Interviewed by Jill Shah
Dr. Jeffrey Zaltzman joined the Division of Nephrology at St. Michael’s Hospital in 1993, where he made vital contributions to the rejuvenation of the kidney transplant program. He is now the director of the program that has become one of the pioneers of Canadian kidney care.
J: What drove or inspired you to first enter the field of transplantation?
Z: Transplant is exciting for many reasons. First of all, you really transform lives and you really save lives. For me, it’s nephrology. Getting people from dialysis to transplant is very transformative for them. Their quality of life improves; they have freedom from dialysis, they feel much better, they live longer, they feel happier, they can travel, they can work, and women can more easily have children. In addition to that, because transplant and organ donation is based on a scarce resource, I like the ethics of the whole field of transplant and how to use a scarce resource in the most equitable way. There is always a tension between equity versus utility or the best outcomes. Equity versus utility are always competing forces with transplant which is really unique to medicine – there are not too many things that share this tension. Besides this, there is some science involved which is good and it’s been nice to watch the field evolve throughout my career.
J: What would you say has evolved the most in the field throughout your career?
Z: The anti-rejection drugs that we use. Although there haven’t been many major changes in recent years, they really have made transplant a success. They’ve helped in treatment of infections and created a better understanding of how to match the correct organ donor to recipient. We have been able to transplant people who we would never transplant before. I’m talking about much older and sicker people who, many years ago, probably wouldn’t even be considered for transplant. But as transplant became more successful, it’s no longer the case. We’ve also been evolving the different types of donors we have available. The deceased donor cohort has changed and the living donor potentials have exploded a lot in my career. We are doing a whole bunch of things that were never possible before.
J: From my understanding, you have also been able to transplant individuals with different blood groups. How does that work?
Z: In our centre, we have been able to use techniques to desensitize the recipients against their donors and this has allowed some people to get a transplant from a close friend, relative or somebody else, which was not possible in the past.
In addition, we have a national paired donation system, which is really an international success story for the same kinds of reasons. It’s for people who are incompatible, either by blood type or other tissue matching issues. With this system, we have been able to expand the living donor pool dramatically. And it’s not that the living donors are not as forthcoming, but we’ve actually built quite a bit and continue to grow, and without the system I think we would’ve diminished a potential pool of living donors.
J: Regarding the ethics and transplant tourism: You’ve had patients that have traveled to other countries in the past for their transplants. Would you say that this is still a major problem in Ontario?
Z: We still have a lot of patients who are coming back from other countries. I wouldn’t say it’s dying down. I would say that it is still prevalent. There are people who are desperate, who don’t want to wait and realize that they would have to wait longer here in Ontario and Canada. We still have patients who have gone abroad for their kidneys and then come back here for their care. It hasn’t diminished, but I don’t think it’s quite as big because there are some countries that have shut it down. But even so it continues in many places.
J: Do you see it diminishing in the near future as there are more advancements in the transplantation field?
Z: I’m not sure, there is nothing right now that makes me think that this is going to make it go away at this point in time.
J: You have played an active role in revitalizing the kidney transplant program at St. Michael’s Hospital in Toronto. How did you go about doing this and what major obstacles did you face during the process?
Z: When I finished my training in transplant, St.Michael’s was going through a lot of changes itself. There were budget constraints, and many kidney transplant personnel had left. At the time, the hospital was thinking about not having transplant anymore and having it at just one centre in Toronto. However, at the time they wanted to get it going as soon as possible. So I was able to get a job at St.Michael’s and in addition they were able to hire a very prominent transplant scientist from another part of the country. That was a start at getting it going again. We just built up, recruited some surgeons, revitalized our nursing staff and promoted ourselves. From there, it picked up. It’s a 25 year old story.
J: How do you think other hospitals should go about it when they want to improve their own kidney transplant programs?
Z: I think – in Canada – it is a small community. Any patient anywhere in the country at any program would do well. Because I’ve looked into most of the programs, I know that some of them are quite small. I think if the program is very small, there is a concern that the staff do not have the expertise to deal with too many challenging cases. However, for the most part I think everyone struggles with operating rooms, surgeons and resources, but there is still a lot of pressure for the programs to continue. I think for the most part, Canadians anywhere in the country, no matter what transplant center they go to, would have a good outcome.
J: Branching off that, what is a common misconception people have when it comes to organ transplantation and donation?
Z: I think there is still a lot of concern about organ donation. I think people are not sure about if they are a candidate: could they do it, and should they do it? There are still knowledge gaps about the benefits of organ donation. Some people think they can’t be organ donors because of certain [health] problems. Bottom line is that they should sign up online and let us know that they want to be an organ donor. The system will then decide if they are suitable donors, and they don’t have to worry about it. The second thing is that people who require a transplant have to talk to their friends and family to let them know about their situation. You may be on dialysis for many years and you have to get a living donor, so you should be open with your communities, friends and family.
J: Ever since people could register online to become donors, how dramatically have the numbers of donors gone up?
Z: Since the online registry started here in Ontario through Trillium life. We are now just over a third of eligible people who have already signed up online. I think the goal is to get as many people as possible but 50% is a great goal to achieve. You can actually go to the Trillium website and see the different communities because it is public information.