Ask the Doctor
Questions about kidney disease? Risk factors? Signs and symptoms? Are you concerned about yourself, a friend or family member? Ask Dr. Spry.
Barbara Weis–Malone, RN, CFNP
83,000 patients wait for a renal transplant every year. 12% die every day hoping for a deceased donor kidney. As much as 10-20% of these have a potential donor that may have incompatible blood type (ABO incompatibility) or high level of sensitization (PRA). The first paired exchange was done at John Hopkins University in 2001, using two pairs who had incompatible blood types who then donated to the reciprocal pair.
The concept of paired donation is now growing in local alliances and has become a national program in many other countries including Canada and Australia. A medically eligible kidney donor who has immunological or ABO incompatibilities with their chosen recipient is matched with another donor–recipient pair if the first donor and the second recipient match and the second donor matches the first recipient. The goal is to do the transplant surgeries simultaneously to avoid donor withdrawal. Frequently, the donor will fly to another state to avoid cold ischemic time of the kidney. A living related donor transplant, on average, will last twice as long as a deceased donor transplant with better function and less rejection. However, as can be imagined, matching these two donors and potential recipients can be problematic.
The newest concept in an answer to this dilemma is the non–simultaneous extended altruistic donor chain (NEAD). Dr. Michael Rees of the University of Toledo developed an advanced software program that pairs three or more recipient and donor pairs across the country based on points for wait time, distance, age disparity, HLA match, PRA match and blood group type. The Alliance for Paired Donation was established in August 2006. In the first eighteen months, 26 paired donation surgeries occurred. Currently there are more than 75 centers in 25 different states who are participating. In July of 2007, ten simultaneous kidney transplants were done at 6 different centers in 5 different states. The concept is that when a non–directed donor identified by this advanced software initiates a chain of transplantation, each subsequent donor makes the donation only after the co–registered recipient in his or her pair has already received a transplant. Thus, the concept of "pay it forward." Dr. Rees has determined for every 100 donor–recipient pairs, there are 4,950 potential paired exchanges! I had the opportunity to hear Dr. Rees speak and he shared that his initial software to develop this program was the only birthday present he asked for from his father that year. He has a true altruistic heart. For more information on NEAD, refer to the New England Journal of Medicine article "A Nonsimultaneous Extended Altruistic–Donor Chain," also posted on the Alliance for Paired Donation website.
As an example, recently, the University of Colorado Renal Transplant Center had two excellent candidates for renal transplant who brought spouses to donate. The recipients were both O blood type and non–compatible with their spouses. One candidate had been on the list for 6 years because of a high immune sensitization level (common in dialysis patients because of blood transfusions). He has four family members that would love to donate a kidney to him. He now is eligible for NEAD. Our nation has committed to increasing the number of kidney transplants done every year. 10,551 renal transplants were done last year, half of which came from living donors. There will continue to be ethical and financial issues but the transplant community is open to new and creative ways to increase the living donor pool.
Carol W. Dahl, NP
The transplantation process is essentially comprised of three phases; the outcome of each phase is largely affected by the success of the preceding phase.
The PRE-TRANSPLANT phase involves referral to a transplant center, evaluation as an outpatient (absolute contraindications are ruled–out), listing (average wait time for a deceased donor kidney is 5 to 7 years), and identification of potential living donors. In an effort to address the organ shortage, recent innovations include the use of non-traditional donors, desensitization, ABO incompatible transplantation, and paired donation. Among these, desensitization is of particular interest as it allows for the transplantation of patients who are highly sensitized or who are blood group incompatible with their donors, and is achieved through protocols using plasmapharesis and intravenous immune globulin.
The TRANSPLANT phase involves final cross–matching, administration of an induction agent, retrieval and transplantation of the organ, and monitoring for complications (primarily those related to technicalsurgical technique, rejection, infection, acute tubular necrosis, and immunosuppression). Alemtuzamab is a powerful humanized monoclonal antibody used as an induction agent; it allows for replacement of the traditional threedrug immunosuppression regimen with a steroidfree regimen. The advantage of steroid avoidance is that the detrimental effects of corticosteroids on cardiovascular risk factors are negated. The agent can be used for most patients, but is not used for those who have previously undergone transplantation or who are otherwise being treated with steroids (such as with rapidly progressive glomerulonephritis).
The POST–TRANSPLANT phase is arguably the most challenging phase, during which the desired outcome is accomplished by maintaining optimal graft function while minimizing the untoward effects of the immunosuppressive drug regimen. The average graft survival following living donor transplantation is now estimated at 10 years. Due to the increasing longevity of patients and their allografts, there is more emphasis on wellness and compliance, through patient education, immunizations, and cancer screening (particularly for squamous cell carcinoma, for which the risk is roughly twenty times that of the general population). Wellness is best maintained through continued care in conjunction with the patient’s local nephrologist, regular lab checks and clinic visits, and diligence in following guidelines for disease prevention and management of comorbid conditions. For specific guidelines regarding the treatment of hypertension, hyperlipidemia and more, search "Improving Outcomes for Kidney Transplant Recipients" at www.kdoqi.org.
by Kim Zuber, PAC, MSPS
Happy fall…leaves are changing and so is CAP. Your Council is holding its first official election. Prior to now, the Executive Committee was appointed by NKF. Now, Lisa, Barb and myself, are running for our positions. At the moment, we are the only declared candidates but we hope to involve more CAP members in leadership positions SOON!
With that intro, we are looking for volunteers for sub–committees. If you have a particular interest, or a possible project CAP could support, we want to hear from you. Contact me with any questions or to volunteer. A volunteer program that we are just starting up and will need help with is "Sydney and Sidney the Kidneys," who are traveling the country promoting kidney health and awareness.
The first Sydney is the creation of Laurie Benton and her sewing machine and is about an 18–inch stuffed kidney–shaped doll. We envision them being the "Flat Stanleys" of the renal world, where members can document the dolls’ travels through photos and then send along to another member. This idea grew out of a request on the listserv from a CAP member who wanted to see where everyone lived. We had thought at first to have the kidneys travel and visit just CAP members. However, this has become an excellent teaching opportunity which we won’t waste – we plan to have an interactive map on our web page with educational content.
As to the other projects in the works: The CKD education module developed by Lisa Farris as a 2010 CAP membership perk is almost ready and looks great! Lisa will discuss her "Nephrology Essentials" program at the CAP luncheon during the NKF Spring Clinical Meetings in Orlando, and we plan to have the program available on the website for members–only.
Speaking of the Spring Clinical Meetings, the final touches are being made and the program looks wonderful. Kudos to the CME planning committee! They also are looking for unfunded volunteers who want to learn the process of what it takes to put together an incredible CME program, and would ideally move into committee roles. Laurie and Carol are wonderful mentors (they have taught me!) and we want input from all areas of the country. Since SCM11 is in Las Vegas, we are looking especially for west coast volunteers.
"Your Treatment, Your Choice"is a slide deck and DVD developed as a CKD4 education program by the NKF’s Kidney Learning Solutions (KLS). The Committee has reviewed the program in advance of its planned distribution in December, and it looks wonderful. Now, we can only hope the final Medicare CPT codes (due in November) increase the reimbursement for each education module. CAP joined with NKF in encouraging CMS to increase the funding for the program. AAPA and the AANP did as well. Thank you to everyone who helped.
The CAP Salary and Job Description Survey is ready!! It will be the first nation–wide survey of job descriptions, salary and benefits for nephrology APs ever conducted. Responses will be completely anonymous and the survey will be open to all APs, CAP member or not, allowing us to gather the most comprehensive data possible. Everyone who responds will receive a synopsis of the results; CAP members will receive the synopsis along with a full breakdown of all results, including the statistical analysis. The survey will be distributed in December 2009 and open through May 2010. So, for anyone who is planning to negotiate a contract, data is coming!!
Dates to watch:
Remember your first day as a nephrology practitioner? Maybe you were fortunate and had a mentor and were able to move into the role. Many APs, unfortunately, are thrust into the role with little to guide them other than prior experience, gut feelings and textbook knowledge.
Relief is in sight! Soon CAP will provide to members an online guide to the essentials of chronic kidney disease. The fact–filled program Nephrology Essentials will guide the new practitioner (and the experienced one as well) through many areas commonly encountered in practice. Data is presented with supporting research studies. The physiology of the disease process is presented along with guidance for treatment.
The program will be launched at the NKF Spring Clinical Meetings in April 2010 and available to view online for NKF–CAP members–only.
Lynn has been a Family Nurse Practitioner (FNP) for 36 years and has worked in the renal community since 1969. She has held many positions both as a nurse practitioner for the University of Virginia Health Sciences Center and as a Director and Manager for renal–related programs for several renal–related organizations.
One of her areas of expertise is Disease Management/Case Management (DM/CM) and she has worked with industry to provide this service to patients with Chronic Kidney Disease (CKD). She was a member of the team at Nephrology Services Group which introduced, developed and implemented the first DM/CM program for patients with CKD stage 5. After the success of the initial program, she was part of the team which marketed and implemented these programs to other providers of renal services.
In addition to her certification as an FNP, Lynn holds certification from the American Nephrology Nurses Association, in Basic and Advanced Motivational Interviewing and Health Coaching and also in Applied Project Management. She is active in her profession and is a member of several professional organizations including American College of Nurse Practitioners, Virginia Council of Nurse Practitioners, American Nephrology Nurses Association, American Nurses Association, Renal Physicians Association and, of course, National Kidney Foundation and CAP. She has served on many committees and initiatives to promote NPs and renal care.
She has been politically involved in the advancement of NPs in Virginia and was part of a grass–roots effort which successfully brought about changes in the laws governing NP practice in the state. In addition, she served two terms on the Virginia Advisory Board to the Joint Committee of Nursing and Medicine. Lynn describes herself as a "political junkie"who enjoys involvement in the political process. She served as Legislative Chair for Virginia NPs and has been involved in changes which have benefited Virginia NPs and which serve as models for other states to follow. She has been actively involved in Fistula First since its inception and continues to promote the initiative.
When she is not serving in her role of independent consultant to nephrology practices, Lynn likes to read, travel and spend time with her extended families. Her current position allows her to travel throughout the country to consult with renal groups. Lynn enjoys a challenge and finds this role to be stimulating and satisfying.