Questions re: Recommendations for Low GFR after Donation

[brenda]

I just had my first anniversary exam here in New Mexico. The nephrologist I had been working with, a living donor transplant specialist, has moved so I was seen by a nephrologist who has no experience with Living Donors.  As many of you are aware, my kidney function never recovered after surgery; my current eGFR is in the low 40's (actually an improvement over 6 month labs).  The nephrologist here recommended:

1. Lisinopril,  5 mg/day. This is an antihypertensive usually given to diabetics with proteinuria to prevent or slow further kidney damage. I am not a diabetic, I have no proteinuria, and my blood pressure is normal.I kind of felt that he was trying to do something, anything, to help. I don't see any harm from this, but I don't like to take a medication without clear reasoning either. Your thoughts?

2. Pneumonia Vaccine: recommended for people with kidney disease, so I will probably go for it, but I've not seen this recommendation elsewhere or had it from my PCP or Transplant Center.

3. Shingles Vaccine: recommended for people 10 years older than me; no indications that I can find for kidney patients, but no contraindications either other than that I'll have to pay out-of-pocket. Any thoughts?

I can't believe how quickly I've begun identifying myself as a "kidney patient."  As always, I don't know what I'd do without your collective support and knowledge.

Brenda
Donated at Georgetown University Hospital 5/17/2011

[Clark]

Best wishes! I recommend consulting with your PCP about each issue, as well as the meta-issue of which professional will be evaluating and integrating specialist recommendations. Do you need a referral to another nephrologist to get the answers you need? Are you formally diagnosed with ESRD? There's an extensive dietary regimen to adopt before medication intervention, if so. Monitoring and stabilizing your internal chemistry is necessary in order to know what medication, for what deficiencies in renal function remain. Take care.

[sherri]

Brenda,

It is always interesting to see how different practitioners treat the same patient with the same symptoms. Maybe the transplant nephrologist who you said specialized in living donors sees donors as the healthy patients and the recipients as the sick patients. So when a donor presents with decreased GFR it may be a little baffling and unexpected. They make the recommendation to donors that this is minimal risk.  Donors are not supposed to need medications after nephrectomy. And since you weren't showing signs of high blood pressure or proteinuria he/she felt comfortable to let things be.

The clinical nephrologist for the most part sees patients in some degree of kidney failure so he/she sees your GFR and may feel they need to be proactive about getting your "numbers up". This may or may not yield a better result. The best thing you can do is to ask for some evidence based research to see if ace inhibitors (like the lisinopril) will protect your kidneys in the absence of hypertension and or proteinuria. Since you now have a low GFR are you at an increased risk for heart disease and if so is the ACE inhibitor a protective factor as well. In terms of the vaccines, the nephrologist is probably used to recommending them to all his patients in kidney failure. Again you can ask for some articles to read. I have found research hospital doctors often are very willing to share the latest research with their patients to explain why they make the suggestions they do. There are websites available like uptodate.com and or others that physicians have access to and they can give you some reading material.

Most important you should feel comfortable and understand the reasoning behind any medication or treatment that is suggested to you. And you can always seek a second opinion if you need more information. I hope you are getting the care you need. Have you ever gone back to Georgetown or pursued what happened when they approved you for donation and you had such a decrease in your GFR? I would hope they too would be in touch with your physicians and you make sure they receive your lab work so this can be put in the UNOS and OPTN data bases. Living donor follow up needs to be much more rigorous.

All the best to you.

Sherri