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Scott Webb (Host): Kidney transplants are fairly common, including those by living donors. And I'm joined today by Dr. Todd Merchen. He's the Director of the Transplantation Program and Chief of Solid Organ Transplant Surgery with PRISMA Health. And he's here today to help us understand kidney transplants, what it means to be a living donor, and tell us about the new transplant program at PRISMA Health. This is Flourish, a podcast brought to you by PRISMA Health. I'm Scott Webb. So Doctor, thanks so much for your time today. We're talking about organ transplants, specifically kidney transplants today. So, when would somebody need, or why would someone need an organ transplant and specifically a kidney transplant?

Todd D. Merchen, MD (Guest): Organ transplantation referrals are made from primary care doctors and nephrologists to a transplant center typically when a patient is beginning to see the signs and have the symptoms of that organ failure. In this case, as you mentioned, we're talking about kidney transplants specifically. When a patient is approaching the need for dialysis, even a little earlier than that, when a physician feels like a patient may be at that time where they need or would benefit from some discussion about what's coming into their future, in this case, in terms of dialysis and the need for organ replacement therapy and kidney transplant. Patients requiring the cleansing of their blood, which is what the kidney normally does for you, would have to go on dialysis in some modality. The types of dialysis that we're talking about are potentially haemodialysis where your blood is removed and cleansed through a filter and then given back, or peritoneal dialysis where there's actually a catheter placed in your stomach or in your abdominal cavity next to your stomach and you're allowed to, multiple times a day, put fluid into your abdominal cavity and then drain it back out. And it cleanses the impurities in your blood that way. So, typically it's for life improvement and extension of life in the kidney transplant population. And other organ systems such as liver and heart, that would be more for survival, as heart and liver is required for survival, actually.

So, that's usually when a patient is referred to us for a kidney transplant is when they're starting to show signs of organ failure and the need for dialysis.

Scott Webb (Host): Yeah, before we get rolling too far along here, what are the major causes of kidney failure?

Dr. Merchen: The vast majority, maybe in the mid sixties percentages would be diabetes and hypertension. Of course, that's goes along with obesity and smoking and cardiovascular disease in our culture. But most of the patients that go into renal failure suffer from those major illnesses. There are others. Genetics can play a part. Polycystic kidney disease certainly plays a role. That's when your kidneys are replaced by non-functional cysts that kind of will get bigger and bigger and bigger over time. And the function of your kidneys, will diminish over time as well. Having kidney stones or other obstructive elements, maybe some abnormalities anatomically with your ureters that drain urine from your kidneys and take urine into your bladder, causing chronic infections and things such as that. Beyond that, patients sometimes will get nephrotic syndrome, which is essentially a loss in the ability of your kidney to function normally. That's one of those causes would be something called FSGS or focal segmental glomerulosclerosis. Auto-immune diseases also can play a part, but all of those other diseases, put together don't reach the frequency of hypertension and diabetes as a cause.

Host: Got it. So hypertension, diabetes, and of course having those things makes us vulnerable to other things as well. And it does sound a bit like kidney transplants, the transplant process is maybe you know, the last resort that you try other things like dialysis first. And I've heard that from other surgeons that we don't just jump right into surgery. We try every other thing we can first. And then if that's what we have left, you know, as an option, that's the way we go. And so I guess I'm wondering what's the process like for obtaining a kidney transplant?

Dr. Merchen: And to clarify, in this particular case, patients tend to not live as long on dialysis or have as good a quality of life. And so what we try to do in timing this is take the patient, educate, take the patient's circumstance and individual circumstance into consideration. If they are having a diminished enough function to have it start impacting their life and have the circumstance come up that they're about to need dialysis or are already on dialysis, we start that process and certainly they can make the decision based on their own personal needs. But for the most part, we know that it extends life and increases quality of life. So, we would try to use that as the optimal renal replacement therapy.

In terms of the process, it's basically the biggest workup you'll ever undergo in your life in medicine and it's because we're trying to improve your life. And so we're trying to lower the risk and enhance any benefits of getting a transplant. So, the process would start with your physician recognizing in the first place the need for attention towards your kidneys. If you start having, for instance, abnormal labs or symptoms that prompt them to work you up, your primary care doctor may send you to the kidney doctor called a nephrologist, and that doctor would assess how much function your kidneys actually have and start making preparations for your care based on that. And you point out very well that the first step in that is trying avoid renal failure. So, it's control of chronic medical problems like high blood pressure, control of diabetes.

And you hope that your own kidneys can maintain you for the rest of your life, but in, in the circumstances where that's not possible, that's when your nephrologist would have a talk with you about the need for an evaluation by a transplant program. And that's a multidisciplinary evaluation, where you come in for almost a full day in most centers and see a transplant surgeon, talks about the surgery, transplant nephrologist that talks specifically about the medical effects on your body of the therapy. And one of those would be the immunosuppression medications and the longterm impact of having to take those medications. So, we go through a long educational process as well with a transplant coordinator who was a nurse specialist who is there to help the patients understand the process, the listing process of going onto a list to wait for an organ, the process of moving through their workup, the need for constant communication about the patient's healthcare changes and things that might impact our ability to transplant you. They'll talk to a financial counselor who is there simply to help work through all the insurance information and understand the impact financially on them of receiving a kidney transplant, paying for the medications downstream after the actual transplant episode, things like that. They'll talk to a social worker, who is a specialist in trying to assess what type of social structure the patient has and support structure they have for after surgery, as they're going to need things like rides into the hospital, and rides into the appointments and assistance sometimes with complex medical regimens. They'll talk to a pharmacist specifically just to go through all their medications so that they understand why they're taking everything they're taking. And that's just the meeting with different specialists at that point. Also the patient will be getting labs taken, and specifically to transplant, we'll be obtaining labs to look at their immune system and its profile and their specific blood type and things like that impact what type of organs in terms of blood type and different immunologic characteristics, we can accept for them.

And then they'll get x-rays like a chest x-ray, ultrasound, EKG, and some cardiac testing typically. So, it's a big process for them to go through and based on that process, we may uncover things that are concerning for us in terms of risk of surgery and the chance of recovery after transplant. So, we may send them to a cardiologist or another subspecialist just to make sure that we're lowering the risk as much as possible by working up any potential impediments to their really speedy recovery. We know that the vast majority of kidney transplant recipients do really well after surgery. And so we would just want to make sure we're ensuring each patient that likelihood.

Host: Yeah, and it's good to hear that the outcomes are good and it does sound like it's an amazing multidisciplinary team. And you mentioned that just the transplant program or any transplant program, but how does the introduction of a new transplant program in the area there really benefit patients?

Dr. Merchen: Well, thank you for asking. That's a great point. We hope and believe that in all likelihood, increasing access to care in an area that doesn't have a transplant program for several hours drive in any, in any direction, will give patients the ability to one, have just another option. Many patients can't travel long, long distances to receive their specialty care. And so having a transplant program alone, we hope will give people an option that didn't before have an option. Beyond that though, we believe in the long run, what our hope is, is by having another program, providing excellent care, in the transplant arena, will give hopefully patients in South Carolina, the opportunity to receive organs faster maybe and lower the overall need in the community. We know that in general, there aren't enough donors. There aren't enough programs to serve this community right now. And so our hope is by increasing awareness, increasing access, we can achieve all of those things.

Host: Yeah, definitely. And you mentioned a shortage of donors. Let's talk about that. What does it mean to be a living donor and what are the requirements?

Dr. Merchen: So, a living donor is someone who presents, they're typically amazing people who are willing to undergo the very small risk to themselves for a loved one, or sometimes even a stranger. But a living donor for a kidney transplant is someone who steps forward to donate one of their kidneys, because we have two kidneys, if you're healthy with good renal function and without a major medical issue, you can commonly donate to a loved one, friend, or even a stranger, occasionally.

What we do when someone steps forward to donate is put them through a screening process. At which point, we'll try to ascertain whether they have any chronic medical problems that will put them at risk in the future, such as hypertension and diabetes as we mentioned, the number one and two culprit probably in terms of leading people down the road of renal failure themselves. So, if you have significant hypertension or diabetes, you're not really a good donor candidate for your own health. We'll then, if they do pass the initial steps of not having hypertension, diabetes of note, not being morbidly obese; then at that point, they can undergo the transplant workup, which is a multi-disciplinary workup, much like the recipient undergoes, a comprehensive medical evaluation to ascertain whether there's anything that makes them a higher risk of donation. And if they clear all those hurdles and especially if they're trying to direct a donation to a loved one, then we look at their immune status and their blood type and make sure they can donate to that person. But even if they can't directly donate to that particular person, if their blood type, for instance is the wrong blood type or if their immune systems don't match in that process that we refer to as the cross-match, what we can still do is a process called a paired donation where we will find another recipient that has a donor that cannot donate to them. And as long as the blood types are correct, and the immune systems match, what we can do is have one donor donate to the other recipient and their donor donate to the first person's recipient, and still obtain transplants for both.

So there's many options. And most of the time we find that a living donor that's a good candidate, can in fact donate, or at least achieve a kidney transplant for their loved one or the person they wish to donate to.

Host: I've always wanted to ask an expert this, when we talk about living donation versus deceased donation, is one better than the other? Does it make a difference to the transplant patients?

Dr. Merchen: To start with, they're both amazing gifts, and we know that any time someone donates be it a deceased donor, which in many cases is a family making a very difficult decision on quite possibly the worst day of their lives, to donate a family's organs it's an amazing gift. But you bring up a very important point for patients to understand and that is that a living donor kidney transplant typically is more advantageous to a recipient. The fact is receiving donor kidney from a living donor is a more controlled process. It's a commonly healthier patient population and because if you look at the deceased donor population, the same reason, those patients very commonly die, are for the same chronic diseases that impact kidney health over time.

We never accept a kidney from a deceased donor we don't think it's going to work, but we know that you get incrementally better results on average from a living donor than you do from a deceased donor. And that kidney is typically going to last a good bit longer than a deceased donor organ, and you're going to recover quite possibly quicker.

So, we do encourage living donation when someone has that ability. And if they don't, then we absolutely are still excited about the opportunity for them to receive a deceased donor organ. But to answer the question quite specifically, there's no doubt, a living donor processe is both humbling and watching a patient being willing to do that and undergo that work up and go through that process. And it's also better for the recipient, most commonly.

Host: Yeah, you used the word humbling there, and I see what you mean. Like it is terribly humbling and such a heroic and an amazing act to donate a kidney while you're living. And how does that turn out typically for the people who donate the kidneys, you know, at the time they were healthy enough to give up one of their kidneys, but then later I sort of had this feeling like, well, what if I'm going to need that kidney later? What if the kidney that I have left begins to fail? And I already gave up one of my kidneys. So, it's a long way of asking, what are the outcomes for the donors?

Dr. Merchen: Absolutely. It's a great question. And it's a question that should be on anyone's mind that's willing to donate. We talk about this at great length during the donor evaluation process, but essentially what it comes down to is if you're healthy enough to donate a kidney, you typically are going to be served quite well by your remaining kidney, the rest of your life. The vast majority of patients do exceptionally well, and don't go into renal failure in the long run. It is a possibility though. And so a lot of education goes into avoiding those major concerning health problems that can lead to any patient developing renal insufficiency over time, which is avoiding obesity, avoiding smoking, avoiding hypertension and diabetes. If someone were to donate at age 25, as an example, and be very healthy with no high blood pressure, diabetes, other indicators of future health problems, in that point in time, then they're educated and do well, after a donation; there is a possibility that in the next 20 years, they become obese, develop hypertension and diabetes. It doesn't happen often. In fact, it's rare, but in those cases, if you were to donate, there is the possibility of going to the top of the list or in that process, having donated an organ yourself. And that's how we've decided those patients should be at minimal risk if that were to happen, but it is a very rare occurrence for the most part, if someone goes through this extremely in-depth donor evaluation, and are healthy in their approach to their own lifestyle, they're going to do quite well the remaining days of their life and are unlikely and don't go on dialysis at any higher frequency has been patients with two kidneys.

Host: Well, that's all good to hear. And this has been a really interesting conversation today. As we wrap up here, what are your takeaways?

Dr. Merchen: Well, I think that best thing for anyone would be to avoid the need for a transplant to begin with by taking good care of themselves and being aware of the major health problems in our community. The things that affect many people, we talked about hypertension and diabetes frequently today. Going to your doctor, getting control of those things, you may be able to avoid the need for dialysis in the future or an organ transplant, in this case, a kidney.

The other thing I would say is don't be afraid to investigate the opportunities you have in front of you. In other words, if your nephrologist or your primary care doctor says you're at the point of needing to consider your options for renal replacement therapy, go to your transplant center that's nearest to you or the one that they recommend and would like to refer you to and hear for yourself what the options are. It's important to educate yourself. Most patients with a kidney transplant will do exceptionally well, have a better quality of life and live longer than if they stay on dialysis. You want to take advantage of that. Don't be fearful and go and hear what your options are. It's the way you're going to make the best decision for yourself.

Host: Yeah, that's great advice from an expert today. And I think one of my takeaways too, the common thread here seems to be education, people educating themselves and educating people on both sides of this, both the donors, the transplant patients. And it sounds like you're doing great work there at your transplant program. So, Doctor, thanks so much for your time today and you stay well.

Dr. Merchen: I greatly appreciate it. Thanks so much.

Host: For more information and other podcasts, just like this one, head over to Prismahealth.org. This has been Flourish, a podcast brought to you by PRISMA Health. I'm Scott Webb. Stay well.