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COVID-19: NEW CHALLENGES IN KIDNEY TRANSPLANTATION

By Gautham Mogilishetty, MD

Chronic Kidney Disease (CKD) is a slow progressive deterioration of kidney function leading to kidney failure. CKD progresses from stage 1 to stage 5, which is the final stage, when a patient is deemed as End Stage Renal Disease (ESRD). These patients require kidney replacement therapies such as Dialysis or Transplantation to survive.

In the Unites states there are more than half a million people suffering with ESRD needing some form of dialysis treatment such as Hemodialysis or Peritoneal Dialysis. This form of treatment is essential for their survival but it is associated with high morbidity and mortality. The 5 year survival for ESRD patients on dialysis is 35%. In other words, if 100 patients were started on dialysis today, only 35 of them will be alive in 5 years.

Kidney Transplantation is the treatment of choice and a potential cure for ESRD. It not only provides qualitative improvement in lifestyle, but also in quantitative terms known as survival benefit. Patients who have had a kidney transplantation survive longer as compared to being on dialysis across all age groups. This survival advantage is most pronounced in younger patients. Those patients below the age 50 have a three fold increase in survival, those above 65 have 2 fold increase, while those above 75 years have only one and half fold increase in survival advantage.

Then the question one would ask is why is transplantation not offered to all. It is standard of care to offer the best treatment option for kidney failure first. The answer to this difficult question is two fold, one is lack of availability of organs and the risk associated with surgery along with life long immunosuppression.

There are about 100,000 patients waiting for kidney transplantation and on an average only 15,000 kidney transplantation are done every year in United States.

The median waiting times for kidney transplantation nationally is 4 years and in some regions it is as high as 8 years. To give you a perspective, every 14 minutes someone is added to the deceased donor organ wait list and every 2 hours someone dies waiting for an organ. These patients wait patiently for their turn, hoping and praying everyday, for their gift of life to arrive. These patient know that time is not on their side and longer their stay on dialysis shorter their life expectancy. It’s a fight for survival and all patients continue to soldier along bravely.

To make matters worse, COVID 19 pandemic has put additional challenges to receiving a kidney transplantation. Who would have thought that the next world war would be up against this invisible enemy. It’s an enemy that we cannot see and more importantly outnumbers us by trillions. People with comorbid conditions are at greatest risk with the highest mortality. CKD patients, especially older population, are extremely vulnerable to this virus.

In this pandemic, CKD patients now face new challenges with regards to their transplantation process. Center of Disease Control (CDC ) has made recommendations that elective surgeries and non-essential procedures that include transplantation to be postponed. However, Transplantation in “high acuity/unhealthy patients” were allowed to proceed based upon centers operational level. Each transplant center will base their decision on issues like circulating COVID-19 infection burden in their areas and operational issues such as testing ability, bed, OR space availability, and personal protective equipment. In the process, transplant evaluations were postponed, transplant wait evaluations were not updated or delayed, living donor surgery was postponed by 28 days and finally only some centers still continued deceased donor kidney transplantations with reduced immunosuppression. Fortunately, patients residing in SWFL who were on the waitlist still received deceased donor kidneys during the peak of the crisis.

Risk of acquiring COVID-19 from organ donation is low. All donors are screened for COVID-19 symptoms and exposure history. If a kidney donor tests positive for COVID-19, the organ is not used for transplantation. Post transplant patients are at high risk for severe disease from COVID-19 with mortality of 30% as compared to general population it is 1-5%.

It is important that one takes measures to help keep yourself safe and reduce the chance of acquiring the COVID-19 infection. Be sure to wear a mask when outside the home, maintain 6 feet distance between you and others, carry hand sanitizers, washing hands frequently, and make trips to labs for necessary tests only. Fortunately, post kidney transplant clinic visits have been facilitated by Telehealth, minimizing patient exposure and in some cases patients also had in home testing depending on their insurance plans.

The most important aspect for the post transplant patient is good nutrition to boost innate immunity, exercise as permissible and finally it is critical to be complaint with immunosuppression medication.

In times of uncertainity, there are people who take advantage upon others who are vulnerable, scamming people who want to prevent and /or treat COVID-19.The best way to avoid being such a victim is to know your facts…knowledge is power. There are investigational COVID-19 vaccines and treatments in early development but have yet to be fully tested for safety and efficacy. Fraudulent COVID-19 products come in many flavors, including dietary supplements, vitamins, minerals, foods(ginger, garlic, turmeric) as well as questionable products like herbal remedies, immune boosters which might interact with your immunosuppression medication putting you at risk for rejection and transplant organ failure.

Transplant centers need to balance the risk of patient dying waiting for a kidney transplantation against the risk of dying acquiring additional challenges been on immunosuppression. COVID-19 is here to stay and like the Influenza, the only real answer is a meaningful vaccination. Until then, using common sense, and shielding one self from the virus is the prudent approach.

We are excited to announce that board-certified transplant nephrologist, Gautham Mogilishetty, MD, has joined Associates in Nephrology.

Gautham Mogilishetty, MD, is a board-certified transplant nephrologist. His areas of expertise include kidney transplant care of immunosuppressed patients, cardiovascular outcomes in kidney recipients post-transplantation, and living kidney donations with long-term outcomes.

Dr. Mogilishetty earned his medical degree from Osmania Medical College in Hyderabad, India. He completed his internal medicine residency at the University of Missouri-Kansas City. Dr. Mogilishetty completed a nephrology fellowship at the University of Arkansas in Little Rock, Arkansas, and a fellowship in transplant medicine from Oregon Health and Science University in Portland, Oregon.

Dr. Mogilishetty is a member of the American Society of Nephrology, the National Kidney Foundation and the American Society of Transplantation and is a member of the Royal College of Physicians, London.

He treats patients 18 years of age and older.

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