State of the Union: Kidney and Pancreas Transplant in 2020


An interview with Lloyd Ratner, MD, Director of Renal and Pancreatic Transplantation.

Let’s start wide, are there any new breakthroughs in the field of kidney and pancreatic transplant that we should know about?

You know, there are no new breakthroughs in that sense. If anything, some people are starting to perform kidney transplants robotically. Though, it hasn't really been shown to have any benefit, except perhaps in patients who are really obese. Because of that benefit it is something we're thinking about doing in the future, once we have the bandwidth after this pandemic and we're able to get robotic training and all that. 

What would be the benefit to patients who are obese? 

Obese patients have a higher incidence of wound complications, the benefit here would be smaller incisions. The smaller the incision, the less likely there are to be wound complications. 

Other than the option for robotic surgery, have surgical approaches to kidney transplant changed at all in the last few years?

That’s the thing with transplant, the operation hasn't changed in decades. We've been doing pretty much the same living donor operation since we introduced laparoscopic donor nephrectomy now 25 years ago. Maybe little minor variations here and there for select cases and stuff, but it's pretty standard for both children and adults.

Diabetes is the leading cause of kidney failure in the United States, any advancement in the treatment of diabetes? 

It is. Diabetes accounts for something like 40 percent of the new cases of renal failure, and it's tied in with obesity. So as people get heavier—and we have an obesity epidemic—we're seeing more and more people with diabetes. 

One thing is that the glucose sensors have gotten better so glucose monitoring has gotten better. Now there are these continuous monitors that you can use with some limited hardware and an app on your phone. They put a little needle with a sensor on it that transmits to the app by Bluetooth. 

It’s actually one of the things that we started talking about in the last few weeks. Why don't we use these continuous glucose monitors in the hospital?  Rather than people having to get finger sticks every hour, or two, or three. That’s something we hope to do in the near future. If people can do it at home, why shouldn't we do it here in the hospital so the nurses don't have to go around sticking the patients all the time?

How long does the needle sensor last? 

10 days. And some of these brittle diabetics [term used to describe hard-to-control diabetes with swings in sugars], they’re checking their sugars six, eight times a day. Certainly, when we do a pancreas transplant we're checking the sugars every hour or two. When people are sick and come to the hospital, their sugars are out of control and they need to get their sugars checked quite frequently. If the technology's there, we ought to be using it in the hospital. 

Absolutely. Especially, right now in this era of social distancing. 

Right! It can limit exposure across the board. If you can check sugars from an app on your phone and get the same information but get it more frequently, safer, easier, and quicker…it’s a no brainer. So, we’re looking into that now. 

Has the management of kidney disease changed at all? 

Yes and no. It depends on the type of kidney disease, there are so many different types, so many different etiologies [cause or set of causes] of kidney disease. They've made a lot of progress in some of these glomerular diseases with new medications, better understanding the molecular biology of them and things like that; understanding the genetics of them too. So, there's been a lot of advancement in understanding kidney disease, but overall once you get to end-stage it's still the same. Either dialysis or transplant, and transplant is still better than dialysis.

Have there been any advances in disease management that buy time so to speak, slowing the progress of kidney failure? 

There has, but it depends on the disease and the etiology. The two most common types of kidney disease are first diabetes and second hypertension. Certainly good glucose control makes a difference, but that's all well known. It's a matter of delivery of care for some of those things, having the right doctor or team. And with an obesity epidemic, preventions don’t seem to be working. What we need to actually prevent is obesity. 

There's so much that you do to kidneys now to make more of them viable for transplant, like filtering or repairing them. How do you match the right kidney to the right person? 

I like to tell my patients getting a kidney that it’s not like you get a brand new one right from the factory; it's like getting a used car. Some have more mileage than others, some have been maintained better than others. So, depending on what a patient needs will determine what kind of kidney we'll use for them. For instance, if you're going to drive to the grocery store twice a week, you might get away with an old clunker Chevy that has 150,000 miles on it. If you have to drive coast to coast once a month, you may want a Lexus with 20,000 miles. They're both used cars, but they're very different. 

We try and utilize as many kidneys as we possibly can because there's such a massive shortage. The government wants to double the number of kidney transplants by 2030, so that poses a whole bunch of questions. There are only three ways you can do that— One is by increasing the capacity at the existing transplant programs, the second is to develop new transplant programs, or the third is some combination of the two. That's going to be one of the things to figure out after the COVID pandemic. How do we double the number of kidney transplants in the next 10 years? 

Do you think the 10-year timeline is feasible? 

Oh yeah, I think it's doable. It makes a lot of sense; transplant is the optimal treatment for kidney failure, period. And it's a lot cheaper than dialysis. Our government is the big payer for dialysis, so if it's better care for the patient and cheaper for the government, that's a no brainer. But it’s going to take sinking in some resources. We're not going to be able to do twice as many transplants with the same resources that we currently have. We've got to have the resources to increase the numbers. You can't just sign an executive order and say, “Okay, well increase the numbers, and then we’ll give you the resources.”

What are some of the roadblocks to getting those needed resources? How would that work exactly? 

Right now, there are bottlenecks in literally every step of the process: identification of deceased donors, increasing the number of living donors, getting consent on the donors, allocating them, the logistics involved. One of the biggest problems is that transplant centers all look at post-transplant survivals, you know the number of people who survive. This is the approach that’s being used by both the national infrastructure and by insurance companies. So, what happens? Transplant centers will cherry-pick their patients and they'll cherry-pick the organs to secure the best possible outcomes that they can get. It's sort of like looking at financial records, if you don't look at the beginning of the equation, if you're only looking at the revenue and you're not looking at the expenses, it doesn't tell you what your bottom line is.

We need to be looking at the front side of the equation: how many people are waiting for kidneys, how many people could benefit from kidneys, and why aren't they getting transplanted? Now in some places, including New York, less than 50 percent of the people who get put on the waiting list ever get transplants. It’s terrible. Imagine if 50 percent of the people who walked into the emergency room with appendicitis never got to the operating room. It’d be scandalous! But this is what people have accepted with transplantation. It's not just kidney transplants, it's all transplants. But for kidney transplants specifically, the government is the big payer so they want to save money. 

Wow. Is the government spending all related to Medicare? 

Yes, because it’s a special case. Basically, if you have kidney failure you're eligible for Medicare. It's the only disease-specific eligibility that could get you into Medicare. Otherwise you have to be old or disabled, or something like that. But because dialysis was so expensive initially, they didn't want people with kidney disease to die because they couldn't access dialysis for financial reasons, and the government agreed to pay for it. 

How does the business of dialysis centers fit into this crisis? 

That's one of the issues. There are two big dialysis corporations in the United States and they make a lot of money, which gives them a lot of political pull because they have a ton of money to spend on lobbying. That's part of the problem that we need to fight hard against, because dialysis is not the optimal treatment, transplant is. 

Is another part of the organ donor shortage related to the low number of registered organ donors, especially in New York state? 

Oh, that's a whole other problem. There is demand and supply, so the demand is not the patients who are actually getting on the list. That list is only a small proportion of those who could potentially benefit from transplant, and less than 50 percent of those who are on the list winds up getting transplanted.

On the supply side, we have 325 million people in the United States, we ought to be able to get enough living kidney donors to get everyone a transplant. We could certainly do better by increasing the number of deceased donor organs, but there's not going to be one solution to all these problems. There's going to be little solutions which pick up 2 percent here or 3 percent there, and then they'll all start adding up to make a big difference. If there were a simple, easy solution it would have happened already. 

What do you want the first steps to be in addressing this crisis? 

I think the very first thing, the lowest hanging fruit, is that we have to change the metrics by which transplant centers are being graded. You know, everyone's studying for the test. They don't want to lose their contracts, they don't want to lose their patients, they don't want to get fired because they don't meet the metrics that have been prescribed. So that's the first step. 

I'm the president of the American Society of Transplant Surgeons right now, and that's been a big push of our organization—to try and get the metrics changed. One of the problems was that there wasn't consensus about what the goals of the metrics should be, but we've had a number of meetings with patients and the government and all that, and I think we've gotten to the point where we have a pretty good consensus of what we want to see. Now we're developing alternative metrics as proposals for people to weigh in on. We're working through all these things, but it takes time. Particularly when you have a full-time job doing something else. 

Sounds like the work never ends. On that note, let’s jump to pancreatic transplant. Have there been any changes in who needs a pancreas transplant? The patient population? 

No changes per se. The most common patient who gets a pancreas transplant is a type 1 diabetic. Type 1 used to be called juvenile-onset diabetes, but it could occur really any time, it’s just more likely to happen in young people. Type 1 is basically where the pancreas doesn't make any insulin. As opposed to type 2 diabetes, which is associated with obesity but not solely. With Type 2 diabetes the body makes insulin, sometimes making even more than normal amounts of insulin, but the body doesn't respond appropriately to the insulin. 

So, while the vast majority of people who get pancreas transplants are type 1 diabetics, we also do some type 2 diabetics who sort of look like (what we say phenotypically) type 1 diabetics. They're thin, they developed diabetes when they were young yet still make insulin, but their pancreas doesn't make enough to meet demand because the body is resistant to it. The vast majority of people who get pancreas transplants also either need a kidney transplant or have had a kidney transplant. Most of the time they're going into patients who are already on antirejection medications for the kidney transplant. 

Are there factors other than availability that determine whether you would do a pancreas or a kidney transplant first in those cases? 

Oftentimes we do them together. If we can get a good pancreas and a good kidney from the same deceased donor, we'll do that. On the other hand, the main benefit in terms of life expectancy and quality of life comes from a kidney transplant. So frequently we'll push people to get a living donor kidney transplant so they can avoid or get off dialysis, and then do the pancreas transplants later from a deceased donor. 

What’s new in research?

There are tremendous things going on in research! There are a lot of new medications coming down the pike. Again, through the American Society of Transplant Surgeons, we've been working both with the pharmaceutical industry, the FDA, and the National Institutes of Health to make it easier to develop new drugs for transplantation. And there are a lot of very promising drugs that will impact transplant in a lot of different ways, not just in terms of preventing rejection, but also improving how the kidney or the organs function. 

There's also been a lot of very exciting work in organ preservation. When you take an organ out of a living human being or a deceased donor you have to preserve it so that it doesn't deteriorate. That used to be based on trying to slow the metabolism down by making the organ cold. Now there are techniques where you can preserve the organ at normal temperature. And if you can preserve the organ at a normal temperature that also opens up the possibility of being able to genetically manipulate the organ, which can't be done in the cold for chemical reasons. 

Wow. Is part of that preservation to increase the amount of time an organ can stay viable before being transplanted, making more organs available? 

It is, which actually brings us to a different side of this. Preservation research ties into research about infrastructure—operational and logistical issues. There's a lot of work going on now that shows the way transplant centers are structured impacts what organs are used and what aren't used, what patients are transplanted and aren't transplanted, and the make-up of regional differences. It’s all very exciting to me. I think this is one of the most exciting times in the last decade or so, in terms of what’s promising in the field of transplant.

Sounds very exciting.

The last really exciting development to add is that a new organ has been transplanted—people are doing uterine transplants. They're actually doing it for women who are born with uterine abnormalities and can't become pregnant. With the transplant, they can have their own babies, and these transplants are actually working out really well. There’s even been a case where a mother donated her uterus to her daughter and then had a healthy baby. 

That’s incredible. 

It’s amazing, right? We've talked about life-saving transplants, we've talked about life-improving transplants, and now with uterine transplants, there are life-giving transplants too.

Of all of these promising developments, what are you most optimistic about? 

There's not going to be one giant magic bullet that's going to fix everything. It’s about chipping away at all these little things, starting with the lowest hanging fruit of operational and organizational aspects. Because those changes don’t really involve science, they involve changing human behavior, and resources. Maybe I ought to say that science is more optimistic than changing human behavior, but I’d like to think that we can change human behavior. 

We can! With all this talk of progress, the last question has to be: what are your goals for the next five to ten years?  

In the next five years, my number one goal is to get the metrics by which we are graded as a transplant center changed so we can improve access to transplantation. And I think we can do it; I know we can.


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