Caring for aging parents; weight and organ transplant; colonoscopy prep: Upstate's HealthLink on Air for Sunday, Sept. 17, 2023
Geriatrics chief Sharon Brangman, MD, discusses caring for aging parents. Transplant surgeon Reza Saidi, MD, explains how a patient's weight impacts a kidney transplant. Colorectal surgeon Kristina Go, MD, shares advice for how to prepare for a colonoscopy.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a conversation with a geriatrics expert about taking care of aging parents.
Sharon Brangman, MD: ... Maybe their parent is just having more and more trouble with repairs and managing the mail, keeping the refrigerator stocked, getting rid of clutter and those sorts of things. And that is often the first sign that something may be amiss. ...
Host Amber Smith: And a look at whether weight should be a factor in deciding who gets a kidney transplant.
Reza Saidi, MD: ... Even obese patients can benefit from kidney transplantation. They have a better quality of life after kidney transplantation, and also they live longer after kidney transplantation. ...
Host Amber Smith: All that, advice about preparing for a colonoscopy, and a visit from The Healing Muse, coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, we'll talk with a transplant surgeon about how a person's weight impacts surgery for a kidney transplant. But first, what should adult children be thinking about as their parents age? We'll cover how to make sure their home is safe, when to consult a geriatrician, and more.
From Upstate Medical University in Syracuse, New York. I'm Amber Smith. This is "HealthLink on Air." Today I'll be speaking with Upstate's chief of geriatric medicine about caring for aging parents. Dr. Sharon Brangman is also a distinguished service professor of geriatric medicine. Welcome back to "HealthLink on Air," Dr. Brangman.
Sharon Brangman, MD: Thanks, Amber. Thanks for having me again.
Host Amber Smith: Now, when do you think adult children need to start turning the tables and thinking about caring for their parents?
Sharon Brangman, MD: Well, it's a very individual thing, and actually the holiday season is a time when we often get the most calls. And that's because that's when families come into town, and they may get a totally different impression as to what's going on compared to what they got while they were talking on the telephone or FaceTiming with their parents. They can see up close and personal what's actually going on in the home. And so many adult children, especially if they don't live in the area, call us during the holidays wanting to get things organized.
And so the first thing they often notice is that the house is not really being kept up well, and maybe their parent is just having more and more trouble with repairs and managing the mail, keeping the refrigerator stocked, getting rid of clutter and those sorts of things. And that is often the first sign that something may be amiss. Sometimes they will notice the car has a lot of unexplained dents on it or things that look like little fender benders, and usually the parent will minimize it and try to say that the son or the daughter is making a big deal about nothing, or something like that. But those are usually the early telltale signs.
And then when they're spending more time with their parents, they may notice that the day just doesn't go in an organized way. There may be long periods of sleeping or not getting dressed and ready for the day, or difficulty organizing meals. I had one family, for example, who came for Thanksgiving, and usually the mother would prepare this enormous meal for everyone. And when they got there, things were in disarray. The food was not prepared. And when you think about making a big meal like for Thanksgiving, that involves many, many little decisions in order to get the food on the table and cooked and ready to go at the right time. And some people, as we get older, start to have trouble keeping track of all those little details.
So there can be any number of little hints, and adult children start to recognize this when they spend time with their parents.
Host Amber Smith: So the things that you've described -- keeping up the house or not keeping up the house -- does that necessarily correlate with a health condition or something physically deteriorating in the person?
Sharon Brangman, MD: Well, not necessarily, but it could be that the parent has too many things to keep track of, and it may be time to simplify their routine or downsize, or get help taking care of some of the details in life. It doesn't always correlate with an illness, but sometimes it can be the first signs of a memory problem, or someone who's just becoming what we call physically frail. That is someone who may not have that robust vitality that they used to have, maybe to mow the lawn or to clear the driveway of snow. And they may not have dementia or any specific medical problem, but just physically it's harder to keep up their previous routines.
Host Amber Smith: Is this the point where an adult child needs to look at their parents home in terms of safety, like they would before bringing a baby home from the hospital, where they just want to make sure everything is safe for the person to exist there?
Sharon Brangman, MD: Yes. That is something that is important to do. But the challenge is, often the parents don't see the same problems or have the same level of concern. So this is often a challenging discussion. There are very few older adults who have that same level of alarm, for example, that an adult child might have. They also are not comfortable with that role reversal with a child, telling them what should be done.
You know, we spend our whole lives looking for autonomy and independence and doing things the way we want, and it's inevitable at some point that we are all going to need some help when we get older. There are very few people that have the insight to recognize when they need that help. And so that's a bit of a challenge for adult children, and for parents. And it can be a source of friction if it isn't approached properly.
Host Amber Smith: How does an adult child determine if their parent or parents can remain in their home, or if they need to move?
Sharon Brangman, MD: Well, again, if there is signs of that house not being kept up, and it may just be too much, too much house. You know, after children are gone and there's no need for three or four bedrooms and a lawn to mow and a driveway to shovel and a house that needs painting or some sort of repairs. You know, a house constantly needs repairs, and that can just become overwhelming.
So it's time to have a frank conversation. And it's usually not settled in one discussion. And it has to be approached with respect and consideration. Now, if the parent does not have dementia or any kind of cognitive impairment, they really have the ability and the right to live the way they want to live. So we cannot impose what we think is appropriate, even though it may be safer and it may make sense. You can't make someone do anything. And you know it, it just doesn't work that way.
So this can be a challenge for adult children, particularly those who do not live near their parents. So, you know, we have a very mobile society, and many of us do not live close to our parents or where we grew up. Or our parents may still live in our hometown, and we adult children have moved elsewhere. So the ability to kind of reach back across the miles can be very challenging. Now, there are a lot of resources for people who recognize a problem and want to seek help, but it can take a while for some parents to have that level of insight to get there.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Sharon Brangman. She's the chief of geriatrics at Upstate, and we're talking about caring for aging parents.
For families facing this issue of caring for aging parents, ADL, or activities of daily living, may be a new term. Can you walk us through what those are and why they matter?
Sharon Brangman, MD: There are two categories of activities of daily living. One of them is instrumental activities of daily living, and these are things we do to kind of interact with the world around us and to keep our lives moving and organized. So those are things like grocery shopping, keeping appointments, paying bills and banking, keeping track of medications, driving from one place to another, keeping the house organized and, say, scheduling repairmen and that sort of thing. Instrumental activities of daily living are usually the first things to go when either there's a memory problem, or there's physical limitations, maybe due to illness or frailty. And those are activities that can usually be purchased by another person to do. So you can get someone to come and mow the lawn and shovel. You can get someone usually to come into the house to help keep it neat and do grocery shopping and maybe even cook some meals. Usually, activities such as setting up medications and keeping track of appointments can be coordinated with adult children, or you can hire a companion to assist with that. So those are things that are done to help assist someone to get through the day.
Host Amber Smith: So somebody might be able to stay in their own home if they can set up some support systems like that?
Sharon Brangman, MD: Exactly. And we usually advocate for people staying in their own home. You know, people sometimes think that because we're in geriatrics, we are just here to sign people up for nursing homes, and that is not true. We want people to live in the most independent setting, they can, with the highest quality of life. So the first option is to see if you can get help to come into your home. And not all adults like that. They don't want someone in their home. Or they can't afford it. It can be very expensive. And now, with our pandemic, it can be hard to find those people to do that work because there's a huge labor shortage. But that is the first step, is to get someone to help with some of those tasks.
There are people who can help you drive. There are car services. There are ways to help set up medications and reminders for that. There are ways to get meals into the home and cleaning services so that you can get some help for those things that we all need to kind of get through the day and stay organized.
The next set of activities of daily living are the basic ones, and those are the things we all absolutely have to do. And those are things like maintaining our hygiene, taking a shower, walking, feeding ourselves, getting dressed, getting to the toilet in time, knowing what to do after you're on the toilet. Those are the basics. And when people start to have trouble with the basics, they need a different kind of help.
Now that can still be done in your own home, but it usually requires more time because those are things that you need, essentially, hour by hour during the day. So depending on how and what kind of help you need, you may need someone for several hours a day or you could need someone for 24 hours a day. And that's what we help families figure out is what the needs are and how much time is needed to meet those needs.
And when somebody starts to need 24-hour-a-day care, that is very expensive. And Medicare does not cover that. Many people get unpleasantly surprised when they start to need home care because they assume it's covered by Medicare. But Medicare pays for hospital care, and it pays for our office visits to your doctor, and depending on what other plans you have, it may pay for your medications. But it does not pay for that hands-on care. Hands-on care is paid out of your own pocket, or if you do not have the funds, you can apply for Medicaid.
Host Amber Smith: I was going to ask how do families afford it if they need 24-hour care for their family member? A lot of families end up becoming caregivers themselves, right?
Sharon Brangman, MD: It's very expensive, and many families struggle. There are some programs where if you are a family caregiver, you can be paid to do that through special programs. But many people just need several hours a day, and even that can be cost prohibitive, and it all comes out of your own pocket. Some people have long-term care insurance plans, and those can kick in and cover some of that expense as well.
Host Amber Smith: Well, we've talked a little about nursing homes, but kind of in between living at home and nursing home, there's some other options. Can you talk about the difference between independent living and assisted living?
Sharon Brangman, MD: Independent living is when you have your own apartment, and you come and go as you please, and you often have a car and drive and make your own meals. It can be in your own home or it can be in a senior complex or a regular apartment building.
Assisted living is really like a real estate agreement where you rent a room and you also get certain services with that room. It is not a medical model because you keep your own doctor, and assisted living does not have nurses in the facility to help with any medical issues. So you are essentially renting a room, and you're getting a meal plan. Some people just get one meal a day, so they may just get dinner, and they make breakfast and lunch in their apartment. Some people get all three meals in their meal plan. And you can add other services, but then you pay for those. So you can pay for a nurse to come and check your blood pressure, for example. But if you were to fall and get hurt, you would have to go to the emergency room because there's no nurses or doctors in those assisted living facilities to provide medical care. It's really a room agreement and a meal plan. They are not nursing homes at all.
Nursing homes, on the other hand, are actually medical models where you get medical care in a residential setting, and you'll have nurses on hand. A nurse practitioner is often there, and a doctor will come in on a regular basis. And if you have a medical problem that can be treated at the facility, that can happen. Serious medical problems, you're sent to the hospital. But you can get medical care in a residential setting in a nursing home, and it's totally different from assisted living. And most people in nursing homes have dementia. They usually have some level of cognitive impairment that keeps them from taking care of themselves. That's the number one reason why someone goes to a nursing home is because they have dementia, and they can no longer take care of themselves.
Host Amber Smith: What is the typical age of someone in a nursing home?
Sharon Brangman, MD: It can vary. I would say the average age is probably in the upper 70s or 80s. There are some younger people with chronic problems who might be there, but the majority of people, I would say, are in their 80s.
Host Amber Smith: Please stay tuned to Upstate's "HealthLink on Air." We'll be back with more of our conversation about caring for aging parents with Dr. Sharon Brangman.
Welcome back to Upstate's "HealthLink on Air." This is your host, Amber Smith, talking with Dr. Sharon Brangman. She's the chief of the department of geriatrics at Upstate.
At what point would you advise people to seek care from a doctor who specializes in geriatrics?
Sharon Brangman, MD: Well, typically, the age of geriatrics is 65 and above, and that was a number that was arbitrarily set a couple of generations ago when people who were 65 had usually done very hard physical jobs and had a lot of injuries and illnesses. But now with the advent of a lot of public health and different jobs and a different kind of medical care, we can postpone that aging process a little bit. And some of those chronic diseases now are happening later on in life so that the majority of patients that a geriatrician sees tend to be people in their 80s and beyond. And these are people who have multiple chronic illnesses. They may have some trouble getting through the day. They may have some memory problems.
Geriatricians are experts in managing the complex, long list of medical problems and medicines that a person may have, and then helping the patient and families figure out the best way to get that care, whether it's in your home or in another setting. And as I said earlier, we really like to have people stay in their own home. We really like people to be at the highest quality of life that they can have in the best setting for them. So we can help families make that determination.
Host Amber Smith: Would a geriatrician take the place of a primary care provider, or are they more of a specialty consult doctor?
Sharon Brangman, MD: Depending on where you live, geriatricians can be your primary doctor or they can be your specialist. In Syracuse, at Upstate, we are specialists. We work with the primary care doctor, and we help the primary care doctor optimize their care. And then we help the family make decisions about care for that loved one if they need care at home or at a higher level of care.
But we also do other things. You know, older adults accumulate a lot of medications as they get older, and sometimes those medications can cause side effects that can make somebody look sicker or have more medical problems than we anticipated. So we can help work on the long list of medications to make sure they all make sense and they're not interacting with each other. We look at someone's physical function to see what we can do to help support them so that they can maintain as much independence as possible. And, of course we help people who have memory problems to help them also optimize their function for as long as possible.
Host Amber Smith: If someone's interested in a geriatric assessment because they're concerned about cognitive decline, what would be the difference between coming to a geriatrician for that assessment versus a neurologist for that assessment?
Sharon Brangman, MD: A neurologist can help with a specific diagnosis that is going on, that might be affecting their thinking ability or their brain power. A geriatrician takes a different perspective. A neurologist is certainly one of our partners in care, but we work on the principle of a comprehensive geriatric assessment. So we look at the whole person. We look at their past medical history. We look at their current medical problems. We look at their cognitive status, their mood, their medications, and their functional status. And then we help them come up with a comprehensive plan for moving forward. So we don't just make a diagnosis. We actually make a diagnosis and then help them set up a care plan.
And in our office we have a team of social workers who can help families identify resources in the area. And we have a team of nurses who are experts in taking care of older people and can help families walk through some of the issues that might come up where you just need to talk to someone and ask a question. So our practice is really geared toward specifically helping people with chronic illnesses and the aging process where they all kind of come together. Because aging itself is not a disease. It's a natural process that we are all going through. So we want to make sure that you're not looking at aging as a disease, but you're actually looking at the diseases you may have and see how they are impacting your aging process.
Host Amber Smith: Now your patient is the senior, but do you involve the caregiver at the appointments, and are they sort of your patient, too?
Sharon Brangman, MD: So yeah, we definitely involve our caregivers because they are an important part of the team. They are really doing the heavy work, and we're just helping them because they have to provide care often 24 hours a day, every day of the week. So most of our patients come in with a caregiver. A caregiver could be a partner or a spouse, or it could be an adult child, or it could be some other relative, like a grandchild. And sometimes it's even a friend or a neighbor. But we have to make sure that the caregivers are equipped and rested and not stressed out because if they are, then we lose two people.
Host Amber Smith: Let's talk about who are the caregivers to these aging parents. What percent are women?
Sharon Brangman, MD: I do have sons who have stepped up, but it is mostly women with their own families and working, and they are overdone. It's usually the oldest daughter. I usually ask them, "Are you the oldest?" And 90% of them say yes. That's my unofficial survey. The oldest daughter is usually the one. And if there are multiple children and they're all cooperating, they often take a different role. Like one will be in charge of making medical appointments, one will be charge of the finances.
Host Amber Smith: What age are these women, mostly?
Sharon Brangman, MD: So these are women usually in their 50s, depending on when their parents had them, but usually 40s, 50s. And it's interesting because some of my patients who are in their 90s, their children are geriatric in their sixties, so we really could have a family practice in a way. But I would say the majority of them are in their 50s. They're still working. They have children. They may have grandchildren. And I have more than one who has a spouse with medical problems, so they're taking care of a spouse as well as parents. And they can be very stressed.
Host Amber Smith: Have you seen families that make it work somehow?
Sharon Brangman, MD: Oh, yeah. Families can make it work, but you have to be an educated consumer. You have to know what the resources are, what the options are, and you can't be too afraid to ask for help. There's no shame in asking for help, and I think a lot of women in particular are used to kind of just making it happen on their own, but you do have to reach out and ask for help.
Host Amber Smith: And you said you are seeing more men that are finding the role of caregiver?
Sharon Brangman, MD: I can think of many men who really step up and take care of their parents, their mothers, coordinate care. So you can't think that men aren't able to do caregiving at all.
Host Amber Smith: Do you ever encounter caregivers who expect that the senior parent is going to recover and get back to the way things were before?
Sharon Brangman, MD: So we have all sorts of expectations that patients and caregivers have, and we try to help them understand what makes sense. We help them understand what are realistic expectations. We don't write anyone off, but we help people deal with the reality of a situation so that we can optimize their care and give them the highest quality of life possible.
Host Amber Smith: You're listening to Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Sharon Brangman. She's the chief of geriatrics at Upstate, and we're talking about caring for aging parents.
What advice do you have for adult children who suddenly find themselves in this new role trying to care for their aging parents? Can they do it alone?
Sharon Brangman, MD: So, yeah, you can do it alone, but that makes it harder. And there's lots of support, and we live in a part of the state where there are lots of resources. So it makes sense to reach out and use those resources. And there's no point in trying to reinvent the wheel because there's a lot of things that are already in place that you just may not know about and you should take advantage of.
Caregivers often feel like this is the first time this has ever happened to anyone, but in reality, this is a very common situation, and we have probably seen most of the scenarios out there and can provide support.
Host Amber Smith: So maybe they would want to set up an assessment with a geriatrics practice. What about a geriatrics care manager? What is that, and do they need one of those?
Sharon Brangman, MD: Geriatrics care managers are excellent. They know the resources, and they can help an adult child or other caregiver figure out the basics of a care plan and rolling them out. There's a national association of geriatric care managers, so that if you have a parent who lives in Texas, for example, you can reach out to a geriatric care manager in that city in Texas.
There's some in Syracuse that we work with who are excellent, and they can help with some of that day-to-day decision making and problem solving. Caregivers, especially if they're out of town, appreciate that because they just can't be there.
Host Amber Smith: What about lawyers and financial planners? Is it time to line those up as well?
Sharon Brangman, MD: That's another piece that can be important, and setting up a power of attorney if you have a loved one who may need help with finances. A health care proxy is important, and that's when you as the caregiver can step in and make medical decisions for your loved one when they are no longer able to do so. Understanding the financing of home care and nursing home care is very important, so having discussions with any financial planners or lawyers is important. And a lot of the laws and rules change frequently, so you really need to be up to date with what's going on.
Host Amber Smith: One of the issues that inevitably arises is when to stop driving. How does an adult child know when it's time?
Sharon Brangman, MD: Oh, this is probably one of the toughest things that we deal with in our office. If you can remember when you were 16, and you got your driver's license, and you drove away and that wonderful feeling of independence. Or even now, if you need to go somewhere, you can just go without having to ask or wait. But there is a time when driving is no longer safe.
And, it is a very, very hard discussion because you have to be able to substitute those services that would be accessed with driving and most older adults tell me, "I've been driving for 60 years, and I'm fine." So we have to have a plan, and we have to discuss it frequently and sometimes it requires having a repeat road test or repeat written exam to make sure someone is still able to follow the rules of the road. There are some driving schools that can do an assessment. And there are some organizations that will do a driving update to refresh someone so that they're safe behind the wheel.
But when they start to have a lot of physical illnesses where they may not have the strength to step on the brake hard or to turn their neck to look to see if there's a car in the other lane, or if they have memory problems and they don't remember how to drive or how to follow the rules of the road, that's when we have to have these hard discussions.
Host Amber Smith: We've talked mostly about adult children looking out for their aging parents, but what about people who have no children? Do you have suggestions for how they can plan for their caregiving needs as they age?
Sharon Brangman, MD: So that is a different category of older adults with no children, and it's a growing entity because there are so many people now who are not having children. And I try to tell them, well, you know, there are some people with children who aren't helping them either. So it doesn't mean that just because you have kids, you have a built-in network of caregivers.
But what you have to do is you have to plan. You cannot avoid the discussion, and if you are living alone and you're by yourself, you have to plan and you have to set up your network. And you have to make sure that you have a health care proxy and somebody who you trust to help with your finances. And you have to have someone who knows what your wishes are and what you value in life, what matters most to you, so that they can help you make those decisions. And then you have to work on setting up that support network. And that takes some time.
Host Amber Smith: It sounds like it. Well, Dr. Brangman, I really appreciate you explaining this to us. Thank you.
Sharon Brangman, MD: Sure. You're welcome.
Host Amber Smith: My guest has been Dr. Sharon Brangman. She's a Distinguished Service Professor of geriatrics medicine and the department chief of geriatrics at Upstate. I'm Amber smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air," should overweight people with failing kidneys be excluded from kidney transplants?
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
A patient's body mass index is one of the factors surgeons consider when someone with end-stage renal disease needs a kidney transplant. Today, we'll learn about how weight can impact transplant surgery with my guest, Dr. Reza Saidi. Dr. Saidi is an associate professor of surgery and the chief of transplant services at Upstate.
Welcome back to "HealthLink on Air," Dr. Saidi.
Reza Saidi, MD: Thanks, Amber. Glad to be here.
Host Amber Smith: Why do surgeons have concerns about body mass index of patients who need kidney transplants?
Reza Saidi, MD: You know, in the past there was some concern that these patients who are obese might have a poor outcome.
That's why some programs would exclude these patients for transplantation, but as we gathered more information, we find that that's not true, and these patients actually enjoy same benefit from transplantation compared to the rest of the patient population.
Host Amber Smith: What is considered a normal BMI?
What's considered overweight or obese?
Reza Saidi, MD: I think for your general audience, they should understand that weight is not a good indicator of patients' overall health. Since the 19th century, actually, this kind of body mass test was introduced, which is a combination of weight and weight/height, and then they will predict how much fat is in the patient's body, and they consider anybody, (with a) BMI of maybe is around 18 to 20, as normal, and BMI of 25 to 29 is considered overweight, and BMI of 30 (and higher) considered obese.
And we know that obese patients have some risk factors, for example, diabetes or cardiovascular disease, but this has been used for many, many years. I think it's a better indicator of the patient's overall health compared to weight itself.
Host Amber Smith: So is there a BMI cutoff for transplant patients at Upstate?
Reza Saidi, MD: No, actually we don't. Actually, we studied our own cohort of the patients that we transplanted in the last five years. And we have transplanted actually patients from BMI of normal up to 56 and find out that these patients enjoy the same outcome compared to basically non-obese patients.
Because remember, chronic kidney disease is a major risk factor for the patient's overall health, and the patients (who) have chronic kidney disease have higher incidence of dying of cardiovascular disease or dying prematurely or have a lot of quality-of-life issues.
And, we find out in our study that patients, even obese patients can benefit from kidney transplantation. They have a better quality of life after kidney transplantation, and also they live longer after kidney transplantation. And on the other hand, also the cost of care for this patient after kidney transplantation is much less compared to the cost of the patients who have chronic kidney disease or end-stage renal disease.
Host Amber Smith: Is the surgery more difficult if you're working with an obese patient?
Reza Saidi, MD: Yeah, absolutely. I think that's no doubt about it. The surgery is more difficult because we have to go through many, many layers of fatty tissue. These patients, their vessels are much deeper. The surgery takes longer, but the overall outcome we found out was the same, and despite the fact that obese patients could have a little bit higher incidence of, for example, wound infection or develop a hernia post-transplantation. But overall outcome regarding their kidney outcome or kidney survival or patient survival is compatible with a non-obese patient.
That's why we also published this data and, it's in (the medical) literature, and currently, at Upstate, we have no BMI cutoff.
The other thing, because their surgery is a little bit difficult, we are also in process to open up a robotic kidney transplant program, and I think they've shown that if you do this kidney transplant robotically, especially in obese patients, maybe it's better, and maybe it's even easier, and they have less postoperative complications, such as wound infection or hernia.
Host Amber Smith: Now, let me ask you, I know some of the transplants that are done are with living donors. Does the donor's weight have any bearing, or do they have to be at a certain level before they can donate?
Reza Saidi, MD: No, actually, also living donors, we have no issue with their weight. Again, remember our BMI is indicative of overall health.
If they have cardiovascular disease or diabetes, that's a different story. But if it is only weight, that should not be a contraindication for donation or kidney transplantation itself.
We evaluate all these patients in a multidisciplinary team, and we look at different factors, but weight itself, as I said, is not a contraindication for donation for organ transplantation.
Host Amber Smith: Are there complications that are more common in obese patients or overweight patients than normal-weight patients?
Reza Saidi, MD: Absolutely. I think that's what I was trying to point out. They have more, for example, wound infection or hernia, and also they're more prone to develop, for example, deep vein thrombosis (blood clots in deep veins).
These are more complications, but their overall outcome, when we talk about outcome after kidney transplantation, we talk about kidney survival and how long that kidney lasts, and also patient survival, how long the patient is going to be alive. Those main indicators of kidney transplantation are not different comparing obese patients with non-obese ones.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Reza Saidi. He's the chief of transplant services at Upstate, and we're talking about research he and his colleagues have done about obesity and kidney transplant.
Are patients who need a kidney transplant ever asked to lose weight before surgery?
Reza Saidi, MD: We do. We do because, again, as I said, if they lose weight, their postoperative course can be much smoother. We encourage them to lose weight. We have a dietitian on our service to help them. And also we have different programs, for example, exercise. We have a comprehensive program to help them lose weight. But again, that's not a requirement per se because we know that patients who have kidney transplant, regardless whether obese or not obese, they have much better quality of life, and they live longer. That's why we don't think obesity should prohibit anybody to receive these life-saving transplants.
Host Amber Smith: Weight loss can be difficult for anyone. Are there additional challenges for someone who is on kidney dialysis?
Reza Saidi, MD: Yes, that's another thing because remember, somebody on dialysis is going to be on the dialysis machine a couple days a week and a couple hours a day, and that's going to be challenging.
But for those patients, we have a comprehensive program to try to help them. Sometimes I say diet is important, exercise important is important, some change in habits is important. And sometimes we refer them for bariatric surgery.
Host Amber Smith: And they do the surgery for weight loss before they are eligible for the kidney transplant?
Reza Saidi, MD: Yeah. If we are referring to a weight-loss center and if they're a candidate for surgery, we recommend that the patient have surgery and then, after that, receive organ transplantation.
Host Amber Smith: In the study that you and your colleagues published recently, you compared three measures, delayed graft function, length of hospital stay, and 30-day readmission rate between patients over and under the BMI of 30, basically obese or not.
What does delayed graft function mean, and why is that important?
Reza Saidi, MD: Delayed graft function's helpful as an indicator of the function of a kidney organ immediately after the surgery. And some of these kidneys, especially coming from deceased donors, these kidneys could be out of body for many, many hours before we transplant them.
And because of that, they might not work right away. Delayed graft function means that the patient required dialysis post-transplantation, which leads to increases in length of stay and resource utilization and increased cost, for our program and for the society.
But that's one of the major factors that we monitor after kidney transplantation. And in this study, we look at it and see that the rate of, for example, delayed graft function, readmission and early and late graft outcome are not different in obese patients compared to non-obese patients.
Host Amber Smith: And then length of stay, what does that say about a patient to a transplant surgeon?
Reza Saidi, MD: Length of stay is factor for, is indicative of, for example, complications after kidney transplantation. And we show that the more they stay in the hospital, usually they require more resources, the cost of organ transplantation goes up, and that means the organ is not working properly, for example. That's an indicator, a health indicator, we'll monitor very closely after kidney transplantation.
Host Amber Smith: And so that goes hand in hand with the 30-day readmission. Is that looking at how many of these patients had to come back after they were discharged?
Reza Saidi, MD: Yes. A few days, for example (is typical. If) they stay longer, usually there's a higher chance that these patients might need readmission after transplantation, too.
Host Amber Smith: So did your study conclude that there really was no meaningful difference between obese and non-obese in all of these categories?
Reza Saidi, MD: Yes, that's correct. Actually, we looked at all these categories -- readmission, length of stay, delayed graft function complications and overall kidney survival and patient survival, and we find that there is no difference between obesity (and non-obesity).
That's why I think obesity, per se, should not be a limiting factor for a patient to receive organ transplant.
Host Amber Smith: Are there other transplant programs where obesity does disqualify someone?
Reza Saidi, MD: Yes, different programs in the country have different thresholds, and they have different practice patterns, and some of them actually require a patient to reduce weight to get to a certain BMI before they transplant.
But in our program, when we look at our experience, we decided that that factor is unnecessary and prevents the patient to receive a lifesaving transplantation. And that's why currently at Upstate, we don't have a BMI cutoff for the patient to receive a kidney transplant.
Host Amber Smith: Is there a takeaway message you'd like for patients or potential patients to understand regarding weight and kidney transplant?
Reza Saidi, MD: Yes, absolutely. This doesn't mean that the patient should have unhealthy lifestyle practices and have (excessive) weight. No doubt that weight loss can actually help the patient to basically have a healthier life and a more productive lifestyle.
But this study basically does show that obese patients can benefit, the same advantage of kidney transplant, compared to obese patients, but that doesn't mean that we would not recommend healthy lifestyle and losing weight. That's a different story.
Host Amber Smith: So someone who's maybe on dialysis and needs a kidney transplant, once they get a kidney transplant, can they then embark to lose weight, and would you recommend that?
Reza Saidi, MD: Yes, absolutely. Absolutely. We are always recommending patients, before, even after transplant, to lose weight and to get to this, healthy lifestyle, diet, exercise. These are all things that have shown that actually can prolong life and improve quality of life. We recommend that.
But again, the point of my paper is that chronic kidney disease is a risk factor, and weight should not eliminate a patient to have access to kidney transplant just because of their weight.
Because their disease is more dangerous than obesity. That's my point.
Host Amber Smith: What percent of patients do you think this would affect? What percent do you think are obese?
Reza Saidi, MD: More than 50% of (the) U.S. population are overweight. And we see the same pattern in our patients who come for kidney transplant. More than 50% of them are basically overweight, and also about 10%-20% of them are morbidly obese. That is a major health care problem in the U.S.
Host Amber Smith: Well, Dr. Saidi, I really appreciate you sharing your paper with us. Thank you.
Reza Saidi, MD: Thank you.
Host Amber Smith: My guest has been Dr. Reza Saidi, the chief of transplant services at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from colorectal surgeon Dr. Kristina Go from Upstate Medical University.
How should someone prepare for a colonoscopy?
Kristina Go, MD: What I tell my patients is, in the week leading to your colonoscopy, to avoid foods that are high in fiber or high residues, such as leafy green vegetables. (Remember to return to that after your colonoscopy, of course.)
The whole purpose of a bowel prep is to completely clean out your colon, which, in no euphemistic terms, it's really just having a lot of severe diarrhea for the day before, while you're drinking your prep. In terms of trying to tolerate this amount of liquid that you're having to drink, I give patients some pointers. Some of them work better than others. Placing your prep on ice or drinking it through a straw can sometimes decrease how unpalatable the flavor of the prep is. Sucking on lemon slices or sugar-free menthol candy drops can also decrease that feeling of nausea.
The day before your colonoscopy, make sure to drink lots of clear liquids in addition to your bowel prep. A patient needs to drink clear liquids, as in nothing that is opaque, nothing with any kind of solid components to it, for the entire day before the day of their colonoscopy. Drinking water or fluids keeps you hydrated and can also decrease the symptoms of nausea that can be associated with this type of prep.
Host Amber Smith: And on the day of your colonoscopy, take a deep breath in and out. It's a relatively painless procedure. And after you're done, you can go back to the regular diet. You've been listening to colorectal surgeon, Dr. Kristina Go, from Upstate Medical University.
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: KB Ballentine's sixth poetry collection, "The Light Tears Loose," can be found at Blue Light Press. The poem she gave us, "After Surgery," is a meditation on all we see and feel as we recover. Here is "After Surgery":
A pair of swans preen, slide
swiftly across the blue cool
of lake -- soon they will taste
the frost before it comes and rise
together finding a thermal draft
that guides them to warmer climes.
The lamps on each bedside table beckon,
downy softness sandwiched
between them where letters turn to words
that take dreams to flight:
promise of light before the final dark.
Following the trail as sure as scent,
the wolf of smoky fur and tender heart
nuzzles his mate. She licks his ear
while they pause beneath an evergreen
leaning with the weight of snow.
Branches bristle, spear the feathery mounds.
Toes seek solace in fuzzy comfort ,
left and right slippers waiting by the door.
Twelve hours constricted in stiff leather
pressing concrete pleads a soothing escape
to stretch and wiggle.
Seahorses couple, anchor themselves
in the reeds, the grass. Undulating
they wrap around each other
and daily dance invisible currents --
nodding to blennies and gobies, to kelp
clinging across the rock and sand.
I didn't know I was grateful,
with my eyes and ears and lungs,
to watch the moon twin the sun: two flawed
globes that balance night and day --
lead the seasons, reel against the dizziness
that unbalances my new walk, my new life.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.
If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.
Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.
This is your host, Amber Smith, thanking you for listening.