Undocumented transplant candidate remains on waiting list for donated organ.

Josh Adler, UC San Francisco

Recent media reports about one of UC San Francisco’s kidney transplant candidates have contained confusing and incorrect information about the university’s policy for evaluating kidney transplant candidates, in particular for undocumented individuals.

Protecting patient privacy is paramount at UCSF, but today (Feb. 9) Jesus Navarro has authorized release of a joint statement with UCSF Chief Medical Officer Josh Adler, M.D.

UCSF is dedicated to providing the highest quality, safest treatment for all of its patients. The university has tremendous compassion for patients, and their families, who face the very difficult issues related to kidney failure. While for some of these patients transplants can be lifesaving, transplant surgery is the starting point of a lifetime of medical care and treatment, including daily use of costly anti-rejection drugs.

UCSF does not reject transplant candidates based on their immigration status and has performed transplants on undocumented individuals. These patients are not refused treatment. Rather, UCSF refers them to community-based and other external services that can help them address issues related to specific access-to-care hurdles faced by non-citizens. Of particular concern is their lack of easy access to the health insurance necessary to receive proper post-transplant follow up. Follow-up care is critical to transplant patients, who otherwise may lose the organ and become less healthy than they were on dialysis.

While the patients resolve those problems, they remain on the transplant waiting list.

Joint statement from Jesus Navarro and Josh Adler, M.D., chief medical officer, UCSF Medical Center

Feb. 8, 2012

UCSF is committed to helping Jesus Navarro and all kidney transplant candidates achieve their goal of a transplant. On Tuesday, we jointly developed a plan that we hope will secure for Mr. Navarro the health coverage he needs for his care during transplant surgery and beyond, including costly anti-rejection medications. While that plan is pursued, he will remain on the transplant list, as was always the case, and will continue to accrue time toward a transplant.

Last May, Mr. Navarro met with UCSF medical, social work and financial staff in preparation for a potential kidney transplant. Like many others, he had been on the UNOS (United Network for Organ Sharing) waiting list for a long time, in his case more than six years. Mr. Navarro still had one year or more until he would reach the top of the UNOS list and UCSF’s standard procedure calls for reviewing patients at that time to ensure they are still good candidates for a future transplant.

As of today, he still is not at the top of the list, but is expected to reach the top in three to six months.

During the May visit to UCSF, Mr. Navarro met with UCSF financial counselors who asked about his immigration status. Mr. Navarro responded that, in fact, he was undocumented. Due to the complexities of the current health insurance industry, this was a concern for UCSF because it increases the risk that Mr. Navarro will not be able to continue to be insured and therefore not receive the follow-up care and medication needed to stay healthy after a transplant.

Per UCSF practice, Mr. Navarro’s status on the waiting list was changed to “inactive” as a result, which means that he would maintain his place on the waiting list, but would not receive a transplant even if he reached the top unless he had a reasonable coverage plan in place. The counselors also referred Mr. Navarro to two community assistance organizations that specialize in resolving immigration issues, as part of our effort to increase the likelihood of transplanted patients maintaining their health coverage for the surgery and critical post-transplant care.

Mr. Navarro has told UCSF that, to him, this meant he would not get a transplant until he resolved his immigration status; this was not what UCSF was trying to convey. Instead, UCSF was following its policy to make sure Mr. Navarro would continue to have the health insurance necessary to receive proper post-transplant follow up. Follow-up care is critical to transplant patients, who otherwise may lose the organ and become less healthy than they were on dialysis.

UCSF regrets the misunderstanding and is committed to reviewing its processes to make sure that communication is consistent and clear with all patients, including Mr. Navarro. UCSF does not and will not discriminate on the basis of immigration status.

The road to a kidney transplant is long, and it may still take Mr. Navarro months to continue through the process. In the meantime, he continues to maintain his health through dialysis, as he has for the past 6 1/2 years.

This situation underscores the many obstacles all transplant candidates face securing the long-term coverage they need because of the patchwork nature of the health care system. These obstacles can be more difficult for undocumented individuals to overcome.

UCSF Medical Center operates one of the world’s largest kidney transplant programs, with more than 5,240 patients on the list waiting to receive a kidney. Sadly, only 350 of those patients will receive a kidney transplant this year, mainly because of a shortage of organs, either from deceased patients or living-related donors.

We encourage everyone to become an organ donor. For more information, contact Donate Life California, or, to become a living donor, contact UCSF.

UC Davis surgeon uses one small incision for life-saving, living kidney donations.

Angela Whalen didn’t seek out a single-incision nephrectomy surgeon. She simply wanted to save her father’s life. The fact that Whalen was able to undergo a unique surgical procedure to donate her kidney, with a barely visible scar to show for it, was the added bonus of a daughter’s gift of life to her dad.

Until she traveled to UC Davis Medical Center after finding out she was a donor match, Whalen hadn’t even heard of the minimally invasive surgical procedure that Christoph Troppmann, UC Davis professor of surgery, routinely offers kidney donors. Troppmann can remove a kidney through a single port – or incision site – at the patient’s navel. He is among only a handful of surgeons across the nation who perform the unique procedure.

“Dr. Troppmann told me about the procedure during one of our preliminary meetings, but it really didn’t register for me,” said Whalen, an Atlanta-area resident. “When it did register was after surgery, when I joked with the doctor, ‘Have I actually been in surgery?’”

Christoph Troppmann, UC Davis

Over the past year, Troppmann performed approximately 65 living kidney donations using the specialized technique. He says it potentially has multiple benefits compared to the conventional type of laparoscopic transplant surgery, which was a minimally invasive technique pioneered by his colleague Richard Perez at UC Davis Medical Center in 1997.

“The main benefit of a single-incision surgery is that you have just one small opening compared to multiple incisions,” said Troppmann, whose patients usually remain in the hospital for only two days. “These donor patients typically have much, much shorter recovery times. That’s where we’ve really seen the difference. It’s still amazing to us that a week after surgery, when we see our donors in clinic and ask them to get up from the exam table, it’s almost as if they haven’t had surgery.”

Troppmann noted that living kidney donors must be in good health, and that donating an organ is an elective procedure. His goal is to provide the safest possible procedure, with the least disruption to a patient’s family life and job. For donors like Whalen, however, the type of surgical technique is secondary to simply being able to improve the health and well-being of a friend or loved one.

“I didn’t think much about the procedure until close to surgery, and then afterwards when I saw the tiny, tiny scar for the first time,” said Whalen. “The main thing was just making sure that I could donate my kidney. My feeling was, ‘He needs a kidney. He’s my father. It’s no big deal.’”

At the time of the transplant, Whalen’s father, Isaiah Ollison, was on dialysis and on the organ transplant list because of kidney disease. He and his wife had resisted the idea that a family member might donate a kidney. But when Ollison traveled to Georgia for his grandson’s high school graduation in 2010, Whalen immediately noticed how weak and tired he looked. It was at that point that she insisted on finding out if she was a match as an organ donor.

“When UC Davis called and said we were a match, I knew we were going to do it,” said Whalen. “In fact, up until we were driving to the medical center on transplant day, he was still saying, ‘Are you sure you want to do this?’ And I said, ‘Dad, we’re doing this.’”

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Finding by UC Irvine team could help prevent cardiovascular complications.

N.D. Vaziri, UC Irvine

UC Irvine researchers have uncovered an important source of inflammation seen in people with chronic kidney disease, which is increasingly common due to the epidemic of obesity-related diabetes and hypertension.

Dr. N.D. Vaziri, professor emeritus of medicine and physiology & biophysics, found that CKD causes massive depletion of the key adhesive proteins, called the tight junction, that normally seal the space between the cells lining the intestines. This breakdown in the colon allows the leakage of microbial products and other noxious material into the body’s internal environment, accounting for the persistent systemic inflammation that frequently occurs in CKD patients.

“In fact, low levels of bacterial endotoxins are often noted in the blood of individuals with advanced chronic kidney disease,” Vaziri said. “However, the source and place of entry of these toxins were previously unknown.”

Understanding the connection between CKD and tight junction disintegration, he added, could lead to novel treatments to curb this inflammation and its many adverse consequences. Study results appear online in the journal Nephrology Dialysis Transplantation.

It’s estimated that nearly 25 million people in the U.S. have CKD, and more than 400,000 have end-stage kidney disease requiring dialysis. Many CKD patients develop accelerated cardiovascular disease — the primary cause of premature death in this population — linked to persistent inflammation.

“The relentless inflammation seen in chronic kidney disease has devastating effects on the cardiovascular system and other parts of the body,” Vaziri said.

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HealthGrades honors UC Davis for third straight year.

UC Davis' Richard Perez during a transplant surgery

For the third year in a row, a leading, independent health-care ratings organization has recognized UC Davis Medical Center as one of the top hospitals in the nation for kidney transplantation.

The medical center’s Kidney Transplant Program was one of only eight of 221 hospitals evaluated in the United States to receive a 2012 Kidney Transplant Excellence Award from HealthGrades, a Colorado-based firm that analyzes publicly available data in order to rate hospitals and their programs based solely on clinical outcomes.

To determine the best hospitals for organ transplants, HealthGrades examined the clinical quality outcomes of hospital transplant centers using the most recent Scientific Registry of Transplant Recipients (SRTR) data for 2011. UC Davis’ ranking was based on data from criteria calculated from the national database of transplantation. Compared to the kidney transplant programs evaluated, UC Davis had better-than-expected three-year patient survival rates. The medical center’s program also had a significantly lower wait-list mortality rate, which tracks patient deaths while awaiting transplantation, and a significantly higher-than-expected deceased-donor transplant rate, which reflects improved transplantation opportunities for individuals.

“The award for excellence reflects our continuing goal of providing the very best in kidney transplantation care and services,” said Richard V. Perez, professor of surgery and director of the UC Davis Kidney Transplant Program. “Our comprehensive team includes surgeons, nurses, anesthesiologists, nephrologists, donor coordinators, pharmacists, dieticians and social workers. Everyone is dedicated to providing the full range of transplant care, both before and long after surgery. And our ability to collaborate with other UC Davis specialists, such as immunologists and cardiologists, helps ensure that every transplant patient receives great care and can enjoy a long life after their transplant.”

Along with low wait-list mortality and higher patient-survival rates, the HealthGrades ranking analyzed the rate at which wait-listed patients received transplants. It also reflects the medical center’s strong one- and three-year graft survival rates, which tracks how long the transplanted kidney is still functioning after transplantation.

UC Davis Medical Center has provided care to transplant patients from throughout Northern California and Northern Nevada since 1985. In recent years, UC Davis also has made it easier for individuals to donate a kidney. A unique, minimally invasive procedure known as a single-port donor nephrectomy, led by Christoph Troppmann, a professor of surgery, enables surgeons to extract a kidney through a tiny, two-inch incision, greatly reducing scarring and often speeding the recovery times for donors.

UC Davis Medical Center has one of the largest kidney transplant programs in the country. In 2011 alone, it has already performed more than 240 kidney transplants.

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The miracle of organ transplantation on UCTV.

Transplantation is accepted as optimal therapy for patients with end-stage organ disease. Successful replacement of the heart, lung, liver, kidney, pancreas and small bowel can now be achieved. As a consequence, more and more patients are availing themselves to this therapy. Currently in the United States, there are more than 110,000 patients listed with the national registry awaiting transplantation; last year there were just over 28,500 transplants performed, underscoring the major disparity between need and supply.

The University of California provides half of all transplants in the state, and UC San Francisco has one of the world’s largest and most successful transplant programs. In this UCTV series from the UCSF Osher Mini Medical School for the Public, UCSF specialists share the whys, hows and what happens of organ failure and transplantation, live donor transplantation, alternative therapies, organ distribution, and organ engineering. In sum, the series will give you an understanding of how spare parts are used to produce miracles.

Programs include:

What Organ Shortage? Just Make Your Own! Stem Cells and Organ Engineering
First air date: Nov. 7

HIV Transplant: The Good, The Bad, The Unexpected
First air date: Nov. 14

Kidney Transplants: Who Needs One? How Do We Do It?
Nov. 21

Immunosuppressive Medications for Transplantation: The Good, The Bad and The Ugly
First air date: Nov. 28

Related links:

More Mini Medical School videos on UCTV

More about the UCSF Osher Mini Medical School lecture series

UCSF: Improving outcomes in organ donor transplantation

UCLA: Index devised for predicting survival after liver re-transplantation

UC San Diego: Domino liver transplant treats two rare diseases

UCLA: Donor heart arrives ‘warm and beating’ (video)

UC Davis: The gift of life: Thanking organ donor families

UCLA launches program to provide face, hand and abdominal wall transplants

UCLA’s first hand transplant patient adapting well (video)

UCSF liver transplant team shares expertise in Latin America

UC San Diego: Two hearts beat as one (video)

UC San Diego: West Coast’s first total artificial heart implanted

UC Davis: Extraordinary larynx transplant restores voice to California woman

UC Irvine recognized for its commitment to organ donation

UCSF bioengineer working to create tiny devices that can treat diabetes or kidney failure.

Tejal Desai, UC San Francisco

The same technology used to create integrated circuits may one day be applied to the body to deliver medicine or serve as implants that act as an artificial organ. Tejal Desai, a bioengineer at the University of California, San Francisco, is working with microelectromechanical systems, or MEMS, to create tiny devices that can treat diabetes or kidney failure. But Desai says they’re also looking at different devices which one could potentially inject via catheter.

“Eventually, the goal is to create an implant that actually would just be a simple injection and that injection would be able to have a device,” Desai said. “It’s made out of a really thin film of polymer material and has small channels that can deliver drugs for many months. “

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Rheumatoid arthritis drug reduces kidney cyst growth in mouse tests.

Thomas Weimbs, UC Santa Barbara

Scientists at UC Santa Barbara have discovered that patients with an inherited kidney disease may be helped by a drug that is currently available for other uses. The findings are published in this week’s issue of the Proceedings of the National Academy of Sciences.

Over 600,000 people in the U.S., and 12 million worldwide, are affected by the inherited kidney disease known as autosomal-dominant polycystic kidney disease (ADPKD). The disease is characterized by the proliferation of thousands of cysts that eventually debilitate the kidneys, causing kidney failure in half of all patients by the time they reach age 50. ADPKD is one of the leading causes of renal failure in the U.S.

“Currently, no treatment exists to prevent or slow cyst formation, and most ADPKD patients require kidney transplants or lifelong dialysis for survival,” said Thomas Weimbs, director of the laboratory at UC Santa Barbara where the discovery was made. Weimbs is an associate professor in the Department of Molecular, Cellular and Developmental Biology, and in the Neuroscience Research Institute at UC Santa Barbara.

Recent work in the Weimbs laboratory has revealed a key difference between kidney cysts and normal kidney tissue. They found that the STAT6 signaling pathway — previously thought to be mainly important in immune cells — is activated in kidney cysts, while it is dormant in normal kidneys. Cystic kidney cells are locked in a state of continuous activation of this pathway, which leads to the excessive proliferation and cyst growth in ADPKD.

The drug Leflunomide, which is clinically approved for use in rheumatoid arthritis, previously has been shown to inhibit the STAT6 pathway in cells. Weimbs and his team found that Leflunomide is also highly effective in reducing kidney cyst growth in a mouse model of ADPKD.

“These results suggest that the STAT6 pathway is a promising drug target for possible future therapy of ADPKD,” said Weimbs. “This possibility is particularly exciting because drugs that inhibit the STAT6 pathway already exist, or are in active development.”

Grant will facilitate study of kidney complications related to both types 1 and 2 of the disease.

Kumar Sharma, UC San Diego

Kumar Sharma, M.D., FAHA, professor of medicine at the University of California, San Diego, School of Medicine and director of the Center for Renal Translational Medicine, has received a $5.9 million grant from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health, to study kidney complications related to type 1 and type 2 diabetes.

Renal complications of diabetes represent one of the major public health problems facing industrialized nations. In patients with type 1 diabetes, diabetic kidney disease is the leading cause of excess mortality.

“Each year in the United States, more than 100,000 people are diagnosed with kidney failure, a serious condition in which the kidneys fail to rid the body of toxins,” said Sharma. “Diabetes is the most common cause of kidney failure, accounting for nearly 44 percent of new cases, so it is critical that we gain a better understanding of kidney complications associated with the disease. Even with early kidney disease there is a major impact on the cardiovascular system and there is a great need to understand the kidney-cardiovascular connections.”

The NIDDK grant awards “groundbreaking original research addressing fundamental questions or major obstacles in type 1 diabetes research, including studies that challenge current dogma.”

Scientists have long believed that that excess calories are processed via hyper-functioning mitochondria, the so-called “energy factories” of the cell, resulting in accumulation of reactive oxygen species. Sharma’s studies, in collaboration with UC San Diego researchers Laura Dugan, M.D., and Robert Naviaux, M.D., Ph.D., will directly examine this hypothesis using live animal imaging and mitochondrial measurements.

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Summer spikes spotted online.

Google Insights for Search heat map displays relative volume of kidney stone searches from 2005 through 2009.

You might save yourself a lot of pain and trouble during the dog days of summer by drinking to your health – with a long, cool glass of water. The incidence of kidney stones – which can cause the kind of pain some women have compared to giving birth – peaks in summer months when temperatures soar and perspiration drips.

Now it turns out that these seasonal variations in kidney stone incidence are reflected in Google search engine queries, according to research by UCSF urologist Benjamin Breyer, M.D., and colleagues that is featured on the cover of this month’s issue of the scientific journal Urology.

“Kidney stones vary by season and region – they are more common in warmer places and during hotter times of the year,” Breyer says. Large kidney stones cause pain as they pass through the ureter, and many require surgery to remove. Keeping hydrated helps prevent the crystallization of stones.

Nationwide, about 13 percent of men and 7 percent of women in the United States suffer kidney stones during their lives, and half who experience one will develop another.

Not surprisingly, some people with pain or other symptoms of a kidney stone go online to see what more they can learn. As a UCSF clinical instructor in urology, Breyer, now a UCSF assistant professor, along with urology resident Michael Eisenberg, M.D., now an assistant professor at Stanford University, used an online tool called Google Insights for Search to see if the varying popularity of search terms would reflect seasonal and geographic differences in kidney stone prevalence.

“Kidney stones” was the best search term they found to mirror trends obtained from hospital data.

In addition to variations due to weather, genetics, diet and obesity also contribute to the likelihood that one develops kidney stones. The impact of kidney stones varies not only by season, but also by geographic location. A region where rates are high throughout the Southeast has been dubbed “the stone belt.”

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Sparing kidney helps prevent chronic kidney disease, reduces risk of osteoporosis.

Ithaar Derweesh (right), UC San Diego

Researchers at the University of California, San Diego, School of Medicine have shed new light on how surgery impacts both chronic kidney disease and bone health, particularly in women. For the first time, their findings point to the importance of pursuing kidney-sparing surgery in an effort to preserve kidney function and to reduce the risk of bone fractures later in life. The study was published in the July 19 edition of Urology and is now available online.

“When weighing the risks and benefits of partial versus radical nephrectomy, doctors and patients should take into account the impact on a patient’s bone health,” said Dr. Ithaar Derweesh, senior author and urologic oncologist at UC San Diego Moores Cancer Center. “This study illuminates the fact that preserving the kidney helps to prevent chronic kidney disease and significantly reduces bone fractures and risk of developing osteoporosis.”

Complete removal of a kidney has been found to be a significant risk factor for chronic kidney disease, which carries increased risk for metabolic complications, cardiovascular disease and death. With partial nephrectomy, functional kidney tissue and healthy cells are preserved and can help prevent or reduce the risk of development of chemical imbalances such as metabolic acidosis which may later lead to kidney dysfunction, muscle wasting and osteoporosis, a direct cause of bone loss and fractures.

“Women facing kidney surgery should investigate whether partial kidney removal is an option to treat their disease as it may help prevent bone brittleness,” said Dr. Christopher Kane, professor of surgery, C. Lowell and JoEllen Parsons Endowed Chair in Urology and chief of the Division of Urology, and paper co-author. “Too often urologists have done radical nephrectomies for patients who were candidates for partial nephrectomy. While partial nephrectomy is more complex for the surgeon to perform, it can offer better quality of life later in life.”

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New approach could potentially remove the need for a clinic-based dialysis process.

Shuvo Roy, UC San Francisco

UCSF researchers have designed a model filtration system that could offer a new approach to treating patients suffering from end-stage renal disease, potentially removing the need for a clinic-based dialysis process altogether.

Initial results of the research were presented as an abstract on June 10 by UCSF nanoengineer Shuvo Roy, Ph.D., during the annual conference of the American Society for Artificial Internal Organs in Washington, D.C. Roy also presented initial results of tests showing that silicon-based membranes are compatible with human blood and thus offer viable options as filters in implanted devices such as the team’s model for an implantable artificial kidney.

The filtration model is designed as a trap for mid-sized molecules that need to be filtered from the patient’s blood stream, with the upstream filter sized to leave large molecules such as proteins and blood cells in the blood, and the downstream filter sized to block urea and creatinine while allowing electrolytes and nutrients to return to the blood stream.

Ultimately, researchers say the system could provide an intermediary therapy for dialysis patients  awaiting a kidney transplant, thus untethering them from tri-weekly visits to dialysis centers. It also could be used in an interim device in developing an implantable bio-artificial kidney, in which cell therapy would augment the function of the downstream filter to replace most of the functions of a real kidney.

Abstracts are published in the March/April issue of the ASAIO journal.

Read a Q&A with Roy.

Blocking a specific receptor pathway may slow or prevent diabetic nephropathy, UC Davis investigators have shown.

Ishwarlal Jialal (left) and Sridevi Devaraj, UC Davis

UC Davis investigators have shown that blocking a specific receptor pathway could slow or even prevent diabetic nephropathy — an often fatal complication of diabetes for which there are few good treatment options. Published online today (May 26) in the journal Arteriosclerosis, Thrombosis and Vascular Biology, the study is the first to clarify the role of the receptor — toll-like receptor 2, or TLR2 — in diabetes-associated kidney disease.

“Diabetic nephropathy is one of the most serious outcomes of diabetes and the most common cause of renal failure,” said Ishwarlal Jialal, UC Davis professor of endocrinology, diabetes and metabolism and senior author of the study. “It is progressive and eventually requires chronic dialysis or transplant. But now we have a precise molecular target for treating this difficult disease.”

Nephropathy, which affects about 30 percent of diabetics, becomes apparent between five and 25 years following a diabetes diagnosis. It occurs when high glucose — often with hypertension — overworks the kidneys’ intricate blood filtration system, eventually causing that system to break down. It is typically diagnosed midway through the disease process, when the kidneys enlarge and protein appears in urine.

“We currently cannot fully predict why some people with diabetes, even some with well-controlled diabetes, get nephropathy while others do not,” said Jialal, whose lab specializes in studying the role of inflammation in heart disease and diabetic complications. “Our goal is to find a way to identify and stop it in its tracks at the earliest possible stages, well before dialysis is required.”

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