Selected Podcast
The Use of New Technologies to Increase Kidney Transplantation in Minority Patients
Keith Melancon, MD, discusses new technologies designed to address the problematic limited pool of kidney donors in African American and Hispanic populations. Dr. Melancon explains the reasons behind donor/recipient obstacles, the importance of increasing options for minority recipients, the protocols used to reduce transplant rejection (plasma exchange, specific medications), and the success The George Washington University Hospital has seen in utilizing these technologies.
Featured Speaker:
is affiliated with The George Washington University Hospital and GW Medical Faculty Associates.
Dr. Melancon received his medical degree from Tulane Medical School. He completed his internship and residency at Tulane Medical Center. He then completed a transplant surgery fellowship at the University of Minnesota.
Learn more about Keith Melancon, MD
Keith Melancon, MD
Keith Melancon, MD is a general surgeon at The GW Medical Faculty Associates and a professor of surgery at The George Washington University School of Health & Sciences. Heis affiliated with The George Washington University Hospital and GW Medical Faculty Associates.
Dr. Melancon received his medical degree from Tulane Medical School. He completed his internship and residency at Tulane Medical Center. He then completed a transplant surgery fellowship at the University of Minnesota.
Learn more about Keith Melancon, MD
Transcription:
Dr. Mike Smith (Host): Welcome to GW Healthcast. I’m Dr. Mike Smith. We’re going to talk today about the use of new technologies to increase kidney transplantation in minority patients. My guest is Dr. Keith Melancon. Dr. Melancon is the Chief of the GW Transplant Institute and is a member of the medical staff at the George Washington University Hospital. Dr. Melancon, welcome to the show.
Dr. Keith Melancon (Guest): Hello, thank you. Thank you.
Dr. Smith: I want to go ahead and start – this was actually news to me, Dr. Melancon, so I want to start with this. This is a -- taken from a study published in the Journal of the American Medical Association, January of 2018, “Black and Hispanic kidney transplant patients are less likely than white patients to receive a kidney from a live donor despite considerate efforts over the past two decades to increase organ transplant donation.” Well, that was amazing to me to find that out, Dr. Melancon. Why do you think that is true, today?
Dr. Melancon: Yeah, that is a great study, and it basically showed what we’ve known for a while. The main issue is if you are African American or Hispanic there is a lot more kidney disease in your family. People that you know, either family or friends, have more kidney disease, they have more health problems. Therefore, your pool of people that could possibly donate a kidney to you is much more limited than Caucasian patients. That’s why it’s so difficult for these patients to find donors when they need them.
Dr. Smith: Very interesting problem, right? Where do we go from – so, now we have – we’ve kind of known this. We have a good study, as you’ve said, that makes this clear. As a matter of fact, I think it said in that study that for white patients, they were able to increase up to 11% in their incidence rate for live donor kidney transplants, but Blacks and Hispanics both decreased. I guess, what do we do with that? What’s the plan? How do we overcome this?
Dr. Melancon: Yeah, so the way you have to address this is you have to increase the options for these patients – for the recipients. The way to do that is to make every possible donor more likely to be able to donate to the recipient. I tell all of my patients that on average, you have to have three to four good options for you to find one donor that works out because there is so much that goes into the testing and diagnostic studies that a lot of people that you might think are healthy will not work out and be donors. Three to four people. Well, if you’re African American -- which in their group there is four to five times the rate of kidney disease -- it’s going to be much harder for you to find a donor.
However, when you do identify someone, we have to be able to bring to fore, all the technology to make that donor work out. What I mean by that is it’s very possible that the donor will be a different blood type. It’s possible that the recipient that needs to receive the kidney will have antibodies director towards their donor. We see this at least 50% of the time in transplantation. This can occur when – like for women that have had children by their husband or when the children – let’s say the children are adults and they want to donate to their mother, the mother could have developed antibodies against her children when they came through the birth canal. These are the things that can disqualify people from being donors, and there is technology available where we can try to make these transplants occur.
Dr. Smith: Right. Yeah, so let’s talk a little bit about that. Just to kind of summarize, it’s almost like the Black and Hispanic kidney patient is really facing two challenges, right? One is simply finding enough donors because the pool is smaller, but once we do – because that pool is smaller – that donor may not be perfect for them, and that’s where these new technologies step in. Am I getting that correctly?
Dr. Melancon: Yeah, that is absolutely correct. That is the gist of the matter.
Dr. Smith: Let’s talk then – we find that donor from that limited pool. How do we make sure that this donor is going to be good for this patient and that that transplantation has a good outcome?
Dr. Melancon: One of the main issues is really just the blood type matching – being blood type compatible. In transplants, just like when you donate blood, usually what you’re looking for is a blood type match or a blood type compatible donor, meaning that if the donor is blood type O – a person that is blood type O can give to a person that is blood type A, B or O. If the person is blood type A, usually it means they can only give to a person that is also blood type A. What we have been able to do -- and this has been around for the last 10 to 20 years – we know that there are ways that we can – it’s called desensitize. We can decrease your ability to react to a different blood type. This is what we will do.
The technologies that we will utilize in order to desensitize a person against a person that has a different blood type are things like plasmapheresis – it’s also called plasma exchange. All you’re doing really is you’re pulling away from these reactive antibodies so that they don’t react against a blood type. The other thing that we do is we give certain medications that target the cells that create the antibodies – these B cells or plasma cells – in order to decrease the antibody production and then that allows a person who is a different blood type to receive a kidney from someone that is a good donor otherwise. Let’s say the recipient is blood type O. They would typically need a blood type O donor, but in this situation when you do an ABO incompatible transplant, someone who is blood type A or blood type B can then donate to the person who is blood type O after the recipient goes through plasma exchange and this desensitization protocol.
Dr. Smith: Let me ask you, Dr. Melancon, when you compare the outcome of transplantation that happens between patients who are compatible based on blood type versus this type of desensitization process you have to go through? What’s the difference? Is it equal, or does one do better than the other?
Dr. Melancon: That’s a great question. I can tell you that nationwide, the outcomes have been very similar between ABO incompatible, live donor transplants, compared to the typical ABO compatible. However, the best outcomes have been at centers that have lots of experience doing this. Throughout my career, we’ve done these many times, and I can tell you at our center, currently at George Washington, our outcomes for these ABO incompatible, live donor transplants are actually better than the ABO compatible. This is not just here, but other centers that have a lot of experience doing this have seen similar results, like Columbia in New York City as well as NYU in New York City.
Dr. Smith: That’s really interesting, right? You would think that wouldn’t be the case. However, is it because in this desensitization process, are you dampening the immune response in general, so they’re not rejecting that kidney as much? Is there something there?
Dr. Melancon: Yes, I think that’s exactly what’s happening because the B cell responses are part of an immune response. Since we’re focusing on the B cells when we desensitize these patients in order to receive an ABO incompatible transplant, I believe that it’s helping to decrease a specific area of the immune system that we don’t focus so much on in the typical transplants. I think that it gives an advantage. Right now, we are theorizing that this anti-B cell therapy that we’re using for ABO-incompatible transplants can be brought to where – or even compatible transplants because the outcomes have been so good.
Dr. Smith: So, let’s just summarize where we’re at. We have a limited donor pool for Black and Hispanic kidney patients simply because there is more kidney disease in those patients, correct? So then, once we do find a donor, it’s often harder to make that donor a perfect match. One of the first areas we deal with is making sure the blood type is either the same, or they have to go through this desensitization, which actually has pretty good outcomes in larger centers. Is there anything else that gets in the way other than blood type for these types of transplantations?
Dr. Melancon: Yeah, well the other thing that happens with these patients that have limited access to transplant is that they wind up sitting on dialysis longer. For your Black and Hispanic patients, they build up antibodies just because their blood has to go through this filter – the hemodialysis machine. The longer you’re on this hemodialysis machine, the more likely you’re to have this other set of antibodies. It’s called anti-HLA antibodies. HLA is the antigen that’s on all of our white cells. When you build up these antibodies, that also encumbers your ability to receive a transplant. We see this a lot more in minority patients.
In much the same way as what we do for ABO incompatible transplants, these patients that have these other sets of antibodies, we also need to desensitize them. We do it in much the same way meaning they receive plasmapheresis or plasma exchange and they receive anti-B cell therapy, like Bortezomib, in order to decrease their B cell responses. And then, they can receive a transplant from patients that might have HLA that they would normally react against. That’s another way to expand the options for those patients.
Dr. Smith: Dr. Melancon, this is fascinating to me, and obviously, this is exciting work because helping more people get to that transplantation and make it successful, changes their life, right? This is amazing work that I think that you’re doing. How about this? In summary, when you look at the whole problem that we’ve been talking about – less donors for these Black and Hispanic Pts, the difficulty that the donor may not be a perfect match – what would you like people to know then about kidney transplantation in minority patients?
Dr. Melancon: Well, I think in summary, the idea has to be that we need more donors across the board. We need more deceased donors, so everyone needs to be signing their licenses and allowing organs to be donated after a tragic death. In addition to that, we need more live donors, so I tell my patients everyone in your circle, all of your family and friends, you need to alert them of your need -- I’m talking about people with kidney disease – so that they can realize that they could save your life if they came forward and were a donor. This is true for everybody, including minority patients.
In our minority patients, I do believe that outcomes have been so good in utilizing these technologies that are available. I really believe that it’s doing more of this and getting the word out like you’re doing with this phenomenal broadcast. It’s going to be a way to increase the number of these types of transplants that are done around the country. I just wrote a scientific paper that’s not published yet but will be soon, and I am pushing the transplant community to do more of these types of transplants in the minority community in order to increase the rates, which are abysmally low when you look at the rate of kidney disease in this population. We just need to do more of it.
Dr. Smith: Wow, that’s fascinating work, Dr. Melancon. I want to thank you for everything that you’re doing, and also thank you for coming on the show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Melancon or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment.
This is Dr. Mike Smith. Thanks for listening.
Dr. Mike Smith (Host): Welcome to GW Healthcast. I’m Dr. Mike Smith. We’re going to talk today about the use of new technologies to increase kidney transplantation in minority patients. My guest is Dr. Keith Melancon. Dr. Melancon is the Chief of the GW Transplant Institute and is a member of the medical staff at the George Washington University Hospital. Dr. Melancon, welcome to the show.
Dr. Keith Melancon (Guest): Hello, thank you. Thank you.
Dr. Smith: I want to go ahead and start – this was actually news to me, Dr. Melancon, so I want to start with this. This is a -- taken from a study published in the Journal of the American Medical Association, January of 2018, “Black and Hispanic kidney transplant patients are less likely than white patients to receive a kidney from a live donor despite considerate efforts over the past two decades to increase organ transplant donation.” Well, that was amazing to me to find that out, Dr. Melancon. Why do you think that is true, today?
Dr. Melancon: Yeah, that is a great study, and it basically showed what we’ve known for a while. The main issue is if you are African American or Hispanic there is a lot more kidney disease in your family. People that you know, either family or friends, have more kidney disease, they have more health problems. Therefore, your pool of people that could possibly donate a kidney to you is much more limited than Caucasian patients. That’s why it’s so difficult for these patients to find donors when they need them.
Dr. Smith: Very interesting problem, right? Where do we go from – so, now we have – we’ve kind of known this. We have a good study, as you’ve said, that makes this clear. As a matter of fact, I think it said in that study that for white patients, they were able to increase up to 11% in their incidence rate for live donor kidney transplants, but Blacks and Hispanics both decreased. I guess, what do we do with that? What’s the plan? How do we overcome this?
Dr. Melancon: Yeah, so the way you have to address this is you have to increase the options for these patients – for the recipients. The way to do that is to make every possible donor more likely to be able to donate to the recipient. I tell all of my patients that on average, you have to have three to four good options for you to find one donor that works out because there is so much that goes into the testing and diagnostic studies that a lot of people that you might think are healthy will not work out and be donors. Three to four people. Well, if you’re African American -- which in their group there is four to five times the rate of kidney disease -- it’s going to be much harder for you to find a donor.
However, when you do identify someone, we have to be able to bring to fore, all the technology to make that donor work out. What I mean by that is it’s very possible that the donor will be a different blood type. It’s possible that the recipient that needs to receive the kidney will have antibodies director towards their donor. We see this at least 50% of the time in transplantation. This can occur when – like for women that have had children by their husband or when the children – let’s say the children are adults and they want to donate to their mother, the mother could have developed antibodies against her children when they came through the birth canal. These are the things that can disqualify people from being donors, and there is technology available where we can try to make these transplants occur.
Dr. Smith: Right. Yeah, so let’s talk a little bit about that. Just to kind of summarize, it’s almost like the Black and Hispanic kidney patient is really facing two challenges, right? One is simply finding enough donors because the pool is smaller, but once we do – because that pool is smaller – that donor may not be perfect for them, and that’s where these new technologies step in. Am I getting that correctly?
Dr. Melancon: Yeah, that is absolutely correct. That is the gist of the matter.
Dr. Smith: Let’s talk then – we find that donor from that limited pool. How do we make sure that this donor is going to be good for this patient and that that transplantation has a good outcome?
Dr. Melancon: One of the main issues is really just the blood type matching – being blood type compatible. In transplants, just like when you donate blood, usually what you’re looking for is a blood type match or a blood type compatible donor, meaning that if the donor is blood type O – a person that is blood type O can give to a person that is blood type A, B or O. If the person is blood type A, usually it means they can only give to a person that is also blood type A. What we have been able to do -- and this has been around for the last 10 to 20 years – we know that there are ways that we can – it’s called desensitize. We can decrease your ability to react to a different blood type. This is what we will do.
The technologies that we will utilize in order to desensitize a person against a person that has a different blood type are things like plasmapheresis – it’s also called plasma exchange. All you’re doing really is you’re pulling away from these reactive antibodies so that they don’t react against a blood type. The other thing that we do is we give certain medications that target the cells that create the antibodies – these B cells or plasma cells – in order to decrease the antibody production and then that allows a person who is a different blood type to receive a kidney from someone that is a good donor otherwise. Let’s say the recipient is blood type O. They would typically need a blood type O donor, but in this situation when you do an ABO incompatible transplant, someone who is blood type A or blood type B can then donate to the person who is blood type O after the recipient goes through plasma exchange and this desensitization protocol.
Dr. Smith: Let me ask you, Dr. Melancon, when you compare the outcome of transplantation that happens between patients who are compatible based on blood type versus this type of desensitization process you have to go through? What’s the difference? Is it equal, or does one do better than the other?
Dr. Melancon: That’s a great question. I can tell you that nationwide, the outcomes have been very similar between ABO incompatible, live donor transplants, compared to the typical ABO compatible. However, the best outcomes have been at centers that have lots of experience doing this. Throughout my career, we’ve done these many times, and I can tell you at our center, currently at George Washington, our outcomes for these ABO incompatible, live donor transplants are actually better than the ABO compatible. This is not just here, but other centers that have a lot of experience doing this have seen similar results, like Columbia in New York City as well as NYU in New York City.
Dr. Smith: That’s really interesting, right? You would think that wouldn’t be the case. However, is it because in this desensitization process, are you dampening the immune response in general, so they’re not rejecting that kidney as much? Is there something there?
Dr. Melancon: Yes, I think that’s exactly what’s happening because the B cell responses are part of an immune response. Since we’re focusing on the B cells when we desensitize these patients in order to receive an ABO incompatible transplant, I believe that it’s helping to decrease a specific area of the immune system that we don’t focus so much on in the typical transplants. I think that it gives an advantage. Right now, we are theorizing that this anti-B cell therapy that we’re using for ABO-incompatible transplants can be brought to where – or even compatible transplants because the outcomes have been so good.
Dr. Smith: So, let’s just summarize where we’re at. We have a limited donor pool for Black and Hispanic kidney patients simply because there is more kidney disease in those patients, correct? So then, once we do find a donor, it’s often harder to make that donor a perfect match. One of the first areas we deal with is making sure the blood type is either the same, or they have to go through this desensitization, which actually has pretty good outcomes in larger centers. Is there anything else that gets in the way other than blood type for these types of transplantations?
Dr. Melancon: Yeah, well the other thing that happens with these patients that have limited access to transplant is that they wind up sitting on dialysis longer. For your Black and Hispanic patients, they build up antibodies just because their blood has to go through this filter – the hemodialysis machine. The longer you’re on this hemodialysis machine, the more likely you’re to have this other set of antibodies. It’s called anti-HLA antibodies. HLA is the antigen that’s on all of our white cells. When you build up these antibodies, that also encumbers your ability to receive a transplant. We see this a lot more in minority patients.
In much the same way as what we do for ABO incompatible transplants, these patients that have these other sets of antibodies, we also need to desensitize them. We do it in much the same way meaning they receive plasmapheresis or plasma exchange and they receive anti-B cell therapy, like Bortezomib, in order to decrease their B cell responses. And then, they can receive a transplant from patients that might have HLA that they would normally react against. That’s another way to expand the options for those patients.
Dr. Smith: Dr. Melancon, this is fascinating to me, and obviously, this is exciting work because helping more people get to that transplantation and make it successful, changes their life, right? This is amazing work that I think that you’re doing. How about this? In summary, when you look at the whole problem that we’ve been talking about – less donors for these Black and Hispanic Pts, the difficulty that the donor may not be a perfect match – what would you like people to know then about kidney transplantation in minority patients?
Dr. Melancon: Well, I think in summary, the idea has to be that we need more donors across the board. We need more deceased donors, so everyone needs to be signing their licenses and allowing organs to be donated after a tragic death. In addition to that, we need more live donors, so I tell my patients everyone in your circle, all of your family and friends, you need to alert them of your need -- I’m talking about people with kidney disease – so that they can realize that they could save your life if they came forward and were a donor. This is true for everybody, including minority patients.
In our minority patients, I do believe that outcomes have been so good in utilizing these technologies that are available. I really believe that it’s doing more of this and getting the word out like you’re doing with this phenomenal broadcast. It’s going to be a way to increase the number of these types of transplants that are done around the country. I just wrote a scientific paper that’s not published yet but will be soon, and I am pushing the transplant community to do more of these types of transplants in the minority community in order to increase the rates, which are abysmally low when you look at the rate of kidney disease in this population. We just need to do more of it.
Dr. Smith: Wow, that’s fascinating work, Dr. Melancon. I want to thank you for everything that you’re doing, and also thank you for coming on the show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Melancon or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment.
This is Dr. Mike Smith. Thanks for listening.