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Dr. Khaled Shamseddin

Medical Grand Rounds featuring Dr. Khaled Shamseddin

Katie Lindale, MSc Candidate (Translational Medicine)

 

Continuous, evidence-based reassessment of clinical guidelines is a cornerstone of translational research and is a major focus when it comes to kidney transplant. Dr. Shamseddin is a Transplant Nephrologist, educator and an active leader in Nephrology and Kidney Transplant initiatives locally, provincially, and nationally. Last Thursday, our class was fortunate to learn about his work towards an improved, evidence-based guideline for asymptomatic heart disease screening in patients waitlisted for kidney transplant.

 

Coronary artery disease (CAD) is the highest factor for morbidity and mortality among kidney transplant patients, and is highly prevalent in this population in part because of its considerable overlap of risk factors with kidney disease[1]. For example, by year 3 on the waitlist for kidney transplant, up to 16.7% of patients experience a myocardial infarction (MI), otherwise known as a heart attack[2]. The need to properly manage the elevated risk of CAD for these patients is amplified by the fact that cardiovascular disease (CVD) accounts for 30% of mortality in the kidney transplant population[3].

 

Current guidelines outline the importance of cardiovascular exclusion criteria for kidney transplant, encourage risk-based, preferentially noninvasive screening options and an emphasis on medical cardio-protection with standard treatments such as statins, aspirin, and beta-blockers[4]. Our class discussion addressed questions relating to the benefits of moving towards noninvasive testing and we learned about Dr. Shamseddin’s evidence-based preference of the utility of dobutamine stress echocardiograms (DSE).

 

Dr. Shamseddin explained that the research landscape for cardiovascular monitoring in waitlisted kidney transplant patients has changed significantly over the past couple of decades. Even then, invasive testing such as coronary angiogram and cardiac catheterization continue to be recommended for those at higher cardiovascular risk. These forms of invasive tests may introduce an unnecessary risk for patients in the form of contrast nephropathy[3, 5], vascular complications[6], and add excess cost for the healthcare system. Trends show increases in noninvasive testing for low-moderate risk groups, and continued invasive approaches for those with known risk factors such as diabetes mellitus and atherosclerotic CVD[7]. Our class discussion highlighted that it is necessary to consider whether there could be a more sustainable CAD testing and management strategy.

 

To tackle these questions during our class discussion, Dr. Shamseddin shared ways in which the presence of renal disease in a patient changes the nature of their CVD, subsequently impacting how they should be treated. With reduced renal function, a patient’s cardiovascular issues and specific microvascular dysfunction may be uniquely affected by urea toxicity[8], along with phosphate and calcium irregularities[9]. With inflammation and oxidative stress as key drivers for CVD in the setting of kidney disease, research is exploring the avenue of immunomodulatory therapies[10]. A critical angle of optimizing cardiovascular monitoring is the consideration of whether the current testing and treatment strategies are addressing the root of the issue for renal patients.

 

A clinical trial that focuses on the intersection of kidney disease and CAD indicates that for low-moderate risk patients, invasive cardiovascular testing does not add benefit to the patient and that medical therapeutics combined with a noninvasive testing approach are sufficient for management of CAD[11]. Despite this evidence, it’s challenging to translate findings to waitlisted kidney transplant patients because of the comorbid interactions between CAD, renal disease and other risk factors found in this population[12]. Many trials have exclusion criteria that leads to minimal representation of the waitlisted kidney transplant population. Existing findings provide a foundation on which to build an evidence base relevant to these candidates.

 

In response to this knowledge gap, Dr. Shamseddin and colleagues are collaborating on a trial called Canadian-Australian Randomised Trial for Screening Kidney Transplant Recipients for CAD (CARSK), with the goal of reducing excess CVD monitoring burden. The purpose of the non-inferiority trial is to establish a patient- and system-level impact of eliminated testing for asymptomatic patients after initial screening for waitlist placement. In addition, to understand the importance of pre-transplantation revascularization of coronary stenoses[13].  A major priority is improving cardiovascular and overall survival outcomes for waitlisted patients, as well as during the critical perioperative period and long-term. Understanding the implications of how current knowledge can be generalized to this population will be invaluable for future screening decisions in this population.

 

Overall, Dr. Shamseddin highlighted how CAD impacts a patient’s eligibility for kidney transplant and perioperative CAD risk, addressed the disconnect between current guidelines and what the evidence is telling physicians and concluded with specific research avenues and considerations to address these issues. Future directions indicate a need to focus on managing CVD with noninvasive testing and mechanism-targeted therapeutics.

 

References:

 

1.       Foley, R.N., P.S. Parfrey, and M.J. Sarnak, Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis, 1998. 32(5 Suppl 3): p. S112-9.

2.       Lentine, K.L., D.C. Brennan, and M.A. Schnitzler, Incidence and predictors of myocardial infarction after kidney transplantation. J Am Soc Nephrol, 2005. 16(2): p. 496-506.

3.       Ramanathan, V., et al., Screening asymptomatic diabetic patients for coronary artery disease prior to renal transplantation. Transplantation, 2005. 79(10): p. 1453-8.

4.       Chadban, S.J., et al., Summary of the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation, 2020. 104(4): p. 708-714.

5.       McCullough, P.A., Contrast-induced acute kidney injury. J Am Coll Cardiol, 2008. 51(15): p. 1419-28.

6.       Nathan, S. and S.V. Rao, Radial versus femoral access for percutaneous coronary intervention: implications for vascular complications and bleeding. Curr Cardiol Rep, 2012. 14(4): p. 502-9.

7.       Markossian, T.W., et al., Low statin use in nondialysis-dependent chronic kidney disease in the absence of clinical atherosclerotic cardiovascular disease or diabetes. Clin Kidney J, 2019. 12(4): p. 530-537.

8.       Vanholder, R., T. Gryp, and G. Glorieux, Urea and chronic kidney disease: the comeback of the century? (in uraemia research). Nephrol Dial Transplant, 2018. 33(1): p. 4-12.

9.       Reiss, A.B., et al., CKD, arterial calcification, atherosclerosis and bone health: Inter-relationships and controversies. Atherosclerosis, 2018. 278: p. 49-59.

10.     Komada, T. and D.A. Muruve, The role of inflammasomes in kidney disease. Nat Rev Nephrol, 2019. 15(8): p. 501-520.

11.     Herzog, C.A., et al., Kidney Transplant List Status and Outcomes in the ISCHEMIA-CKD Trial. J Am Coll Cardiol, 2021. 78(4): p. 348-361.

12.     Gill, J.S., et al., The impact of waiting time and comorbid conditions on the survival benefit of kidney transplantation. Kidney Int, 2005. 68(5): p. 2345-51.

13.     Ying T, Houchmand C, Riou-Green B, Ogniben A. Canadian-Australasian Randomised Trial of Screening Kidney Transplant Candidates for Coronary Artery Disease [Internet]. CARSK Trial. [cited 2022Mar17]. Available from: https://www.carsk.org/

Name
Kiera Liblik

Fri, 03/18/2022 - 12:11

Hello Katie,
Thank you for doing such a wonderful job facilitating and summarizing this MGR. It was interesting to hear about the transplant process and possible inequities that exist in transplant medicine.
Interestingly, in Canada there is an 'opt-in' process for organ donation in all provinces except for Nova Scotia.(1) One of the main benefits of an 'opt-out' or presumed consent system is that if not otherwise specified, it is assumed that individuals would like to donate their organs, increasing donations and decreasing preventable mortality. Given that in 2019 a total of 223 Canadians died while waiting for a kidney transplant, it is critical that we find ways to increase organ donation.(2) Notably, following the introduction of presumed consent in Nova Scotia, record numbers of organ donations have occurred.(3)
Following your reading on this topic and consideration during our MGR talk, do you think that presumed consent should be implemented across Canada or do you foresee ethical issues in this approach?
Warm regards,
Kiera
1) Tennankore, K. K., Klarenbach, S., & Goldberg, A. (2021). Perspectives on Opt-Out Versus Opt-In Legislation for Deceased Organ Donation: An Opinion Piece. Canadian journal of kidney health and disease, 8, 20543581211022151. https://doi.org/10.1177/20543581211022151
2) Canadian Institute for Health Information. e-statistics report on transplant, waiting list and donor statistics, 2019. 2020; cihi.ca/en/e-statistics-on-organ-transplants-waiting-lists-and-donors. Accessed January 26, 2020.
3) Ray C. N. S sees record number of organ donations in 2020. https://www.cbc.ca/news/canada/nova-scotia/record-number-organ-donation…. Published 2020. Accessed May 5, 2021.

Name
Kiera Liblik

Hi Kiera, very insightful post about different approaches to organ donation in Canada! And Katie, thank you for your excellent post! You did a great job facilitating the discussion even though we had to wait a few days to speak with Dr. Shamseddin, and I appreciated your recap at the beginning of the class!

While I hold the personal hope that my organs will be donated post-mortem, I understand that this is not the case for everyone. Your comment, along with the known racial disparities in kidney transplant recipients (1), got me thinking about how religious and cultural values impact one's decision to donate organs. This is important to address because it is one potential concern with the opt-out system. Interestingly, no religion explicitly forbids the donation or reception of an organ, although some groups do discourage it (2). For example, scholars of South Asian Muslims oppose desecration of the body after death which would be necessary for organ retrieval (2). In the UK, leaders of various faith and belief groups were interviewed to elucidate potential barriers to donation. The majority of these individuals were supportive of opt-in systems, with any concerns being the apparent failure of this system to meet organ donation needs rather than an ethical or moral concern (3). Similar to most discussions regarding the two systems, the question comes down to whether presumed authorization equals consent and the necessity of informed consent when it comes to the human body. I do acknowledge that there are countless faiths, organizations, and definitions of religion and thus my research for this post could not cover all possible belief systems. However, I was surprised to learn how most religions do not take a strong stance on organ donation, further enforcing the universal importance of individual informed consent for all decisions related to one's body.

Citations

1. Purnell TS, Luo X, Cooper LA, et al. Association of Race and Ethnicity With Live Donor Kidney Transplantation in the United States From 1995 to 2014. JAMA. 2018;319(1):49–61. doi:10.1001/jama.2017.19152

2. Bruzzone, P. (2008). Religious aspects of organ transplantation. Transplantation Proceedings, 40(4), 1064–1067. https://doi.org/10.1016/j.transproceed.2008.03.049

3. Randhawa, G., Brocklehurst, A., Pateman, R., Kinsella, S., & Parry, V. (2010). ‘opting-in or opting-out?’—the views of the UK's faith leaders in relation to organ donation. Health Policy, 96(1), 36–44. https://doi.org/10.1016/j.healthpol.2009.12.012

Name
Georgia Kersche

Hi Kiera,
This is a super exciting topic, thanks for the insight! With our knowledge of how long organ transplant waitlists are and as you mentioned, how many Canadian deaths there are each year while on waitlists, the 'opt-out' system provides a hopeful avenue. Some ethical issues with this system include the inaccessibility of legal information and avenues for opting out of donation, as well as the issue of 'family veto' for consent on behalf of a loved one (1). The implementation of this law in Nova Scotia can be reflected in transplant donation statistics, with a 40% increase of tissue donations after the law came into effect (2). The medical director of the program, Dr. Beed, explained that while there is a possibility of the opt-out numbers increasing over time, public education needs to be improved as many individuals request to opt-out because they assume they wouldn't qualify to donate (2). Altogether, I think that it's a step in the right direction, as long as there is infrastructure to properly educate the public on the program, and opting out is accessible for all.

(1) Toews M, Caulfield T. Evaluating the "family veto" of consent for organ donation. CMAJ. 2016;188(17-18):E436-E437. doi:10.1503/cmaj.160752
(2) Doucette K. Big jump in tissue donations, organ referrals after N.S. Presumed Consent Law | CBC news. CBC News. https://www.cbc.ca/news/canada/nova-scotia/ns-presumed-consent-organ-do…. Published January 21, 2022. Accessed March 19, 2022.

Name
Katie Lindale

Name
Lubnaa Hossenbaccus

Sun, 03/20/2022 - 19:18

In reply to by Kiera Liblik (not verified)

Katie, I really enjoyed reading your discussion post and Kiera, that's a really interesting question!
A systematic review of research studies published between 2006 and 2016 on the topic of out-in vs. opt-out consent found that opt-out consent was associated with increased organ donation and transplantation rates of deceased individuals (1). This may reduce the waiting time for organ transplantation and result in more lives saved.
Additionally, researchers found that opt-in consent carries more administrative burdens, often with professional-initiated involvement resulting in greater participation (2,3).
While it seems like opt-out consent may be more advantageous in the long-run, are there any challenges that need to be considered?

Lubnaa

References
(1) https://pubmed.ncbi.nlm.nih.gov/31428836/
(2) https://pubmed.ncbi.nlm.nih.gov/29573159/
(3) https://pubmed.ncbi.nlm.nih.gov/31951362/

Name
Lubnaa Hossenbaccus

Hi Lubnaa,
Thanks for your comment! One main challenge with opt-out organ donation is public education (1) and opt-out accessibility. With education, it's important to emphasize the value of organ donation, as well as the criteria that would make one eligible to donate. With this system, we must work towards accessible opt-out education and options so that those who wish to opt-out aren't facing difficult administrative hurdles in the process. If anyone else in the class has ideas for challenges of implementing an opt-out system for organ donation, I'd love to hear it!

(1) Byrne MHV, Ashcroft J. Organ donation: educating the public about the "opt-out" system is crucial. BMJ. 2020;368:m1207. Published 2020 Mar 26. doi:10.1136/bmj.m1207

Name
Katie Lindale

Hi Katie,
Thank you for doing an excellent job summarizing an interesting MGR. Organ donation is a topic I am very passionate about. I would encourage everyone to checkout, and consider joining the club (instagram: @qtoda_) that I have founded here at Queen's. In discussion with community members, health professionals, and organ recipients, one of the challenges that I've identified to the opt-out system (and that Katie briefly mentioned previously) is family veto. In an opt-in system, like Ontario, family veto occurs when an individual has registered their wish to donate their organs, but the deceased individuals substitute decision maker overrides that consent for legal or ethical reasons (1). In the opt-out system, family veto may occur when an individual has not opted out of organ donation, and the substitute decision maker objects to the deceased individuals organs being donated. Public education as has been brought up several times within this thread is vital. However, I believe it is just as important that individuals discuss their beliefs surrounding organ donation with their substitute decision maker. In the opt-in system, individuals that do not discuss this topic and consent to having their organs donated may have their consent overridden because the substitute decision maker is not aware of this belief or believes that they felt indifferent about organ donation. However, this may become an even larger issue in an opt-out system that does not require individuals to make clear their support of organ donation. If conversations are not had surrounding intention to donate, the proportion of family vetos may increase. In summary, while I think that an opt-out system is a good start to increase the number of organ donors in Canada, we cannot afford to stop having conversations surrounding the topic!
Thanks,
James
1. Anthony et al., 2021. Family veto in organ donation: the experiences of Organ and Tissue Donation Coordinators in Ontario. Can J Anaesth.

Name
James King

Thank you James for sharing these insights, it's something I haven't considered before! That's fantastic that you're leading and educating our community about organ donation, your page looks fantastic. I wholeheartedly agree about the importance of talking to loved ones about intention to donate, and also agree that it is certainly overlooked. I imagine that there could be a great increase in donor organ transplants if loved ones making the decision are aware of and understand the donor's wishes. Something that we should all be thinking about, and I'm curious to know how we may tackle that question from an education standpoint in the future.

Name
Katie Lindale

Name
Trinity Vey

Fri, 03/18/2022 - 17:22

Hi Katie,

Thank you for facilitating this week’s discussion and providing a great synopsis of our discussion with Dr. Shamseddin. You’ve done an excellent job of highlighting the connection between cardiovascular disease (CVD) and kidney disease. In addition to the overlap in risk factors, the cardiovascular system is impacted by chronic kidney disease due to the pro-inflammatory state it causes, impacting myocardial and vascular remodelling processes (1). Alarmingly, the leading cause of death in patients with advanced chronic kidney disease is cardiovascular and not renal (1).

In reflecting upon our discussion, I was reminded of the MGR last semester with Dr.’s Moran and Silver where we discussed onco-nephrology and the intersection of kidney disease with cancers. This prompted me to wonder about the potential for a subspecialty of cardio-nephrology. A paper by Diez & Ortiz describes the “need” for cardio-nephrology specialists, characterizing chronic kidney disease as a renal disease that inevitably progresses to be a CVD (2). The authors believe that the current nephrology specialization curriculum is lacking in in-depth cardiovascular training, especially considering that the cardiovascular field is rapidly evolving.

As such, I’m wondering your thoughts on a widespread cardio-renal service – do you think this is an appropriate solution to support patients with advanced chronic kidney disease and apparent CVD co-morbidities? Do you anticipate any challenges with such a service/subspecialty?

Looking forward to hearing your thoughts! Thanks again for facilitating such a thought-provoking discussion.

Best,

Trinity

References:

1. Jankowski J, Floege J, Fliser D, Böhm M, Marx N. Cardiovascular Disease in Chronic Kidney Disease: Pathophysiological Insights and Therapeutic Options. Circulation. 2021;143(11):1157-1172. doi:10.1161/CIRCULATIONAHA.120.050686
2. Díez J, Ortiz A. The need for a cardionephrology subspecialty. Clin Kidney J. 2021;14(6):1491-1494. Published 2021 Mar 10. doi:10.1093/ckj/sfab054

Name
Trinity Vey

Hi Trinity,
Thanks for the comment, I love that connection! It's an interesting thought, a subspecialty of Cardiology and Nephrology. In the case of CVD monitoring in nephrology patients (and vise versa), it makes great sense. My first thought is to reflect on the conversations between the Cardiologists and Dr. Shamseddin after MGR last week. The question period consisted of a fascinating discussion about how the interplay between cardiovascular and renal disease changes the nature of each of them independently, and subsequently how they should be treated. This is especially relevant to inflammatory disease of these (and other) organs as well. I am confident that a huge amount of treatment innovation would arise through addressing these questions by a multidisciplinary treatment team as a whole system rather than in isolated, organ- or sub-system- specific consults.

Name
Katie Lindale

Hi Trinity and Katie,

Thank you for your excellent summary of the MGR. The topic of a Cardio-Nephrology subspeciality is a very interesting idea. I found a very recent review paper advocating for the creation of a dedicated nephrocardiology subspecialty. (1) The author argued that this speciality is relevant beyond the cardiac risks associated with kidney disease, as these two disciplines often interact. For example, prophylactic anticoagulation to prevent blood clots is difficult in patients with chronic kidney disease. Additionally, diagnosing myocardial infarction is more challenging in patients with kidney disease, as cardiac markers may be elevated at baseline. Importantly, many cardiovascular and nephrology diseases have similar risk factors, including diabetes, high blood pressure, high cholesterol, and obesity. (1) This suggests to me that prevention for these two types of disease could be communicated to patients in a coordinated manner. I look forward to hearing everyone’s thoughts on a nephrocardiology subspecialty!

Samantha

References
1. Hatamizadeh, P. Introducing nephrocardiology. 2022. CJASN, 17 (2) 311-313; DOI: https://doi.org/10.2215/CJN.10940821.

Name
Samantha Ables

Name
Alyssa Burrows

Fri, 03/18/2022 - 21:31

Hi Katie,

Excellent summary Katie! I really appreciated that you summarised last week’s talk before leading the facilitated discussion I found that extraordinarily helpful. As you have highlighted kidney transplants are a very complex process. In 2019, 4419 Canadians were on the waitlist for a kidney transplant which has times that can range from years to months [1]. Currently, two options exist, living donors and deceased donors. The Canadian blood services found in their 2019 data that there was an increase in rate of organ donation from deceased donors of 21.9 donors per million people compared with 20.6 per million in 2018. Further there was a 42% increase in kidney transplants compared to 2010. However, more patients (n=250) died on the wait list in 2019 than did in 2018 (n=223, the number that Kiera mentioned above). This identifies a gap that needs to be addressed [2]. A population that is severely under-addressed and under studies in Indigenous peoples, living kidney donors who were First Nations or Métis had higher rates of long-term complications, such as new hypertension (adjusted OR 6.3, 95% CI 1.8–22.1), and diabetes (19.4% v. 1.6%, p = 0.005), recipients were more likely to experience graft failure [3, 4]. During your research did you come across any advocacy or experimental strategies to try to decrease wait times and increase access, particularly for vulnerable groups.

Look forward to hearing from you,

Alyssa

1. Be an Organ Donor. https://kidney.ca/Get-Involved/Be-an-Organ-Donor. Accessed 18 Mar 2022
2. Data offers hope to patients waiting for organ transplant | Canadian Blood Services. https://www.blood.ca/en/stories/data-offers-hope-patients-waiting-organ…. Accessed 18 Mar 2022
3. Storsley LJ, Young A, Rush DN, Nickerson PW, Ho J, Suon V, Karpinski M (2010) Long-Term Medical Outcomes Among Aboriginal Living Kidney Donors. Transplantation 90:401–406
4. Dyck RF (1994) Rates and outcomes of diabetic end-stage renal disease among registered native people in Saskatchewan. CAN MED ASSOC J 6

Name
Alyssa Burrows

Hi Alyssa,
That's an important observation that you make about access and outcomes in vulnerable groups, and is incredibly complex to address. As we have learned, racism in medicine drives inequitable care, and management of cardiovascular risk factors in racialized patients pre-and post-transplant is no exception. Especially in the case of compounding risk factors leading to worse cardiovascular and renal outcomes, in populations that have been systemically unsupported by the healthcare system, transplant outcomes are less successful. Through my reading, I came across several articles discussing the barriers and inequities that exist in Canada in terms of transplant eligibility and success, however, their findings report that there is a long way to go in terms of defining more barriers before being able to find the appropriate actions to improve outcomes for vulnerable and racialized populations. To start, we are working towards shifting the outdated perspective of race as a risk factor in medicine to systemic racism as the true culprit (1). A systematic review on perspectives from Indigenous peoples in New Zealand highlights the disconnect between medical practice and Indigenous Knowledge, emphasizing an absence of cultural competence in healthcare workers and high levels of prejudice when interacting with medical personnel (2). These findings are consistent across Canada as well, demanding a conscious shift in perspective and focused action to combat our current systemic inequities. I'm curious to hear the class's perspective on how we can bring antiracism and action to improve outcomes in vulnerable populations to all of our research and clinical endeavors.

(1) Dryden O, Nnorom O. Time to dismantle systemic anti-Black racism in medicine in Canada [published correction appears in CMAJ. 2021 Feb 16;193(7):E253]. CMAJ. 2021;193(2):E55-E57. doi:10.1503/cmaj.201579
(2) Walker RC, Abel S, Reynolds A, Palmer SC, Walker C, Tipene-Leach DC. Experiences, perspectives and values of Indigenous peoples regarding kidney transplantation: systematic review and thematic synthesis of qualitative studies. Int J Equity Health. 2019;18(1):204. Published 2019 Dec 30. doi:10.1186/s12939-019-1115-y

Name
Katie Lindale

Name
Kyla Tozer

Mon, 03/21/2022 - 08:20

Hello, Katie,

Thank you for a very well written and thought-out blog. I think you did an incredible job capturing the key take away from this week’s medical grand rounds. I had similar thoughts as Alyssa, regarding access to care. As it was brought to our attention the waitlist for these procedures is long and the procedure in itself if very complex with ongoing care needed post-surgery. It was shown that specific groups, such as the indigenous population experiences additional barriers in accessing medical care [1]. One of the interesting things I noticed in this paper, was that access to information was a barrier, on top of the medical intervention itself. It had me thinking, how is accessing information a barrier, in such an internet focused world[1]. With the pandemic shedding light on virtual care, do you think this [lack of access to care] is something we may see go away in the future?

Thank you so much for your wonderful post.
Excellent summary!

References:
[1] El-Dassouki N, Wong D, Toews DM, et al. Barriers to Accessing Kidney Transplantation Among Populations Marginalized by Race and Ethnicity in Canada: A Scoping Review Part 1—Indigenous Communities in Canada. Canadian Journal of Kidney Health and Disease. January 2021. doi:10.1177/2054358121996835

Name
Kyla Tozer

Hi Kyla,

Thanks for sharing your thoughts! So many access-related issues have changed during the pandemic, and with increasing digital literacy. With that said, I think that many groups who are underserved by the healthcare system, especially Indigenous populations, need access to information and resources that align with cultural values and ways of knowing that aren't currently represented in the healthcare system. While remote options are useful for those who are far from large healthcare centres and have access to stable internet connection, there's much more structural change that must be done in order to make these resources truly accessible. For example, Indigenous models of health take a multi-faceted and highly integrated approach to care, which our current medical system is not set up to support (1). We have a lot to learn from Indigenous Medicine and a long way to go in terms of supporting populations who are underserved by our current system.

(1) Rogers, B. J. (2019). At the interface: Indigenous health practitioners and evidence-based practice. National Collaborating Centre for Aboriginal Health.

Name
Katie Lindale

Name
Nolan Breault

Mon, 03/21/2022 - 13:01

Hi Katie & all,

Thanks to Katie for summarizing this compelling MGR topic and congratulations on doing such a great job of hosting the associated discussion!

I found premise of kidney dysfunction and its strong correlation with cardiovascular comorbidities really striking. This cross-talk between organs also reminded me of Dr. Boyd's rounds regarding neurological impairments secondary to acute and chronic kidney disease, which when compounded with Trinity's comment regarding onconephrology, really goes to show how pivotal healthy kidneys are for so many aspects of homeostasis.

In doing a little digging myself, it seems that there've been connections made between renal disease and bodily systems ranging from the lungs (high prevalence of pneumonia) to the skin and bones (renal hyperparathyroidism mobilizes calcium and phosphorus from the bones, leading to skin irritation and potentially osteoporosis) (1, 2). These connections really do help to highlight how important rapid access to donated kidneys is.

Prior to our attending MGRs in TMED 802, I never gave much thought to how vital the filtration role of kidneys, as well as their role in the endocrine system, really are across the many domains of health. They're certainly an under-appreciated organ for laypersons!

Nolan

References
1. Sorino, C., Scichilone, N., Pedone, C., Negri, S., Visca, D., Spanevello, A. (2019). When kidneys and lungs suffer together. Journal of Nephrology, 32(5), 699–707. https://doi.org/10.1007/s40620-018-00563-1
2. Yuen, N. (2016). Hyperparathyroidism of Renal Disease. The Permanente Journal. https://doi.org/10.7812/TPP/15-127

Name
Nolan Breault

Hi All,

Thank you so much Katie for your wonderful summary of our time with Dr. Shamseddin! Like Nolan, this MGR presentation really put the systemic vitality of the kidneys into perspective for me. With this in mind, I am wondering if this could be used as a starting point to consider new non-invasive techniques for CAD screening in CKD patients. Although I am far from knowledgeable on the topic I am curious if maybe lung function tests or blood calcium levels could find some use in screening. I would be very interest to research this more in depth! At the end of our discussion, Dr. Shamseddin mentioned that patients on the transplant list often die of heart disease, indicating that something is missing in screening. Perhaps, the answer lies in the broader systemic effects that CKD has on the body?

Cassie

Name
Cassie

Thanks Nolan, I completely agree! In this class in particular, we've had the gift of exposure to a huge amount of interdisciplinary knowledge, and had conversations about the intersections of many fields in academic medicine. We're in a unique position where we have the opportunity to learn about how different organs and systems interact, and how these interactions could inform research innovation. Glad you enjoyed it, I did too!

Name
Katie

Name
Bethany Wilken

Tue, 03/22/2022 - 10:12

Hi Katie,

I want to first commend you on an excellent summary and discussion. Dr. Shamseddin offered great insights into managing CVD with non-invasive testing in kidney transplant patients. Every Grand Rounds topic is so different yet, interconnected. This highlights our body systems as a team working to complete the job of living.

During our discussion with Dr. Shamseddin the question of wait times was brought up. I had assumed since kidney donors can be alive, that wait times for kidney transplant would be less than other organs. Dr. Shamseddin explained that this was not the case. Other organs do not have a “back-up” machine like dialysis for kidneys. This allows patients to survive longer while organ function declines. This has me wondering if similar “back-up” machines or techniques could be invented for other organs to help address wait list deaths. Most recently, genetically altered pig hearts have made their way onto the heart transplant scene. The New York Times shared the story of David Bennett, the first pig heart recipient in America. Although David recently passed after two months with the pig heart, the transplant was considered a success because the pig’s heart was not immediately rejected and continued to function for well over a month. The process, called xenotransplantation, is applicable to other organs as well and could offer hope for the shortage of donated organs. Of course, ethical issues are considerable, but I think this is an exciting possibility for transplant patients! I am always amazed by the discoveries of science!

Link to New York Times article: https://www.nytimes.com/2022/03/09/health/heart-transplant-pig-bennett…

Best,
Bethany

Name
Bethany Wilken

Name
Katie Lindale

Fri, 03/25/2022 - 14:01

In reply to by Bethany Wilken (not verified)

Thanks for the insightful comment Bethany! It's fascinating to consider how medical alternatives can prolong wait times for transplant by changing the eligibility threshold. I'd be curious to know the impact that these opporunities have on patient quality of life as well as healthcare system resource use.

Name
Katie Lindale

Name
Pierce

Wed, 03/23/2022 - 10:48

Hi Katie, First of all, thank you so much for such a great summary of Dr. Dr. Shamseddin's presentation. I think you highlighted the key points beautifully and have helped promote an active discussion surrounding CKD.

The question I would like to pose surrounds the topic of moderate CKD, or those patients who are not dialyzing, and are yet to require a kidney transplant, however, experience many discomforting symptoms of kidney disease. A study by Schipper et al. from 2016 looked at this group (moderate to severe CKD) from the perspective of patients and reported some interesting findings involving the lack of attention and care given to these patients (from their perspective). Dr. Schipper reported that many participants expressed their struggle with existing ideas about CKD in society. The interviewees described their interactions with strangers and stated that the people they interacted with often only associated CKD with dialysis or transplantation. Participants often perceived those in their environment as being unaware of the problems of this particular category (moderate to severe CKD) of patients. This inaccurate image formation surrounding CKD was seen to be an issue that many of the participants felt had a multifactorial impact on their treatment. Not only does society not recognize their condition, but some participants reported that they felt their medical complaints were not taken seriously by healthcare professionals. Some participants even went as far to say that they stopped reporting their symptoms because they felt until they needed dialysis or a transplant, they would not be taken seriously. My question is if you think addressing and managing CKD more effectively as a moderate stage disease, could lessen the future burden before a patient requires transplantation. There is no cure for CKD however lifestyle changes and treatment are major contributing factors to keeping healthy. If patients with moderate stage disease are not even reporting their symptoms it makes it impossible for doctors to recommend treatment and lifestyle change, which could prevent them from developing symptoms that contribute to kidney failure and potentially needing transplantation for the foreseeable future. if patient complaints were managed earlier on in their disease course maybe less transplantation would be required and hence less CAD and death would result.

Thank you again for your great summary!

Schipper, K., van der Borg, W.E., de Jong-Camerik, J. et al. Living with moderate to severe renal failure from the perspective of patients. BMC Nephrol 17, 48 (2016). https://doi.org/10.1186/s12882-016-0263-1.

Name
Pierce

Hi Pierce, thank you for shedding light on this commonly overlooked subset within the CKD community, your reflection of Dr. Schipper's work rings true from so many angles. It's so important to consider the huge amount of patients living with chronic diseases who are not eligible for the available treatments yet still experience considerable health issues. Notably, for patients who lose the motivation to report symptoms with their clinicians after having so many life-altering symptoms that can't be addressed with current medical guidelines and tools. As you mentioned, one way to mitigate this challenge is to focus treatment development on these population subsets that are currently under-resourced. In the meantime, I believe that consistent validation of patient concerns, and acknowledgement that our knowledge and resources are incomplete in these areas is a critical aspect of maintaining patient-clinician rapport and trust. Considering patients who are left behind in the healthcare system is a topic near to my heart, and I'm grateful that you brought up this important issue in our discussion.

Name
Katie Lindale

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