Episode Transcript
Speaker 0 00:01:00 And hello you great listeners. This is cafe I 90.3, FM, Minneapolis and KFC I dot O R G. You're a 202 CA uh, disability and progress where we bring you insights into ideas about and discussions on disability topics. My name is Sam. I'm the host of the show. Thanks so much for tuning in Miguel is my engineer. Thank you, Miguel. Um, Charlene dolls, my research team. Thank you, Charlene. The topic is trans. Great topic is transplant and transplanting during COVID time. Dr. Roger Candace Swami will be with us heals. He is joining us. Dr. Candace Swami is a professor at the university of Minnesota medical school and medical director of the solid organ transplant unit at M health Fairview at the university of Minnesota medical center. Good evening, Dr. Candace Swami.
Speaker 2 00:01:57 Good evening, Sam.
Speaker 0 00:01:59 Thank you so very much for giving your time and joining us. We greatly appreciate it. I think this is really an important topic to cover, um, times are changing so much and with that so much medical stuff changes too. Can you just start out by giving me just a little brief history on you?
Speaker 2 00:02:21 Sure. Um, Sam, um, as you introduced, my name is Roger Kansas army. I, um, am a transplant surgeon at the university of Minnesota. Um, I direct the kidney and pancreas transplant programs at the university. I also direct the inpatient transplant unit. I'm also involved in education of future transplant surgeons. I direct the transplant fellowship. I am involved in major national and international organizations in the field of a transplant patient. I grew up in India, um, during my early years and, um, immigrated to the west in the late eighties, uh, right after medical school. Uh, I did a brief stint and I'm in psychiatry residency at the university of Toronto, uh, late eighties, early nineties, uh, then switched from psychiatry to surgery and Washington DC. Um, and that lasted through the five years of training. I got fascinated by organ transplantation. I was exposed to the first liver transplant in the district of Columbia, um, back in 1991 and I was an intern, um, who held a retractor for 16 hours straight, um, during a liver transplant fell in love with it.
Speaker 2 00:03:35 So that was the bug that bit me, and then decided to try and specialized in organ transplantation, um, decided to seek the best program that's available. And certainly university of Minnesota had the reputation of being one of the best programs in organ transplantation under the leadership of Jon Najarian and David Sutherland back in the nineties. And, um, so I applied and came here, uh, in 1997 and, uh, did my transplant fellowship became a transplant surgeon and was retained to be a fellow here as a, uh, assistant professor and then have moved up the ranks now to be a professor and a head of the kidney and pancreas programs.
Speaker 0 00:04:14 Well, we are glad to have you, so thank you. Um, can you tell us currently how many organs can be transplanted?
Speaker 2 00:04:23 Well, the, um, there are various organs in the body that can be transplanted. The most common of course is kidney transplants. And, uh, that's, uh, the most commonly performed transplants followed by liver transplants. So those two probably predominate other transplants that are performed or, uh, pancreas, um, small intestines, uh, heart lungs, and also, uh, more recently, uh, uterus transplants, which have been performed. Yes. Uh, in addition, yes, that's been done. It's not very common, but it's been done in a few selected centers and we have an interest in it as well. Uh, the, uh, other transplants that are done are, um, vascularized composite allografts, I'll tell you what I mean by that. Those are, um, those belonged to tissues that come along with their own blood supply. And those include hand and transplants with people who may have lost their hands due to, uh, accidents and trauma. And the, uh, second is face transplants. So those are, uh, other types of transplants that are being performed. Now, the cell transplants, in addition, which I'm not covering in this particular session, which include eyelids and, uh, you know, there's, um, bone marrow and, uh, there's certainly skin grafts, which is the most common type of transplant.
Speaker 0 00:05:45 Okay. Well then prepare for another show. Um, let's see. So I think that's fascinating. I'm just curious how, how successful are the uterus transplants?
Speaker 2 00:05:59 Uh, the Urus transplants are a, uh, a transitory transplant. If you will. They have a very defined purpose to provide a, uh, childbearing option and biological bearing option for the mother. Uh, and so, uh, the need for long-term success is not as, uh, important for uterus transplanted has to, uh, take your first of all, it has to be technically successful and that the operation has to go well, the blood supply and things have to connect. Okay. And the uterus has to thrive. Secondly, it has to get the ability to get pregnant. And thirdly, it has to be able to bear a, um, uh, a full-term pregnancy and once that's done, then the uterus can be removed basically. So, um, it's, it's only done in, uh, in a handful of cases so far in the United States, and there's been, uh, the, uh, the Swedish or the pioneers in that. Uh, so I think there's a small, um, it's a small start, but there's a potential for it to grow in the future. It all depends on competing technologies, as well as to, uh, in vitro fertilization and now surrogate motherhood. And it's a whole area. We look at the biology of uterine transplants and concentrate on whether or not we can make it work.
Speaker 0 00:07:21 That is fascinating. All right, well, we got a whole lot to get to, so I can't concentrate too much on this, but at some point that would be a fascinating topic. Um, so what are the organs that can be donated without someone having to be a dead donor and donating them? I know kidney is one theoretically liver two.
Speaker 2 00:07:46 Yes. You've touch upon an important, uh, classification of organ donors. Um, there's a, um, one is a living organ donor versus a deceased organ donor. Um, the, uh, if you're talking about, uh, living donation, which is what we'll discuss first, um, uh, a healthy volunteer can donate, um, one kidney since we have two kidneys. Um, at least the majority of first, a lot of the great majority of us are blessed with two functioning kidneys. And so are perfectly capable of functioning with one kidney for the rest of our lives. So we could give one up and that's the most commonly performed, uh, living donor transplant, uh, as far as liver, there's only one liver, but fortunately that's the largest organ in the body, uh, outside of the skin. And therefore there is enough reserve in the liver to be able to give up, uh, up to one half of deliberate, even a little bit more, um, if required, um, if you're a healthy donor.
Speaker 2 00:08:50 So, uh, a partial liver donation can be performed and is being performed in the country, uh, with fair regularity. And, uh, it's a bigger operation for the donor than a kidney, but, uh, it's certainly doable the third, uh, organ that that's, uh, performed as a pancreas transplant. Um, pancreas is done in cases where someone has advanced diabetes and has problems with diabetic control. Often it's combined with a kidney transplant, uh, because diabetes is one of the leading causes of kidney failure. So again, we only blessed with one pancreas. Therefore it'll have to be a partial pancreas transplant and that's performed, uh, less commonly, uh, intestine. A portion of the intestine has been donated and has been performed here at the university of Minnesota and a couple of other centers. And finally lung. Um, you could certainly give a lobe of the lung, um, from a living donor and be able to, um, utilize, uh, two living donors, in fact, make a lung recipient, oh, well from a chronic lung failure. So those are the organs where a living donation has been utilized and have been successful.
Speaker 0 00:10:05 I assume that there is a partial amount of our listeners who might be kind of freaking out as opposed to the thought of giving their lifts and whatnot. But my understanding is that the liver can grow back, you know, it can regenerate. So yes,
Speaker 2 00:10:22 The liver has an amazing capacity to regenerate. Um, in cases, in extreme cases, the liver can regenerate after losing 85% of its volume, uh, which is, uh, an extreme example. Of course, we would not be pushing those kinds of limits and healthy donors, but most donors can give up, uh, safely 60% of the liver. And, uh, the other 40% will gradually grow back and compensate to provide 100% of the function that the body needs.
Speaker 0 00:10:54 And so when you do the liver transplant, are you taking exactly half of the liver are only up, less than that.
Speaker 2 00:11:01 So there's a variety of considerations, uh, in, in a adult to child transplant, for example, where the mother or father donates to a baby or a young kid, you probably do not need to take anywhere close to one half. So the liver is divided into eight segments, if you will, a one through eight, and we can just take two segments of the eight and do a baby transplant with that from an adult, um, in a, um, you know, from when you transplant from one adult to another, you may need more than two segments. And usually it's one half of the liver. And one half of the liver is not exactly a half because the right lobe is larger than the left. Um, so if you do a, uh, if you take the right half of the liver, you're taking probably about 60% of the liver. And if you take the left half of the liver, you're taking about 40%, which one we take will depend on the recipient and donor size matching, uh, the suitability of the donor to be able to donate 60% of their liver and a variety of other factors. So yes, up to 60%, but, uh, yes, many cases lower.
Speaker 0 00:12:11 And so when you do that, then presumably as you said that the liver can start regenerating, um, will it make, like it's the new part B like it's a whole new liver, or is it regenerating from what you already have? And if you already have an older liver, you're going to get an older liver regenerating.
Speaker 2 00:12:32 Uh, it's not like the liver's adding new, uh, let's say you, uh, uh, you downsized from a, uh, I don't know what a good analogy would be, but, uh, you downsized, um, uh, from a liver that's, um, uh, 1.5 grams down to one brand. Um, I mean, no, when I say, I mean, 1000, 1500 grams to 1000 grams, okay. What can happen within two to three months is that liver that's now downsized to 1000 grows back up to 1500 and sometimes even more, uh, it doesn't form a new, um, if the cells hypertrophy, meaning they, they, uh, they proliferate and they get, um, more functional and can compensate for the, uh, the rest of the, uh, missing liver. Now it doesn't form any new blood vessels. The basic anatomical structures remain the same. It's just gets to be a larger to be able to accommodate the function.
Speaker 0 00:13:36 Gotcha. Dr. Kevin Swami me, I'm wondering, how does one become a donor? Can you talk us through the different ways that you can do that? Yeah.
Speaker 2 00:13:44 Um, I will, there are two types of donation, as I talked about, uh, earlier two types of organ donors. One is deceased donors, which is after your demise. And second there's a living donor. I first talked about the donation. Um, the, uh, of course those choices are made while one is alive of, for example, I am a registered organ donor, uh, and you can make that choice, um, by signing up during a driver's license renewal. And, um, in the last few years, both fishing and hunting licenses as well, you can sign up to be an organ donor at that time. And, and most recently I was just told by, uh, life source, which is our local organ procurement organization, um, that, um, that you can sign up through some tribal ID cards as well in, in the, in the Indian reservation. So there's a variety of ways you can do it, and it's not prevalent across all tribes yet, but at least there's been a breakthrough with, uh, one particular, uh, tribal ID card, which is a great start, but the more opportunity to become a donor, the better it overall for transplantation.
Speaker 2 00:14:53 So I encourage people to discuss with their family and, uh, while they are alive and well, and, uh, it's not, it's not any different from, uh, planning a will. Uh, and, uh, you talk about organ donation. It is very important to talk to family because, uh, uh, you are not around at that time when the donation happens and the teams will be talking to the family. And to the extent the family is already aware and agreeable, it makes the whole process go much smoker. Um, that's the process of a deceased donation. I can move on to living donation, unless there are any questions about deceased donation.
Speaker 0 00:15:32 No, I think it gets tricky talking to them if you hadn't, um, talked to them before and they don't know what you want, and then it's a tragedy. Um, but I do have a question real quick. Um, so let's say you actually get old, you die because you're older in your nineties. Would they actually use your organs then?
Speaker 2 00:15:56 So the, the, uh, donor has to have healthy organs, uh, to be able to transplant. Uh, it does not just because one is 90 years old and, uh, it does not mean that all the organs are not healthy. They could have died from a stroke, which is, uh, which is a specific, uh, brain-related um, the debt. Um, and so, uh, there is opportunity, although I don't think we've done any 90 year olds, that's an extreme example, but we've gone out to 80 years of age in terms of taking organs, uh, from, uh, from older people. So yes, advanced age is not a contraindication. Um, within limits of reason provided the mechanism of death, uh, is not, uh, something that has, um, that has resulted in gradual deterioration of all organs. If that's the case, then they may not be suitable donors, but in either case the choice to become a donor, uh, is made well before, you know, what your mechanism
Speaker 0 00:16:55 That's right. And I do want to, um, impress upon people that too, that, um, you, my understanding is you can certainly, um, donate and, and make sure people know if you can't, you know, they can't use your, um, organs in a person that first research would be great.
Speaker 2 00:17:16 Yes, absolutely. And there's a lot of opportunity that we're constantly trying to learn more to advance the field and help future generations. So being able to utilize, um, the organs that cannot be used for transplantation for research purposes, uh, uh, just as, uh, useful in many cases and just as important. And then there's also tissue and eye donation that can be done in patients. So there's a variety of opportunities, uh, when one signs up to be an organ donor besides, um, just, um, you know, the Oregon study I mentioned before. All right,
Speaker 1 00:17:52 I'm ready for the live thing
Speaker 2 00:17:53 Now. Yes. So live donation is fast becoming the most common form of, um, a transplant in the United States. The us is the leader in the world in the area of live donation. And, uh, I think that really is the future. Um, and, uh, for, for, for organ transplantation, like I said, um, by nature, people are, um, are good and generous and want to help. It's just awareness as to what can be done and what are my options and how safe it is. And am I going to put my own health or my family's interests in jeopardy by going through an unnecessary, medically unnecessary procedures, to the extent we can educate on this topic and make, and reassure donors that this is a safe option to go through. I think live donation has been to continue to grow, uh, live donation one, uh, can a first step to becoming a live donor in, in the United States.
Speaker 2 00:18:50 The most common form live donation is in response to a recipient request. So a most often you either have a loved one, a friend, a family member, a relative, or somebody who is in need of a kidney transplant, and people hear about it and then want to help that person out. So that's the most common method of, um, of, uh, finding, uh, live donors, uh, volunteering. The second has been where, um, and, and this has taken off in a big way. The university of Minnesota is a pioneer in this, uh, in this area. In fact, I was involved in the one of the first such donation processes back in the late nineties, when we had people that showed up at our door and said, out of the goodness of their heart, they said, uh, we read about kidney donation. We know that it's safe to do.
Speaker 2 00:19:42 I don't have anybody in need that I know of, but I'm sure you do as a transplant center. Therefore, I want you to utilize my kidney to provide the someone in need, uh, this post, a lot of questions for us back then, because it's easier when there's an emotional attachment and we didn't have a structure to, uh, uh, to be able to, uh, take organs from people who are what we called back then altruistic donors or non-directed donors as we call them now, meaning they don't direct where the organ should go, rather it's for the goodness of society and transplant centers, as good to, as if that Oregon then, um, utilize our transplant waiting list and the priorities that we already have in place to assign that organ to the best possible recipient, uh, without, uh, any favoritism or bias. So that, that program was started at the university of Minnesota.
Speaker 2 00:20:42 We did some pioneering work on it, the process of non-directed donation. And now we have done over 150 donors that way in the last 20 years at the university of Minnesota. And it is the largest program in the world in that particular subset. And subsequently a lot of other programs have followed our lead and nationally now a non-directed donation is growing, especially amongst young, uh, altruistic individuals, um, eager to help, uh, people that are unknown to them. And, uh, it's a, it's a great opportunity, uh, to donate. And that program is growing. I want to touch upon this a little more in detail if I have time. Um, but this there's a, uh, and I can come back to it later about a live donation and not direct donation, but that is another method of, of donation. There are ways to find information about a living donation on the, on the web.
Speaker 2 00:21:40 Um, the national kidney foundation has some good resources. You can go to their website, the national kidney registry, which is the largest exchange for living donor organs in the country. Also has some very interesting information and very detailed information. Their website is kidney registry, that orgy, um, to get information on it. And then our on university of Minnesota, um, M health website, which is M health fairview.org has links to organ donation. And if one is interested in, um, trying to see if they could be an organ donor, you could fill out a questionnaire at M health, that donor screen.org. And, uh, we would go through the screening questionnaire and someone will call you back to talk over the process of, uh, of trying to become a donor. It is by no means a commitment to donate. It just shows that you want to get some information and, um, think about donating
Speaker 0 00:22:36 One of the things that always hit me funny, and this is my understanding, you correct me if I'm wrong, is that here in America, you have to opt into donating. And my understanding is in parts of Europe, you are just donating unless you opt out, is this correct?
Speaker 2 00:22:56 Yes, that's absolutely true. Uh, the system,
Speaker 0 00:22:59 Uh, they just have it the same
Speaker 2 00:23:01 Here. Yes. So this is a, uh, this is as much an ethical question as it's a legislative
Speaker 2 00:23:09 Legislative question. Um, the, the, uh, the most common, uh, shining example in the world, that's cited as the country of Spain, where, um, unless you just, like I said, before you go and sign up in a driver's license to be an organ donor, it's the exact inverse in Spain. If you everybody's assumed to be an organ donor after they die. And if you do not want that to happen, then you sign up to opt out of organ donation. So unless you opt out, you are considered a donor. So the whole process is much more systematized, more efficient and a high yield, and they have the highest organ donation rates in the world. Yes, so often. And, and it's in, in many cases, it's not bad because people have not signed up to be a donor, just because of the inertia of going through the process, seeing it, and, um, actually actively signing up.
Speaker 2 00:24:06 Uh, but in their hearts, if you quest them that whether you'd like to be a donor, the answer is probably yes. And so it works well in the great majority of, of, of, uh, individuals, but the ethical pushback has been, uh, this needs to be an active decision. Um, someone has to think about this. The, uh, the system cannot assume that everybody wants to be a donor. Uh, just as much, uh, just as there is inertia for making a decision to donate. There may be an inertia for, for, uh, for the decision not to donate an opt out, even though they may feel that way. And therefore we do not want to, around that side, that's been the us philosophy and it's a legislative deal. It's a, it's the law. And there's been a lot of efforts over the last 30 or 40 years to try and propose changes to it, to go to an opt out policy. Um, but, uh, so far we haven't had that change.
Speaker 0 00:25:05 Well, just so you can, I can air my opinion. I really feel like they should, um, have this because, um, just like anything there's so much lesser important things that you have to, um, sign up for and, and say, if you don't heck half the time, I have to check that I don't want junk mail if I don't, if I don't want it. So to me, this is so much more important. If you don't want to be a donor, you should be able to just opt out, but just think of the, like you said, the high yield you'd have. If people were just assuming that they were donors and then made that specific choice themselves, if they didn't want to, um, I want to quickly touch on, you know, I know it's tricky when you need an Oregon. Obviously you have to be sick and if you're too sick, you can't get it. And if you're not sick enough, you can't get it. So where is that happy balance? There are not so happy dance.
Speaker 2 00:26:06 Well, that's a, that's a great question. Um, so, uh, organ transplantation is a advanced and complex, uh, surgical procedures, generally speaking. And so there's two major risks of organ transplantation, just like any operative procedure. They always come with the risks. And the reason we undertake those risks is for the benefits we get at the back end of it. If you have a broken bone and you have to have an operation, those risks are that operation, but you do it because that's the way you can use that limb again, or walk or whatever the case may be. And therefore you, you take the risk for the benefit and in organ transplants, the risks are outweighed by the benefits greatly in, in most transplant, but that equation can be altered by, um, the recipient's medical characteristics. Uh, if the recipient is very sick and their operative risk, um, meaning their risk of having complications of being able to survive the organ transplant surgery, uh, goes up higher.
Speaker 2 00:27:07 There may be a tipping point beyond which the risk may be higher than the potential derived benefit. Of course, it's a hypothetical calculation that we have to constantly make in every clinical scenario. It's a challenge we face, uh, in, in many situations. And we talk to, um, recipient families, uh, who are on the margins of candidacy because they are too ill to be transplanted and get through a transplant. Uh it's um, it's, it applies to all organs. Um, and, uh, we like to transplant patients before they get to that stage. Um, it's often limited, it's often limited by, I would say the number one reason why the there's a limitation to that is the availability of organs. If there was an unlimited supply of organs, hypothetically, uh, in the utopian world, we would be able to transplant the great majority of people. Well, before they get too sick to have a bad outcome from transplant and would greatly enhance their outcomes.
Speaker 2 00:28:09 Um, there's 120,000 people waiting for kidney transplants. That number was about, uh, 25,000 or so when I first started, when I first started in the field, that number was just, uh, you know, 20 or 30,000, and that's grown every year, uh, by a great percentage. So we are adding to the list. So we cannot seem to be, um, you know, making a dent on this list. We have barely keeping up. So, uh, kidney, right. That's kidneys. Yeah. And, uh, and we're all, Oregon's, there's, uh, there's the number of organs available, um, in, in most organs, the number of organs available versus the need. There's an imbalance with greater number of organs needed to, uh, get people freed up from their disease. So that's really the limiting factor, but yes, we like to transplant patients before they get ill. And that's where living donor transplantation makes a huge difference because deceased donor transplants have to be rationed according to medical need or waiting time.
Speaker 2 00:29:10 Right? So in liver transplants, for example, if there is a patient who is very ill and doesn't have a long time to live, they do get priority on the list and get moved up. Um, so if you transplant all the sickest patients first, then by definition, you're setting up your system to only do patients that are very sick. When there's a shortage of organs, you never get to the, not so sick patients because you just don't have enough organs, but if you have a living donor available, um, then you can intervene earlier because that donor is donating to a particular recipient. Um, and therefore you can get, um, access to transplantation earlier and do better. That's part of the reason why a living donor transplants as a group do better than the ceased donor transplants in terms of longevity and publication risk in all organ types.
Speaker 0 00:30:05 I'm finding myself really juggling all the questions I have for you. I'm having to pick my pick my best ones, which is disappointing. I think we could make two shows out of this. Um, I do want to get to what I said. I would talk about, um, in the, in the email and talk about donating organs during COVID, because I think this pandemic has been a big deal for everyone, um, even anti-vaxxers, but they it's a big deal and people still get sick. In fact, I believe if I'm not wrong that, um, COVID often messes with the heart and the lungs, and there's a whole bunch of stuff that goes on. So talk about what the process has it changed during COVID is, um, there are different things that you do talk a little bit about that.
Speaker 2 00:30:59 Sure. I'll be happy to. So just to attract back to the history of when COVID started, just to give, uh, your listeners perspective on how it, how it all began when things went down in March of 2020, um, it was of course, a big shocker to, to the nation and to the healthcare field as well. And we, um, in transplantation, uh, went into a, uh, dormant mode for a couple of months with, um, except life-saving organs where patients would not survive. We, uh, had a freeze on, uh, elective living donor transplants, uh, for a couple of months, until we figured out what this new process was and how it affects donors, how it affects recipients and so on and so forth. So national transplant activity dropped greatly in that quarter of second quarter of 2020. Um, but once it became clear that, uh, we could, uh, we started understanding, uh, the, the, uh, mortality restroom already risk and, and how we could still navigate, uh, safely, uh, transplant process through COVID, even though we didn't have all the answers such as vaccines and more recent treatment protocols that have been in place, we were able to resume activity, um, in the third quarter of 2020, uh, for living donor transplants.
Speaker 2 00:32:25 And, uh, by, by, by the end of 2020, our living donor transplant volume rates were back to, um, where they were prior to COVID in 2021, actually, um, transplant volumes, um, outpaced that of 2019, which is the baseline year. You would compare it to 20, 20 being a COVID year. We got composed compare it. Now, why did that happen? I think part of it is because there was a backlog, right, because 2020 was a slower year. And therefore the patients who hadn't received their transplants, who were waiting. So there was an, um, um, backlog of, uh, uh, transplants that needed to be done. Plus there were more donors in 2021, um, and 2021 had some of the highest donation rates, both in deceased donation and in living donation nationally, uh, which is, uh, which is, uh, terrific. Considering the country was still right for a pandemic, maybe adversity brought us together and, uh, stoke the altruistic fires within people's minds.
Speaker 2 00:33:27 I'm not sure what the mechanisms were, but we had, um, nationally a banner year in 2021, uh, for transplantation. And so, uh, that begs the question, which you asked, which is how do you handle transplantation doing during COVID? How do you do it safely for both donors and for recipients? So we have performed over, I want to say about 500 transplants since the start of COVID at the university of Minnesota. Um, and we have not had, uh, we have had one COVID related, uh post-transplant uh, that in a, in a patient out of those, uh, four to 500 transplants that we have done. So the rates of mortality is, uh, while it was still there. And one is, one is one too many, but, uh, it certainly was not an explosion of mortality that we saw in transplant patients. And so therefore we continued on, uh, transplanting patients.
Speaker 2 00:34:26 We did rigorous testing in, uh, in, uh, patients to be sure that they were COVID negative going in. Uh, we did a few other modifications to the amount of immunosuppression that they would take, especially in the area of kidney transplants. And we screen donors carefully for COVID as well, uh, prior to taking organs from them for transplantation. So we've been able to navigate COVID I would say pretty, um, well in 2021 to keep transplant volumes at, or higher than the rates that they were at pre COVID. And I think that same trend is continuing in 2022. The biggest challenge seems to be, uh, how can we, um, uh, increase the utilization of, uh, Oregon's from COVID positive donors, because right now, if you look at the seat, donors, 30% of our deceased donor referrals from hospitals are COVID positive. That's one in three. Uh, if you have one in three COVID positive donors that are trying to, uh, that are signed up for donation, uh, when COVID first started, we would not take any of them.
Speaker 2 00:35:32 But over the, over the months, we have learned that we can take many of them provided they meet certain criteria that was provided. We know that they're not, um, uh, transplanting the COVID, the risk of transmission was lower. None provided. We know that the organs that we're trying to take are not affected by the COVID or the COVID as resolved. So that's what we're in the process of doing now. And we have done a handful of COVID positive donors into COVID negative recipients with no transmission, uh, and it's happened in hundreds of cases, nationally with only reported transmissions in lung transplant COVID transmission, because the COVID, as you know, is predominantly a lung infiltrative disease. It can involve other organs, but in no other organ has COVID transmission being recorded in the country.
Speaker 0 00:36:23 So, uh, okay. So then my question is you would take somebody who has COVID and take if they want to donate, and they're a live donor, you would still allow that, or you wouldn't wait till they were negative, that they tested negative
Speaker 2 00:36:40 Live donation is different. I'm going to talk about live donation. I'm glad you brought that up. I was talking about deceased donation because there we do not have the option to wait when a donor dies and they have had COVID either we take, and we can't wait for the next three or four weeks for their COVID to resolve when they're brain dead, because they are already past due that. So it is a time sensitive, uh, judgment that has to be made. And there's no health consequence to the donor because they are already passed, but in a living donor, it's a completely different deal. Uh, if someone has active COVID, uh, the first order of priority is to take care of the donor and get them better because COVID, while it seems to be running more benign courses in most patients, there's still some pages, some patients who do get bad complications and possible mortality from COVID.
Speaker 2 00:37:27 So we do not take a COVID and prospective donors lightly, if any donor that we are in the process of evaluating, uh, uh, ends up with COVID. We tell them to, um, make sure that the COVID symptoms have resolved. And there's a cooling off period of about three weeks after which we would, um, um, be and make sure that they are fully resolved before we would, uh, take the organ. So, no, we do not take it during the time of, COVID not because of the risk of transmission, as much as, uh, to look out for donors safety. Our first priority in living donor transplantation is donor safety. Okay.
Speaker 0 00:38:05 What about the long holler COVID?
Speaker 2 00:38:08 So we have, um, we have had a couple of patients who have approached us who have had chronic symptoms with, uh, with COVID and our general, um, advice to people is if you have active symptoms, that's limiting your functional ability, it will limit your ability to get better from surgery as well, because it is a major operation, a living donation, even though it's done laparoscopically, it's meant to be a minimally invasive operation. It's still involves going in there and getting a kidney from the deep recesses of the abdomen. And therefore it will be classified as major surgery. So if, uh, if you are, um, already debilitated from, um, chronic symptoms, uh, recovery from major surgery can be complicated. Uh, I think, uh, the, the, the couple of patients that we saw, we have advice that they hold off for a while. Um, but, um, I think it will have to be done on a case by case basis, because as you know, long COVID is not a well-defined, uh, uh, condition yet, it seems to vary in severity, vary in its, um, in its manifestation. Some people are minimally disabled, some people are, you know, are, um, not able to move around very well. And so it depends on where they sit, but I think by and large, a patient has to be functional and well before they can donate.
Speaker 0 00:39:36 So Len correct me if I'm incorrect was what I heard in regards to the deceased donor that you take the organs and you must have tests that you can do on them to confirm that they're not infected or they're not damaged. And then you can use those.
Speaker 2 00:39:53 Yes, we do. Those tests are rapidly in evolution as we speak. Um, there was a point in, uh, we do both nasal pharyngeal swabs and, uh, in, in, uh, almost all of the sea stoners, they're usually ventilated and intubated, so we can get deep, uh, lung washings for, uh, for COVID. And even if those are positive, if there's enough science to show that there is no, uh, invasive COVID disease in the tissues of the lung and or other organs, um, then we could potentially, uh, transplant those organs. Then that's an area that's right on the cutting edge right now. We're just delving into the area of,
Speaker 0 00:40:36 It was a little scary to me. That would be a little scary.
Speaker 2 00:40:41 Yeah. Having said that if we have a 30% of our donors that are COVID positive and we're throwing away all those organs, when there's an opportunity to use it, knowing that that deceased donor had the desire to, um, um, to donate it's, we are beholden to them to try and explore every avenue safely, safely. That's a, I would underline safely to, to make every effort possible and to, um, to, to see how we can utilize those organs. And like I said, hundreds of them have been done in, uh, in non lung organs and with zero transmissions, um, so far. And as of now, if the donor, if the recipient is vaccinated, even if they do contract COVID, this is hypothetical. It hasn't happened. Even if they do contract COVID, uh, with the latest treatments, monoclonal antibodies, the antiviral medications. And if they've been vaccinated with preexisting antibodies, we feel reasonably confident that the we can get them well from the COVID. So it's, uh, we haven't had to face that, but that's, that'll be your safety net, if that should happen.
Speaker 0 00:41:52 Ah, yes. I want to jump back Dr. Candace Swami too. You know, you were talking about, um, the whole COVID thing with, with donation, but, um, I think you've explained that pretty well, but I'm just curious, cause I think a lot of people get a little bit shy when they're donating, if they're a alive donors, especially like recovery time. So can you talk a little bit about how quickly, you know, donors recover from donating something?
Speaker 2 00:42:24 Yes. So I'll talk about the most common form of donation kidneys. Uh, there's uh, you know, over 10,000, um, kidney, um, donors living donors in the country today, uh, on an annual basis. Um, and so the donors typically, um, go through the, the, um, I, I can walk through the process, but I'll, since your question relates specifically to the surgery, I'll touch upon that. I can walk through the rest of the process later, if need be. Um, the surgery is done laparoscopically, um, meaning there's a small incision, just big enough to deliver the kidney. That's about two and a half inches. Let's see the man in the midline lane or in the lower abdomen. And then there are two or three buttonholes, a little laparoscopic portholes for, um, the, uh, laparoscopic ports to be placed. And we do most of the surgery. We're looking at a, um, a TV screen and looking at the insights of the patient and operating from the outside.
Speaker 2 00:43:21 Um, and, uh, so the procedure is less invasive than an open operation that we do used to do back in the nineties, which had a significant morbidity and a longer recovery. I would say most of our patients leave the hospital within one to two days. Um, for example, I do my surgeries on Tuesdays and, uh, about one half of my donors leave on Wednesday and, um, most of the other half leave on Thursday. So, uh, they're home in two days. Um, and then they stay the first two weeks. There's, it's a little bit of, uh, uh, limitations in terms of what you're able to do. Even as far as activities of daily living may need some pain medications and, um, some, uh, laxatives to make sure you're regular. But after that, after two weeks, things start, uh, starting to feel normal and at add about three or four weeks, there's usually a day that they wake up and say, wow, I feel pretty much back to normal again.
Speaker 2 00:44:19 And so I see patients at two weeks and six weeks post donation, and usually, uh, at the two week mark, they say they're feeling better, but they haven't hit that point where they feel normal again. And six weeks they say, I feel back to normal and it happened around the three week mark and they're back to full activity by that time. So that's the normal course of a post-transplant recovery. And in most jobs, uh, donors or many donors are high functioning people, they have jobs. Um, so, uh, unless you're a construction worker or a weightlifter or some kind of, uh, extreme, uh, physical activity, a vocation, you can go back to full activity and six weeks. And I, if you are at a desk job or, uh, you know, you're an office job, which doesn't require much physical activity, you could go back in three to four weeks, but there is an opportunity to take up to six weeks off, uh, with most employers, um, based on documentation that we provide. And, uh, I would say the majority of employers do, uh, grant that, uh, leave as they, uh, in fact, there's legislation that's being pushed through to make that a law in Minnesota.
Speaker 0 00:45:33 Excellent. Yes, that would be good. You know, that's, that's, that's right up there with the importance, like having a baby, donating an organ, you're giving somebody the opportunity of, of life. Um, I do want to dump to, um, a recent thing, uh, that I read in regards to new science happening in the donation, uh, department, which is donating organs, that from a pig. Um, and the, the article that I read talked about kidneys being donated to a brain dead party, you know, recipient who, um, the kidneys did. It was a quote successful donation or, um, yeah. Transplant, I guess I should say. And then a heart that was transplanted into a live, uh, recipient and presumably hopefully that's still going well as well. Can you talk a little bit about that? And, um, I'm curious to know what they consider, I'm sure there's different steps, but a quote success, a donation success, and I'm sure, you know, you can discuss more on that. Yeah.
Speaker 2 00:46:52 So this is a fascinating area of transplantation. The area you're referring to is, uh, broadly classified as xenotransplantation xenotransplantation refers to transplantation from one species to another. Uh, in this case, we are talking about, um, pigs to humans. Uh, Xeno transplantation research has been done for 30 or 40 years. There have been isolated cases of Xeno transplants in humans that have been performed in Pittsburgh, Tom stars perform the Babylon to human liver transplant. And there's a, um, a heart transplant that was performed in the largely with not much success because our species knows how to protect itself from other species in terms of the immune system. But so we have antibodies built against other species. Um, and so if you try to put a pig organ into a human, um, the human body immediately reacts and, uh, and rejects it, calling it, um, it's called hyper acute rejection.
Speaker 2 00:47:54 Um, and that was related to a certain, uh, type of, uh, sugar molecule that was expressed in the, in the pigs, um, which, uh, the humans, uh, tissue does not possess and therefore was identified as foreign and rejected right away. This was the age old issue with, uh, xenotransplantation. So over time they tried to knock out that one particular sugar that they identified was so important. So we had a new category of pigs, um, called gal knockout, pigs, which, uh, they tried doing some work with, even that was met with a better success, but not quite where we needed it to be more recently in the last few years. But what has changed is, uh, gene editing. Uh, so most of what we do today with the success that's been achieved in the last, uh, over the last few months, uh, should be attribute it to the advances in gene therapy and gene editing.
Speaker 2 00:48:49 Um, so now we're able to, uh, modify genes, uh, in, um, to be able to present themselves differently. So, uh, things such as clotting rejection inflammation in the natural responses of the body to a foreign, um, tissue can be moderated by altering the genes in the pigs, uh, so that they do not post those same, uh, triggers, uh, to the human, to, to start reacting. Um, so that is the, uh, advance. There's been a lot of animal experiments in this area. And finally, they came to about three different clinical transplants that have been performed in the last few months. Um, the first one was what was at NYU, uh, document galleries team, where they, um, did a genetically modified, um, pig kidney into a brain dead, uh, recipient. Uh, the reason they chose a brain dead recipient is because, you know, obvious, uh, obviously they want to make sure they show proof of principle, that it can actually work without acutely rejecting, uh, because the immune system is still intact.
Speaker 2 00:50:03 The brain doesn't function. So they put that in and it lasted two days and they were able to show that the kidney made urine. And that was proof of principle, the university of Alabama replicated that. And they had their organ in for about 77 hours, which is a little over three days. So both of those showed good proof of principle. Meanwhile, at the university of Maryland, they actually we're able to do it in a live human recipient model, not a brain dead model. And the reason for that was they identified a patient in heart failure who was receiving a heart assist device, who, uh, was too sick. The category we talked about earlier, someone's too sick for transplant. Surgery is so much, they will not survive a heart transplant. That's done the routine way. So they were given up by all centers. In fact, I was told by one of my cardiothoracic colleagues that they referred this patient to five of the leading centers in the country to assess their candidacy for a human to human heart transplant.
Speaker 2 00:51:05 And all the senators said that he would not qualify based on the fact he's too sick. And therefore he, for him, this was a hail Mary of sorts, right? So it was no longer for him. This was something that was better than the alternative. So he signed up to receive a pink heart that was genetically modified with 10 different genetic edits, I believe to control inflammation, clotting, and multiple other mechanisms that could lead to a reaction from the recipient. And so that was transplanted successfully and the patient was on still heart and lung support for a couple of weeks. Again, I got an update yesterday at that life source from a cardiothoracic surgeon that the patient came off of the heart and lung, a support machine about two or three weeks after, and it's doing well. Um, that's a, that's the report. So that's a great, uh, um, breakthrough.
Speaker 2 00:52:01 We haven't had that kind of success in the field as of yet. Um, and, uh, it's, of course we have to be cautious because it's an N of one and it's, uh, very early in the, in the face of, uh, it's still proof of principle only whether this can be reproduced across multiple, um, patients and multiple scenarios remains to be seen. And then there's a whole another scenario, which is, um, what are the, um, what are the untoward effects that can occur from this? There's nothing that we saw in two to three weeks, but, um, altering genes then modifying, um, these, these genetic edits. Do they have other unintended consequences there in, in the recipient that we will see long-term, um, those are things that we always worry about, but, uh, the, the, you know, this very cautious, optimism and excitement, uh, based on these early results, but there's also a question of whether or not you could, um, have any transmissions of, uh, infections from, uh, animals to human.
Speaker 2 00:53:07 Uh, you know, uh, there are other examples of famous viral illnesses that I don't need to mention that have jumped from animals to human. And so those are kinds of things that one has to worry about. Uh, and, uh, and then the ethics of, uh, you know, animal to transplants also has to be, so there's a lot of things to be considered and talked about, but, uh, first is proof of principle and knowing that it can actually work. And they've shown that in the short term, in an N of one patient that they could make it work. And that's a significant breakthrough.
Speaker 0 00:53:44 Thank you so much. We're about out of time, I would encourage people that, well, my con my comment to the ethics is that people are eating less animals. So come on. And to me, there's no greater gift than the gift of a life. So if you can save someone's life, why not? Um, I'm sure the pigs are well raised, get people, um, once more at the place where they can go to find out more about transplantation and how they can do it, please.
Speaker 2 00:54:11 Yes. So I, again, like I said, the, if you're planning to be an organ transplant donor, especially in the kidney area, that you can either go to the M health website, um, or to, uh, the national kidney registry website, um, for, uh, information on it. The kidney registry.org is the website for national kidney registry, em, help that very.org for, um, for our center. Then there's national kidney foundation that has a lot of information in a transplantation. There are, uh, similar sites for, um, liver and other organs as well. Um, and, uh, I would say sign up to be a donor, whether it's a living donor or a deceased donor and, um, uh, help out another human being a will. Um, this will make a huge difference in, uh, in eradicating, um, chronic, uh, organ failure in this country, which is a significant problem.
Speaker 0 00:55:07 Thank you, Dr. Kendra Swami and I too have signed the back of my driver's license. So I am a believer. So I encourage everyone to take a look at this. Thank you so much for being on the show. I really appreciate it. This has been disability and progress. The views expressed on the show are not unfairly. Those of KPI or its board of directors. This is caffeine 90.3 FM Minneapolis, and bfci.org.
