Flu, COVID and RSV; kidney transplants in children: Upstate Medical University's HealthLink on Air for Sunday, Feb. 11, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," an infectious disease specialist discusses respiratory viruses, including flu, COVID and RSV.

Elizabeth Asiago Reddy, MD: ... We worry about any of these respiratory illnesses progressing to pneumonia. So what they usually cause is sinusitis, bronchitis, laryngitis. Those are all upper-respiratory infections. They haven't gone down into your lungs. But when you start to feel short of breath, we worry that the infection has gone down into the lungs. ...

Host Amber Smith: And a transplant surgeon talks about pediatric kidney transplants and the value of donations from living people.

Toby Le Nguyen, MD: ... Living donors is a healthy donor out of friends, families, strangers, even, who can donate one of their two kidneys, and they can live for the rest of their life with one kidney. ...

Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll hear from a transplant surgeon about how sometimes children need kidney transplants, and the best organs come from living donors. But first, how can you tell if you're sick with COVID or flu or some other respiratory virus?

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

When someone is sick this time of year with a cough, maybe a fever, maybe body aches or congestion, it's tricky even for doctors to tell whether it's COVID or the flu or something else. Here to explain is the chief of infectious disease at Upstate, Dr. Elizabeth Asiago Reddy.

Welcome back to "HealthLink on Air," Dr. Asiago Reddy.

Elizabeth Asiago Reddy, MD: Thank you, Amber. It's great to be here.

Host Amber Smith: Let's first talk in the aggregate about how each of these respiratory diseases are distinguished. Do you want to start with COVID?

Elizabeth Asiago Reddy, MD: Sure. So I think the important message here is that it's actually testing that really allows us to distinguish these viruses, one from the other. The symptoms between them are so similar that for any given patient, we really can't guarantee what they might have just based on their symptoms. So it is testing that allows us to distinguish them.

Host Amber Smith: Does it matter then if it's COVID or flu or whatever? I mean, are they all treated the same?

Elizabeth Asiago Reddy, MD: Great question. When I talk to my patients, and they call into our practice, saying, "I feel sick. I have an upper-respiratory infection," I'm trying to figure out whether or not I should bring them in for testing or what kind of testing they should have. And the few things that I think are especially important are, do they have something that I could treat? OK, so that's No. 1.

And we do have some treatments for COVID and flu, so that's one thing that I might want to find out in order to determine whether or not they're a candidate for treatment. And then also, are they around people who might be at high risk if they were to have specific infection? So let's say that I know my patient is a caregiver to their elderly parent, and now they're telling me, oh, they have these respiratory symptoms. So not only am I thinking about what might be going on with them, but whether or not they might be placing their parent at risk. And specifically in that scenario, I'm thinking about COVID, which has an outsized risk for elderly patients compared to other viruses, even.

Host Amber Smith: So respiratory viruses, COVID, flu, RSV (respiratory syncytial virus), and maybe there's others. Which one is the worst to get?

Elizabeth Asiago Reddy, MD: It really depends on what age group you're in and what underlying conditions you have. So we've been hearing a lot about COVID, flu and RSV, and generally speaking, those are the worst, and that's why we're hearing the most about them.

There's a lot of dedication towards trying to prevent them, trying to treat them, et cetera, but any of the known respiratory viruses could potentially be quite bad and specifically (for) immune-compromised individuals. But those three are generally the worst. And specifically, sometimes, as I kind of alluded to before, there are age groups that might be most especially impacted.

So for young infants, RSV is really a big danger situation. And a lot of the research and efforts that we've put into RSV vaccines or preventatives have been for that young age group. That's the individuals who are most likely to end up in the hospital, have very severe outcomes as infants, especially less than 1 year old, but including up to less than 2 years old.

And then, for COVID, it's been the opposite in elderly individuals, and it just goes up exponentially every 10-year blocks of age, so 60-year-olds, 70-year-olds, 80-year-olds, et cetera. They are at heavily increased risk of bad outcomes from COVID.

Now, that has changed a little bit with COVID as we've had increased access to vaccines and treatment. But if you look at the broad spectrum of the pandemic from the beginning, older individuals have been very severely impacted.

Host Amber Smith: Is that true with influenza as well?

Elizabeth Asiago Reddy, MD: Influenza is a little bit more of a biphasic age impacter, in that the youngest and the oldest are going to be the most severely impacted.

But people across the age spectrum can get very sick from the flu, and also similar to COVID, people with immune-compromising conditions can also get very sick with the flu.

Host Amber Smith: Can you explain what a "triple-demic" is and why infectious disease experts are concerned about it?

Elizabeth Asiago Reddy, MD: Yes. So last year was the year where we really saw all three of these pathogens take the big stage together.

Prior to that, at the beginning of COVID, of course, we implemented a lot of measures, including masking and social distancing that reduced our risk of acquiring other respiratory infections. So what we saw during the periods of time where we were implementing those preventative measures for COVID was that influenza and RSV decreased significantly.

So entering the fall of 2022, so about a year and a half ago, people were dropping those preventative measures as we found the risk of death from COVID to be dropping. We had ways to treat COVID. We had ways to prevent COVID. More people had been exposed to COVID, so it was not as dangerous as it had been, and we said, OK, it's time to open things up.

And when we did that, we found that our immune systems had not been exposed to these pathogens that we likely are exposed to on some lower level, typically, on a regular basis. And so we did end up in a situation of a triple-demic last year, and particularly our RSV, I would say, was really heavily impactful last year. There was a very early peak in RSV infections in children and hospitals. Many of the pediatric hospitals were really struggling even to find beds, including in our area. We had to expand the network of hospitals that were taking children during the fall last year. And then influenza last year also experienced a very early peak.

And so by this time last year, we were almost done with our flu peak already. We had a really high peak, around November, December, that was more shifted towards the earlier fall than what we would normally see. And of course we still had a lot of people sick with COVID, so that was really the triple-demic that we experienced last year.

We are experiencing it again this year. It appears to be following a more normal pattern with respect to RSV and flu in terms of what we might have seen in years prior to COVID, but of course now we have COVID added into the mix.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with Dr. Elizabeth Asiago Reddy, the chief of infectious disease at Upstate Medical University.

So I'm curious about these respiratory illnesses and whether they follow the same seasonal patterns across the world, or if they vary depending on the different cultures in the different countries. Because I've always wondered, is it the temperature or the climate that influences the spread of the disease, or is it the human behavior that may be tied to the weather that influences the spread?

Elizabeth Asiago Reddy, MD: It looks like it's both, with influenza as kind of the most classic example of this in that we see the influenza peak in the Southern Hemisphere happening during the summer of the Northern Hemisphere, and then it flip-flops during our Northern Hemisphere winter, then they're done with their flu and enjoying the nice weather in the Southern Hemisphere.

That one we can say is definitely highly weather related. It's also related to patterns of migratory birds because we see that the strains of influenza that impact humans can come from birds, and birds are following patterns of migrating from the south to the north. Again, some of this is going to be impacted by climate change in the future, but those are the typical patterns that we see.

So, I would say influenza is a very classic weather-related example, but behavior does play a role, so one of the things we saw during the most impactful times in our COVID infection period in the United States was that Southern states oftentimes experienced big spikes of COVID during the hottest months of the year because people were congregating indoors and turning on the air conditioner.

And so Florida, Texas, Arizona had major spikes during July and August that we don't typically see as frequently with other respiratory infections. And I think that was definitely behavior related in terms of congregating indoors. Of course, that is an impact of the weather, but then also was impacted by the immunological naivete (lack of exposure) of our systems at the time, that we just didn't have the background immunity to fight it off.

Host Amber Smith: It seems like most of the people who come down with symptoms of a respiratory illness are never going to know what it was, so how do they go about, at home, taking care of themselves, if they've got a fever or body aches or a cough, and they know they're sick? What do you recommend? Are there any over-the-counter medicines or any practices that they should follow?

Elizabeth Asiago Reddy, MD: I know you said people are never going to know what they have. Hopefully, we can talk a little bit about COVID home testing during this conversation.

But I'll go back to the question about how to treat your symptoms. These are really like the time-tested types of interventions, such as taking acetaminophen for fevers, taking lots of fluids, especially non-sweetened beverages, water, tea, giving yourself the time to get some extra rest.

If you have a cough, dextromethorphan, which is the ingredient, and I guess the most commonly known brand name would be Robitussin (cough syrup). That definitely can be helpful for people who have bad coughs.

Pseudoephedrine can be helpful to clear out the sinuses in people who have a lot of sinus congestion, although it can raise blood pressure for people who have blood pressure issues, so there are alternative medications that you can look at when you're purchasing medications over the counter that will say, a lot of times, "suitable for people with high blood pressure."

And that's usually Mucinex. It's suitable for people with high blood pressure, though its efficacy, I would say, is a little bit more questionable. Pseudoephedrine is definitely very effective.

For anyone who uses the nasal sprays, it is important to keep in mind that nasal sprays can be highly effective. So over-the-counter nasal sprays, such as Afrin, which is a pseudoephedrine-based nasal spray, can be highly effective in reducing congestion, but it's extremely important to follow the instructions of only using them for a few days. Three days really should be the max because they can actually make your symptoms worse if you get used to them over time.

Host Amber Smith: You brought up the home testing kit for COVID. Do we still need to do that? Is that still something that needs to be on our minds?

Elizabeth Asiago Reddy, MD: Yes. I think these still do play a role, and they can be helpful. The most important thing to remember is that they are excellent at detecting a true positive, meaning that if you have symptoms that you suspect are related to COVID, and you take a COVID test, and you get those two lines, it looks positive, then in all great likelihood you have COVID. That is considered to be a dead ringer for a positive test, that we really think would be a true positive. It's very, very, very rare that you would have a false positive, almost negligibly rare.

A false negative, on the other hand, is pretty common. And this is why I feel like a lot of people get confused, so that, if I have symptoms that I'm concerned might be COVID, and I take a COVID test at home, and it's negative, there's still a 20% to 30% chance that I actually do have COVID.

So, I think people are catching up on the idea of retesting. That can help. If you test every day for three days, that can help to try and determine whether or not you truly have COVID, but it still doesn't reach the accuracy of a PCR test.

So why is this important? It's important for those people who are age 60 and up, or who have severe immune-compromising conditions who may benefit from one of the therapies for COVID, so an oral outpatient therapy, such as nirmatrelvir (with) ritonavir, which is known as Paxlovid. I think that still does play a role for certain high-risk individuals who really have a risk of progressing to severe COVID. And so those folks should try to figure out whether or not they really do have COVID because they might benefit from treatment.

And unfortunately COVID is the only test that we have regularly available for outpatient use. There have been flu tests designed and strep throat tests that have been designed, but they have not really reached heavy circulation, the way COVID tests have.

Host Amber Smith: For people who are home sick, how long should it take before they start feeling better?

And are there any red flags that would tell them they really should see their doctor?

Elizabeth Asiago Reddy, MD: Yes. Most of these illnesses, your first five days are going to be the worst. And it's still not unusual, especially for COVID and flu, for people to feel quite poorly for five days, be spending a lot of time in bed, be having fevers, but after that five-day mark, and a lot of times, even after the three-day mark, symptoms should start to improve, especially now that, like I said, we do have a little bit better background immunity to these infections.

But every person is different, so there are people, unfortunately, who are still having a couple of weeks of symptoms from either COVID or flu. Whether or not you got recent vaccinations might impact that, so certainly people who have recently been vaccinated for flu or COVID are likely to have a milder version of the illness, compared to someone who's not been recently vaccinated.

And then, other types of conditions that people might have in the background may impact the severity of their illness.

What should you be worried about?

Certainly shortness of breath is a big red flag. We worry about any of these respiratory illnesses progressing to pneumonia. So what they usually cause is sinusitis, bronchitis, laryngitis. Those are all upper-respiratory infections. They haven't gone down into your lungs. But when you start to feel short of breath, we worry that the infection has gone down into the lungs, and that is a signal of pneumonia. That's dangerous, potentially dangerous, and should be evaluated by your provider. And certainly if somebody's severely short of breath, by an emergency physician.

And then, other things, really inability to keep down anything. So sometimes, COVID or flu could be associated with gastrointestinal symptoms. If you really can't eat, you can't drink, you're becoming dehydrated, especially in the setting of fevers going on as well, then that would be another reason to seek medical attention.

Chest pain would be concerning. So, if you're feeling a lot of chest pain when you're breathing or chest pain at any time that's just not going away, that's disturbing to you, that would also be concerning.

I think those are really the major red flags that you would definitely want to give your provider a call. Or if it's very severe, go to the ED (emergency department).

Host Amber Smith: So what is done for someone who comes to the emergency department with a respiratory illness?

Maybe they do have shortness of breath or some chest pain along with it, and they've been sick for more than five days. What is done for them there? Do you test right away to see what virus it is?

Elizabeth Asiago Reddy, MD: We do the respiratory virus panel (tests) as part of routine care at Upstate. A lot of other places may not have the full panel, but they may have a rapid test for COVID, flu and RSV that will help to distinguish what's going on, at least, as we've talked about, for ones that are the most severe.

And then, you would also want to determine whether the person could possibly have a bacterial pneumonia, and that would be a constellation of signs and symptoms to include chest X-ray and reviewing what's going on with them, the severity of their illness. And if someone is considered to be at risk for having a bacterial infection, that would be something that would need to be treated with antibiotics.

Host Amber Smith: Well, let's talk about prevention. Are there vaccines available for adults and children for flu and COVID and RSV?

Elizabeth Asiago Reddy, MD: Yes, there are. So, RSV, there's a little subtlety to that answer, but I'll just go through them individually.

COVID is available for all age groups, starting at 6 months, and it has this year been formulated into a new formulation that is covering Omicron strains only. So it doesn't have any of the old strains of COVID in it, which is the first time that's been the case for the COVID vaccines. And we have the three major COVID vaccines available are Moderna, Pfizer and Novavax.

And Novavax is the only one that is a protein-based vaccine, so there's no mRNA, and that's what some people still find concerning. So those are the main COVID vaccines. And it's very simple because the vast majority of people would just need to be updated with one shot. So there's a few exceptions to that for possibly young children who have now been previously vaccinated or are (in) severe immune-compromising conditions.

And then, for influenza, the very similar situation, age 6 months and up is recommended to have an annual flu shot, and the vaccine formulation changes a little bit depending on age groups, and some younger age groups may be eligible for a nasal flu vaccine.

And then, for RSV, this is where there are some subtle differences. So for infants, there is a monoclonal antibody infusion available specifically for the youngest infants who would be experiencing an RSV season during the time they're a young infant. So the problem with that has been availability. It's highly effective, but it was impacted by lower availability than what was predicted in terms of the demand for it. So I think that one is now being reserved for infants who have immune-compromising conditions.

And then, for older adults, 60-plus, there are two new RSV vaccines. So I mentioned when I spoke about RSV that infants are at the highest risk, and that is the case, but also older individuals can experience very severe RSV infection, including RSV pneumonia. If you do end up in the hospital with RSV as an older adult, your risk of death is actually very high. So most of the people still aren't going to end up in the hospital, but if you do get to the point where RSV has driven you into the hospital, that is actually a very bad and dangerous situation.

The RSV vaccines are a single dose at this point for those individuals who are eligible, age 60 and up. And it is across the board. There's no specific conditions that you would need to have in order to be eligible. It's just based on age. And at this point, there is not a clear recommendation for any future vaccines. We need to give it some time to pan out and see. The studies have shown that at least through two years, it's offering good protection.

Host Amber Smith: Now what about pneumonia? Is there a vaccine for that?

Elizabeth Asiago Reddy, MD: A lot of people will hear their providers mention the pneumonia shot. And what the pneumonia shot actually refers to is vaccines that are used to prevent pneumococcal pneumonia.

So pneumococcal pneumonia is caused by a bacteria called Streptococcus pneumoniae. And for many, many years it was by far and away the most common cause of bacterial pneumonia. That actually changed with the advent of the vaccine. So it remains an important cause of bacterial pneumonia, and it can also cause other types of severe infections, including things like meningitis and bloodstream infections.

But the universal use of the vaccine, because it's also offered in children, the universal use of the vaccine has actually changed the landscape so that it is less common than it used to be, but it's still there as a risk, and it can make people very, very, very sick. So what has happened is that over the last several years, there have been different iterations of the pneumonia vaccine that have covered additional serotypes (strains) that are seen to be causing severe disease. So most recently, we have a vaccine that actually covers 20 different serotypes, and individuals who have immunocompromising conditions, and this is pretty broad, to include things like diabetes and heart disease, or anybody age 65 and up, should be getting a dose of that vaccine.

Host Amber Smith: In addition to vaccination, during the COVID pandemic, we heard so much about hand sanitizers and masking. Are those things that you would still recommend people do to stay healthy during the respiratory viral seasons?

Elizabeth Asiago Reddy, MD: Absolutely. Those are definitely still very important components of keeping yourself healthy, obviously. Washing your hands, across the board, even though we found that COVID doesn't tend to be transmitted through surface contact as much as some other viruses. There are plenty of viruses, including the common cold virus, rhinovirus, that is its most efficient mode of spread, is by touching things.

So, washing your hands, 100%. It'll prevent a lot of what might make you sick.

Masking, we have re-implemented masking in hospitals. Why have we done that? We really only had a very brief time where we weren't wearing masks most of the time, and they came back online. We've done that because so many of the patients who are in the hospital have severe immune compromising conditions. And obviously the conditions in the hospital are ones where people are in very close proximity to one another. So, if you're a nurse working with a patient, you have to move them in bed, you have to help clean them, you have to give them medications where you're very close by. Many of our patients are still sharing rooms in the hospital.

So, for all of those reasons, it becomes a lot more important in those environments, where we have so many high-risk people, to be extra cautious.

But definitely, for anybody who has conditions that put them at increased risk of getting sick from respiratory infections, we've been able to show that masking is effective. I definitely counter the kind of notorious, I'm going to say it's notorious now in my medical field, Cochrane study that said that masking was not effective.

It's effective. There's so much other evidence to show that masking is effective. It really is. And there's different levels to which it can be effective depending on the type of mask that you're using, but it is a very viable option to reduce the risk of catching a respiratory infection, and it's also a very viable option to reduce the risk of spreading a respiratory infection if you have one and you happen to go out somewhere.

Host Amber Smith: Well, Dr. Asiago Reddy, I appreciate you making time for this interview. Thank you.

Elizabeth Asiago Reddy, MD: Thank you. It's great to talk with you, and stay safe.

Host Amber Smith: My guest has been Dr. Elizabeth Asiago Reddy. She's the chief of infectious disease at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Kidney transplants for children -- next on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Dr. Toby Le Nguyen recently joined the transplant team at Upstate University Hospital, and one of the things he specializes in is pediatric kidney transplants. I'll talk with him about that, and I'll ask him about living donor kidney transplants, which are increasing in number.

Welcome to HealthLink on Air, Dr. Le Nguyen.

Toby Le Nguyen, MD: Thanks for the invitation.

Host Amber Smith: I'd like to start by asking you about probably one of the more rare kidney transplants, those that are done in children. You specialize in these operations. Can you tell us in general how a kidney transplant differs in a child versus an adult?

Toby Le Nguyen, MD: So for kidney transplant, there are the basic steps for surgery. No. 1, we need to make sure that there's blood going into the kidney. No. 2, we need to make sure that blood's coming out of the kidney. And the kidney makes urine, so we need to make sure that the urine's going somewhere. So those basic steps are very similar between adult and pediatric transplant.

However, there are more special attentions paid toward the pediatric population, given the fact, No. 1, their size. And No. 2 is the cause of the kidney failure. What that means is that there's a different approach from a surgical standpoint.

Host Amber Smith: So there's different diseases that cause kidney failure in children?

Toby Le Nguyen, MD: Correct. So in adults, the majority of time currently in the U.S., the kidney failure is due to severe high blood pressure, diabetes. We think in our health system, those are modifiable diseases.

In pediatric populations, most of the diseases that cause kidney are congenital or genetic diseases. And,depending on the congenital disease or native disease, the pediatric nephrologists sometimes recommend the removal of the native kidneys,either at the same time or before doing the transplant -- versus an adult, usually, most of the time, don't remove the native kidneys unless there are true indications. And usually the indications for that are infection or severely large cystic kidneys.

Host Amber Smith: Now, can children receive a donor organ from an adult?

Toby Le Nguyen, MD: For sure. Absolutely. The majority of my work in training was that it was usually from a related adult.

So parents, family, who donate to the kids.

Host Amber Smith: Now are you looking at this, will this transplanted kidney be a lifetime organ for that child? Or how long do they last?

Toby Le Nguyen, MD: So, for living kidney, we usually hope between the average, between 10 to 20 years. What I've noticed within a pediatric population is that it can last for 10 to 15 years.

The biggest component is the compliance of medication. So this is why we want to involve social worker, pediatrician, nephrologist, and everybody's involved because putting a kidney into a patient works fine, but they need to make sure that they follow up with medication, they follow up with labs, taking appropriate anti-rejection medications. Because if they don't, that can increase risk of rejection.

Host Amber Smith: And non-compliance can be a big barrier for young pediatric patients because there's a lot of learning. Can you compare the outcomes for a kidney transplant from a deceased donor with that of a living donor, for a child?

Toby Le Nguyen, MD: Yeah. Living donor kidneys always work much better in both adult and pediatric setting. Like I said, usually between 10 to 20 years for the living donors.

A deceased donor kidney -- what that means is that a patient who has irreversible brain damage or who is brain dead, he or she is an organ donor, and family approves for a organ donation, so then one of the kidneys will be up for donation. Unfortunately, with a deceased donor, there's many variabilities that can affect the what we call, how long it lasts for, or "shelf life." So compared to a living donor, deceased donor shelf life is a bit lower.

Host Amber Smith: So let's talk a little bit more about who can be a living donor, and how do you go about doing that.

Toby Le Nguyen, MD: So this is what I talk to every single potential transplant recipient who comes to see us for evaluation, is that a living donor's kidney works much better. And that should be your ticket to get a transplant.

Living donors is a healthy donor out of friends, families, strangers, even, who can donate one of their two kidneys, and they can live for the rest of their life with one kidney.

The living kidney lasts longer, has better quality, and the surgery itself is more planned because deceased donor is unpredictable, is whenever there is an available organ, you get called in. Besides of that, there is a biggest disadvantage on the deceased donor because there is a wait list. It's making sure that there's fair for the entire system or everybody (who is) on the wait list. And when you get activated on the wait list, you start at the bottom of the list. You only move up on the top of the wait list based on how long you've been waiting on the wait list. So time, and your blood type. So usually in this region, Central Region, for blood type O, we expect patients to wait between four to six years to be on the top of that disease wait list to be able to see good offers for a deceased donor. So that is a pretty big disadvantage.

Host Amber Smith: So they obviously have to be healthy to be a donor. Are there any other disqualifiers for someone who would like to donate?

Toby Le Nguyen, MD: Yeah, so the main reason is living kidney donation -- this is coming from a donor who, this surgery is not needed for that person. There's no physical benefits. However, there are significant emotional benefits, either being, "I'm saving a child," "I'm saving the life of my spouse," or "I am supporting somebody, a stranger." So there is a huge emotional benefits in there. You know, we rely on that. So we want to make sure that patients are physically and mentally, emotionally, prepared for the whole process.

Usually the disqualifiers, the absolute contraindications would be if they have any risk factors that can affect the kidney disease. So as I said before, any severe hypertension, any uncontrolled diabetes, any recent cancer. And also, at the same time, significant obesity. So those are the absolute contraindications. When I said it has to be severe and uncontrolled diabetes, we do see people who are sort of pre-diabetic or maybe just have hypertension is not monitored by one blood pressure medication. Those patients can still be evaluated.

Well, what sorts of medical testing is done? Once you have someone who's willing to donate, what lays ahead for them before you determine whether their kidney can be used?

Yeah, so at Upstate, this is our process. They fill out a questionnaire. The questionnaires basically screen out people who there are absolute contraindications. So again, significant obesity, severe hypertension, uncontrolled diabetes, or recent cancer.

After they pass through that questionnaire, our living (donor) coordinators will contact them and will do a 24-hour urine collection to see the function of the kidneys. There are patients who have overall poor kidney functions; then they cannot proceed, because if they have poor overall kidney function, they should live with two kidneys versus one, obviously. After we determine that patients have enough kidney function to undergo the donation, then we see them in clinic.

At that clinic visit,the potential donor sees a surgeon, a nephrologist, finance coordinator, and social work who support and identify any issues that a donor has. We also have a living, we call it "elder," which is an independent living donor advocate. So that person also making sure that donor does everything in an ethical sense and not being pressured by anybody.

After that clinic visit, they will do basic labs. So we check for their diabetes, check for a cholesterol level, check for blood type. And we do a CT scan. And we meet as a group, the social worker, elder, the nephrologist and I meet as a group, and we determine based on the those data points if the patient is approved to be a donor.

Host Amber Smith: So you're really looking out to make sure that this person will be able to remain healthy afterward?

Toby Le Nguyen, MD: Absolutely. And like I said, because this is a strict process, we always strongly suggest potential kidney recipients who are on dialysis or still waiting to be on dialysis, that they spread the word out a lot, significantly becausethe potential donors go through a lot of hoops to get to that point. So we eliminate a lot of people.

Host Amber Smith: Well, once you do approve someone and they're matched with someone who needs a kidney, can you walk me through what happens on the day of surgery? Both the donor and the recipient are at the hospital ready for surgery. Do you, as the surgeon, do you operate on both of them, one after the other?

Toby Le Nguyen, MD: I would like to also get back a little bit after the process of approving them to be a donor. So the kidney (that) goes into the recipient, that kidney has to be blood type matched and has to match the antibodies of the recipient.

So let's say if that recipient has a potential donor who unfortunately doesn't have the same blood type or antibodies doesn't match well with the recipient, it's not an automatic rule out that donors can proceed. So what we do is that we participate in a national kidney exchange. It's another way to say that there's a kidney bank, run by a national program. What we do is that we take this pair, the donor and the recipient who are not a match, and put them into a kidney bank. And we sort through the whole national kidney bank to find an appropriate match based on size, age, antibodies, blood type to that recipient. And that recipient's donor is donated to somebody else who has a similar profile. Does that make sense?

Host Amber Smith: So a donor here at Upstate, their kidney may not go to a patient at Upstate, correct?

Toby Le Nguyen, MD: Correct.

Host Amber Smith: I see.

Toby Le Nguyen, MD: If that donor at Upstate doesn't have a matching profile, right? So that's, I think that's important to point out is that I think a lot of people have the myths that I have to find someone to match me. It does not need to be that. It needs to be, the kidney has to match to the person, but that kidney can come from anywhere.

So the more important bottom line is if you can find an approved donor, we will make sure the transplant can happen.

In regards to the donor, briefly, how do we decide which kidney to take? If both kidneys are similar in size and function, we usually go for the left kidney, remove the left kidney because it has more preferred anatomy for the recipient surgery. Let's say if one kidney is bigger than the other, we will let the donors keep the bigger and better kidney and proceed with removing a quote-unquote "lesser" kidney to the recipient. That's how we determine which one to remove.

Toby Le Nguyen, MD: The day of surgery is a well-orchestrated day in the sense that we make sure that the donors and the recipients are being seen before surgery. We make sure that they have all the lab tests and everything done. The day of surgery, the donor surgeons, usually either me or my partner, Dr. (Matthew) Garner, will proceed with the donor surgery first.

And then the recipient surgeon will go in usually 30 minutes to an hour after we start the donor surgery. We remove the donor's kidney, and we quickly bring it over to the recipient's surgeon to proceed with the recipient surgery.

Host Amber Smith: So you have two separate operating rooms and two separate operating teams, it sounds like.

Toby Le Nguyen, MD: Correct. Absolutely. The reason we do that is that want to make sure that No. 1, that the recipient surgeon, the recipient, can undergo surgery, make sure that we have identified appropriate anatomy for it to be transplant.

Let's say the recipient can't undergo certain things, or if something happens, we should not remove the donor's kidney for the recipient. Does that make sense?

Host Amber Smith: Yes.

Upstate's "HealthLink on Air" has to take a short break. Please stay tuned for more about kidney transplants with Dr. Toby Le Nguyen.

Welcome back to Upstate's "HealthLink on Air." This is your host, Amber Smith, talking about kidney transplants with Upstate transplant surgeon Dr. Toby Le Nguyen.

So the kidney connects to the bladder by a long, thin muscular tube called the ureter.

Toby Le Nguyen, MD: Yeah.

Host Amber Smith: Do you connect the donor kidney to the recipient's ureter, or do you also remove the donor ureter and connect that to the recipient's bladder?

Toby Le Nguyen, MD: I see you did your homework. So, the basic step, like we discussed earlier, there is an inflow blood going to the kidney, and then it's also blood draining the kidney. And then the kidney has a ureter, which makes urine. We have to hook it up somewhere. So there are three main connections for the kidney transplant.

No. 1 is to establish inflow, which is the artery, blood going in, and then establish the outflow of the blood, which is the vein. So we put two blood vessel connections. And then the third connection is the ureter. Most of the time, we hook it up to the the donor's kidney. We hook the ureters, we hook it up to the recipient's bladder.

There are a few instances where, let's say the bladder has issues, or we can't reach the bladder. Then we hook it up to the recipient's ureter. But most of the time it's the recipient's bladder.

Host Amber Smith: OK. And how long do the operations take usually?

Toby Le Nguyen, MD: So the donor surgery, the living donor surgery, technically usually takes between two to three hours. Then the recipient surgery, between three to four hours.

Host Amber Smith: OK. And getting back to the size of the organ that's transplanted, if you take a smaller kidney and you put it into an adult that's large, does the kidney grow? Does it get bigger?

Toby Le Nguyen, MD: It does not grow.

So there are certain special cases where we use what we call "en bloc" pediatric kidneys. So these are unfortunate events where very young babies who suffer severe brain damage and pass and have brain death. The parents proceed with organ donations. So the babies donate their organs. So these are deceased donors. We take these babies en bloc. That means we take both kidneys from the patient and we place them into, potentially, an adult patient, very small patients. So in those cases, you can see these babies kidneys grow over time a little bit. However, the majority of time when you put an adult small kidney to an adult larger person, that doesn't grow.

Host Amber Smith: Well, let's talk about recovery. For the donor and the recipient, how soon can they each return to normal activities?

Toby Le Nguyen, MD: Let me focus on the donor. For donor, I do laparoscopic surgery. So I make small incisions using laparoscopic tools. I do have to make an incision about 6 centimeters in order to extract the kidney out of the body. For the left kidney, there are three incisions. For the right kidney, there are four incisions. The fourth incision is very tiny incision to lift up the liver. So basically they're very similar.

But donors, they stay in the hospital between one and two days. The criteria to be discharged from the hospital are if they can walk, if they can pee afterwards, passing gas, if they can eat, and pain well controlled, then we'll let them discharge from the hospital. They come back to see us at two weeks after surgery and six weeks after surgery. And we do labs every six months, 12 months, 18 months and two years. That's the donors.

For the recipient, they stay in the hospital between three to four days. Similar criteria to be discharged: pain control, walking, eating, and peeing.

Usually with a living donor kidney, they pee right away, which is how we know, that it works right away. With a deceased donor, that doesn't really happen all the time, so we usually monitor that more closely.They stay in the hospital between three to four days. After that discharge from the hospital, they see the surgeon twice a week for one month, once a week for one month and once every other two weeks for one month, and monitor very closely with weekly labs.

Host Amber Smith: So are there any recommendations for lifestyle changes, or are there certain activities that they are advised not to do because of the kidneys?

Toby Le Nguyen, MD: For the living donors, we usually recommend no heavy lifting and strenuous exercises for at least six weeks to make sure that all the incisions are healed nicely. Otherwise, the biggest component about living donor is maintaining a healthy lifestyle for the rest of their life. What that means is that you live with one kidney. So this is about how long can you live with one kidney, and are there any medical risks? We, as a nation, we've done living donor kidney transplant over the past 40 to 50 years. So there are tons of data that show that this is a very safe surgery, and in regards to any risk of developing high blood pressure or kidney disease on the remaining kidney, the donors actually have a very similar or slightly higher risk than the general population. Very minimal risk. They actually, the donors, live longer than the general population.

What we encourage and emphasize are No. 1, healthy lifestyle. No. 2, making sure that not significant weight gains or weight loss. If you are slightly obese, start to lose some weight, essentially trying to save that kidney. So those are usually the recommendation for the donors.

For the recipients, with the working kidneys, you get off dialysis. You're able to do more things (that) are more enjoyable. But the most important aspect is that you have to change your lifestyle a little bit in the sense that you're taking anti-rejection medications for the rest of your life. And then you need to make sure that you are aware (that) you are basically immunosuppressed. Compared to general population, you have higher risk of developing infection. So those (are the) things that we impress on the patients.

Host Amber Smith: I think you said that the native kidney is usually left inside.

Toby Le Nguyen, MD: Correct.

Host Amber Smith: If it is diseased, will that spread to the new kidney?

Toby Le Nguyen, MD: Yeah, great question. So, like I said, if patients have kidney failure due to hypertension and diabetes, which are the highest causes of kidney failure in America, that shouldn't be transferred to the new kidney, if your high blood pressure and diabetes are well controlled after the transplant.

If your blood pressure and diabetes are poorly controlled after transplant, that can affect the kidneys for sure.

So, the third kidney disease, such as polycystic kidney disease, or in other words, these kidneys have innumerable cysts, and they grow so large that disease should not be transferred to the new kidney. Otherwise, there are some genetic diseases, similar to pediatric, that adults can have, such as IgA nephropathy, or vasculitis. Those diseases can recur with a new graft, usually between 10% to 15%. So it's not that absolutely zero recurrence. So that's why patients do get to have a very close follow-up with a transplant nephrologist.

Host Amber Smith: Let me ask you why people should consider becoming living kidney donors.

Toby Le Nguyen, MD: I think that's a great question in the sense that there's still a lot of people on the wait list, and they can stay a long time. And then organs are, deceased organs, don't come around all the time. And like I said earlier, deceased organs also have very variable shelf life. So the best way for a patient to fully have the best benefits from transplant is through living donors. And there are people who are willing to donate their kidneys out of the goodness of their heart. When I talk about the kidney chain, the national kidney bank, we have a lot of patients who have a lot of antibodies in the system. So these recipients are very difficult to match, or difficult to find donors.

So the more donors who donate and put in a kidney bank, that can essentially set off a new chain. And the ability to increase availability, to find a donor that matches that recipient.But yeah, that's why I think people should donate.

Host Amber Smith: Well, Dr. Le Nguyen, thank you so much for making time for this interview.

Toby Le Nguyen, MD: Thanks for all the questions.

Host Amber Smith: My guest has been Dr. Toby Le Nguyen, a transplant surgeon at Upstate University Hospital. I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Annie Przypyszny is a student at American University and the assistant poetry editor at the Adirondack Review. She sent us an exuberant poem that celebrates the return to health, those first moments of felt healing. Here is "This Moment and the Next."

It's raining

but the clouds, mild as cows,

welcome the glow of the sun.

The trees are glossy, and the puddles dimple

with full,

healthy drops.

Today I discovered

I'm in love with my breath, and my blood,

and my brain.

I never want the world to stop spinning.

Satisfaction

settles into this house,

this body. I move

with the eagerness

of something beautiful,

an iridescent fish,

or something very young,

a kitten. I look

in the mirror and my eyes

are gems of luck. I open

the window and say

to every wonderful thing:

Don't kill me!

I'm not done

with playing,

and speaking,

and thanking,

and making good guesses,

and thinking,

and hoping,

and waiting

for the next moment,

the next nourishing and vital moment,

which could be much like today's moment,

which I live with ease,

my cupped palms filling

with a lambent elixir of rain

and sun. I sip,

and it tastes as pure

as a kind-hearted lie,

a lie that says

you will never be punished for this.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air," who may benefit from a cochlear implant?

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.