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Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And we have a panel for you today in a thought leader conversation highlighting living kidney donation. Joining me is Dr. Ashraf El-Hinnawim, he's an Associate Director of the UF Health Adult and Pediatric Cancer Center and Pancreas Transplant Program and the Director of the Living Donor Kidney Transplant Program. He's also a Clinical Associate Professor in the Division of Transplantation and Hepatobiliary Surgery at the University of Florida College of Medicine. And Dr. Georgios Vrakas, he's the Director of the Adult and Pediatric Kidney and Pancreas Program and Clinical Associate Professor in the Division of Transplantation and Hepatobiliary Surgery at the University of Florida College of Medicine.

Doctors, thank you so much for joining us today. And Dr. Vrakas, I'd like to start with you. I'd like you to speak about kidney transplant and indications for referral, how many you do a year and your program does a year because there is a large demand for kidneys. And so, speak about kidney transplant and how common this is.

Dr. Georgios Vrakas: Thank you very much for having us and for having this discussion for our program. So when it comes to kidney transplantation, as you said, the indication are expanding. And also, we aim to transplant as many people as possible. So, people that used to be older in the past or with significant comorbidities, they used to be excluded for transplantation in general a few years ago, but that's not the case now. So, we try and transplant as many people as we can, keeping it safe, of course, to make sure that people do not stay on dialysis. And that's the main indication, obviously, for transplantation, is the need for dialysis. The chronic kidney disease with the GFR less than 20, that's the cutoff, let's say, for someone to be active on the UNOS waiting list is less than 20. So, people with less than 20, as we say, are nearing dialysis status. You don't have to be on dialysis to have a kidney transplant. So, people can have a transplant earlier than that. But of course, we aim to time it as best as we can so that people do not have the immunosuppression burden on them for a longer time.

And indications for the transplant, the various comorbidities, the commonest, let's say, would be diabetes. It is one of the main reasons that people will reach end-stage kidney failure or the presence of hypertension. These would be the commonest ones. But, of course, there are lots of other issues. Let's say, the problems with glomerulonephritis or with polycystic kidney disease, just to mention a couple of them out there.

And when it comes to our program, I mean, myself and Dr. El-Hinnawi arrived here three years ago, and we aim to provide the best kind of outcome. So, our program is number two in the U.S. when it comes to the kidney outcomes. And we managed to increase the volume from 50 a year that used to be before here to 200 plus a year. And last year, for example, was a record year for us here at the UF. We've done more than 230 kidney transplants. And it's just myself and Dr. El-Hinnawi that we achieved these numbers. And we're very proud of the program that we managed to direct here.

Melanie Cole, MS: Thank you so much for that. And Dr. El-Hinnawi, tell us a little bit about the waitlist experience as you're increasing the volume and there are so many people needing kidneys. And we're going to get to living donor and the donor themselves, but speak a little bit about the waitlist experience and managing those comorbid conditions as dialysis is very quality of life-limiting. And tell us a little bit about what goes on with the patients while they wait.

Dr. Ashraf El-Hinnawi: Thank you, Melanie, for having us for this talk. So, I'll start with a few general facts. So, last year in the United States, more than 90,000 patients were waiting for kidney transplantation, and only around 20,000-21,000 of them got kidney transplants. Of those, only 6,000 got living donor kidney transplants. So, you can imagine the difference between the demand and the availability of organs. In the state of Florida in general, there's a lot of big programs providing good numbers of kidney transplant, but we are proud that we provide numbers and quality and excellent outcomes. The growth in our volume helped our community a lot by minimizing the wait time and still having excellent outcomes.

We have many patients start coming from nearby states and all the area of Central and North Florida. We see patients from those areas. Even from South of Florida, they come to us for multi-listing sometimes. So on the waitlist, once they are approved, we keep a close eye on them. We have pre-transplant coordinators who keep following them up depending on their medical condition. We follow them every six months or every year to follow up on their workup, check on them, make sure they are still okay being active on the waitlist.

Once the good match offer come to them, we call them for a transplant. Because of our experience, me and Dr. Vrakas, we're able to use organs that are not used by other centers due to anatomical complexity or putting some risks on them, because we have the expertise and we have the skills to match organs to recipients in a way that we can have the best outcome possible. So, this also helps us expand our organ pool that we use and help more patients on our list.

Melanie Cole, MS: Dr. El-Hinnawi, sticking with you for a second, and much is discussed about the recipient, but not as often the donor. I'd like you to speak about what's important to note as far as donor protection, support, safety, the psychosocial aspects for the living donor, how your program addresses that selection criteria. Give us a summary of all of what's involved in the Living Donor Program.

Dr. Ashraf El-Hinnawi: If we're talking about living donors, those are people who are not in need of this operation. They are just doing this out of goodwill. So, the number one rule is causing no harm for them. When somebody approaches to be living kidney donor, then there is a thorough medical workup done. There is a thorough clinical evaluation by a multidisciplinary team, including the transplant surgeon, the transplant nephrologist, transplant social worker, transplant dietician, and we have the living donor advocate, which is someone who's on favor of the donor. They talk to them. They are on their side. They want to make sure they understand what's happening, what they're doing, and provide them with all the help they need through the process.

The main questions we want to answer for the workup is that is it safe to take one of the kidneys of the donor? Would that leave the donor with enough kidney function to have very low or negligible risk of requiring dialysis themselves at some point in their life. We want to make sure that they can tolerate an operation safely without any extra risk of complications. And we want to make sure which kidney we take so we keep the better kidney for the donor. These are the main questions we ask, in addition to make sure that the donor is doing this fully aware of the process and doing this out of goodwill and really want to do it. So, these are the main things we assess for living donors and make sure that they are the most important part of the whole process for us.

Melanie Cole, MS: Thank you both. And I'd like to give you each a chance for a final thought here. And Dr. Vrakas, as we've spoken a little bit about the ongoing shortage of the donor organs, what do you see as some of the best ways to increase living donation? And are there other alternative therapies for failing kidneys that you see a use for, such as alternative donors? Tell us a little bit about any research or things that are exciting that you're looking to to increase that donor pool that we're looking for.

Dr. Georgios Vrakas: It's very true that we need a lot more kidneys and that's been the problem over the years that we have a lot more recipients than donors. And, of course, I mean, we're trying also to expand the disease donor waiting list. So, we are using more kidneys, let's say, that are not optimal to start with, but we know ways to make them work. So, we'll be utilizing more and more kidneys. Of course, living donation is expanding as well. So, we're trying to get more people to donate their kidneys, trying to, of course, doing all the tests to reassure them that by donating the kidney, they're not going to get in trouble themselves. And these two are the two traditional ways to expand the donor pool.

And as you mentioned, of course, there are some recent advances in transplantation. So, we're trying to use xenotransplants. So, there are a couple of centers now that are trying to utilize transplants from genetically modified pigs. So, we can use them and try to see what would be the effect of using a xenotransplant in a human. These are still ongoing studies though, so we don't have any kind of results now that we can rely on and start doing xenotransplants for everybody. That would be ideal if you ask me, because if we know that there's a safe way to do a xenotransplant, then there will be no waiting lists. We would have a vast donor pool with kidneys that can go in any potential recipient without using even humans. But, unfortunately, we are far from this reality and there's lots of research ongoing trying, of course, to make sure that these kidneys do not reject straight away, do not have problem with thrombosis and, of course, do not have any potential viruses that can be life-threatening for humans.

Melanie Cole, MS: Dr. El-Hinnawi, now a last word to you. I'd like you to speak about what's on the horizon. Any exciting research in kidney transplantation, and what you would like other providers to know about referral to the program at UF Health Shands Hospital and the Living Donor Program specifically?

Dr. Ashraf El-Hinnawi: I would like to encourage all physicians taking care of patients with kidney disease that the best timing and the best way to achieve the best outcomes is through living donation before the patients are on dialysis. So, any patient reaching the point of needing dialysis in the near future, we should educate them about living donation. We should start helping them, finding a suitable living donor, so they can avoid being on dialysis and get the best kidney.

A lot of the work is by educating patients and putting the word out there. Many people, they come, "Oh, no, we didn't know about living donation. We don't know it's possible," "Oh, I had somebody, but they're not matched." Even if they're not matched, we still are able to do paired exchange. We are still able to help in many other ways. So, this is the message I would like people to know for the Living Donor Kidney Program, is that it is the best outcome approach. And once we educate people, we will be surprised how many of them will come forward to try to help their loved ones or their friends or their family. And the donor will have a lot of also satisfaction, by doing this and it's definitely the way to go in my opinion.

Melanie Cole, MS: It's really an amazing thing to do for somebody. And I thank you both for all the great work that you're doing to save lives and for sharing your incredible expertise with us today. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org. And to listen to more podcasts from our experts, please visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. For updates on the latest medical advancements, breakthroughs, and research, please follow us on your social channels. I'm Melanie Cole. Thanks so much for joining us today.