Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices ensuring you stay at the forefront of your field. I'm Melanie Cole. And today, we're going beyond dialysis, understanding kidney transplant options.

Joining me is Dr. Khaled Nashar. He's the Chief in the Division of Nephrology and Hypertension at Allegheny General Hospital and an Associate Professor of Medicine at Drexel University College of Medicine. Dr. Nashar, thank you so much for joining us today. Tell us a little bit about the evolution and how common kidney transplants really are and how many you do there at AHN.

Dr. Khaled Nashar: Thank you, Melanie, and great to be with you, and I appreciate the opportunity. I'm always excited talking about transplant. Transplant is the best option for patients with kidney failure. In 2024, the United States have accomplished one million organ transplants. So, this was a milestone in the world of transplant.

Now, in Allegheny General Hospital, we started doing kidney transplants since 1987. And so far, we've done over 3,000 kidney transplants with great outcomes. Kidney transplant is common, is increasing due to the increasing incidence of kidney disease, and the awareness that this is a much better option for patients with kidney failure compared to dialysis. There's so much exciting stuff in the pipeline also that I'd love to discuss with you.

Melanie Cole, MS: Well, we will get into so much of it, because it really is an exciting time in your field. And before we even get into the time for referral, why is kidney transplant sometimes a better option for patients with kidney failure than dialysis?

Dr. Khaled Nashar: Yeah. So, options for patients with end-stage kidney disease include transplant dialysis or conservative care, sometimes doing nothing, meaning hospice. We think that transplant is a much better option than dialysis, and that's been documented in clinical trials and patient outcome studies.

Patients with kidney transplant live longer and have better quality of life compared to those who are receiving dialysis. As you know, kidney transplant can be from a deceased donor or living donor. Outcomes are better obviously if patients receive living donor kidney transplant. Currently, statistics are around 15 to 20 years survival for the kidney in the living donor case compared to eight to 12 for deceased donor.

Now, these numbers are general and averages. I've had patients who've had 40 years out of their kidney transplant. I have patients who had much less than these averages. So, it varies, and that depends on the recipient, on the donor, and other factors.

Melanie Cole, MS: Well, then let's talk about disease processes necessitating kidney transplantation. Give us some indications for referral to a transplant center and why you feel that early referral is better.

Dr. Khaled Nashar: Absolutely. So, patients who receive kidney transplant before needing dialysis do better than those who've been on dialysis. Now, it's never too late to refer or to receive a kidney transplant, but we always encourage early referrals because it takes time for patients to get on the list, to get all their testings, and there is a wait time also.

So, wait time varies by region in the United States. And in our region here in Western Pennsylvania, it's about three to five years. So, that's why we always encourage providers to refer their patients as early as possible. Now, sometimes it can be too early. So, the best time, I'd say, when patients reach stage IV chronic kidney disease, patients can be referred, they can be evaluated, testing can begin. And then, we list them for kidney transplant when their GFR is 20 or lower.

And this also allows patients to accept transplant as an option to look for a living donor. So, there's so many benefits to referring patients early, list them on time. And again, their outcomes post-kidney transplant are better if they received what we call preemptive kidney transplant, meaning before needing dialysis compared to if they've been on dialysis for a long time.

Melanie Cole, MS: If you would, Dr. Nashar, speak about what's involved in your pre-transplantation evaluation. Let's speak about patient selection, because that really is so important for those better outcomes, and any conditions that would preclude kidney transplant as an option.

Dr. Khaled Nashar: Pre-transplant evaluation is a very scrutinized process. We evaluate the patient in a multidisciplinary fashion. Patients come in for evaluation. It's usually a full day process where they meet with multiple team members, a transplant nephrologist, a transplant surgeon. They will be assigned a coordinator. They will also be evaluated from a psychosocial standpoint by a social worker and a transplant psychologist. They will meet with a transplant pharmacist to go over medications post-transplant expectations and such. They will meet with a financial coordinator to understand also the, you know, financial implications of transplant and copays and such. If they need a dietician, we refer them to a dietician as well. And so, it is a multidisciplinary approach.

Now, the idea is transplant is not for everyone. So for example, conditions that preclude transplant would be active malignancy, so cancers. We would want them to be free of cancer. Depending on the cancer, most cancers, wait time's about two years after remission. Some cancers, they have to wait five years if it's metastatic and such. So, those are the things that we look at. Also, they have to be free of infections. They have to have a healthy heart. No chronic conditions that limit life expectancy.

Again, from a psychosocial standpoint, they have to have good support. They have to have also no peripheral vascular disease, because the kidney is transplanted into the iliac artery and vein, and we want to make sure that those are patents to receive perfusion to the kidney. So, that's important part of the evaluation as well.

So, the patients go through an extensive workup to make sure that they don't have any of these conditions that would preclude transplant as an option.

Melanie Cole, MS: So, that's so interesting and how that's evolved over the years. And Dr. Nashar, what have we learned about obesity and kidney transplant? How does that affect candidacy and post-transplant outcomes?

Dr. Khaled Nashar: I'm so glad you brought this up, Melanie, because it's something near and dear to my heart. Obesity used to be a barrier to transplant, and most centers have a BMI cutoff of 40 and some may be even more strict. They would have a cutoff of 35. But the idea that if BMI is higher than that, especially if the fat distribution is around the belly and the waistline, this will increase the chances of complications post-operatively, meaning wound infection, wound healing, and sometimes it affects the kidney function after transplant.

So, the classic thinking is that BMI should be below 40. However, you know, at Allegheny Health Network now, what we do at AGH is that we accept patients for evaluation regardless of their BMI. We have a great relationship with our weight loss program, medical and surgical here at AHN, where we refer patients so they can undergo either medical or surgical bariatric treatments to achieve the weight necessary for them to have a safe transplant.

I also treat obesity medically. I received a certification by the American Board of Obesity Medicine. So, I participate in that process also, and that helps keeping the patients within the transplant program. Because in the past when we see patients with high BMI and we refer them, they may lose follow-up and may never come back.

So now, having an integrated program within the transplant program allowed us to work on this condition with the patient, with the specialists, and get them to a BMI that is safe for transplant in a timely fashion. So, this gave the hope to patients to get a transplant sooner and quicker than before, especially with the availability now of so many weight loss medications that are proven to be safe and effective even for patients on dialysis. So, that's one.

The other thing also at AGH, our surgeons started using robotic transplants. So, we are the first and only center in Western Pennsylvania that performs robotic-assisted transplants. So, this is not for the donor, this is for the recipient. One of the advantages of this technology is to allow a safe transplant for patients with high BMI. So, the incision is smaller, the recovery time is shorter, and patients who used to be deemed high risk from a weight standpoint now can undergo robotic-assisted kidney transplant safely. So, it's exciting. Obesity is becoming less of a barrier to transplant and this allowed so many patients to be listed for kidney transplant safely.

Melanie Cole, MS: That is truly amazing and really opens up the pool. Now, when we think of the wait list, which is what everybody talks about when thinking about transplantation, there are a number of ways to abbreviate that wait for a kidney, and one is living donor transplantation. Can you speak to us about deceased versus living donor kidney transplant? Tell us a little bit about how that works, the process for both the donor and the recipient.

Dr. Khaled Nashar: There is critical shortage in organs. This is why there is over 100,000 patients on the wait list nationwide in the United States. And that's why the government, professional societies, and all involved entities are pushing centers to do more transplants because outcomes are better for transplant.

However, with the limitation in organs availability, patients are left with the option of receiving living donation. And living donor outcomes, again, are much better than deceased donor outcomes. Kidney starts working immediately, less chance of complications, less chance of delayed graft function and such. It is a programmed process. So, again, less chance of complications and the kidney lasts longer. As I said, you know, earlier stats on average we tell patients the average allograft life for living donation is about 15 years compared to eight to 12 for deceased donor kidney transplants. So, we always encourage patients to search for donors.

Now, it's not easy for patients to go and ask people to give them a kidney, obviously. But we empower patients to make their case known to others, to tell their story, to say, that they're most of the time on dialysis, they go three times a week. They feel very fatigued and tired after dialysis. And it's important to increase awareness of that, and let people know about the wait time for deceased donation being three to five years. And, you know, people connect the dots.

Now, the living donor evaluation process is done by a separate team, not the same team that evaluate the recipients. And the idea behind this is that We want to protect the donors, right? So, it's very private process. It's very scrutinized process for the donor to make sure that donation is not going to harm the donor and that donors will not need two kidneys in the future. So, we have again a dedicated team for donor evaluation.

Donors go through extensive evaluation and workup to make sure that a donation's going to be safe for them and harmless. Most people can live with one kidneys, but some people may need two kidneys, and it's our job to make sure that the donor we're evaluating is not one of those people.

So, meaning they don't have any risk factors for kidney disease, for diabetes, and such. They don't have any condition that will preclude donation as an option for them. So we, screen them for cancer, for infections, for chronic diseases and such. They get also an extensive psychosocial evaluation to make sure they really want to do this and there's no coercion, there's no pressure or guilt feeling and such that's making them want to donate. Obviously, no financial incentives and such.

We follow these donors also for two years post-donation. And we make sure that they have primary care follow-up and we perform laboratory testing to make sure their kidney function's not been affected by donation. Donors also in Pennsylvania are protected by the Living Donor Protection Act. So, what this means, they're entitled for medical leave and leave to donate. And they also should not be discriminated against by insurance companies and others for preexisting conditions or by employers. If they want to donate, they cannot lose their job. And so, this law really advanced living donation and helped increasing the number of living donor transplants.

Melanie Cole, MS: Dr. Nashar, what makes the transplant center at AHN stand out compared to other centers in the region? Tell us a little bit about your team, the multidisciplinary approach, and why it's so important to refer.

Dr. Khaled Nashar: First of all, I want to tell you that the transplant program at AGH is what kept me working here for all these years, and this is the only job probably that I have in my career, because I love working here. I love our team approach to patient's care. We work extremely well together with our surgical colleagues with our transplant coordinators.

We're all one family, and we have a truly one team approach to patient care. And patients feel that. Patients always comment on the customer service really, if you will, that they receive here at AGH, the personalized care, the individualized attention that they receive from their coordinators, the prompt responses.

But not just that. So if you look actually on the SRTR, that's the Scientific Registry for Transplant Recipients data, this is a governmental agency that tracks transplant data and outcomes across the country. You will see that the likelihood of a patient receiving a kidney at our center is much better compared to other centers in the area.

We rank number one or two in the state of Pennsylvania for the likelihood of getting a kidney transplant, and also for outcomes. Our outcomes are great. And this is not by accident or by chance. This is a true teamwork, a thoughtful process. We work extremely well collaboratively with the rest of the transplant team.

Also, we embrace innovation. And as I mentioned earlier, the robotic transplant, the obesity management for the transplant recipients, all of these things really make us stand out compared to other centers in the area.

Melanie Cole, MS: Dr. Nashar, speak a little bit about life after transplant. You mentioned follow-up before. Speak a little bit about immunosuppression after kidney transplant, and what are you looking for?

Dr. Khaled Nashar: So, first of all, this is a very rewarding part of what we do. It's great to see these patients' lives transformed after receiving kidney transplant. I wear too many hats, and I see patients on dialysis, and I can see how their lives are transformed after they receive a life-saving organ transplant.

Patients live, for the most part, a normal life. They are not restricted by the dialysis three times a day or more if they're doing home dialysis. They feel better, they live longer. And immunosuppression management has advanced over the years to the point that there's actually very little research now for new drugs because the current drugs provide excellent outcomes in terms of graft and patient survival after transplant. We are active in using newer drugs when they come out. For example, we use belatacept. Belatacept is a monthly infusion that replaces CNI, meaning tacrolimus and cyclosporine agents for the appropriate patient. This is a great option that decreases side effects from tacrolimus and cyclosporine and decrease the need to take medications on daily basis.

So, immunosuppression management has really advanced in the last decade or so. And we're always on the lookout for new protocols where we minimize the use of steroids for our recipients and for newer technologies for early detection, non-invasive ways to detect a rejection by urine test and blood test as opposed to doing biopsies all the time.

One thing I'd like to improve about patients' care after transplant is the incidence of obesity and diabetes after transplant. Patients after transplant feel better and their appetite picks up, and subconsciously they eat more and gain weight, and some of them develop diabetes post-transplant. That is an area that I would love for this to improve for our patients. So, that's why we're always encouraging patients to embrace a healthier lifestyle to try to maintain low caloric intake and engage in physical activities and exercises to prevent weight gain and diabetes. But overall, transplant is an excellent option. Patients feel better and they live longer and better with transplant compared to dialysis.

Melanie Cole, MS: Dr. Nashar, as a final thought here, please tell other providers what you would like them to know about the key takeaways about what you're doing there at Allegheny Health Network, and anything exciting about the future of kidney transplantation that you would like to mention, because there's so much going on in your field right now.

Dr. Khaled Nashar: Sure. I love my job. I love our program and our team at Allegheny General Hospital, and that's what keeps us going. Our outcomes are great. We're always looking out for new technologies, new protocols. The patient care delivered at Allegheny General Hospital is exceptional, and that's reflected by our outcomes as reflected by the SRTR and other data.

Now, one thing exciting in the world of transplant that is still exclusively in the research arena for now is xenotransplant. And I know you may have heard about it. Lots of people are curious about where we stand with that. So, this is meant to address the critical shortage in organs and organ availability.

And so far, this is a research area only. It may be a while before this gets close to human applications. So, let me take a step back first. Xenotransplant is the idea of transplanting animals' kidneys into humans. And the animal that is most compatible is pig kidneys and pig hearts. So, that's what's been tried in clinical research. And again, this is not new. There was an attempt in 1964. However, kidneys failed due to thrombosis and then, later on, rejection. But last year, we've made the best outcome out of this trial when a patient in Mass General Hospital received a pig kidney. His name is Tim Andrews, and he was on the news and, you know, it was highly celebrated. The pig was called Wilma, and the kidney lasted for over 270 days, and it was a bridge to a human kidney transplant. So, the patient received the pig kidney and was able to have a life free of dialysis until he was able to receive a human kidney. So, this was a huge success and a milestone in the journey to successful xenotransplant.

I think we have ways to go. We're not close to primetime in any way. But the future is encouraging. And I think, in several years, this may become an option, especially for patients who may not be able to find or receive human kidneys.

Melanie Cole, MS: Wow. Really such a fascinating discussion. Dr. Nashar, thank you so much for joining us today and sharing your incredible expertise and your passion. I can hear that when you speak, your compassion. So, thank you again for joining us. And to learn more or to refer your patient, please call 844-MD-REFER or visit findcare.ahn.org.

Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.