Surgical Innovations for Kidney Transplants

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health, from end to end.

Hi everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And I am very pleased to have our guest today, Dr. Hannah Kerr, who's a urologist in Cleveland Clinic Glickman Urological and Kidney Institute's Center for Renal and Pancreas Transplantation. Dr. Kerr, thanks so much for joining us here on Butts & Guts.

Dr. Hannah Kerr: Hi Dr. Steele, thanks for having me.

Dr. Scott Steele: I'm super excited because we talk a lot about DDSI type things and we haven't had a lot of the general urological type thing, so you're one of our very first guests for that, so super excited to have you here. So, as many of our listeners know, we like to first start out by learning a little bit more about you. What's your background? Where are you from? Where'd you train? How did it come to the point that you're here at the Cleveland Clinic?

Dr. Hannah Kerr: I'm an Ohio native. I did all of my medical school here in Northeast Ohio. I did residency in urology at the University of New Mexico, and then I completed my kidney and pancreas transplant fellowship training here at the Cleveland Clinic. After finishing fellowship, I went back to New Mexico where I became the Surgical Director of a transplant program there, and I was able to actually start the first pancreas transplant program in the State. I was there for close to seven years, and while it was a very exciting and rewarding experience growing transplant in such a medically underserved area, it was time for me to return home and I accepted a position at Cleveland Clinic at the beginning of this year.

Dr. Scott Steele: We're really pleased to have you here, and today we're going to talk about surgical innovations for kidney transplants, and let's just start with a very high level overview. Why does somebody need a kidney transplant?

Dr. Hannah Kerr: Someone would need a kidney transplant when they reach the point where their kidneys are no longer functioning well enough to continue to remove toxins from the bloodstream.

Dr. Scott Steele: So how do you know when it's time to get a kidney transplant?

Dr. Hannah Kerr: We measure something called GFR, which is the patient's kidney function. When that level drops below 20%, at that point, someone could consider being listed for a kidney transplant. The decision as to when to start dialysis generally comes from the patient's nephrologist or medical kidney specialist.

Dr. Scott Steele: Give me a little bit more about this, let's say I'm just somebody that's out there and I got a lot of health issues, and one of which, my kidneys are failing. Can I still get a kidney transplant? Or do I got to be otherwise healthy and it's just my kidneys that are problematic?

Dr. Hannah Kerr: Sure, so many patients who need kidney transplants have other health issues. Some health issues are a barrier to transplant, some are not. We perform an extensive medical evaluation and surgical evaluation before listing someone for a kidney transplant to make sure that our patients are healthy enough to undergo the surgery, and healthy enough to take the anti-rejection medications.

Dr. Scott Steele: Okay, so Hannah, it's been a long, long time since I participated in kidney transplants, and all I remember on my transplant rotation in residency is it seemed like I got there on a Thursday and I went home on a Tuesday. So, what does the operation involve? What do you do? Where do you get your kidneys from?

Dr. Hannah Kerr: A kidney can come from either a living donor or a deceased donor. Once a patient completes the pre-transplant evaluation process, if they meet the criteria, they get listed. If someone has a living donor, those are the cases we can schedule on a Monday to Friday, regular type of surgery schedule basis. But if someone doesn't have a living donor, they wait on the deceased donor waiting list until a kidney becomes available for them. Those are the kidneys that we do on the weekends, in the middle of the night, whenever they become available is when we do the transplant.

Dr. Scott Steele: You briefly mentioned a little bit about dialysis. So, dialysis, that's kept people alive for decades. What are the risks and benefits of getting a kidney transplant versus just staying on dialysis? And why would somebody who's on dialysis not qualify for a kidney transplant?

Dr. Hannah Kerr: So there's risks and benefits to both ways you look at it. In general, we know that most patients have better survival, and better quality of life, with a kidney transplant compared to dialysis. But a kidney transplant is considered major surgery. When we're looking at risk benefit, you have to consider the risks of the surgery, and also the risks of taking the anti-rejection medications, which are lifelong medications for transplant recipients. These medications lower the immune system, and therefore the patients are considered immunocompromised and can be at higher risk for infections.

Dr. Scott Steele: So if you have a successful kidney transplant, does that last longer, typically, than just being on dialysis for a lifetime?

Dr. Hannah Kerr: Most of the patients can't stay on dialysis for a lifetime. The longer you're on dialysis, the higher the risk you are for developing other chronic medical problems, and survival is poor, long-term, for most patients on dialysis.

Dr. Scott Steele: So let's talk a little bit about a deceased donor versus a living donor, is one better than the other? You said earlier that maybe the living donor is probably the best, why is that? And how do the two differ between?

Dr. Hannah Kerr: Sure, so living donor kidneys are going to come from healthy people. In order for us to use the kidney for donation in someone who is living, they really have to be healthy with very few medical problems, and therefore that person is going to have really good kidney function. Those kidneys last a lot longer than most cadaveric kidneys. Now does that mean that a cadaveric kidney isn't a good kidney? Absolutely not. We still have a screening process for cadaveric kidneys where every time we get a deceased donor offer, we're reviewing the age, the comorbidities, the kidney function, and the story of that deceased donor. In general though, because living donor kidneys last longer, we really try to encourage patients to pursue a living donor transplant if they're fortunate enough to have that option.

Dr. Scott Steele: Hannah, how long can a kidney, let's just say that it's a deceased donor, how long does that kidney have before you have to transplant it into another individual?

Dr. Hannah Kerr: Well, that really depends, things have changed in the last few years with transplant. We now have devices such as a kidney pump machine where we actually place the kidney, once it's recovered, on a pulsatile profusion machine. This tends to preserve the kidneys for a longer period of time and can actually help them recover faster. Most of the time with the deceased donor kidney, though, we're still going to want to try to do that transplant within about 40 hours of it coming out of the body of the deceased donor.

Dr. Scott Steele: So most people are familiar with dialysis, and they may either see a special port that they place in, or they may be familiar with a fistula that is oftentimes a connection in the arm, but when you put the kidney?

Dr. Hannah Kerr: So the kidney transplant goes in the front, it goes in the lower abdomen, usually a diagonal incision from the middle, up towards the hip bone.

Dr. Scott Steele: And do you have to go in and take out the kidneys that aren't working?

Dr. Hannah Kerr: You know, most of the time we actually don't. I know that's surprising to a lot of people. It really depends on the situation with the transplant recipient. Occasionally we do, like if someone has very large polycystic kidneys and we don't physically have enough space for the transplant itself, or if there's some other sort of anatomic abnormality in the urinary tract that would require us to remove a kidney, but most of the time we don't.

Dr. Scott Steele: So let's go into a segment I like to call Truth or Myth. So Truth or Myth: You typically have to wait months for a kidney transplant.

Dr. Hannah Kerr: Truth. There's a national shortage of donor kidneys. It can be a very long wait for a kidney transplant, up to several years actually, depending on the situation.

Dr. Scott Steele: Truth or Myth: Kidney transplantation should be the first option for someone with advanced kidney disease.

Dr. Hannah Kerr: Truth. We know, on average, most patients live longer with transplant as compared to dialysis, so we always encourage patients with advanced kidney disease to pursue transplant. It depends on the overall health of the patient though, as to whether or not transplant is an available option or the best option.

Dr. Scott Steele: Truth or Myth: You can still have a kidney transplantation if you've undergone dialysis.

Dr. Hannah Kerr: Truth. A patient being on dialysis is not a barrier to transplant. Most patients are on dialysis, actually, before receiving a kidney transplant. Sometimes what we see, however, is the longer patient is dialysis, the more overall health problems they develop, so we recommend people pursue transplant as early as possible to avoid developing other health problems that could later be a barrier to transplant.

Dr. Scott Steele: Hannah, you mentioned earlier that there has been a lot of changes, especially even recently, so one of the things we're talking about here is surgical innovation. So what surgical innovations for kidney transplantation has Cleveland Clinic had in the past few years, whether it's recovery time, whether it's the operation itself, whether it's rejection or success rates?

Dr. Hannah Kerr: The Cleveland Clinic transplant program has been doing really, really well. The program has been transplanting high volumes of patients with good outcomes. Surgical advances have been including performing some transplants robotically, reducing the inpatient hospital stay to as little as two days in a lot of cases, and also developing the traditional transplant surgery incision to be smaller and less painful. The SRTR is the national database for transplant center outcomes, and the most recent data has the Cleveland Clinic Kidney Transplant Program in tier five, or the top tier, for one year kidney survival.

Dr. Scott Steele: Do you have to stay on transplant medications for the rest of your life? Or do you eventually go off of those?

Dr. Hannah Kerr: You do. With kidney transplantation currently, every patient has to stay on anti-rejection medications for life.

Dr. Scott Steele: How do you see kidney transplantation advancing or changing in the future?

Dr. Hannah Kerr: The future of kidney transplant would really be to develop a way to alleviate the organ shortage, and improve kidney function without having to use immunosuppressive medications. A lot of research right now in transplant is going into projects like engineering and developing something like an artificial kidney. While we're still a ways away from seeing something like this in practice, it's exciting, and we look forward to the future developments of transplant.

Dr. Scott Steele: We always like to learn a little bit more about our experts and our guests, so we'd like to end up here with a little bit of quick hitters. So first of all, what's your favorite food?

Dr. Hannah Kerr: I would have to say pizza.

Dr. Scott Steele: What's your favorite sport?

Dr. Hannah Kerr: College football.

Dr. Scott Steele: College football, fantastic, and I have to ask you, what's your team then?

Dr. Hannah Kerr: I have to tell you I'm from the Columbus area, so has to be Ohio State.

Dr. Scott Steele: I thought you were going to say the Ohio Bobcat's for Bill, our behind the scenes guy out there. What is the last non-medical book that you've read?

Dr. Hannah Kerr: That one was probably Talking to Strangers, by Malcolm Gladwell.

Dr. Scott Steele: And you said that you're an Ohio girl, and you went out to New Mexico, so what is it that you like about here in Northeast Ohio?

Dr. Hannah Kerr: Honestly, it has been so nice to be back, seeing all of the green everywhere, after spending several years in the desert, it's been really great to see.

Dr. Scott Steele: That's fantastic, something that often we take for granted. What is your final take home message regarding kidney transplantation in the future, or just about this entire theme of kidney disease, to our listeners?

Dr. Hannah Kerr: I think the biggest take home, which really I cannot stress enough, would be early referral to transplant. There is such a huge demand for organs and a national shortage, which means long waiting times for patients who need a kidney. The longer a patient is on dialysis, the more overall health problems they develop, which could later become a problem when they need a transplant. We also know that there's an increased survival benefit for patients receiving a preemptive kidney transplant, or a transplant that happens before initiation of dialysis.

Dr. Scott Steele: That's fantastic stuff and words of advice that I hope all of our listeners and all our health care providers who are dealing with kidney disease take heed to. So to learn more about the options for kidney transplants and to download a free treatment guide, please visit clevelandclinic.org/kidneytransplant, that's clevelandclinic.org/kidneytransplant. You can also call 216.444.6996, that's 216.444.6996.

Finally, please remember, it's important for you and your family to continue to receive medical care, regular checkups and screenings. Be rest assured, here at Cleveland Clinic, we're taking all the necessary precautions to sterilize our facilities and protect our patients and caregivers. Dr. Kerr, thanks so much for joining us here on Butts & Guts.

Dr. Hannah Kerr: Thanks for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.