Puneet Sood, MD, Medical Director, UPMC Kidney and Kidney Pancreas Transplant Program, discusses some of the misconceptions about living-donor organ transplantation and explains the process for both donors and recipients.
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– This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgments when advising their patients. Patients in need of medical care should consult their personal care provider. It is the preferred method of organ transplantation these days, but there are still lots of misconceptions about living-donor organ transplants. Hi, I’m Tonia Caruso. Welcome to this UPMC HealthBeat Podcast. And, joining us right now is Dr. Puneet Sood. He’s a nephrologist and the medical director of the UPMC Kidney and Kidney Pancreas Transplant Program. Thank you so much for joining us.
– Thank you for having me.
– We sit here at the home of transplantation, where it was pioneered by Dr. Thomas Starzl. And, things continue to evolve. And, why now is living donor such an important focus?
– That’s a great question. So, the issue is each year, we have about 42,000 patients who go on the wait list, where we have only 25,000 transplants we actually do. And out of those 25, only 6,000 are living donors and the rest – 19,000 – are deceased donors. Now, as the rest of the people who are on the list – on average, about 6,000 people – will actually die waiting for a transplant on the wait list. And about 4,000 will become sick that they are now no longer considered transplant candidates. So, the wait time continues to grow. Now, we cannot really increase the number of deceased donors available to us. But for living donors, sky is the limit. So, that’s how we, there is more impetus to go after the living donation. And, with time, we have also found out it’s a pretty safe procedure to do. The long-term outcomes are pretty acceptable, and that’s how we are going for living donations.
– How do you define living-donor donations?
– Yeah, so living donor basically means the organ is coming from somebody who is alive. They’re not deceased, or it’s not a cardiac transplant. So, one of the things that we make sure we do is when a living donor comes forward, we want to make sure three things. Four things, actually. One, we want to make sure they are in absolute good health before they donate. No. 2, we want make sure they give away enough kidney function for the recipient to benefit from their gift. No. 3, very important, we want to make sure they are left with enough kidney function to sustain them a healthy life with one kidney. And No. 4, which is the crux, is the most important thing, we don’t want any harm coming to the living donors. If we find anything on their testing that puts them in the harm’s way, we don’t let them donate at all. So, more than the recipient, we want to make sure the donor is not harmed in the process.
– And, so, you talk about living-donor kidney transplants, living-donor liver transplants. So, when we talk about liver, right, it’s just taking a portion, and then your liver grows back?
– Right. That’s right. Exactly. So, liver has a remarkable ability to regenerate itself. So, within a few months, I would say four to six months, most people will regenerate enough liver to kind of compensate for what they lost as part of their donation. While, for kidneys, we are born with two kidneys, but we only need one kidney to sustain us a perfectly healthy life.
– I’ve heard people say, friends in just conversation, “OK, the liver makes sense because I’m just going to give you a piece and it’s going to grow back.” If we only have two kidneys and I give away my kidney, what happens if my other kidney fails? And, talk about how common or uncommon that is, and really what people should think about.
– So, first of all, I want to stress this point that when we choose our donors, we want them to be in perfectly good health, and they undergo more extensive testing than the recipients will just because we want to make sure they’re not at risk for something that will put their remaining kidney at risk in the next several years, like two, three, four decades. So, the actual incidence of kidney disease requiring dialysis in donors remains pretty low. Overall, actually, the donors end up doing much better than the general population. Again, as I said, not because they donated a kidney, but because we cherry-picked the healthiest person from the population because they passed all the tests which allowed us to pick them. So, they end up doing very well in the long run. And, now, the other point, again, you know, sorry for this long-winded answer, but the other point I want to make is, you know, with one kidney, what happens is that remaining kidney starts functioning extra hard. And, even though you have donated a kidney and you would think one kidney is gone, you should have 50% kidney function left, that’s not true. The other kidney takes over right away. So the lowest your numbers go down to is about 60, 65% of pre-donation level. And, over the next year or so, that remaining kidney works extra hard. By the end of the year, most people are up to 70 to 75%, which is enough to sustain them a perfectly healthy life.
– From a recipient perspective, they might actually do better with a living donor? Is that true? Like, what makes that more beneficial than a deceased donor besides just waiting?
– Waiting is an important part, and there are enough studies which have come out in the last decade, the longer you wait for a kidney transplant on dialysis, the worse your outcomes are. So, to shorten that wait time with a living donor is a major, major thing that we want to do. That’s No. 1. No. 2, they can actually schedule their surgery based on their donor and recipient availability. That’s a huge thing other than, you know, if it’s a disease on a transplant, you’re brought in in the middle of the night, and that’s not ideal in most situations. The third main reason is the living-donor organs tend to be just better just because they don’t spend too much time on ice outside the donor’s body. And, secondly, most people don’t realize that deceased donors, when they’re dying, their body’s undergoing some rapid changes which actually impacts the kidney that they’re going to end up donating, which is not the case with the living donor. So, if you look at the living-donor outcomes, on average, a deceased-donor kidney will last about 11 to 12 years, while the living-donor, on average, will last about 18 years.
– Eighteen years?
– That’s average. So, what that means is if I transplant 100 people with a deceased donor and 100 people with a living donor, at the end of 11 years for deceased donor, 50 of those kidneys will be working. While, for living donors, 50% of them will still be working at 18 years. So, that’s what the half-life is.
– Wow. And is it safe to say that if you have a living donor, and so you’re not on a wait list with, you know, all these other people, that you’re actually, in most cases, healthier undergoing the surgery because you haven’t been on dialysis as long?
– In general, that’s true because the longer you are on dialysis, and the average wait time for dialysis for transplantation is 4 to 6 years, at least at our center. On the course, it can be up to 7 to 10 years. So, the longer you are on dialysis, the worse outcomes you have. So, it’s fair to say the transplants do better also because you spent less time on dialysis with a living donor.
– So, I’m sitting here and I’m listening to you, and I’m thinking, why does anyone have a deceased-organ transplantation these days? Why wouldn’t everybody have a living-donor one? What are some of the roadblocks, and what are some of the misconceptions in your mind?
– I think the biggest roadblock is awareness. A lot of people just don’t know that they can donate a kidney to somebody. And, one of the major issues with that, and we have seen it quite a lot, is people think they have to be a match with their recipients. And, that’s not true. Nowadays, we have these new technologies where you don’t have to be a match with your recipient. As long as you’re a healthy donor, we can actually do a donor exchange program where I can, if I’m an incompatible donor to you, I can donate to somebody else, and somebody else in equally good health will end up donating to you. So, we have actually eliminated that barrier of blood group incompatibility, other incompatibility. So, I think it’s awareness that is playing a role.
– How much do you find a person who is in need of a transplant is hesitant, or afraid, and doesn’t want to ask someone for help?
– Yeah, that’s a great question. I think it’s very common, actually, especially when it comes down to people thinking that they can get a transplant only from their own family, and they’re extremely reluctant, and that’s especially true for elder population. They don’t want to ask their kids, their grandkids, to help them. Other times, people just don’t want to approach anybody, period, because they think that they’re going to end up harming the donor in the process, which is a myth I want to break. The donors are chosen such that there’s no, there’s minimal risk to them in the long term.
– And so, you actually do, UPMC has what’s known as the Champion Program. And, let’s tell folks about that. And, that’s really a way to try to make it easier to help someone find a donor.
– Right. So, the Living Donor Champion Program, we started about, I want to say about 6 or 7 years ago with exactly the same thought in mind where recipients are not comfortable approaching their loved ones, their friends, or anybody, for that matter, for a living donor. So, what we started doing is we actually arrange a class with the donors, and we ask them to bring family members with them. So, we do two things. One, we identify somebody from the family or from their circle who will become their champion or their advocate on their behalf, who will actually reach out to other people, and not the recipient himself, telling their story, “Look, you know, so and so, or dad is in need of transplant, and this is what you can do.” That’s one thing. Once you have an advocate or a champion from their circle identified, it makes things much easier, so the recipient is not having to directly ask somebody. No. 2, what we do is we actually also help them set up a Facebook page, where we help them write up their story so they can disseminate with Facebook. Things actually go to a lot of, you know, as you know, the reach of Facebook is astonishing. And, we have had people who were perfect strangers who read the story, came forward, wanted to help somebody, and ended up donating. The third thing we do through the Champion Program is we also help them identify other ways to get a living donor. Basically, we tell them, you know, what are the other situations they can tell their story. So, for example, if you go to a church, they can disseminate their story in a church.
– All right. So, let’s talk, if we can talk in more specifics about the requirements to be a donor. Are there age requirements? You know, you’re saying there’s really no such thing as a perfect match, that you can grow from that. So, let’s talk about some of the requirements.
– Yeah, so as I mentioned earlier, our focus is to make sure the donor is not harmed in the long run. So, age-wise, the donors have to be adults, so 18 and above. The upper age limit is 75 years for kidney donation at our center, which is actually a pretty wide range. Most centers would actually have at least 70 or 65 to 70. But big centers with a lot of experience like ours, we picked 75. But, other than that, we want to make sure they don’t have any active infection going on. No active cancer, no active psychiatric history, want to make sure they have an adequate support system, and they understand what they’re getting into. The risks and benefits of being a donor, they should be able to comprehend that. And, they should also know that there is no pressure on them coming from any side. No coercion, no financial gains and stuff.
– Right. So, is there any BMI requirements?
– Yeah, so, that’s a great question. So, BMI at our center is dependent on the age of the donor. So, for younger donors we want to keep their BMI, for donors less than age 30, the BMI cutoff is 32. For donors above 30, the BMI cutoff is 34.
– OK. You’ve mentioned a few times, like, the health and the wellness of the donor is just as important as the health of the recipient. They obviously come in, they go through a ton of testing. How long does that take? And, is really, is that where all the real work is? Because I want you to tell me about that, and then tell me about what the procedure is like, what the recovery is like.
– The workup process is literally one and a half days. So, the one day that they come, we actually ask them to come in person to meet all the team members. So, they basically end up seeing six different teams. So, one is a transplant nephrology, which is me. Then, they also see a transplant surgeon, then they see a transplant social worker, a transplant pharmacist, a transplant financial analyst, and independent living-donor advocate. So, six different teams they will see. In addition, all donors will get specialized tests. One of them is the CT scan of their belly, basically to look at the anatomy of their insides, which is what allows us or helps us to plan their surgery. The second important thing that we look at is what we call nuclear medicine GFR. It’s a test that we get done at Children’s Hospital. It’s a test which tells us how good their kidney function is when both kidneys are put together. It gives us an idea if we remove one, how much will they be left with, and how much will go to their recipient. So, again, we have age-, race-, and gender-specific cut-offs for what is normal. Other than that, all the donors will undergo extensive blood testing to make sure they don’t have any active disease right now. And, we also make sure we try to look ahead 20 to 30 years from now, make sure they don’t have any tendency to develop disease. In addition to that, we also check for their blood pressure. So, as we know, you know, hypertension in the long run can impact kidney function, especially if you’re left with one kidney. So, we make, we make all our efforts to make sure they don’t have high blood pressure now and that they don’t have a strong family history of hypertension. And, the last thing is for donors, we make sure the age-appropriate cancer screening is up to date. So, for example, if they’re above 45, we do Cologuard or colon screening. For women, we do pap smear, mammograms. PSA testing for men, stuff like that.
– So, once all of that is complete, and someone is a match, and they do want to donate their organ, what is that day like? How long is the surgery? And, I guess, really talk about it from both perspectives: from the donor side, but, I guess, first start with the recipient. And, you know, once they get this organ in there, I’ve heard stories that instantly they start to improve. Is that true?
– That’s completely true. We have seen people, as soon as we make our connections between the donor kidney and the recipient blood vessels, we see urine spurting out of the new kidney like this. That’s amazing.
– Wow.
– But, the recipient surgery is about three to five hours depending upon how complex the recipient is in terms of, you know, if they’re obese, if they have prior surgeries, how much scarring they have, and stuff like that. So, the recipients, once they come out of the OR, they spend about three to five days in the hospital, and then they get discharged. Donors, actually, you’ll be surprised. So, we do laparoscopic donor surgery, which has quickly become the standard of care at most centers now. So, the donor surgery is about three hours long. Once they come out, say if you donated your kidney today, by tomorrow, often, I would say almost 80% of our donors are home.
– The next day?
– The next day, afternoon. The rest are probably home by day two or day three. They do extremely well. First four to six weeks, we ask them to take it easy, meaning no heavy lifting or anything. But, after that, they should not have any restrictions on their lifestyle, whether it is eating, drinking, traveling, pursuing their hobbies. We have had people who at three months post-donation actually ran marathons. We had a gentleman seven months post-donation, he was in his mid-50s, he actually participated in an Ironman competition.
– Wow. Is there prep work leading up to this in terms of diet, exercise, no drinking, no smoking, I would assume? What sort of does a donor have to do leading into a surgery?
– Yeah, I think nothing special. We just want to make sure they have a healthy lifestyle. There is no special diet, there is no special exercise. Just healthy lifestyle, and then, smoking, as you mentioned, we have them quit smoking for good, if possible, but at least for four to six weeks before their donation.
– And, what is it like for you when a patient goes through this operation, and you see the, as you said, like instantly starting to do better. What’s your greatest sense of gratification there?
– Yeah, I think it’s the fact that as the patient is getting wheeled out of the OR, they’re free of dialysis, they’re free of kidney disease. That’s life-changing because if you imagine, these recipients, they were, many of them are on dialysis, they’re hooked to a machine four hours every other day to dialysis. And, once they’re done, the rest of their day is gone because they’re wiped out from dialysis. So, the quality of life that you have at that time with being on dialysis is minimal, and that quality of life comes back with a bang. Just like this.
– Why was this the field that you wanted to get into, out of everything you could do in the world of medicine?
– Right. That’s a great question. I think it starts with my first exposure when I was an intern was in a nephrology unit, and it was a transplant unit. That was back in early 2000s. And, I could see what I just narrated to you: people on dialysis for years not doing well, they have a transplant, and all of a sudden, everything has changed for them. And, I thought that I wanted to be part of that story.
– And what about UPMC? What would you say to people about, you know, really what sets UPMC apart? And, do you feel like carrying on this legacy of this is where it was really pioneered and began to be mainstreamed?
– Yeah, I think UPMC is very unique in so many ways. First of all, as you mentioned earlier, Dr. Starzl pioneered it. And, that trend of innovation and breaking the ceiling, it continues. And, we have the best surgeons and the best medical people from the world here working with us. And, every day we sit together and see what new we can do here. The other thing is, actually, the UPMC’s focus on patient care. I think that’s what sets UPMC apart.
– And, how important that you do so many? What does that bring to the table for patients, knowing, you know, this is one of the leading centers? And, is it this idea, it’s not a factory, but the more you see, the better you are at it?
– That’s right. So, we get patients from all over the country just because of our expertise. We have seen almost everything. We see more, and we do more. And, I often feel we don’t do enough. We still need to do more given the situation we have with the people on dialysis. I think if we have more donors, we’ll be happy to do more.
– Yeah. So, last question. What do you want to say about someone in need of a transplant, or someone who might think about donating, but might be a little worried or afraid?
– Yeah, I think this is a situation we encounter quite, not uncommonly, and what I tell the recipients is have your donor contact us, and we take it from there. We do our due diligence, make sure all the donors’ fears are allayed. We also make sure that we are not causing any harm to the donor. They will undergo all extensive testing, all their questions will be answered. If at the end, the donor doesn’t feel comfortable or the recipient doesn’t feel comfortable moving forward, that’s completely fine. But at least go through the process.
– Right. Well, doctor, we thank you so much for coming in and spending time with us today. Some great information. We appreciate your time.
– Thank you very much.
– I’m Tonia Caruso. Thank you for joining us. This is UPMC HealthBeat.