By Bob Aronson
Antibiotics and drugs called antimicrobial agents have been used for the last 70 years to treat patients with infectious diseases who might genotherwise have died. Unfortunately these “Miracle” drugs were used for such a long time and so indiscriminately that the organisms they were designed to kill have mutated and become more resistant to them. In some cases the drugs don’t work at all anymore.
Each year in the United States, at least 2 million people become infected with antibiotic resistant bacteria and at least 23,000 of them die as a result. While 23,000 is a significant number it does not even come close to being in the catastrophic category so there’s not much media attention given to the problem – until now and this headline.
Is Antibiotic resistance: the greatest public health threat of our time?
The WHO says we are in a “post-antibiotic era”, in which even the most minor bacterial infections could mean death, a statement made true because of antibiotic misuse, overprescribing and poor diagnoses.
A world without antimicrobials would be a world without modern medicine, so why is there not more urgency in addressing the global rise of drug resistance? The New Statesman brought leading health experts together to discuss the problem. http://www.newstatesman.com/sci-tech/2014/07/antibiotic-resistance-greatest-public-health-threat-our-time
Antibiotic-resistant infections can happen anywhere. The CDC says that most of them happen in the general community; however, most deaths related to antibiotic resistance happen in healthcare settings such as hospitals and nursing homes. http://www.cdc.gov/drugresistance/threat-report-2013/index.html
The Threat to You
Diseases that either are or are becoming antibiotic resistant http://www.cdc.gov/drugresistance/DiseasesConnectedAR.html
A growing number of disease-causing organisms or pathogens, are resistant to one or more antimicrobial drugs—including the bacteria that cause tuberculosis, the viruses that cause influenza, the parasites that cause malaria, and the fungi that cause yeast infections. All are becoming resistant to the antimicrobial agents used for treatment. Curious about other diseases that may not respond to your antibiotics? Here’s a partial list from the CDC. The full list can be seen by clicking on the above link.
Acinetobacter is a type of gram-negative bacteria that is a cause of pneumonia or bloodstream infections among critically ill patients. Many of these bacteria have become very resistant to antibiotics.
Anthrax is a serious disease caused by Bacillus anthracis, a bacterium that forms spores. Anthrax most commonly occurs in wild and domestic mammalian species, but it can also occur in humans when they are exposed to infected animals or to tissue from infected animals or when anthrax spores are used as a bioterrorist weapon. Some strains of B. anthracis may be naturally resistant to certain antibiotics and not others. In addition, there may be biologically mutant strains that are engineered to be resistant to various antibiotics.
Untreatable and hard-to-treat infections from carbapenem-resistant Enterobacteriaceae (CRE) bacteria are on the rise among patients in medical facilities. CRE have become resistant to all or nearly all the antibiotics we have today. Almost half of hospital patients who get bloodstream infections from CRE bacteria die from the infection.
Group B Streptococcus (GBS) is a type of bacteria that can cause severe illnesses in people of all ages, ranging from bloodstream infections (sepsis) and pneumonia to meningitis and skin infections.
Methicillin-resistant Staphylococcus aureus (MRSA) causes a range of illnesses, from skin and wound infections to pneumonia and bloodstream infections that can cause sepsis and death. Staph bacteria, including MRSA, are one of the most common causes of healthcare-associated infections.
Non-typhoidal Salmonella (serotypes other than Typhi, Paratyphi A, Paratyphi B, and Paratyphi C) usually causes diarrhea (sometimes bloody), fever, and abdominal cramps. Some infections spread to the blood and can have life-threatening complications.
Shigella usually causes diarrhea (sometimes bloody), fever, and abdominal pain. Sometimes it causes serious complications such as reactive arthritis. High-risk groups include young children, people with inadequate hand washing and hygiene habits, and men who have sex with men.
Streptococcus pneumoniae (S. pneumoniae, or pneumococcus) is the leading cause of bacterial pneumonia and meningitis in the United States. It also is a major cause of bloodstream infections and ear and sinus infections.
Tuberculosis (TB) is among the most common infectious diseases and a frequent cause of death worldwide. TB is caused by the bacteriaMycobacterium tuberculosis (M. tuberculosis) and is spread most commonly through the air. M. tuberculosis can affect any part of the body, but disease is found most often in the lungs. In most cases, TB is treatable and curable with the available first-line TB drugs; however, in some cases, M. tuberculosis can be resistant to one or more of the drugs used to treat it. Drug-resistant TB is more challenging to treat — it can be complex and requires more time and more expensive drugs that often have more side effects. Extensively Drug-Resistant TB (XDR TB) is resistant to most TB drugs; therefore, patients are left with treatment options that are much less effective. The major factors driving TB drug resistance are incomplete or wrong treatment, short drug supply, and lack of new drugs. In the United States most drug-resistant TB is found among persons born outside of the country.
Salmonella serotype Typhi causes typhoid fever, a potentially life-threatening disease. People with typhoid fever usually have a high fever, abdominal pain, and headache. Typhoid fever can lead to bowel perforation, shock, and death.
Staphylococcus aureus is a common type of bacteria that is found on the skin. During medical procedures when patients require catheters or ventilators or undergo surgical procedures, Staphylococcus aureus can enter the body and cause infections. When Staphylococcus aureus becomes resistant to vancomycin, there are few treatment options available because vancomycin-resistant S. aureus bacteria identified to date were also resistant to methicillin and other classes of antibiotics.
Malaria is a mosquito-borne disease caused by a parasite. People with malaria often experience fever, chills, and flu-like symptoms. The development of resistance to drugs poses one of the greatest threats to malaria control and has been linked to recent increases in malaria morbidity and mortality. Antimicrobial resistance has been confirmed in only two of the four human malaria parasite species, Plasmodium falciparum and P. vivax.
WHO: Antibiotic Resistance Now a ‘Major Threat to Public Health’
Antibiotics are powerful tools for fighting illness and disease, but their overuse has helped create bacteria that are outliving the drugs used to treat them.
Antibiotic resistance is a quickly growing, extremely dangerous problem. World health leaders have described antibiotic-resistant bacteria as “nightmare bacteria” that “pose a catastrophic threat” to people in every country in the world. Many more people die from other conditions that were complicated by an antibiotic-resistant infection.
In addition, almost 250,000 people who are hospitalized or require hospitalization get Clostridium difficile each year, an infection usually related to antibiotic use. C. difficile causes deadly diarrhea and kills at least 14,000 people each year. Many C. difficile infections and drug-resistant infections can be prevented.
How Bacteria Become Resistant
When bacteria are exposed to antibiotics, they start learning how to outsmart the drugs. This process occurs in bacteria found in humans, animals, and the environment. Resistant bacteria can multiply and spread easily and quickly, causing severe infections. They can also share genetic information with other bacteria, making the other bacteria resistant as well. Each time bacteria learn to outsmart an antibiotic, treatment options are more limited, and these infections pose a greater risk to human health.
Infections Can Happen to Anyone, Anywhere
Anyone can become infected with antibiotic-resistant bacteria anywhere and anytime. Most infections occur in the community, like skin infections with MRSA and sexually transmitted diseases. However, most deaths related to antibiotic resistance occur from drug-resistant infections picked up in healthcare settings, such as hospitals and nursing homes.
What you can do to protect yourself against drug-resistant infections
Bob’s Newheart is providing two answers to this question. The first from the CDC and the second from a panel of physician experts who were interviewed for the PBS TV show, Frontline.
There are many ways you can help prevent the creation and spread of resistance. First, when you are sick, do not demand antibiotics from your doctor or take antibiotics that were not prescribed to you directly for your specific illness. When taking antibiotics, do not skip doses, and make sure to follow the directions about dose and duration from your doctor.
Second, like all diseases, common safety and hygiene methods can prevent disease and spread. Make sure to:
- Get updated and regular vaccinations against drug-resistant bacteria
- Wash your hands before eating and after using the restroom to avoid putting drug-resistant bacteria into your body
- Wash your hands after handling uncooked food to prevent ingesting drug-resistant bacteria that can live on food
- Cook meat and poultry thoroughly to kill bacteria, including potential drug-resistant bacteria
What healthcare providers can do to protect patients from drug-resistant infections (CDC)
- Follow all necessary infection control recommendations, including hand hygiene, standard precautions, and contact precautions.
- Diagnose and treat resistant infections quickly and efficiently. Treatment options change often because resistance is complex. Make sure to follow the latest recommendations to ensure you are prescribing appropriately.
- Only prescribe antibiotics when likely to benefit the patient, and be sure to prescribe the right dose and duration.
- Be sure to clearly label dose, duration, and indication for treatment, and include appropriate laboratory diagnostic tests when placing antibiotic orders. This will help other clinicians caring for the patient to change or stop therapy when appropriate.
- Take an antibiotic time out, reassessing therapy after 48-72 hours. Once additional information is available, including microbiology, radiographic, and clinical information, a decision can be made on whether to continue the same therapy.
- When transferring patients, ensure the other facilities are notified of any infection or known colonization.
- Keep tabs on resistance patterns in your facility and in the area around your facility.
- Finally, encourage prevention methods with your patients. Make sure they understand how to protect themselves with vaccines, treatment, and infection control practices such as hand washing and safe food handling.
From PBS “Frontline”
Eight Ways to Protect Yourself from Superbugs
October 22, 2013, 9:32 pm ET by Sarah Childress
Everyone is at risk of becoming infected by drug-resistant bacteria, especially as some have begun to appear outside of hospitals in the general community. So how worried should you be?
The PBS investigative show, “FRONTLINE” asked three infectious disease doctors these questions: what the risks are, how to protect yourself, and what questions to ask when a loved one is in the hospital.
|Dr. Sean Elliott is the medical director of infection prevention at the University of Arizona Health Network||Dr. Brad Spellberg is an infectious diseases specialist at Harbor-UCLA Medical Center||Dr. Wendy Stead is an infectious diseases specialist at Beth Israel Deaconess Medical Center in Boston|
Frontline condensed their advice into eight handy tips to help keep bugs at bay.
Of course, none of this substitutes for actual medical advice. For serious concerns, always consult your doctor.
1. Don’t Panic
Everyone may be at risk, but the chances of catching a drug-resistant bug outside of the hospital are small for most. “For the average healthy person walking down the street? Those organisms are not much of a threat,” Stead says.
“The first principle is to try to live a healthy lifestyle to reduce the need to be in the hospital” where you are more likely to encounter these bugs, Spellberg says. Keep your home and work space clean. Be aware of the food you eat: Wash fruits and vegetables carefully and cook other food properly to reduce your chance of coming into contact with harmful bacteria.
2. Know What to Look For
How do you know if you have a superbug?
“You don’t. And your doctor won’t either, at least at first,” Spellberg said. “The infections caused by antibiotic-resistant bacteria do not cause different symptoms than infections caused by antibiotic-susceptible infections.”
While it’s impossible to give broad advice about so many different kinds of bacteria — and if you’re concerned, you should call your doctor first — there are some signs that an illness might be more serious. “In general, fevers, if they’re accompanied by shaking chills, if they’re getting worse instead of better, that would suggest there’s a bacterial process,” Elliott said.
With community-acquired MRSA, many people first notice a skin infection or boil that becomes larger and more painful, Stead says.
But if you do suspect such an infection, don’t rush to the emergency room, where you might be exposed to other bugs or infect others. Call your primary-care doctor first for advice.
3. Wash Your Hands with Soap and Water. Really wash them. Doctors say they cannot recommend this enough.
“Wash your hands regularly and religiously in the normal times that you would think you should wash them,” Stead says. “Give it a good amount of time” — about 15 seconds — “scrubbing hands thoroughly, not just in and out of the water.”
Turn off the faucet using a paper towel.
Alcohol-based hand-sanitizers are handy too, but remember that one bug, C.Diff, is resistant to that as well. But it does respond to soap and water. So Wash. Your. Hands.
4. Be Careful with the Antibacterial Soap
The FDA hasn’t determined whether these soaps are more effective than regular soap, and some doctors don’t recommend using them. “You do not need to take ‘antibacterial’ soaps for routine use,” Spellberg says. “There may be specific medical circumstances that warrant special antibacterial cleansers, but these should be prescribed by your physician.”
“A lot of the antibacterial soaps are more drying to the skin than would be a simple soap,” Elliott says. “So the more that we break down our skin barriers the higher the risk of getting superimposed bacterial. The real key is the soap and water and the physical action — and keeping hands moisturized. “
5. Ask Your Doctors to Wash Their Hands
“It is every patient’s right to have every health-care provider entering the room to have clean hands,” Elliott says. “We’re supposed to do it, we mandate 100 percent hand- hygiene compliance, but the reality is that doesn’t happen,” he says.
Some hospitals even make health-care providers wear buttons encouraging patients to ask them if they’ve washed their hands. Even if they’re buttonless, you should feel free to ask your providers about it.
“Really — we are not offended by that,” Stead says.
6. Get A Flu Shot
“When people get influenza, they actually become at higher risk as they recover for complicating bacterial infections,” Stead says, because people with weakened immune systems are more vulnerable to other bugs.
“Community-acquired MRSA is a big risk in patients who have recently had influenza,” she notes. “They get influenza and they start to get better, and then the staph comes in. … That’s life threatening. They wouldn’t have been at risk for that if they hadn’t had influenza in the first place.”
7. Ask Whether You Need that Antibiotic
Doctors sometimes feel pressured by patients or their families to prescribe an antibiotic, even if it’s not necessary. Don’t assume you need one — antibiotics don’t work on viral infections like colds or the flu. If your doctor does recommend one, ask whether you really need it.
“Using antibiotics does kill off non-resistant bacteria in your body and makes you likely to acquire antibiotic-resistant bacteria in their place,” Spellberg says. “If your doctor says that they think your infection is probably caused by bacteria and that you do need an antibiotic, ask, ‘Do I need a broadly active antibiotic, or can I take a narrower antibiotic?’ The broader the antibiotic, the more damage to your normal bacteria can be caused. We want physicians to try to prescribe antibiotics that are as narrow as possible for a given infection.”
8. Advocate for Loved Ones in the Hospital
One of the ways drug-resistant bacteria spreads in hospital is through tubes inserted in the body, such as catheters. If someone you care about is on such a device, don’t be afraid to ask doctors whether they still need it, and when the tubes can come out.
“Hospitals are much more aggressive about removing things if they’re not needed anymore,” Stead says. “But having patients be aware and try to get things out too is good.”
“Every day that decision needs to be made: Do these things need to stay in or do they need to come out?” Elliott says. The key, he says, is “empowering patients or their advocates to stand up for their health-care needs.”
While physicians and health care workers have a responsibility to provide the best health care, patients also have some responsibility for their own well-being and it boils down to being informed and not being afraid to ask tough questions.
Most of us don’t like challenging physicians, we just assume that will all those many years of education and the raft of framed diplomas on the wall that they must know what they are doing, but the practice of medicine is as much art as it is science. That means even highly educated medical experts can come to the wrong conclusions, so it is extremely important for patients to expand their knowledge of the conditions to which they are exposed or have contracted, ask tough, knowledgeable questions and then, demand clear unequivocal answers. Doing so could mean the difference between life and death.
Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s over 4,000 member Organ Transplant Initiative (OTI) and the author of most of these donation/transplantation blogs. You may comment in the space provided or email your thoughts to me at firstname.lastname@example.org.
Bob’s Newheart was established to support and help everyone, but particularly those who need or have had organ transplants. Some of our blogs are specifically related to donation/transplantation issues while others are more general, but they are all related. Because anti-rejection drugs compromise immune systems, transplant recipients are more susceptible to a variety of diseases. We provide general health and medical information to help them protect themselves while at the same time, helping others live healthier lives and avoid organ failure.
Bob’s Newheart mission is three-fold; 1) to provide news and information that promotes healthier living so people won’t need transplants; 2) To help recipients protect their new organs and; 3) to do what we can to ensure that anyone who needs an organ can get one. About 7,000 Americans die every year while waiting for a life-saving organ. I am sure you will agree that should not happen.
In the U.S. the great majority of people support organ donation, but only about 40% of us officially become organ donors. Many have good intentions but just don’t get around to it. It is hard to accept, but no one knows how long they will live. My transplanted heart came from a 30 year old man. I’m sure he had no intention of being a donor at that age. If you are not yet a donor, please register at www.donatelife.net it only takes a few seconds. Then, tell your family so there is no confusion when the time comes to donate. One organ donor can save or positively affect the lives of up to 60 people. There is no nobler thing you can do than becoming an organ donor.
Founder of Bob’s Newheart
Established November 3, 2007
When you become an organ transplant recipient your life changes. Not only does the quality of life improve but you have a new awareness of the importance of healthy living. Transplantable organs are in short supply and those of us who are fortunate enough to get one have a special obligation to take care of it. It is a gift of life that many never receive and your transplant center will make every effort to help you take care of yourself and your new organ. Follow their advice, eat healthy, live healthy and by all means, exercise as much as possible.
I have researched and written the great majority of blogs that are published on Bob’s Newheart but not this one. It was researched and published by the American Society of Transplantation (AST). I only made some minor editing and formatting changes (the complete post can be found here– http://tinyurl.com/pcteky5).
This entry is longer than most because it offers critical information that you will need. It is not only comprehensive in scope, it is easy to understand and the principles are immediately and easily applicable. Please take the time to read and thoroughly consider every point. The information contained here can ensure not only a longer life but one of enhanced quality as well. And…while this post is meant for transplant recipients, the advice contained here will keep you healthy even if you haven’t had and don’t need an organ transplant.
KEEPING A HEALTHY OUTLOOK ON LIFE
After an organ transplant, there is hope for the future. However, there are a number of health concerns that you will face. For example, there is the chance that your new organ will not always function as well as it should. Transplant recipients also have a higher risk of developing certain conditions such as high blood pressure, high blood lipid levels, diabetes, kidney problems, liver problems, and bone disease. Infection and cancer are also conditions you need to keep in mind. Some conditions can affect any transplant recipient and some conditions are specific to the type of organ transplanted.
CARING FOR YOUR NEW ORGAN
Lab Tests for Measuring Organ Function
It is important to keep all of your scheduled checkups and lab appointments for monitoring organ function. Testing allows your transplant team to monitor the status of your transplant, detect rejection early, and start effective therapy right away.Common tests for checking organ function are listed below:
Liver function tests — Blood tests are used to monitor liver function (e.g. albumin); damage to liver cells (e.g., alanine transaminase [ALT], Aspartate transaminase [AST]) and some with conditions linked to the path by which bile is produced by the liver (e.g., gamma-glutamyl transferase and alkaline phosphatase)
· Pulmonary function tests — Tests like spirometry show how well you lungs are working
· Bronchoscopy — A test that uses an instrument (bronchoscope) to view the airways and diagnose lung disease
· Chest x-ray
· Upper and lower gastrointestinal (GI) endoscopies — These evaluations can detect abnormalities of your esophagus, stomach, and intestine
· Hemodynamic monitoring — Sonar-type echos may be used to detect high blood pressure in your heart and lungs or a catheter may be placed in the heart for periods of six to 12 hours
· Echocardiogram — Sonar-type echos can show abnormalities in the heart and lungs
· Electrocardiogram (EKG or ECG) — Asseses the electrical activity within your heart
· Renal function studies — Your doctor may ask you to collect your urine (usually for 24 hours) to evaluate if your kidneys are working properly. Blood tests such as serum creatinine are performed to measure kidney function
· Biopsy — A biopsy may also be taken to determine if a rejection episode has occurred. This is done by collecting a small piece of tissue from the organ and examining it under a microscope
OTHER HEALTH ISSUES
Anti-rejection medications increase your risk of developing certain conditions such as infection and cancer. Other side effects of some anti-rejection medications include high blood pressure, diabetes, high blood lipids, kidney disease, heart attack, stroke, and bone disease. Knowing the risks and taking steps now to prevent them is a good way to keep you and your new organ healthy.
HIGH BLOOD PRESSURE
High blood pressure (hypertension) is a common complication in patients who receive a transplant. High blood pressure can damage the arteries and the heart, increasing the risk of a stroke, a heart attack, kidney problems, or heart failure.For many patients, the cause of hypertension is not known. However, people with kidney disease, diabetes, or high blood pressure before the transplant are at higher risk of high blood pressure after the transplant. Other factors that contribute to high blood pressure after a transplant include a diet high in salt, clogged arteries, high blood lipid levels, smoking, obesity, and some anti-rejection medications such as cyclosporine, tacrolimus, and steroids (prednisone).
Recommended Blood Pressure Levels
People with a blood pressure of 140/90 mm Hg or higher are considered hypertensive. While most transplant recipients should have a blood pressure of 130/80 mm Hg, the ideal blood pressure can vary from person to person. The American Heart Association (AHA) guidelines for the target blood pressure in the general population can also be used as guidelines for organ transplant recipients. Normal blood pressure values for children are based on age, sex and height and in general are much lower than in adults.
- Normal Systolic (top) 120 Diastolic (bottom) 80
- Prehypertension Systolic 120-139, Diastolic 80-89
- Stage 1 hypertension Systolic 140-159, Diastolic 90-99
- Stage 2 hypertension Systolic 160 or higher, Diastolic 100 or higher
High blood pressure usually does not cause any symptoms so it is important to have your blood pressure checked by your transplant team at regular follow-up exams. Your transplant team may also want you to monitor your blood pressure closely while at home.
Reducing High Blood Pressure
- Making some lifestyle changes can lower your blood pressure and prevent hypertension
- Sometimes hypertension can be controlled with lifestyle changes such as diet and exercise, but most patients also require medication.
- There are a variety of medications for treating and controlling high blood pressure
- The most commonly prescribed medications include ACE inhibitors, ARBs, calcium channel blockers, beta-blockers, and diuretics. Some of these medications may have interactions with certain anti-rejection medications.
HIGH BLOOD LIPIDS
While lipids (cholesterol and related compounds) in your blood are necessary for good health, too high levels of some lipids can increase your risk of cardiovascular disease, a leading cause of death among transplant recipients. Most transplant recipients develop high blood lipids. Kidney, heart, and liver transplant patients usually display similar elevations in total cholesterol (TC) and low-density lipoprotein (LDL) cholesterol (“bad cholesterol”).Eating the wrong foods, lack of exercise, and being overweight can increase your risk of developing high levels of LDL cholesterol (“bad cholesterol”), high levels of triglycerides, and low levels of HDL cholesterol (“good cholesterol”). Transplant recipients who are obese, smoke cigarettes, or have high blood pressure are more likely to have high cholesterol. Steroids and some of the other anti-rejection medications, such as cyclosporine, sirolimus, and tacrolimus, can also cause high blood lipid levels.
Recommended Blood Lipid Levels
Be sure to ask your doctor what your cholesterol levels should be. In some instances, transplant recipients can follow target levels of blood lipids recommended in the National Cholesterol Education Program (NCEP) guidelines.
Reducing High Blood Lipid Levels
Making healthy lifestyle changes can lower your chances of developing heart disease. You can help lower your blood lipid levels with a proper diet and regular exercise. A diet low in cholesterol and saturated fats may also help reduce your risk of coronary artery disease. In addition to making healthy changes to your diet, exercising for a minimum of 20 to 30 minutes 3 to 4 times a week can also reduce your lipid levels and lower your risk of heart attack or stroke. If you smoke, it is important that you STOP! If adjustment of your anti-rejection drugs, diet, and exercise are not successful in reducing lipid levels, your doctor may want you to take cholesterol-lowering medications. T
Here are several medications that work to lower blood lipids. The most commonly prescribed medications are called statins, which include atorvastatin (Lipitor®), simvastatin (Zocor®), pravastatin (Pravachol®), fluvastatin (Lescol®), rosuvastatin (Crestor®), and lovastatin (Mevacor®). If your doctor prescribes a statin, you will need to be monitored for side effects because the risk of side effects is greater when taken with anti-rejection medications. You will also need blood tests to monitor liver and muscle function. Other types of medication that your transplant team might prescribe to treat high blood lipids include bile acid sequestrants, nicotinic acid, fibric acids, and cholesterol absorption inhibitors.
High blood glucose can cause many health problems, including diabetes, heart disease, kidney injury, nerve damage, and eye problems.Post-transplant diabetes (PTDM) is more common in transplant recipients who have a family history of diabetes as well as those who are overweight, are taking steroids, or have hepatitis C. Diabetes after a transplant is also more common among African Americans and some other ethnic groups such as Native Americans. Other risk factors for PTDM include older age of the recipient.
Controlling Blood Sugar Levels
Most transplant recipients with diabetes can follow the American Diabetes Association (ADA) guidelines. Patients with PTDM should establish a healthy (weight-reducing, if necessary) diet with a structured exercise program. A healthy diet is needed to prevent diabetes or to help control your glucose if diabetes does occur. For all transplant recipients, it is best to eat a healthy diet and exercise regularly to avoid weight gain and reduce the risk of developing high blood glucose or diabetes. Your transplant coordinator or dietician can help determine your recommended daily calorie intake. Limiting the amount of fats and sugar in your diet can also help to maintain a healthy level of blood glucose.
Treatment Options for Controlling Diabetes
There are several types of medications available for patients with diabetes. Depending on the level of glucose in your blood, treatment with oral hypoglycemic drugs and/or insulin may be indicated. For many transplant recipients, insulin injections or an insulin pump is an option for controlling blood sugar. Or, you may be given an oral medication to control blood glucose levels. Your transplant team will determine which medication is right for you.
Kidney function is often decreased in transplant recipients. This may be caused by a pre-existing condition such as diabetes, high blood pressure, or injury to the kidney before a transplant. Or it may be caused by medications used to prevent rejection after a transplant.The best way to help prevent kidney disease is to keep your blood pressure and blood glucose under control and to maintain a healthy weight. In addition, regular checkups with blood and urine tests will give your doctor important information for detecting early changes in kidney function and allowing appropriate steps to be taken.
BLOOD VESSELS DISEASE
Transplant recipients have a higher risk of developing blood vessel disease. Some anti-rejection medications increase the risk of high lipid levels, which can clog arteries and restrict the flow of blood to the heart and brain. Deposits — called atherosclerotic plaque — can completely or partially block blood vessels resulting in a myocardial infarction (heart attack) or acute coronary syndromes.Likewise, a stroke can occur if an artery that supplies blood to the brain becomes blocked. Partial blockage may temporarily reduce the blood supply to the brain. A complete loss of blood supply to the brain results in a stroke.
Bone disease is a problem for many organ transplant recipients. Organ failure before your transplant may cause bones to become thin and brittle (osteoporosis). Other causes of osteoporosis include use of some anti-rejection drugs (corticosteroids), overactive parathyroid gland, cigarette smoking, and not enough calcium in your diet.
Preventing Bone Disease
There are some basic things you can do to help prevent or treat bone disease.
Exercise regularly, including weight lifting or strength training — be sure to discuss weight limits with your transplant team before beginning an exercise program
Eat foods that are high in calcium, including low-fat yogurt, cheese, and milk
Choose foods and juices with calcium added
Get plenty of dietary protein (unless restricted by your doctor)
Take calcium supplements if directed by your doctor
Take vitamin D only as directed by your doctor
Your doctor or transplant dietician will tell you if you need to take calcium or vitamin D supplements. Your doctor may also want you to take medications that prevent bone thinning, including bisphosphonates such as alendronate (Fosamax®), etidronate (Didrocal®), and risedronate (Actonel®) or calcitonin.
Diet – Things are shaping up
The recommended diet for transplant patients consists of 30% fats, 50% carbohydrates and 20% protein.
Your transplant dietician will give you specific instructions about your recommended daily allowance of specific nutrients. Some tips for following a healthy diet include:
Eat high-fiber foods such as raw fruits and vegetables
Increase your calcium intake by eating low-fat dairy products and green leafy vegetables or by taking calcium supplements (if directed by your doctor)
Eat less salt, processed foods, and snacks
Use herbs and spices to add flavor instead of salt
Drink plenty of water (unless you are told to limit fluids)
Eat as little fat and oil as possible
Eat high-protein foods such as lean meat, chicken (without the skin), fish, eggs, nuts (unsalted), and beans
Select healthier condiments such as mustard, low-fat mayonnaise, and low-fat salad dressing
Instead of frying, try baking, broiling, grilling, boiling, or steaming foods
Instead of using oil to cook, use nonstick, fat-free spray
Exercise is a great way to help increase your energy and strength after a transplant. A regular exercise routine will also help you maintain your ideal weight, prevent high blood pressure and high lipid levels, and keep your bones strong. It also helps relieve stress and overcome feelings of depression.Soon after your transplant, you’ll want to start slow with a low-impact activity such as walking. With time, you can increase your workout with more demanding activities such as bicycling, jogging, swimming, or whatever exercise you enjoy. Training with dumbbells, cuff weights, or weights will increase strength and help prevent bone loss, but check with your transplant team first to determine how much weight is safe for you to lift. Stretching exercises are also important for muscle tone and flexibility. Be sure to check with your doctor before beginning or changing your exercise routine.
Smoking also contributes to already high risk of cardiovascular, particularly in patients with diabetes and may be detrimental to kidney function. Transplant recipients who smoke should to STOP smoking as soon as possible.
Routine dental care is important both before and following transplantation as oral infections can cause significant medical problems and even death. According to the American Heart Association (AHA), pre-treatment with antibiotics is not needed for routine dental care unless the patient has an underlying heart condition that increases the risk of developing a heart infection. These include patients with heart transplants with graft valvulopathy (or a previous history of endocarditis, prosthetic valves, and certain forms of congenital heart diseases.)Gingival overgrowth (hypertrophy) is a dental issue that can arise in transplant patients especially those using cyclosporine. This occurrence of gingival overgrowth can be reduced by practicing good oral hygiene.
ROUTINE FOLLOW-UP EXAMS
All people should have regular exams to help prevent illness.
As we get older, there are some specific tests that should be done on a regular basis
In addition to the tests that your transplant team will perform at regular follow-up visits, you will need to do some self-testing at home. Here are some things you will need to monitor:
Weight – Weigh yourself at the same time each day, preferably in the morning. If you gain 2 pounds in a day or more than 5 pounds total, call your transplant team.
Temperature – You should take your temperature daily, especially when you feel like you have a fever. Call your transplant team if your temperature is too high.
Blood pressure – Check your blood pressure as often as your transplant team recommends.
Pulse – You should check your pulse daily. A normal heart rate when not exercising should be 60 to 100 beats per minute. (If you have had a heart transplant, your resting heart rate may be as high as 110 to 120 beats per minute.)
Blood sugar – If you have high blood sugar or diabetes, you will need to monitor your blood sugar using a glucometer.
Do not take any pain medication (for example, Tylenol®, Motrin®, or Advil®), cold remedy, antacid, herbal medication, or any over-the-counter medication unless your transplant team tells you to.
PREGNANCY: BENEFITS AND RISKS
For female transplant recipients of child-bearing age, fertility is usually restored immediately after a transplant.
There have been thousands of births among women with transplanted organs.
Although pregnancy is now an expected part of the benefits afforded to women by organ transplantation, there are also a number of considerations. Getting pregnant is generally not recommended within the first year after a transplant because the doses of anti-rejection medications are highest; there is a greater risk of rejection; and many other medications are prescribed that are toxic to the developing fetus. Female transplant recipients of child-bearing age should continue using birth control until the doctor says that it is okay to get pregnant. Male transplant recipients may also be concerned about their ability to have children. Men may have fertility problems related to some transplant medications, but many men have been able to father healthy children after a transplant. If you are interested in, or thinking about, becoming pregnant you must talk to your transplant team first. Pregnancy should be planned when organ function and anti-rejection therapy are stable and there are no signs of rejection, high blood pressure, or infection.
High Risk Pregnancy
According to National Transplantation Pregnancy Registry (NTPR) over 70% of births to female transplant recipients are live births and most have favorable outcomes for child and mother. Although this success is encouraging, these pregnancies are still considered high risk. There are risks of complications during pregnancy for the transplant recipient as well as risk of infection and exposure to anti-rejection drugs for the fetus.For example, there is a greater risk of high blood pressure during pregnancy in the woman who has received a transplant. The risk of infection is higher for all transplant recipients, and urinary tract infections are the most common infections during pregnancy.
Other infections that may cause concern during pregnancy include herpes, hepatitis, toxoplasmosis, and cytomegalovirus. Other risks include preeclampsia and preterm delivery. The fetus is also at risk for infections such as cytomegalovirus and herpes simplex virus related to the suppression of the mother’s immune system by anti-rejection drugs. A common question is whether the baby born to a woman with a transplanted organ will be normal. We know that some babies are born premature to mothers with transplants and that they have low birth weights. It is not known whether there are long-term effects on the baby’s development. You should inform your baby’s pediatrician that your baby was exposed to anti-rejection drugs in the womb.
There is a higher risk of birth defects with some anti-rejection drugs especially mycophenolate mofetil and azathioprine. The levels of anti-rejection drugs in the mother’s blood must be monitored closely. Monitoring of blood levels is particularly important in the third trimester, when fetal metabolism may increase the clearance of anti-rejection drugs from the blood. Ask your transplant team whether or not you should breast-feed. It is not known whether breast-feeding while on certain anti-rejection medications can harm the baby.
A major concern for transplant recipients is whether pregnancy will lead to organ rejection or decreased function of the transplanted organ. In general, pregnancy does not affect organ function or patient survival as long your organ is working very well. But, it is very important to discuss with your transplant team whether or not a pregnancy will be too risky. Because pregnancy is considered high risk for transplant recipients, your transplant team may recommend and work with an obstetrician who specializes in high-risk pregnancies.
Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s nearly 4,000 member Organ Transplant Initiative (OTI) and the author of most of these donation/transplantation blogs. You may comment in the space provided or email your thoughts to me at email@example.com. And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one persBon to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and love.
People who are diagnosed as needing organ transplants are end-stage patients. That means medical science has run out of alternatives to extend life and a transplant is the last and most beneficial approach. Transplants are not cures but they can offer a considerable extension of life provided the patient adheres to the program and has on-going, expert medical care.
At least twice very day a transplant recipient must take the daily dose of anti-rejection drugs. They are effective but expensive. They can run as high as $1,500 a month and if you quit taking them you can and likely will die. If you are of retirement age or disabled your Kidney transplant is covered by Medicare and most of the cost of the drugs as well. If you are under 65 and not disabled and diagnosed with End Stage Renal Disease (ESRD) your kidney transplant will still be covered by Medicare but your anti-rejection drugs will only be covered for 36 months and then you are on your own (detailed explanation below).
If after 36 months you go into rejection because you can’t afford the meds, Medicare will pay for dialysis and even pay for another transplant but not for the drugs which would prevent needing either. The drugs would be a fraction of the cost of the two alternatives that are covered. At best that is just plain dumb!
Someone said a long time ago that, “If you like either sausage or the law, you should watch neither being made.” Well, that certainly applies to this issue. Another of my favorite expressions which also applies here is, “No one’s life, liberty or property are safe when the legislature is in session.” These two expressions apply perfectly to the anti-rejection medicine silliness.
The entire situation and what to do about it is explained below.
The Current State Of Access to Post transplant Care
Christine S. Rizk, JD, and Sanjiv N. Singh, MD, JD
Virtual Mentor. March 2012, Volume 14, Number 3: 250-255. American Medical Association
This article provides historical perspective on the evolution of coverage for kidney transplant patients and attempts to identify what initiatives would most effectively and efficiently improve their survival.
As of January 24, 2012, in the United States, there were 112,767 waitlist candidates on the various national transplant registries . Of those candidates, 90,563 were waiting for kidneys, but in 2011 only 13,430 kidney transplants were performed . The need for kidneys far outweighs the availability of suitable donor organs, and some postulate that the Patient Protection and Affordable Care Act of 2010 (ACA) may worsen the shortage by eliminating barriers to insurance coverage based on preexisting conditions, lifetime coverage caps, and required periods of pretransplant dialysis .
Even more critical from a clinical, economic, and moral perspective is the fact that the additional end-stage renal disease (ESRD) patients now expected to receive transplants by 2014 will be most vulnerable in the posttransplant phase of care. Coverage for pre transplant dialysis and maintenance drugs for ESRD, but not post transplant care, receives strong support in Washington from large dialysis and pharmaceutical companies, which derive significant profits from dialysis, ESRD drugs, and dialysis-related services . For ESRD patients, dialysis is covered by Medicare for life .
For posttransplant care, however, Medicare coverage is limited, providing only 80 percent of the cost of immunosuppressive medications for 36 months after transplantation (for those whose Medicare entitlement is based on ESRD) and no coverage thereafter. Despite the fact that effective and long-term immunosuppression is essential for survival of transplant patients , the vast majority are left to fund 20 percent of the cost for the first 3 years of immunosuppressive drugs ($13,000 to $15,000 total cost per year per patient) , and, for patients under 65 who are not disabled, all of the cost of immunosuppressive drugs thereafter .
Not surprisingly, this system leads to noncompliance. Many patients cope with the financial burden by “spreading out” their anti-rejection drugs, taking them less often or not at all [10, 11]. A recent meta-analysis reports that “about 22.6 of 100 adult transplant patients per year fail to take anti-rejection drugs” . If allograft failure occurs due to nonadherence or a patient is considered unable to pay for posttransplant costs, with few exceptions, she is typically not relisted [13, 14]. According to a study focusing on medication nonadherence among transplant patients, nonadherence was more prevalent among kidney recipients than among recipients of other organs and more prevalent in the United States than in Europe .
Congress has continually struggled with the tension between supporting low-income patients and controlling the costs of government-funded health care. The legislative history of renal-transplant drug coverage highlights this struggle.
The Social Security Act Amendments of 1965, which created Medicare and Medicaid, initiated medical insurance for seniors, families with dependent children, the blind, and the disabled . At the SSA’s inception, Medicare provided for prescription drugs that were administered in the physician’s office but did not provide coverage for outpatient prescription drugs .
In 1972, on the eve of President Richard Nixon’s reelection, after much debate and political pressure to expand health care insurance, amendments were passed that provided increased coverage in specific areas. They specifically designated chronic kidney disease patients “disabled” for the purpose of receiving Medicare coverage but only after at least 3 months of dialysis and only for 12 months after transplantation .
Undoubtedly, these amendments were the original and now obviously outdated roots of the notion that posttransplant care benefits should be time-limited. At the time, such a notion was defensible. Dialysis was then a cost-effective and, more importantly, still superior way to extend lives, while kidney transplantation was a risky medical procedure on the frontier of available therapies. In the decades that would follow, however, renal transplantation outpaced dialysis in mortality reduction and overall clinical outcomes . Meanwhile, the number of eligible patients who used dialysis far exceeded expectations, and the ESRD entitlement became quite costly .
In the last 3 decades, the dialysis entitlement has remained largely intact while posttransplant entitlements have waxed and waned in small stutters.
- As a response to the increased costs of dialysis, Congress passed an amendment in 1978 extending Medicare posttransplant coverage from 1 year to 3 years; however, this amendment did not cover the cost of outpatient immunosuppressive medications .
- In 1984, Congress passed the National Organ Transplant Act of 1984 to ban the sale of organs ; extended coverage for immunosuppressive drugs was considered but ultimately left out of the bill, mostly due to funding concerns and political bargaining .
- Posttransplant drug coverage gained some traction in the Omnibus Budget Reconciliation Act of 1987 which included Medicare coverage of 80 percent of a kidney transplant recipient’s immunosuppressive drug costs (including outpatient immunosuppressive prescription drugs) for 1 year after transplant [14, 19]. This was eventually extended, in 1997, to cover 36 months of immunosuppressive drug costs .
- In 2000, Congress extended Medicare coverage of immunosuppressive drug costs to the life of the patient, but only for those who are disabled or over 65. This often leaves those patients most at risk for nonadherence and noncompliance—i.e., younger kidney recipients under 65—uninsured after 3 years .
Despite decades of legislative history and clinical data revealing the obvious gaps in posttransplant care entitlements, extending the duration of coverage for immunosuppressive-drug costs was not included in the ACA. In a provocative piece published in 2010 in the Clinical Journal of the American Society of Nephrology, Cohen and colleagues assert that “in response to pressure from the corporate dialysis community and their kidney coalition, several members of Congress acted to prevent the patient immunosuppressive provision from being included in the final health care reform package. Some of these opposing voices on Capitol Hill have been generously supported by the large dialysis providers for years” .
It is theoretically possible that the ACA’s insurance exchanges will include lifetime coverage for immunosuppressive drugs. These exchanges will not be implemented until 2014, however. Moreover, it is not clear exactly what type of coverage will be offered and whether such lifetime coverage will be offered in the lower-priced options, where it is most needed .
Cost Savings for the Federal Government
Continuing the current limitations on coverage of posttransplant medications is actually costing the health care system more money in the long term. Studies have shown that it is less costly to continue covering the cost of immunosuppressive drugs for kidney transplant patients after 36 months than it is to cover the costs of resuming dialysis for the same population. For example, a University of Maryland study concluded that it was more cost-effective to continue covering immunosuppressive drugs than it was to pay for dialysis, finding that “the breakeven point was 2.7 years for all of the cases [it] analyzed and for 30 percent of all patients who did not need to be readmitted to the hospital during the year after their transplant, the breakeven point was only 1.7 years” . A study conducted by the Institute of Medicine (IOM) also concluded that lifetime coverage of immunosuppressive drugs would lead to cost savings because it would reduce nonadherence and thereby improve kidney allograft survival, reducing long-term reliance on dialysis .
The Comprehensive Immunosuppressive Drug Coverage for Kidney Transplants Patients Act of 2011, currently pending in committee in both the House and the Senate, would extend coverage of immunosuppressive drugs for kidney transplant patients for the lifetime of the kidney [20, 21]. The bill is bicameral, bipartisan, and supported by the transplant community . As noted by Cohen et al, however, similar attempts have failed in the past, most recently with the proposed Durbin amendment to the ACA . Similar attempts by Congress in 2003 and 2007 to extend lifetime immunosuppressive coverage also failed in the wake of funding concerns and political jockeying .
Extending immunosuppressive drug coverage for the lifetime of kidney patients is a cost-effective way for the federal government to increase the value of health care by improving clinical outcomes for those with ESRD while avoiding the costs of resuming dialysis and allograft failure. Low-income kidney transplant patients currently suffer heavy financial burdens and are denied access to transplant relisting because of their inability to pay for critical drugs. There is a clinical, economic, and moral imperative to, at long last, bridge this coverage gap—a gap that lies at the core of effective transplant care and detracts from the movement for comprehensive coverage begun by the Affordable Care Act.
Transplant Living http://tinyurl.com/brwj3je suggests you contact your Senators and Congressional Representatives to urge their support of the measure that would extend anti-rejection medication coverage from 36 months to lifetime.
Dear Representative :
I am contacting you to request that you cosponsor important legislation for chronic kidney disease patients. H.R. 2969, the “Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act of 2011,” was introduced by Representatives Burgess and Kind to help kidney transplant recipients obtain the life-saving immunosuppressive medications that are necessary to maintain the viability of their new kidney.
Individuals with chronic kidney failure require kidney dialysis or a transplant to survive, and are eligible for Medicare regardless of age or other disability. There is no time limit on Medicare coverage for dialysis patients. However, transplant recipients who are not aged or disabled retain Medicare eligibility only for 36 months following their transplant. After their Medicare ends, they often face the challenge of obtaining group health insurance or other coverage, greatly increasing the risk of organ rejection if they cannot afford their required medications. If the transplanted kidney fails, they return to dialysis or receive another transplant, both of which are more costly (Medicare spends more than $77,000 annually on a dialysis patient and about $19,100 per year for a kidney transplant recipient, after the year of the transplant).
H.R. 2969 would extend Medicare Part B eligibility, and only for immunosuppressive medications. Coverage for any other health needs would end 36 months after the transplant, as under current law. The legislation also requires group health plans to maintain coverage of immunosuppressive drugs if they presently include such a benefit in their coverage. Lifetime immunosuppressive coverage will improve long term transplant outcomes, enable more kidney patients who lack adequate insurance to consider transplantation, and reduce the number of kidney patients who require another transplant. Nobody should lose a transplant because they are not able to pay for the drugs to maintain it. On behalf of thousands of transplant recipients, I respectfully request your support of this legislation.
Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s nearly 2,500 member Organ Transplant Initiative and the author of most of these donation/transplantation blogs.
You may comment in the space provided or email your thoughts to me at firstname.lastname@example.org. And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one person to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and love.
Please view our video “Thank You From the Bottom of my Donor’s heart” on http://www.organti.org This video was produced to promote organ donation so it is free and no permission is needed for its use.
If you want to spread the word personally about organ donation, we have another PowerPoint slide show for your use free and without permission. Just go to http://www.organti.org and click on “Life Pass It On” on the left side of the screen and then just follow the directions. This is NOT a stand-alone show; it needs a presenter but is professionally produced and factually sound. If you decide to use the show I will send you a free copy of my e-book, “How to Get a Standing “O” that will help you with presentation skills. Just write to email@example.com and usually you will get a copy the same day.
Also…there is more information on this blog site about other donation/transplantation issues. Additionally we would love to have you join our Facebook group, Organ Transplant Initiative The more members we get the greater our clout with decision makers.