transplants from deceased donors.

[...]

a total of 1,239 patients were followed for up to 12 years. Night home hemodialysis patients were compared to patients who received either a deceased donor kidney transplant or a living donor kidney transplant. The study found that the survival between night home dialysis patients and those who received kidney transplants from deceased donors was comparable, while the survival of the patients who received a transplant from a living kidney donor was better than both the other groups.

These results are encouraging considering the shortage of organs. It provides a means for those waiting for a transplant to maintain good health and good quality of life. In certain situations, it may also be a good alternative to high risk patients that aren't approved for transplants and those who aren't able to get a kidney transplant.

The full article can be found here.
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Single Kidney Transplants from Young Donors Effective

In the August publication of The Clinical Journal of the American Society of Nephrology, researchers reported that transplanting a single kidney from a young deceased donor is sufficient in maintaining health in an adult with kidney failure.

In most transplant centers, the kidneys of very young deceased donors are transplanted together into one patient. According to a study appearing in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN), a single kidney from a very young deceased donor maintains the health of an adult with kidney failure.

[...]

The researchers' study included all 79 adults who were transplanted at the Tulane Abdominal Transplant Institute with single pediatric kidneys from deceased donors aged 10 years or less between January 1996 and June 2007. Physicians transplanted a single pediatric kidney if it was healthy enough for splitting and the recipient consented. Half of the adults received single pediatric kidneys from donors less than five years of age. The other half received single kidneys from donors aged five to 10 years.

[...]

Patients in the two groups experienced similar rates of kidney rejection and delayed kidney function. In both groups, kidney function improved dramatically in the first year after transplant, and it continued to improve into the third year. Furthermore, patients in the two groups lived a similar length of time. The youngest donor in the study was a nine-month old female; both of her donated kidneys remain healthy more than six years post-transplantation into two different recipients.

The article is saying that based on their findings, using a single kidney from very young diseased donors are able to sustain good health in adults. Often, when the donor is of very young age, both kidneys are transplanted into adult recipients.

This report contradicts previous studies where it has been noticed that adults given single kidneys from very young donors produce more complications compared the those from adult donors.

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Wearable Artificial Kidney

The wearable artificial kidney that is being developed has been successful in preliminary trials. It looks promising with the ability to allow patients to strap on their 'portable dialysis' machines and receive dialysis 24 hours a day, 7 days a week.

While it is still going through tests, things look promising.

"Our vision of a technological breakthrough has materialized in the form of a Wearable Artificial Kidney, which provides continuous dialysis 24 hours a day, seven days a week,"

[...]

The device—essentially a miniaturized dialysis machine, worn as a belt—weighs about 10 pounds and is powered by two nine-volt batteries. Because patients don't need to be hooked up to a full-size dialysis machine, they are free to walk, work, or sleep while undergoing continuous, gentle dialysis that more closely approximates normal kidney function.

[...]

The Wearable Artificial Kidney is successful in preliminary tests, including two studies in dialysis patients. The new study provides important information on the technical details that made these promising results possible.

This will be a great innovation that will allow dialysis patients not only avoid having to sit around the dialysis machine during dialysis sessions, but also allow continuous filtering of the toxins from the body, resulting in better health and quality of life.
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Pros and Cons of Kidney Biopsies

Although the kidney biopsy is a very thorough test that is able to provide a good assessment of kidney function, it isn't always the first option doctors go to in diagnosing kidney issues. Other procedures such as blood tests, urine sampling, ultrasound and CT scans are often done first. Only when these have been exhausted and there are still some unanswered questions, or the need to get a more definitive answer to a lingering unknown does the biopsy come into play.

Knowing the pros and cons of having a kidney biopsy should help explain why physicians often take this route.

PROS

• Gives a clear cut picture of what is happening, what is affecting the kidney, how much is functioning, amount of renal mass that is still working and any infection or malignancy, if present.
• It can find the cause of the kidney problem and tell what the best treatment will be.
• Biopsies enable you to avoid being given unnecessary treatment which could have side effects.

CONS

• The procedure is invasive, because there is penetration of the skin more risk is involved. The most common complication is bleeding. Another complication is possible damage to the kidney or other parts near it, if the kidney biopsy is done incorrectly. Though complications especially the latter one are very rare.
• A kidney biopsy is expensive. The procedure itself which uses an imaging machine, like an x-ray or CT scan, along with the testing and doctors' fees cost significantly more than regular blood tests.
• In a biopsy, the doctor will take a part of the kidney, so the sample may not be a complete representation of the health of all the tissues in the kidney. For this reason, some doctors may get elect to take a number of samples from different areas of the kidney during the procedure.

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Warning Signs of Infection

A common side effect of immunosuppressive agents is increased susceptibility to infection. These drugs, such as kidney transplant medications, weaken the immune system to prevent rejection. Therefore, you must take precautions to avoid infection.

If you experience any of the following signs of infection and or rejection as mentioned here, you should notify your transplant coordinator immediately. They will be able to give you the proper instructions on what to do.

Here are common warning signs of infection.

1. Sore throat
2. Cough, cold or shortness of breath
3. Flu symptoms
4. Fever over 100°F or 37.8°C
5. Pain over transplant area
6. Gastrointestinal discomfort, diarrhea, nausea and vomiting
7. Skin irregularities like sores, redness, swelling, or wounds that don't heal

Looking after yourself and being careful often reduces the possiblity of getting infections. I remember my doc telling me what to watch out for. But the most important things that came out of his lips then was “use common sense.”

As transplantees, we should be wary of infections because when they occur, our body's immune system becomes active and sends out its soldiers to knock out that infection. During this process, our immune system goes into attack mode and is more vigilant to foreign substance, including our kidney, increasing the possibility of causing a rejection episode.

It is important to inform your transplant center when you notice these symptoms and not to just take any over-the-counter drug that other people take. Many over-the-counter drugs can harm our transplanted kidney.

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Post Transplant Watch: High Blood Pressure

After a kidney transplant, there are a number of health issues that doctors will ask you to watch out for. Often, most of the kidney related problems that appeared when you had kidney disease go away after having a kidney transplant. There are some, however, that will remain even after a successful kidney transplant.

This is a part of a series that I call Post Transplant Watch, where we will look at the different issues that may linger after kidney transplantation and steps doctors often take to treat them.

We begin with the most common problem and main cause of transplant (graft) loss-- cardiovascular disease or heart disease. Because there are many things that lead to cardiovascular disease, we will go through them one at a time, beginning with high blood pressure.

You will notice a number of levels listed below. Beginning with level 1, we start to solve the problem, in this case hypertension. If that doesn't work, we move on to the next level to see if that works better, and so on. These are the steps I've noticed doctors take in dealing with particular issues.

I hope this can be a guide for you so you will have an idea about what your doctor doing. Remember, this is meant to give you an idea of what to expect and is not a substitute to your doctor's advice. Only your doctor will be able to tell you what to do because they know your medical history.

Here goes.

Level 1: Target BP: less than 130/85

How? Weight loss if overweight, limit salt in diet or low sodium diet, reduce alcohol intake, increase exercise.

This is the best way to do it, without any drugs or medication. All natural. Your doc will probably want to have your BP at 120/80 or 110/70.

If these aren't able to control blood pressure, we proceed to level 2.

Level 2: Calcium channel blockers

What? Calcium channel blockers (CCBs) are blood pressure medications. Often the first line of defense used by doctors for high blood pressure in kidney transplant patients.

Research has shown that they help improve renal function by controlling blood pressure. The also protect you from the hypertensive effects of CNIs like cyclosporine and tacrolimus. Examples are amlodipine and lercanidipine.

Level 3: ACE Inhibitors and ARBs

What? These are 2 different classes of blood pressure medication. ACE inhibitors and ARBs work differently to achieve the same goal — lower blood pressure. Often you will be told to take one or the other with most doctors favoring the use of ACE inhibitors first before trying ARBs if the ACE inhibitors don't work well enough or produce side effects.

There are times that either ACE-I and ARBs aren't able to achieve the desired results on their own. In this case, the some doctors will use a combination of an ACE inhibitor and ARB.

The reason why CCBs are tried before ACE-I or ARBs is because the latter two have more side effects. One very known side effect is coughing. Increase in creatinine level and anemia in some patients also happen.

There is one instance though, where your doctor may opt to use an ACE inhibitor or ARB over a CCB. This is when there is protein in your urine. ACE-I and ARBs are known to have anti-proteinuric effects. And by lessening the amount of protein spilled in the urine, it protects the kidney.

Examples of ACE inhibitors are lisinopril and ramapril, while valsartan, losartan and candesartan are some known ARBs.

Level 4: Beta-Blockers

What? Beta blockers are yet another type of blood pressure drug. They work differently from those mentioned above and are known to be used for coronary heart disease.

They should be avoided for people with asthma. One example of a beta blocker is atenolol.

Level 5: Immunosuppressive medication adjustments

Why? Some doctors may actually try this before level 2. The reason I place this here is that adjusting medication is risky and often more troublesome. Having your kidney transplant medication adjusted may cause possible rejection if you become under suppressed. It also means that you'll probably be having labs done more often in the coming weeks to monitor if everything is okay with the change.

That said, lowering steroid doses helps in bringing down blood pressure. Another well known anti-rejection drug that causes hypertension are CNIs, like cyclosporine (Neoral) and tacrolimus (Prograf), so keeping it within therapeutic range will be helpful.

One thing to remember is that not everyone will have to deal with these issues. At times, these issues are caused by kidney transplant medications themselves. If you do happen to notice them make sure to inform your doctor so they can treat it accordingly. Read more...

Warning Signs of Transplant Rejection

After having a kidney transplant, or any other organ transplant, you will be required to take anti-rejection medicine for as long as your organ is functioning. The purpose of kidney transplant medications is to prevent our bodies from attacking our new kidney.

This is needed because our body's immune system cannot tell the difference between a new kidney and viruses or bacteria that might attempt to harm out body. In order to keep us healthy, our immune system destroys all foreign objects like viruses and bacteria, but in the process will also try to destroy our transplanted kidney.

The process where our immune system mounts an attack on your new kidney is called rejection. Rejection has a bigger chance of happening during the first year after transplantation and goes down over time, but it never goes away.

Here is a list of the warning signs of rejection.

1. Fever over 100°F or 37.8°C
2. Elevated Blood Pressure
3. Sudden and rapid fluid retention (rapid weight gain or swelling of the ankles)
4. Flu-like symptoms (dizziness, vomiting, headache, fatigue)
5. Discolored, bloody, or foul-smelling urine
6. Reduction of the amount of urine
7. Pain over the transplant site
8. Pain or burning during urination
9. Elevated serum creatinine level

Of all the warning signs, I have noticed that the most indicative is a rise in creatinine. Most of the time, you don't feel anything during a rejection episode except that the creatinine results have gone up. This is why it is important to have regular labs and doctor check ups.

As a guide, a sudden rise of 0.4 from your normal levels is a sign that something is happening. For example, your regular creatinine levels are 1.2, so a value of 1.7 or above will be a cause of concern.

Before you start to worry, I've learned that a sudden rise in creatinine does not always mean a rejection episode is happening. There are other possible reasons for a rise in creatinine which we'll talk about in a later post.

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The Issue of Generic Cellcept

Earlier this year, the generic version of Cellcept came into the market after Roche's patent on Cellcept expired in May of this year. This was and is still a much discussed topic. On the issue of kidney transplant medication or immunosuppressive medication as a whole, the issue of generics is a very touchy subject.

There are actually two main causes of this, on one side, is cost. Transplant medications are very expensive. Depending on what doses and which drugs you are on, costs may range from high to exorbitant. Not to mention that, more often than not, you have additional drugs and supplements aside from the anti-rejection pills.

At the other end, is drug efficacy. How well does the generic drug, in this case Cellcept, stack up against the branded one. Patients who have had their transplants have been on the Cellcept brand for a while and are now facing the choice between the cheaper generic and costlier but proven brand.

The sad fact of the matter is, as much talk as there is, transplant patients may not really have a choice. Most patients have their transplant medications covered by some sort of health insurance. In most cases, it has been the insurance agency that is prompting the move to generic. For those who pay out of their own pockets, depending on where you source your immunosuppressive drugs, the cost difference between Cellcept and its generic may vary from 10% to more than 50%.

Doctors, on the other hand, are more hesitant. Given the option, they prefer that patients take the branded product. As a whole, they seem to agree that the difference in efficacy matters. Some say there is a 10% variance, others say the effects may be +15% or -15% the effect of the branded product depending on the person taking it.

Another thing they seem to agree is that though they prefer that we use the brand name, and should you shift to generic, to make sure to inform them so that they may monitor your progress and the cellcept blood levels closely during the initial conversion period.

So what has happened since?

Some transplant patients have avoided the generic because their doctors and clinics forbid it. Their doctors have provided branded scripts that explicitly state “no substitutions”, “use branded name”, “no substitutes,” “original as written” and the like.

Others have opted to add to their co-pays or pay for the extra cost it takes to have the branded name.

One creative method I've heard from few was they were asked to switch to Myfortic because the insurance didn't want the branded Cellcept.

There are also quite a number of transplants who have moved and are now using the generic. Some clinics have given it the go signal for their patients.

Generally, the generic seems to be working okay. Some have said they have no problems with it, others say it is less troublesome for their stomachs. Then again, I've also heard a few problems like stomach issues and skin problems, proving once again that everyone reacts differently to medication.

Luckily, my being on Myfortic allowed me to sidestep this issue. But whichever way you look at it, this is a learning lesson for all of us. It has happened before, with cyclosporine (Gengraf) and now Cellcept, and it will happen again.

Soon, Prograf will have a generic then all our other drugs will go past their patent. At least next time, we'll be better prepared.

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