Rania Habib, DDS, MD (Host): The National Institute of Health estimates that over 800,000 patients are living with end-stage renal disease in thU.S.S. Sixty-nine percent of these patients are managed on dialysis and 31% by renal transplant. But which is better?

Welcome to MD Cast by Tampa General Hospital, a go-to listening location for specialized physician-to-physician content and a valuable learning tool for world-class healthcare. I'm your host, Dr. Rania Habib. Joining me today is Dr. Pranjal Jain, a partner at Florida Kidney Physicians and the Section Chief at Tampa General Hospital. He also serves as the Living Donor Medical Director.

Today, we will discuss transplant and dialysis, the advantages of living donor transplantation versus a deceased donor transplantation, discuss paired kidney donation and living donor resource tools. Thanks, Dr. Jain, and welcome. We're so excited to have you on the podcast today.

Pranjal Jain, MD: Happy to be here.

Host: Let's begin by just a general question. Is transplant better than dialysis for patients with end-stage renal disease?

Pranjal Jain, MD: Yes, absolutely. A transplant is definitely better than dialysis at any given age. It is a better quality of life and more quantity of life. So, this has been studied in the last 30-40 years. All the studies point towards transplantation always being better than dialysis.

Host: Now, in terms of actual numbers, what is the quality of life that transplantation affords the patient compared to dialysis?

Pranjal Jain, MD: So yeah, that's a good question. Transplantation itself, on an average, offers you at least 15 to 20 year more quality of life years, which has been studied in the past. So, it's a no-brainer that every patient approaching dialysis or on dialysis should be evaluated for transplant at the least.

Host: When we look at costs, let's say, from a hospital standpoint for transplantation versus dialysis, is there a large difference there as well?

Pranjal Jain, MD: It's interesting you ask this, because the dialysis patients make up about less than a percent, but the Medicare spending on them is almost 6-8% and is rising every year. So, transplantation not only offers a better quality and quantity of life, as I said, it's better for our burgeoning health system as well. The grafts cross over after one to two years, and there is a significant cost savings of transplant, especially with a living donor transplant. So, it's a win-win for everyone.

Host: That's fantastic. Now, I know we said we're adding years onto a patient's life when they choose transplantation. So, let's move on to what do you think is better, living donor transplantation or deceased donor transplantation?

Pranjal Jain, MD: Having said that, the transplantation is better than dialysis, if we have an option on the table, a living donor transplant, hands down, is better than a deceased donor transplant.

Host: Okay. And can you go into the details on why?

Pranjal Jain, MD: So, a living donor transplant, first of all, it's an elective surgery. You exactly know who the donor is. We have a better match, as far as the typing, HLA typing. We have exact details about donor history, their kidney function, the kidney size, what kidney we are putting in, and it can be accomplished faster. There is a wait for a deceased donor transplant or a cadaver transplant, as we call it. So, the living donor transplant can be accomplished as early as a month to a few months. So, it really brings you the quality of life, the quantity of life that you're hoping for with transplantation. And the mileage in a living donor kidney is much more than a deceased donor kidney, almost double.

Host: Oh, wow. So, what is that average lifespan between the living donor transplanted kidney versus a deceased donor?

Pranjal Jain, MD: Yeah. So, a living donor kidney nowadays with the high-resolution matching and everything that we are doing, and again this is an average, would last 20 to 25 years. So, this is half the kidneys, would last 25 years. I have many patients who have had a living donor transplant and have well taken care of, they can last 30, 40 years, as opposed to a deceased donor transplant where again the average lasts 10 to 15 years.

Host: Wow. So, there is a significant difference in how many more years they're getting out of the living donor transplantation.

Pranjal Jain, MD: Absolutely.

Host: Now that we've established that living donor transplant has this advantage over deceased donor transplant, how does one find a living donor and what are those next steps to transplantation?

Pranjal Jain, MD: Yeah. So, if I am a patient approaching dialysis or on dialysis, the onus is fortunately or unfortunately on me. You know, I am the person who needs help and I have to seek it, pursue it. So, there are resources, there are websites nationally like the National Kidney Registry, Tampa General has a website, there is a National Kidney Foundation, there are online communities on social media, which help you find a living donor, but you have to be comfortable putting yourself out there. And, you know, as I always say, if you need something for a business or a personal thing, nobody's just going to come and hand it to you. So, you have to ask for that help with the expectation that it may not come through, despite your best efforts. But unless you try, you won't succeed.

Host: So once a patient makes that commitment to finding a living donor transplantation, you said you mentioned that they get on these lists to try to find the living donor, but what does the dialysis patient now have to undergo in terms of steps to getting to that transplantation?

Pranjal Jain, MD: Yeah, that's good. You know, you have to reach out to family, friends, at your workplace, social media, Nextdoor app, print media. You know, "I am so and so, Mr. Smith, looking for A healthy living donor who is willing to donate a kidney." And I often come across that, "Oh, I don't want to ask my family and put them through this." And again, as I said, you know, the expectation should be, "Let me ask for help and then, we'll see, as nothing is happening, there's no living donors who have come forward." But unless you ask, people are not going to help you. And if you are open with the mindset that this may still not turn out and, you know, you have no hard feelings, I think, as a patient, I would put myself out there and ask for help. Then, tell them, you know, that this is the place where you can fill out your information. So at Tampa General, we have a very seamless intake process where they can just fill out their information online, sitting in a couch.

Host: Okay.

Pranjal Jain, MD: So once a living donor filled out that intake, we, as a transplant institute, get it at the back end. And we call the donors, and of course, the donation has to be without any coercion, no guilt. We'll assess the living donor intake, and then we will send them a kit. Some basic blood tests will be done. And all the tests will then be scheduled when the donors come in for an evaluation. And of course, it's like getting a thorough medical checkup. They go through blood tests, they see a nephrologist, a surgeon, independent living donor advocate, a psychologist, a financial person, a dietitian. They get some imaging to look at their kidneys, and age-appropriate screenings are requested. And if there are any additional tests, the transplant center will let you know. But this is basic workup, which most of the donors undergo. Again, during this entire process, the donors can walk away if they feel this is not what they had envisioned.

Host: Absolutely. Now, once that living donor goes through the evaluations and let's say they've now been accepted as a donor, what can they now expect from the surgical standpoint and the followup and recovery?

Pranjal Jain, MD: Yeah. So at Tampa General, we have been very blessed and lucky. We have world-class surgeons who are now doing robotic surgeries, a single incision through which they extract the kidney, so to say. And then, the donors after surgery stay in the hospital for a day or two maximum. There is some recovery about the abdomen, because the air is insufflated into their belly. So, that's a little uncomfortable for a few days, but the donors can return back to light duty work as early as two to four weeks.

Host: That's fantastic. Now, what are the main risks that are associated with living donation?

Pranjal Jain, MD: It's a surgery under full anesthesia. So, there are risks associated with anesthesia, bleeding, infection, postoperative recovery, clotting, generalized pain. But overall, it's a very, very safe procedure, and these are the risks immediately after the surgery. And then, the long-term risks in and of itself, donation does not increase your chances of the donor developing end-stage kidney disease. In fact, quite to the contrary, the donors actually live longer than the normal population, maybe because they were the healthier lot to begin with or they signed themselves up for a healthier lifestyle. The blood pressure does go up in the long run by a few points. So, that is something that needs to be monitored. And again, that is checked out before the surgery. So all in all, a very safe procedure.

Host: Absolutely. Now, do living donors have to watch out for any of the renal-based medications? Do they have any restrictions on medications?

Pranjal Jain, MD: That's a very good question, I think. So most of the medicines, you know, we don't know what exactly might happen in the future, but most of the medicines, except the pain medicines, which they know right off the bat, especially the kinds, which are the Motrin. Apart from that, most of the medicines, our donors can take. There is no restriction. For that matter, even the patients who receive a transplant, they're almost free to take most of the medicines.

Host: Now, if a living donor is not ABO compatible, what happens?

Pranjal Jain, MD: Yeah. So, this question comes up a lot when I talk to my potential patients who are now in need of a transplant. "Hey doc, what's my blood type? So that when I talk to people, I know the next question I get asked sometimes is 'What blood type are you looking for?'" So again, this was I think 15 to 20 years ago or maybe more than that, even if you are not directly ABO compatible. So, kidney transplant can only be done from the same blood type. So if you're a blood type B, you can only get a kidney from a blood type B or O, and O being a universal donor. But if you find a donor who is a blood type A, we can evaluate that donor and maybe another pair is in a similar situation, and we may be able to swap the kidneys. And there is a whole national list where we can swap these kidneys or we can swap them at the transplant center itself. So again, if there is a healthy donor available, any blood type, they're welcome to be evaluated.

Host: That's fantastic. Dr. Jain, we know that immunosuppressive therapy has evolved over the years. Could you talk about some of those advances?

Pranjal Jain, MD: Quite a ways now. From when I trained 20 years ago and now, you know, we're not to a point where it's individually tailored to that patient, but we have so many tools in our armamentarium that we can tailor the immunosuppressives to the particular recipient. Previously, it was one-size-fits-all. And now, we have so many molecular tools to know ahead of the transplant how this matching looks.

At Tampa General, we are doing something called a high-resolution HLA typing, which exactly at the epitope level, very, very detailed level to the size of microns, can tell if this is something, which is not a good epilate match or it's not matching very well. And now with molecular cell-free DNA techniques, molecular microscope, a lot of these tools are getting automated, and we can really tailor the immunosuppressors, in turn prolonging the longevity of the graft, the kidney.

Host: That's fantastic. Now, you have done a wonderful job about really telling us the difference between transplant and why it's better than dialysis and why living donor transplantation has advantages over deceased donor transplant. As the Medical Director of the Living Donor Program at Tampa General Hospital, what final thoughts would you like to leave with our audience

Pranjal Jain, MD: You know, being a Living Donor Director, I'm biased, but I have reasons to be, right? There's such great outcomes, and I see this every day. So, every patient I see, I always tell them, "There is a living donor out there for you." We just have to find them." We, along with you, we can partner and find that living donor. We can identify a living donor champion, but we need your help and we need a lot of outreach to educate the masses that overall it's a very safe procedure, which can really help your friends or families enjoy a normal life.

Host: If physicians want to send their patients to you to have their patients evaluated for your transplant program or dialysis, how do they do that?

Pranjal Jain, MD: We are one of the largest practices in Florida. Florida Kidney Physicians, we are almost in every county. It's very easy online. You can fill out our intake, and we can see these patients on dialysis. As far as living donors are concerned, Tampa General has a very well-integrated process. You can just google Tampa General living donor form. It takes you to a questionnaire, which is in English and Spanish. You can fill it out. It has some hard stops. But once you submit it for your loved one, you know, we will get it and call you.

Host: Well, thank you so much for joining us today, Dr. Pranjal Jain. We really appreciate all this amazing information you left with us today.

Pranjal Jain, MD: It was a delight.

Host: Again, that was Dr. Pranjal Jain, a partner at Florida Kidney Physicians and the Section Chief at Tampa General Hospital. I'm your host, Dr. Rania Habib, wishing you well. Thank you for listening to MD Cast by Tampa General Hospital, which is available on all major streaming services for free. To collect your CME, please click on the link in the description. For other CME opportunities, including live webinars, on-demand videos, and local events offered to you by Tampa General Hospital, please visit cme.tgh.org. Thank you.