Chapters Transcript Video HLA, Graft Survival, and the Genetics of a Better Match in Kidney Transplantation The Best therapy I can offer is a living donor. I can't write a prescription for it. I can only offer it if a patient actually goes and finds a living donor and that's, that's the trick. And so what we do here, and I think we do a great job, uh, is we try to give patients resources to actually go and find a living donor. Hi, I'm Lindsay Carrillo, director of business development at UCI Health. Hi, I'm Doctor Sunil Verma, Associate Chief Medical Officer for ambulatory and a laryngologist here at UCI Health. Welcome to Physician Huddle by UCI Health. I'm really excited today. We're joined by Doctor Robert Redfield, the Chief of division of Transplantation at UCI Health. Welcome, Doctor Rodfield. Thank you. Glad to be here. Tell us a little bit about your clinical role at UCI. So, uh, here, uh, I'm a kidney and pancreas transplant surgeon, um, um, and I help lead the team. It's a multidisciplinary team. Uh, we have probably about 50 employees here, uh, from nurse coordinators, pharmacists, nutritionists, social workers to make transplant happen here. And, um, there's a team of transplant nephrologists and Me with my medical counterpart, uh, Doctor Reddy, we, uh, lead the program here. So tell me a little bit about kidney and pancreas transplant, like who gets it, uh, what are the indications for it and how do patients find you? Yeah, so, uh, the vast majority of patients, uh, come to us just for a kidney transplant. If you're a diabetic as well, we can consider you for a kidney and pancreas transplant. Uh, some diabetics that don't have kidney failure, uh, can also just get an isolated pancreas transplant. Uh, but most of our patients find us because they have chronic kidney disease or end-stage renal disease and are referred for a transplant evaluation. And are these patients that are on dialysis then is that almost the, the rule for the patients? The vast majority are we would prefer to actually engage with our patients prior to, to dialysis treatment. So when patients are. You know, in, uh, what we say, you know, before dialysis, they're preemptive. We would like to have seen them to talk about transplants so that we can get everything lined up, get them educated about living donors to, to get a living donor transplant, uh, which is the preferred treatment option that we can. For patients. So tell us about, yeah, perfectly in what is a living donor transplant? Yeah, so really, you know, the treatment option for patients with end-stage renal disease, so their kidneys have failed, um, is either have dialysis, um, or get a transplant. Um, usually it's a combination of it where they have some dialysis and then get a transplant. We would like patients to never go on dialysis and just get transplanted. The only way to definitively avoid. Dialysis is to get a living donor kidney transplant because that is, uh, otherwise you have to wait for a deceased donor kidney transplant and that we, uh, it's a long line. Uh, the wait can take upwards of 10 years uh to wait for a deceased donor organ. Uh. Living donation, you know, if you have someone who can donate a kidney, uh, we can transplant you whenever, you know, it's elective, it's scheduled, um, we could do the transplant before you even need dialysis. The outcomes are clearly superior with living donor kidney transplants, especially if you can get patients transplanted before dialysis. Dialysis is hard. Uh, it's a hard way of life, it's hard on the body. Um, and so, you know, for the community, you know, the more that we can do to to partner together to try to help raise awareness about the treatment options, raise awareness for the importance of living donation, um, that will be best for our patients. And how did they find this living donor? Yeah, so, um. That's the tricky part, you know, so when they come, you know, to see me in clinic, the best treatment option I can offer somebody is a living donor kidney transplant. The problem is, is I can't write a prescription for it, you know, so, you know, as an oncologist, you could say I, I have the best chemotherapy, just got, you know, approved or this cutting edge trial, they can write a prescription for it, you know, the best therapy I can offer is a living donor. I can't write a prescription for it. I can only offer it if a patient actually goes and finds a living donor and that's, that's the trick. And so what we do here, and I think we do a great job, uh, is we try to give patients resources to actually go and find a living donor. Uh, give them the language, give them the icebreakers, tell them kind of, you know, in clinic, I spent about 30 minutes practically role playing on how to even bring it up. I mean, The first thing patients need to realize is that it is a superior therapy. I mean, I have a lot of patients that come in, they, they don't want to burden their family by asking them for a living donor. They would just say, I'd rather Sit back and go on the list, but then I have to spend time to say, all right, what would that look like? It's just, let's just, let's walk through that. So you're gonna start dialysis, you know, you're gonna need to get access, you know, and what does that look like, the modalities of that. You're gonna be, you know, potentially hooked up to a machine 3 days a week. Like, how is that gonna affect your life? Hard to work? Like, are you gonna have energy for your kids, you're gonna have energy for your spouse, um. And that could go on for 8 years, 10 years. Now, you know, if that's the only option, that's fine, but just to like just to kind of, you know, set the expectations of what that's like. Now I have an easier path, you know, that path is a living donor, where if we can really spend a lot of time to figure out how to get you a living donor, you can avoid all of that, get back to life, you know, get back to, to work, you know, get back to. You know, having energy and being able to to travel. And I think when once you frame it like that, you're like, yeah, OK, um, now, maybe I will ask my kid. And and this is typically a blood related relative, uh more often than not, more often than not, it is an immediate relative, you know, um, so, you know, we have kind of two populations that we are educating, you know, we are educating our recipients on how to find the best therapy. Then we also need to educate the general public that actually There's a lot of need like as a good Samaritan, as what we call a non-directed donor, as you know, someone, you know, just in Orange County alone, just in our own health system, there's enough healthy people walking around that could get all of our patients transplanted if someone was, you know, called to think about, you know, or felt, you know. Um, the need to say I would like to donate to anybody and about 5% of living donors are what we call non-directed donors, yeah, which is pretty remarkable, but yes, most people donate um to a loved one. So usually it's an immediate relative, immediate family member, spouse to spouse, you know, um, child to parent or vice versa. Uh, or brother, sister, uncle, uh, but then we, we sit down and we talk about like, all right, what is your social network? What does it look like? All right, so that's the immediate family, are they healthy? Cause they have to be healthy, uh, and willing, um, and we go through an extensive um evaluation where we Um, you know, do genetic testing, we really assess their risk of end stage renal disease as a donor, and, and the question we're trying to answer is, do we think this person can live a normal life with one kidney? If the answer is yes, then you could donate. If the answer is I don't know, um, then you're not going to be able to donate, you know. Why is the living donation so much more superior and what are some of the downsides and challenges of dealing with the donations from the deceased? Yeah, so it is so superior for a number of reasons. So, you know, a living donor is healthy. So it's a healthy kidney. Uh a deceased donor is Um, a kidney that went through the dying process. So it had to, the person had to die, donate their kidney. Typically people die because they have comorbid conditions, diabetes, hypertension, coronary artery disease, smoking, um, old age, and so just by that nature and of itself, a deceased donor kidney is not as good as a living donor. And it had to go through the dying process and it had to stay outside of the body for typically about, you know, 24 to 36 hours where a living donor, we can just take it out, put it in. Additionally, there's no weight, you know, so like the waiting time with a living donor can be a weight at all. Uh, with a deceased donor, it could be a 10 year wait and that patients, their body gets worn down, um. And it's harder to recover from surgery. It's not elective, you know, we have to do it in the middle of the night, you know, you have to race the patient in, um, so all of those things combined means that a living donor kidney lasts about twice as long as a deceased donor. It's remarkable. So, you know, if you're. You know, really, in your 50s, getting a living donor kidney transplant potentially from someone who you're related to, um, that kidney could last the rest of your life. Talk to me about some of the hoops you jumped through when you get the call. We had, we have a kidney, it's now available. We were talking about some of these things like, oh no, the patient had a burrito earlier today. Now they can't get their kidney, you know, like some of these things, these crazy calls and these things that you have to go through just to get I mean, it's really different than doing a hip replacement where the hip is on the shelf, right? Like it's available when it's available. Tell us about that experience. Yeah, it's, it's pretty wild. So we have a large team, um, and me and my colleagues in the team, we screen organ offers. So we actually screen probably hundreds of kidneys for each transplant we do on the deceased donor list. So we're getting calls from all over the country. Uh, about organs that are available and we're trying to decide is this organ appropriate for our recipient, um, if not this recipient, somebody else, um, and, um. Yeah, so we're, and oftentimes those kidneys have already been out of the body and they're trying to be allocated and we have to, you know, organize logistics and the flights and, you know, we get it here in time. Is there an OR that's available? Oh, now we need to have a patient come in to the hospital? Have they been NPO? Did they just have a burrito, you know, do you have a bed available, um, all of those, all of those logistics where a living donor is. Yeah, we're gonna do it uh 2 weeks from now on Tuesday and uh it's gonna be a first start at 7:30 and everyone's gonna kind of just nice and come into the operating room and it's we've had, you know, weeks to plan and it uh it's, it's a much more planned situation, yeah. Absolutely. So this is done um synchronous ORs then. Uh, oftentimes, yes, um, you know, you know, um, usually side by side or depending on the timing. Now we do a lot of uh paired kidney exchanges and I can get into the that a little bit more where Um, the donor and the recipient are not compatible, and so the donor's kidney, we're gonna ship up to San Francisco and that's gonna go, you know, UCSF is gonna go transplant that kidney and then we're gonna get a kidney, uh, from Duke across the country for the recipient and so, you know, we sometimes spread those out over a day or we will do them one in the morning and, and one at night, um. And that allows us to uh get patients transplant that are not compatible. Reality is is with paired kidney exchange, um, I think everyone should consider it because even if you are compatible, you know, husband donating to a wife and your blood type compatible, so you're both blood type O, OO, we can do the transplant, but they're not, it's not a great HLA match. So we can shop for a better HLA match. We know, I just saw a lady in clinic who got a kidney transplant here 50 years ago. Um, I was like, wow, I didn't know UCI did a kidney transplant they did, you know, it's the, you know, it's the oldest kidney transplant program in Orange County. Got a kidney transplant here, uh, about 50 years ago from her sister. It was a very good match and it lasted that long. So matching, you know, does matter. So I encourage my patients, hey, I know you want to have your spouse's kidney in you, and they often like it because they can hold their spouse accountable, you know, um. Um, but, um, Um, If I can find them a better match, that kidney could last a lot longer. So I encourage everyone, um, donor recipient, we do. Next generation sequencing, high resolution typing, we can see, you know, not just the HLA disparities, but we can look it down to the applets and so, you know, you know, HLA molecules determine you for me and uh but we can actually You know, you know, say it's HLAA2 versus HLAA4, they're different, but sometimes the HLA molecules are kind of closer, um, they're more closely related than than disparate, so like the difference between when I tell my patients, chocolate chip and or you know, chocolate ice cream and, you know, Rocky Road is they both have chocolate ice cream, it's, but you know, chocolate ice cream and strawberries is very different, you know, you know, and it's like. We're closer there, you know, and that could be a little bit more favorable of a match. We do all that and then we're able to put them into what we uh the National Kidney registry, which is an organization we we partner with that helps on a ton of levels on on living donation. Uh, and we can look at all of the donors in the United States that have, that are gonna be living donors that are part of the National Kidney register. I can say, hey, there's actually a really close match in Ohio, you know, can we, can we try to get that kidney for you, you know, so it's great. tell us a little bit about the scale of the program here. Yeah, um, what makes this successful? What's changed over time? Um, is this something you guys do a kidney transplant once a month or once a how often? Yeah. So, um, over the last 10 years, this program has undergone, you know, extraordinary growth, um, and I would say we are now poised for even, you know, more growth, but it was a smaller program doing um. You know, somewhere between 20 and 50 kidney transplants per year, per year, uh, and last year we did, I believe, 224 kidney transplants, which is great, you know, um, there's a lot of patients. We have a large list or list of patients that are waiting for a kidney transplant here at UCI. It's about 1000 patients or so and um there's a big need and I think we can continue doing more, you know, our goal. Uh, at this program is, you know, you know, we wake up every day to advocate for our patients. Can we get you the best transplant possible? Obviously, we're gonna work really hard and give you the tools and equip you with all the resources to try to find a living donor. We have more resources here than any other transplant program in Southern California to equip donors with protections and safety, um, for instance, um, Living donors here, we help them with lost wage reimbursement. You have to take time off of work. On every job is gonna say, hey, you know, that's fine, go donate a kidney and uh you can have paid leave for 3 weeks or 6 weeks. Um, our partnership with the National Kidney registry will, will cover their lost wages. If they need help, donors say, you know. Uh, with childcare stuff around the house, we can, we have resources down but our goal is to reduce the barriers. To donation. Um, we also, um, if you donate here at UCI because of our partnership with the National Kidney registry, if God forbid, the worst thing that could happen potentially is you needed a kidney transplant yourself. It's very rare, but if that were to happen, um, you would get a living donor kidney transplant immediately. It's a huge insurance policy, you know, you know, and should alleviate. Um, some concerns. And so, you know, um, I think, you know, those, those protections are, are really, really, um, you know, fascinating and helpful. And then the other thing is if we can't get you a living donor, we are going to hustle to try to get you, you know, The best deceased donor we can. And, you know, the wait time for a deceased donor is about 10 years for a blood type O, And I have a lot of conversations with patients like, hey, there's a kidney out there, um, that, you know, no one at the top of the list wants, but, you know, I think it's really good and um you just got on the list, it could be a little riskier, but if we're right, and we're oftentimes right, like we're right like 99% of the time. Like, you might not need to be on dialysis for 10 years. Like, do you wanna, this may not be your first choice kidney, but it's a really great second choice. It's a great choice and it's like, and, and that takes a lot of work, you know, because who does that? Like, how do you match this up? I mean, is this AI, is this a computer program, it's right for AI solutions, but right now it's Doctor Reddy and Doctor Redfield and the rest of the team doing this and honestly, my partner Dr. Reddy deserves an enormous. Um, debt of gratitude because he, um, is very good at being able to match, you know, the donor and the recipient. We do it collaboratively, but it's a lot of work. Um, you know, last night, you know, I was answering the phone, um, at, uh, you know, 3:34 in the morning about a kidney, you know, that nobody else wanted. We got up, we looked at it, we looked at the biopsy, we asked them to put it on a pump to see how it's Flowing to get some physiologic data, pump numbers looked great, biopsy looked great. You know, some times they get turned down because it's like a story, like it gets a bad story, you know, it's like a, and you're like, but it's not really true cause we're looking at the kidney looks perfect, the biopsy looks good, all the, you know, physiologic numbers look fantastic. I think it just got a bad name and somehow it just got branded as a bad kidney. We're gonna go scoop it up and we're gonna go transplant in our patient and that's getting transplanted, you know, this afternoon by one of my partners, Doctor Ichi. And uh it's gonna work, you know, it's gonna get a patient off dialysis. It takes effort and, and, and. You know, not only are we, I think, you know, I really do believe we are the best kidney transplant program in Southern California, and it's not just because of the expertise, uh, of the surgeons and the physicians, it's, it's the hustle, it's the commitment and And it it does ring true when, you know, our CEOs like, we want to be the friendliest transplant program or the friendliest healthcare system, like I do think we are the friendliest transplant program, and I think our patients feel that when they come and see us, uh, in the clinic in all phases of care. That's um, you know, I'm impressed that's all so much effort that occurs, uh, behind the scenes if you will uh you know, being a surgeon, one of the things that's always challenging in surgeries you go in and the unexpected. So how well prepared can you be for either of these? How often do you have a kidney that you didn't know what you're getting yourself into, either in harvesting or in or in implanting? Um, how do you manage that and mitigate that risk? Right. So first, you know, the, the first is uh patient selection, um, and managing patients while they're waiting through the process and that I have a huge debt of gratitude to my medical colleagues and um uh. Cardiology, pulmonology, transplant nephrology, all the expertise in this health system to kind of optimize our patients for the day of transplant. Um, our anesthesia colleagues are unbelievable, um, honestly, all of them, and I've worked at a number of transplant centers, uh, best in the business and, um, but in the operating room, yeah, you know, I. Uh, the analogy I give is, uh, like you said, you know, this is not joint surgery or where things are off the shelf, and that would be really nice and we could get to that. There could be a day where transplanted organs are off the shelf, but, um, I do think human tissue is probably gonna be the most superior, so it's all gonna be, um, for kidneys, it's probably gonna be the best, but, um, before I digress, it's, we get what we get, you know, so everyone's Looks different here. Guess what? On the inside, as you know, um, it's even more variety, you know, you know, blood vessels here, so it's different, there's more variety on the inside than there is on the outside and that's the same with transplanted kidneys. Some people have, you know, you know, 40-50% have one artery and the rest have 234 arteries. I gotta figure out how to hook those up, you know, because they're all critical, um. Some people have 1 ureter, some people have 2 ureters, some people have 3 veins, you know, some kidneys are big, some kidneys are small, you know, um, so I, I, I liken myself to like a tailor of like used clothes of some sort, you know what I mean? It's like, Sunil, if I got a suit, you know, uh, that was like 5 sizes too big, and I had to say, hi Sunil. I got if you look good and they fit you in this, and this is the only suit there is. This is it for 10 years. It's either that or no. Like the red carpet is in like 2 hours, you know, but you do it, but yeah, so we have to, we have to craft it and it is craftsmanship and uh we, everyone's, you know, so a nice, you know, single artery, single veins, single ureter, you know, kidney still has to be crafted. I gotta find a nice place, you know, on the iliac. Where the artery is gonna lay, I gotta find a nice appropriate place so we, I mean, we're, we're in there kind of measuring some stuff and we're marking and we literally like a, like a, a tailor uh with a chalk, you know, um, this is where we're gonna put this, this is where we're gonna put that, where is it gonna lay, it's gonna look good. And there are sometimes where it's just like this is, we gotta make this work, you know, and it does. And, and that's where, you know, um, all the surgery has some degree of this, but this is, this is extreme, you know, and um. That's where coming to an experienced place with an experienced surgical staff, you know, uh, matters. So, you know, um, I've had, you know, kidneys, I've had living donor kidneys that nobody wanted a transplant that had multiple arteries. Um, and the patient wouldn't have gotten the transplant. We, we make it work. We hook it up to, um, one of the arteries will harvest the epigastric artery, you know, just like you're doing, uh, you know, a Lima to LAD bypass, but we're just doing it to the lower pole artery, you know, and so you gotta be incredibly flexible to make this stuff work and creative. It's fun, you know, how, what's the, um, so we talked a lot about kidney transplant. You also mentioned you do pancreas transplant. Take me a little bit through who gets those and is what's similar and what's different, right, so, um, we could spend another couple of hours on that, uh, but it's a great operation. The, the pancreas transplant, especially a pancreas transplant with a kidney transplant, so what we call an SPK, a simultaneous pancreas kidney, um. Is typically for a type one diabetic, you know, so they had diabetes in childhood, typically, um, autoimmune diabetes. And over the course of uh their diabetic course, they develop end-stage renal disease, so they need a kidney transplant. They're already gonna be on immunosuppression, um, and we can offer them a pancreas transplant to liberate them from insulin. It's a very special population of patients, um, is when I, when I usually counsel them, the thing that's really gonna save their life is a kidney transplant. Um, the pancreas transplant, for all intents and purposes, it's hard to show that it's life saving, but there's clear benefits from a quality of life. But when you talk to a type 1 diabetic who's been injecting themselves with insulin since they were 5 years old, they literally do not remember life without taking an insulin shot, um, checking their blood sugars, the trauma of being a teenager and going through that, and that's typically when the wheels kind of come off the bus a little bit because They don't wanna be sick, you know, they don't want to be, you know, you know, medicalized. They're like, I don't really care about the kidney. I just wanna live like experience a day without having to like work, you know, it's unbelievable. So this isn't gonna extend their life, but it's gonna make those days a lot happier, a lot less and Potentially relieve some of the trauma that they've had. Yeah, I would argue nowadays, you know, if you did the proper studies, um, you could actually show that having uh um elycemia for an extended period of time has some long term benefits. How can it hurt you, right? I mean, it just makes inherent sense. So, you know, uh, type one diabetics, uh, for sure, um, any type one diabetic that comes to us that needs a kidney transplant, we talk to them about it. Simultaneous pancreas, kidney, where we kind of deviate is if you have a living donor. So if you have a living donor. You know, It can, it can go either way, but usually the conversation is, well, the the pancreas kidney you're gonna have to wait for and the wait time is not as long as a kidney alone, but it's still a wait. You have a living donor kidney transplant, let's just go get, get you a living donor kidney transplant, and then we can do a pancreas after kidney OK and we do a pancreas after kidney. Um, and then we do do them in type 2 diabetics too. Uh, some type 2 diabetics can, they have to be on the leaner side. Um, so usually like a BMI 30, 31, 32 can get up to 35. They can't have a ton of C peptide to suggest that um there's a lot of insulin resistance because we're transplanting it for, you know, insulin. We don't want to, you know, so, um, but. There are certain patients that would benefit from that. Um, and then there is a patient who is a type one diabetic that doesn't have renal failure but has such severe diabetes, either they have allergies to exogenous insulin and we see that they're very brittle. The biggest thing is hypoglycemic unawareness. So, you know, they've developed neuropathy, so, you know, just like peripheral neuropathy, they've developed autonomic neuropathy so they can't feel their lows. So instead of, you know, they get down to Blood sugar of 30s and they're not getting sweaty and tachycardic and lightheaded, it's fatal. I mean, I've had patients who have um You know, driving their car, hypoglycemic unawareness, kids are in the car and they've had an auto automobile accident. Um, so those are situations where an isolated pancreas transplant would be actually life saving actually. So you alluded to a little bit, future of transplantation. We've seen some things on the news. Um, tell us where you think it's headed. Transplant's exciting. I mean, it's like we live on this intersection of life and death and constant innovation right now, um, there's a lot of great stuff on immunosuppression and try how to, how do we, how do we convince the immune system to accept these organs. We have a couple of phase 3 trials looking at novel immunosuppression, um, um, regimens that I think are gonna be game changers in the short and the long term, um. We have some studies and development to try to do transplants, especially living donor transplants without immunosuppression, and that's the way we do that is concurrent with a bone marrow transplant where we kind of make the immune system. Of the recipient, the same immune system as the donor, has been done, um, at many places, we are a part of a consortium to try to kind of scale that and really um. Um, Do that after after transplant. Uh, it's a really exciting uh uh space. So I do think, you know, in the future we'll be doing transplants with better immunosuppression, we'll be doing transplants potentially with no immunosuppression because the immunosuppression does have some side effects, you know, um, well, there's no doubt about it, right? So if you can minimize the post transplant life. You're gonna make things a lot easier. The side effects of immunosuppression are still less than the side effects of dialysis, and that's where the risk benefit comes in, but um we can make that better. And then, you know, I do think, you know, in kidney transplantation, the reality is is how do we inspire people to donate, you know, and uh with living donation, as I said, it's, it is the best therapy, um. There is enough donors in Southern California that we could get everyone transplanted, you know, here. So how do we continue to reduce the barriers? How do we, you know, inspire people. So one thing I would like to say is one of the things that we did develop in partnership with the National Kidney registry as a community in the United States, we developed these um vouchers. So um if you are a non-directed donor, so say Sunil, you walk out of here and you're like, This is amazing. I'm going to donate. I'm donating, you know, like I just want, I want to save a life. You can donate a kidney, but you can name your family members or friends, up to 5, that's how it's been modeled that if any of them needed a a kidney transplant in the future, or. It's only for one of them, but like if one of them needed, they would get a kidney transplant back because of your donation. So the, the concept of the Good Samaritan donor or the non-directed donor has now completely changed such that Um, you really are kind of donating, you're banking a kidney for your kids, you know, if they needed one, you know, you know, I, this is so impressive because it's not just about the science, it's not just about the connecting of the arteries. I mean, there's just so much of a Social humanitarian, even logistical aspect of this that to me is just been really fascinating to sit down and learn from you today. Yeah, yeah. OK, last question. Pig transplant, we gotta talk about it. I've been, I've been, I've been delaying. No, it is very exciting. It is. I mean, it is, it's the holy grail, right? The, the idea that we can get made to order off the shelf organs for transplant, um, whether it's heart, liver, Lung, kidneys, all of it, um, that, that is the holy grail. Uh, it does appear that, you know, through decades of work that pigs are probably, you know, the ideal source now with gene editing, CRISPR. They can gene edit all these things out. Uh, there's a couple of companies leading the way, um. You know, some are taking different strategies, knock out a couple, and then modify some of the immunosuppression versus knock out 70 genes. Um, both of those have, um, had some emergency use authorization applications. Um, it's exciting. Things seem to be, you know, working, you know, in the early term. Um, it's, I think it's gonna be an active area of research for quite some time. Then the question is if you can show it as a proof of principle, can you scale it? I do think, um, You know, at some point, we could potentially make it a reality. I do have some hesitation that the species, the animal species barrier is, is real, you know, it's real, like, you know, like getting, you know. Um, Animal organs to work in humans. There's a lot of barriers. I think we can probably genetically engineer ourselves out of it. The big question is, is if you genetically or yourself, genetically engineer yourself out of it, can you scale and breed the the animals because they tend not to breed very well when you when you when you when you do that. So now you're a farmer as well as a right, but I think it's really exciting and I think it's it's great from the kidney space. I think we shouldn't take our foot off the pedal of trying to convince people to get living donor kidney transplants, which I think likely will be the best therapy. You know, it's hard to beat human engineering, like what, you know, what we can do with it at least for the foreseeable future, right, for the foreseeable future, yeah, it's an exciting time. This is great. Thank you so much for being with us. You don't want to do more. I can't do another couple of hours. I'm sure. All right, that was good. A lot of fun. Thanks guys. Thank you so much for being with us today. This has been Physician Huddle by UCI Health. This was an episode of the Physician Huddle podcast by UCI Health, produced by Brett Shaheen, Angelica Ugubi, and Victor Ting. For more episodes, information on clinical trials at UCI Health, or to refer a patient, review the show notes or visit clinical connection. UIhealth.org. Created by
