Martha Gershun and John Lantos, NKF Oklahoma Kidney Conference

Kathy Nugent

Hello everyone and welcome back to the stage. We're on the home stretch now. In case you missed it earlier, my name is Kathy Nugent and I am the Outreach Transplant Social Worker at Integra's Kidney and Pancreas Transplant in Oklahoma City. We have one more great session for today. And all of the sessions today I think have been awesome. I hope you all have enjoyed them as much as I have. In fact, I have plans to go back and listen to the recordings again because there's a lot of good information. And I'll also be encouraging my coworkers to go ahead and sign up so that they can watch them too. There's really good information today. So before we get started with the last session, a few quick housekeeping reminders. You will receive an email next week with directions on how to complete your CME or CE evaluation and where to download your certificate. So keep an eye out for that. We hope you'll make this session interactive. Please use the stage chat tab to interact with other attendees about the presentation or you can ask questions. As a presenter shares his or her screen or slides, you can maximize the view by double clicking on the screen. You want to make larger and then double-click again to minimize the screen. So now I would like to introduce our next two distinguished faculty who will be presenting the Ethics of Living Organ Donation. Tuning in with us today from Kansas City, let's welcome John D. Lantos, MD. Dr. Lantos is Director of the Bioethics Center at Children's Mercy Hospital. and professor of pediatrics at the University of Missouri, Kansas City School of Medicine.

Kathy Nugent

Joining him today is Martha Gershon. Martha is a nonprofit consultant, writer, and community volunteer. Previously, she was executive director of Jackson County CASA, which is Court Appointed Special Advocates, and the Reach Out and Read National Center. In 2018, she donated a kidney at the Mayo Clinic to a woman she read about in the newspaper. Wow, this is gonna be a great. So Dr. Lantos and Martha, the virtual stage is yours.

Dr. John Lantos

Oh, thank you very much. And thanks everybody for sticking around late in the afternoon. We're gonna try to make this fun because it was a lot of fun to write this book. We went through, Martha and I are old friends and we went through the experience together. It's a little bit like being pregnant together. Martha was the donor. I was

Dr. John Lantos

talking to her about some of the issues that arose and trying to put them into context because some of her experiences as a living donor were a little strange. What we're going to try to do today is sort of recreate some of the conversations that the two of us had. So we'll be going back and forth. I'll be giving a little background about some of the bioethical issues. Martha will talk about her own experience, and we'll try to leave some time at the end for questions and discussion. Everybody in this conference, I'm sure, knows the facts. On these slides, there's a desperate need for more kidneys, over 100,000 people in the US now on the waiting list, and more than a dozen dying every day. And we know that living kidney transplants have better outcomes for all sorts of medical and logistical reasons, but very few people donate, relatively few, certainly not enough to meet the need. 17,000 kidney donors in 2020, about two-thirds of them deceased, about a third living donors, and most of the living donors were to biologic relatives, spouses, life partners, either directly or through paired exchanges. People who need kidneys are desperate. This is a sign in a Kansas farm field. Somebody painted over a billboard begging for a kidney. The American Transplant Foundation now teaches people how to crowdsource. Good Housekeeping Magazine has heartwarming stories. But it wasn't always so straightforward, the process of donating a kidney, particularly not to someone

Dr. John Lantos

other than a family member. In fact, in the early days of transplantation, there were a lot of questions raised about whether people who wanted to donate a kidney were crazy. This was a paper describing a study that was done in Canada when transplant centers in Canada were considering allowing people to donate anonymously to a stranger, what they called the living anonymous kidney donor. And the question in the paper, were these people lunatics or saints? And the conclusion after they did in-depth psychological evaluation of these people is that contrary to the medical community's fears, there's a significant number of psychologically stable, altruistically motivated individuals who want to donate a kidney anonymously to a stranger and seek no material compensation. in return. But that suspicion, the suspicion that led to this study, which was published in 2003, so relatively recent, that idea that people who would like to donate a kidney to someone that they don't know ought to be considered, as the title of this paper suggests, a lunatic, or at least ought to be carefully screened for psychological problems, for lack of voluntariness or coercion. or for other psychosocial issues that might make such an act of altruism seem inappropriate and something the Transplant Center should not be a part of.

Dr. John Lantos

The suspicion, or at least reticence, to accept donations from living donors goes back to the early days of transplantation. Renee Fox and Judith Swayze are medical sociologists who've been studying this for decades. And they recount in this book how transplant surgeons were always reticent to do an operation. In fact, Tom Starzl, one of the pioneers of transplantation, once quipped that a living donation could be the only operation with a 200% mortality rate. Both the recipient and the donor should unfortunately die. It requires serious wounding of an individual who's not sick. And our surgeon said, you know, if you're donating to a loved one, if a parent's donating to a child or a child to a parent, that could be the sort of altruism that we understand. But people who want to donate to someone they haven't met,

Dr. John Lantos

there were a lot of concerns. And in the 1980s and 1990s, most centers would not accept such donors. For living donors, there were all these psychological benefits, loving relationships, greater self-esteem, relieving the family of the burden of caring for a seriously ill family member. But the suspicion led to laws, even in the UK, for example, that made it illegal to donate to anybody who was not a genetic relative. That law was passed in 1990. It was eventually challenged and overturned in 2005. But it just indicates, and I'm setting this up as background to Martha's story, indicates how there's been a deep background of distrust, suspicion, and reticence to allow strangers to donate to people they don't know. Over to you, Martha.

Martha Gershun

Thanks, John. This is Deb Porter Gill. She's the pretty blonde on the left who I donated a kidney to in September of 2018. I first read about Deb in an article in the Kansas City Jewish Chronicle, and her story grabbed me right away. She was a 56-year-old mother of two adopted adult daughters. She lived in Fort Lauderdale, but she had spent her formative years in Kansas City, where I lived at the time and still reside. And she had raised her kids in the synagogue that I had raised my children in. We had a lot in common.

Martha Gershun

Deb's health was a serious consideration. In her 30s, she had been diagnosed with both diabetes and kidney disease. And she had received a cadaveric transplant, both kidneys and pancreas. And it was a very successful surgery. She kept the kidney for 18 years. It was highly functional. The pancreas had continued to function, but now the kidney was failing. And doctors told her that she did not have long enough to wait out the cadaveric transplant list. It was going to take too long. She needed to find a living donor. Her children who had been adopted from Russia were not a match. Her siblings were not a match. Her parents were too old. And so she was appealing to the general community to see if someone altruistically wanted to step up to become her kidney donor.

Martha Gershun

I thought this was a great idea. I was newly retired from my work in the nonprofit sector. I had time, I had resources, I had a supportive husband. I had something else that often is true, not universally, but often for living kidney donors. I already had some experience with the phenomena of living organ donation. My cousin Anne had received a living kidney donation in 2002, a long time ago, early in the years that that was done with non-relatives. Her best friend in Omaha had been a match, and in her mid-50s, Anne had received a kidney transplant that gave her another nine years of healthy, good, joyous life. That joy wasn't just for Anne and her immediate family. It extended to my family, her cousins. We got to see her at bar and bat mitzvot, at weddings. When my mother died, she was able to come to Kansas City for our memorial service. I knew firsthand the extraordinary blessing to an entire extended family of the extra years that a living kidney donation can bring.

Martha Gershun

I was all gung-ho for the procedure and was not particularly concerned about the medical barriers or the surgery. I'm very healthy. I've had surgery before. They took out my gallbladder. They'd once before taken something out of my abdomen that had gone well. but I did not anticipate the significant psychosocial stigma and logistic barriers that separate a living donor who wants to do this from actually getting all the way through. Even though I met the miraculous benchmark of matching with Deb, which as you all know is unusual for non-related people.

Martha Gershun

There were several things in my background that gave the medical clinic pause and caused a lot of problems. I had disclosed on my intake form that I, from time to time, saw a mental health professional here in Kansas City. That turned out to be a tremendous red flag. And a lot was asked of me. I was asked to reach out to my therapist. I was asked to sign HIPAA forms. I was asked to have my therapist. fax my entire mental health record up to Rochester, Minnesota at the Mayo Clinic where Deb was a patient. And my therapist said no, that my personal issues with my family of origin, my decision to retire, all the things that she and I had discussed were nobody else's business and shouldn't be in a medical record that might eventually touch someone else's medical record. and she instead wrote a letter to the clinic saying I was mentally stable and that this procedure would not be damaging to me. They accepted that, but that was the beginning of my wondering to what extent my privilege as a middle-class, highly educated white woman might be playing in this system. Would the indication that their entire therapy record had to be sent up to a clinic be a barrier for someone without my significant practice in advocating for myself? The same thing happened when I disclosed to the clinic that I occasionally smoked recreational cannabis.

Martha Gershun

This was on vacation. This was in a state where it is illegal, as it is now legal in 23 states. But in the kidney transplant world, that raised a lot of red flags. And I was asked to make a second trip to the transplant clinic. I was already going up for medical, surgical, psychological, and financial evaluation, but they wanted me to come a second time to see a substance abuse counselor. They didn't have time on the regular schedule when I was gonna be there for a whole week. They wanted me to come back. That too was a big barrier. I was already... driving six hours to get to Minnesota, spending a week in a hotel to get a lot of things done. The fact that they could not accommodate my schedule and that I was going to have to come back for a one hour substance abuse appointment was a pretty significant barrier and very annoying.

Martha Gershun

There were many, many other times that logistics really got in the way and required a lot of advocacy and effort on my part. As you all know, anyone who's a living donor needs to be tested 30 days before surgery, within 30 days, for HIV, hepatitis, and AIDS. Makes perfect sense. We do not want an infected organ to go into a patient who's about to be immune suppressed. But it turns out, if you don't live near the clinic and they need your blood to be shipped for that test, They asked me to find dry ice to ship my blood on. Now, I don't know if any of you have ever tried to be a shipping and receiving expert and go find dry ice and ship something by FedEx to a medical clinic, but it is not easy to do. And I spent two days tracking down dry ice, finding a way to procure it, finding a way to safely package and ship it. All things that I felt were not appropriately the burden of the donor, and were much more appropriately the burden of the clinic where this transplant was to occur. There were a lot of other barriers. The clinic forgot to tell me that they needed my records from my colonoscopy, my mammogram,

Martha Gershun

several other tests that people do as part of their routine health. They forgot to tell me until the day before I was going to the committee for review. And I had to run all over Kansas City getting faxes and records and screenshots and things to be sent up. I missed a day of work to get that done. I had a consulting project at the time. All things that can be very significant barriers for people who might need to work for money, might not have a fully functioning car, might not have gas in the car, and might not be as stubborn as I was. One of the reasons that John and I decided to collaborate on this book was to explore the barriers that living organ donors face and see to what extent the system might be able to lower those barriers to allow more people both to have the blessing of making this gift and to save more lives.

Dr. John Lantos

So we spend a lot of time in the book talking about... I'm getting a weird echo here. Okay, now I think it went away. Talking about ways to increase the supply of organs, some of the hassles, bureaucratic barriers, the demands placed on Martha as an altruistic donor seemed bizarre. They kind of made sense in light of this history of suspicion, but some of them were just careless or poor customer service, which was Sort of surprising, given that this was at the Mayo Clinic, which has a stellar reputation for customer service. People come from all over the world because of that reputation and their reputation for medical excellence. So we wondered how much this occurs in other places. It's been fascinating to hear stories from various other places. We end up in the book, and I'll spoiler alert here. Talking about number three on this slide, how centers can provide more support for living donors. But along the way, we spend a little time talking about other proposals that could theoretically increase the supply of organs for transplant. One that's been used in some other countries is to make donation and opt out.

Dr. John Lantos

approach rather than an opt-in approach opt-in you check the box saying i'm willing to be a donor opt out there's presumed consent unless you say i'm not willing to be a donor talk a little bit about some countries that do that talk a lot about markets in the book and particularly about markets sort of uh uh in the gray zones between donation and a pure free market uh including chain donations, paired donations, and vouchers. And I'll go through that in a minute as well. Here's the data on opt-out. Spain and Croatia are two countries that have presumed consent. They have the highest rate of cadaveric organ donation in the world. You can see on this graph, they're the two bars on the left. And the rest of the world is about 10 or 20% lower in terms of recovering organs from people who have died and who are eligible to donate. Doesn't completely answer the question of whether a presumed consent approach would function as well in other countries, because it's not clear whether these countries accept presumed consent because they have a culture of solidarity or whether presumed consent leads to these changes in families' behavior. But as with so many other things that we talk about in the book, we suggest that pilot projects might be the way to try to figure this out in a culture like the United States, which is very different from that of Spain or Croatia. Paired exchanges have now become one of the most common ways that living donors give kidneys a basic idea. If a donor is not a good match for their loved one or their chosen recipient, if they find another donor who is and they are a match to that donor's intended recipient, then they just swap. This was proposed by an economist who said this is clearly a market approach. It is reimbursing through a barter system someone who is giving something of market value to a stranger by giving that person something of market value as well. Once the idea is accepted in principle, then instead of just having two-by-two paired donations, you can do extended chains as pictured. In the little cartoon on the left, the longest of such chains was written up in the New York Times a couple of years ago. 30 people, 30 pairs, 60 people participated in an extensive chain donation. As I'm sure all of you know who are involved in these sort of things, the logistics are very complicated the longer the chain gets. technical aspects of matching, procuring the kidneys, getting them to where the recipient is so that the transplants can take place and doing it all in a sequential fashion are difficult, but not impossible. These have even been done internationally. There was a heartwarming story in the news just last month about a chain donation between Israel and the UAE, so across political and religious lines. People have also extended the idea of chains as a sort of pseudo market or a barter market to include vouchers. So if donor one gives to recipient two, donor two to recipient

Kathy Nugent

N.

Dr. John Lantos

But there's no donor who could give to recipient one at the time recipient one can be given a voucher. And when a donor becomes available,

Dr. John Lantos

if that donor's recipient has already gotten a kidney, that donor then might agree to give their kidney back to recipient one. We bring all these things up and discuss them because each of them is essentially a market arrangement. And as I said, these were developed by a man named Al Roth, who won the Nobel Prize in economics for developing this, and as a result, saving many lives. Professor Roth, who teaches at Stanford, suggests that if we stopped being hypocritical and saying these aren't markets we might accept, well-regulated markets in which cash was exchanged, and in his view, thereby generate even more organs, save more lives in a way that he and many people believe could be done fairly. So lots of arguments for markets and organs. As many of you know, There are many body parts that it's now legal to sell, including eggs, sperm, breast milk, bone marrow, blood, plasma, hair. You can rent your womb as a surrogate mother. And market exchanges, fairly well regulated, although with some free market elements, seem to work well. Donation is still legal for all these things, but... The fact that you can get paid for it seems to increase the number of people willing to offer their body parts to people who want them. This is one of those situations, and we could spend some time in a discussion on this, where there's been a set of arguments on both sides

Dr. John Lantos

that are powerful, and it's kind of a stalemate in favor of markets' respect for autonomy, the idea that it would save lives, and a call for consistency. We allow people to do many other dangerous things for compensation, some of them far more dangerous than living kidney donation

JoAnna Rogers

in

Dr. John Lantos

low-risk, carefully screened individuals. The arguments against markets are equally coherent and powerful. There are fears that they would lead to coercion or exploitation. including objectification, instrumentalization, and commodification, all treating a person as merely a means rather than an end in themselves, and therefore violating some fundamental principles of medical ethics. In the end, we conclude that perhaps a pilot project of a well-regulated market to test which of these two sets of arguments would more accurately describe what goes on might be a way forward. What's been done though in most places is more of an approach similar to what goes on in the United States where there's a little bit of nudging, but not much use of financial or other incentives on this rising line of greater levels of intervention to induce people to give their vital organs uh we in most countries draw the line sort of halfway up this uh ladder providing information enabling choice guiding the choice through changing the default to presumed consent but not giving too many incentives unless you see paired exchanges as a sort of incentive some people have talked about disincentives but if you don't check the donor box on your driver's license you won't be eligible for a transplant if you yourself need one But not too many countries have tried those either. With those theoretical concerns about ways to increase the supply of organs, let's get back to Martha's story.

Martha Gershun

Thanks. Could you all hear my cat in the background? That is not a baby. That is a cat.

Martha Gershun

Speaking of one of the barriers of being a living organ donor, Ollie and my husband and I were away from Kansas City for 16 days, including the evaluation and both a failed attempt at the surgery and then eventually a successful attempt at the surgery. And we had to pay for a cat sitter. So if you would like to list one of the more bizarre barriers to living organ donation, I would put... pet ownership in the list. These are pictures after our successful surgery. The first time I went up to the Mayo Clinic to donate to Deb, we made it all the way through the screening tests, the evaluation the day before, but the night before the surgery, as I was chugga lugging a bottle of laxative to prepare, I got a phone call that Deb was too sick and they were calling the surgery off. I later found out it's very unusual to call surgery off that close. Usually the issue has shown itself sooner, maybe sooner in the day, sooner in the process. But in fact, my husband and I were sent home to wait out a week and see if treatment would get Deb to a place that the surgery would be safe. That was another time that the clinic kind of forgot about me. I got a call that... Deb was okay that the intervention had worked. And could I please be at the clinic the next morning for tests prior to surgery the next day? And I said, do you guys want me to drive all night there? And they were like, what do you mean? I said, well, I live in Kansas City. I'm six hours away. You live in Kansas City, which is pretty peculiar because I've been in the system for nine months and it sort of says on my chart that I live in Kansas City.

Martha Gershun

So there was yet another time when, as a living organ donor, I had kind of been misplaced in the system. My participation as a patient was always very satisfying. I was medically and surgically cared for extremely well. But as a part of the supply chain, I seemed to sort of get lost. They seemed to forget that the part... necessary to make this transplant possible was in a living, breathing person who had a life somewhere other than the city in which the transplant clinic was.

Martha Gershun

Our surgery was a complete success. The second picture there is Deb and me about a year and a half after surgery. She came to Kansas City on a visit to see her parents before COVID hit and took me out to lunch for sushi. And that's a picture of us standing outside the restaurant. I got a text from her yesterday. Her life in Fort Lauderdale continues to be adventurous, to be satisfying. COVID's put a little damper on life for all living organ recipients because the immunosuppressant regimen makes it very dangerous if they catch COVID. But other than those restrictions, which Deb seems to be pretty cheerful about, she's very healthy and very happy. I'm healthy too. I did not have medical consequences from the surgery. I've actually lost 10 pounds since the surgery, which should make all the nephrologists very happy. And I walk five miles a day. And really, if I didn't know that I did it, I wouldn't know that I had done it. I'm kind of one of the poster children for good results.

Martha Gershun

But it's been important to me to share my story and with John's help on both the medical and the ethical side, to let people understand that the logistic, the financial, the barriers that are raised, not the ones to protect the health of the donor, but to make it easier, possibly on the clinic or possibly on the donor or possibly on the insurance company or possibly on Medicare, put an undue burden on the one person in the system who's just trying to do something good. John, you want to take us home?

Kathy Nugent

So

Dr. John Lantos

we conclude in the book there are three kinds of barriers, each of which could be addressed, medical, psychosocial, and financial. The medical ones are the most straightforward, although the talk prior to this one by Dr. Doshi suggested that even there, there's plenty of gray zones. And the question of who should get to decide when a person's risk is too high requires both criteria of the transplant center, comprehensive medical evaluation, but then a gray zone where judgment calls have to be made about whether a BMI above 28 or 30 is an absolute or a relative contraindication, or a GFR of 80, or a you know, certain genetic risk factors.

Dr. John Lantos

Psychosocial ones, it seems, are more straightforwardly a remnant of the era when suspicion of donors' motives was much higher than it is today. Today, many transplant centers participate in the recruitment of living donors, even living donors to strangers, and yet there are these remnants of the old distrust and suspicion. We don't say that All psychological evaluation is inappropriate, but just suggest that it ought to be evidence-based. And if you're going to have criteria to screen out people for, say, drug use, having them talk to a substance abuse counselor because they've smoked a joint on vacation in Colorado, but never even ask them about alcohol intake seems a little bizarre as a psychosocial screening. Furthermore, predicting who's going to have a bad psychological outcome after donation or even who is being coerced is a

Dr. John Lantos

radically uncertain scientific enterprise. So we suggest maybe a little more critical evaluation of these requirements in the donor evaluation process. Finally, we talk about the financial barriers. Mark and her husband were at about $5,000 out of pocket for everything from dry ice to cat sitters, hotels in Rochester, days of lost work.

Dr. John Lantos

And taken together, all these barriers lead to a world in which most people who start the process of being evaluated as a living donor don't make it to the end. There aren't a lot of studies on this, but this was one from the Washington Hospital Center, the MedStar program, of the nearly a thousand donors, a thousand potential donors who started their way through the evaluation pipeline, only 15% ended up donating. It's not clear from this study how many were screened out by some of these barriers. About a third were medical rule-outs, but a third were donor opt-outs, whether that was because they didn't want to fax their psychological records or didn't want to talk to a substance abuse counselor. We just don't know. The study didn't go into that much detail. But it did show there was a big racial difference in who made it through the pipeline, twice as many white folks as African-Americans eventually ending up as a donor. For the financial barriers, there is some help. Medicare offers

Dr. John Lantos

reimbursement for lost wages, travel costs, and dependent care needs, but it's a means-tested program and somewhat bizarrely is based on the income of the recipient. not the donor. So if the recipient is below 350% of the federal poverty level, then the donor can get reimbursed for these expenses. What Senate subcommittee that was hammered out in, one can only wonder, but it doesn't seem to make much sense. There are also some nonprofits like the National Kidney Registry that for paired and chain donations, seek to fill the gap by providing cost reimbursement, travel expenses, and even donation insurance, life and disability coverage. But why should it either be means tested or left to the nonprofit sector? Why shouldn't this be a program that the transplant programs themselves do? We ended up concluding that living donors are sort of like college athletes. They're the only people who are not making money in a system where everybody else is making money. College athletes at least aren't losing money the way many living donors are. So we ended up concluding with a modest proposal that hospitals should treat kidney donors the way they treat financial donors. Most hospitals have large departments of philanthropy that are very good at courting people who might give money to the hospital. We suggest that present programs, which in most programs include a donor advocate, but don't fund them to the extent that they fund development offices or offices of medical philanthropy, and that donors ought to be honored the way financial donors are a hall of benefactors, put their names on the wall, or at least give them help with travel expenses, shipping blood specimens on dry ice, and staying in touch with them so they know what's going on. and knowing where they live. So thanks so much for sticking around and listening. We'd love to hear from people who are involved in these programs about whether some of these

Dr. John Lantos

issues and some of our proposed solutions make sense. Thank you.

Kathy Nugent

Well, thank you both for a wonderful presentation. We have a few minutes left for some questions. We don't have any now. If anybody has any, if you'll put them in the chat. While we're waiting, Martha, I just want to say your story is fascinating. Our program, our living donor program is very different. And so I would really love to talk more with you about your experience. My question is, what is the primary thing that you would like a transplant center to know to improve on or focus on to better support living donors from your perspective?

Martha Gershun

I think frequent and consistent communication could make a big difference. Sometimes weeks or months would go by where I had no idea what was happening on the back end. I didn't know what was happening either with my selection or with my recipient. And it's very hard to plan your life if you don't know when you're going to have surgery and take four weeks off work and ask your husband to travel out of town with you. I wish someone had called me every Wednesday at 10 a.m. and told me where the case stood. Even if there was no action whatsoever, I would have felt like that connection was real. It took nine months from the day I first called the clinic until the day we successfully concluded our transplant surgery. I could have used a lot more very consistent communication. They were great about responding when I called, but I know enough from my business career and from lead management that if you're nurturing a prospect, you call them.

Kathy Nugent

Very good. And after your donation, It sounds like you know about some of the psychosocial issues that can come up and the emotional issues that might come up. Did you experience any of that post-donation?

Martha Gershun

There was one point in time when I went up for my six-month medical checkup, which again, at the expense of the travel was my expense, but everything else was the expense of my recipient's insurance. It looked like my recipient might be rejecting her kidney. And that was really scary to me. I hadn't thought that we would go through all of this and possibly lose the kidney at the end. It turns out that Mayo's immediate intervention, the fact that they do a needle biopsy even at six months, made it possible to get Deb on a really modified medication regimen and save the kidney. But that was really scary. Other than that, I think I felt nothing but elation, gratitude. to have been able to do this and to have saved someone else's life. It's a gift to the donor too.

Kathy Nugent

It is. It's a remarkable story. And like I said, I'd love to talk with you more. So we don't have any other questions. Any final comments from either of you?

Dr. John Lantos

Just to be clear, when Martha talks about communication, I mean, the whole process from her initial... filling out the application to be a donor until the transplant was nine months. So with lots of ups and downs and scheduling problems and trips for evaluation. So when she says weeks would go by, I mean, it was a long drawn out process. The other thing is the studies of bad psychosocial outcomes for donors almost all involve situations where the transplant didn't work out well. So it's interesting that screening the donor for psychological problems is commonly done. But the biggest predictor is not the pre-existing psychiatric state of the donor, but the outcome of the transplant.

Kathy Nugent

OK.

Dr. John Lantos

Thanks. Yes,

Kathy Nugent

it was a wonderful session. Thank you both for being here. And from here, I think Dr. Budo will be joining me on stage momentarily for the closing remarks. And just a reminder that there's going to be a evaluation. So be sure that it's the non-CMA one so that we can know what we can do next year. as we move forward and provide relevant content and things that everyone would like to hear. So thank you very much.

Martha Gershun

Thank you so much. Thank you.

Usman Bhutta

Hi, Cathy.

Usman Bhutta

Thank you, everyone. It's been a wonderful conference. Thank you to everyone who joined us for this. Thank you to all the speakers who gave us presentations. I do want to take a moment to thank the National Kidney Foundation for all the work they do for the kidney community. The list of ways that they work to improve the patient's lives is very diverse. So they help with the KDOKI guidelines, funding research, patient advocacy. We have materials and resources on the website. So please make sure that you look at the virtual tote bag that will be sent to you via email, and it'll have a lot of resources as well as information from the exhibitors from today. As we heard from Miriam Godwin, the NKF has made a lot of strides in patient advocacy efforts. I have been involved with some of them in Oklahoma, but you will get some more information on that also.

Usman Bhutta

some links will be shared in the chat and you can click on those you can follow the nkf advocacy on twitter and stay up to date with that i think either uh joanne or someone can share that in the chat box also i would again once again like to thank our amazing sponsors uh velocis horizon astrazeneca care dx alexion ardilix nephew vifor trevor Trevier, GSK and Bayer, along with all the other exhibitors that have supported us for this conference. You guys can still visit the Expo Hall, watch some of the videos. You can hang out in parts of Hopin until 6 p.m. Central today.

Usman Bhutta

When just another reminder, when you guys registered for the program, you did create an account on NKF's Professional Education Center. It's called Case Hippo. you will be able to access your certificate of completion take the evaluation and track any other nkf professional education programs you attend there's a thousands of online cme activities that you can attend and selection is free for anyone the majority are also free for nkf professional members so if you haven't then maybe this is a good time to sign up and upon completion of this symposium nkf will be sending an to all the attendees with a link to access the program evaluation and certificate. And you must complete the program evaluation in order to obtain the certificate. Instruction recordings after the conference will also be in the email. And lastly, I would again like to thank the program committee for working hard to execute this amazing online program. Joanna has been amazing through all of this. um and you know all the people who joined it's been a long year of virtual events hopefully uh next year we have uh the opportunity to welcome you all in person and thank you bye

JoAnna Rogers

yes and i um just wanted to also add um thank you dr buddha you um did an excellent job um as program chair for this conference the third year in a row we are really grateful for your support and continued efforts to bring programming like this to our local community. So thank you for that. And

Usman Bhutta

also

JoAnna Rogers

to the pleading committee. So everyone expect some emails from us next week to get your evaluations and feel free to stick around, continue participating with each other in the chat. We will see you next year. Thanks guys. Bye.

Dr. John Lantos

Thank you.