Health Topics – Johns Hopkins Medicine Podcasts

Anchor lead: How risky is Covid-19 for transplant recipients? Elizabeth Tracey reports

People who’ve gotten organ transplants experienced more severe Covid-19 disease than many others at the beginning of the pandemic, but Dorry Segev, a transplant surgeon at Johns Hopkins, says the picture is much more optimistic today.

Segev: So far what we know is that if we treat properly we can lower the mortality risk in transplant patients down to what would be equivalent in an immunocompetent patient. At the beginning of the pandemic mortality rates in transplant patients were near forty to fifty percent. This was very very scary for transplant patients. But we’ve learned a lot. One of the things we know is that the medications that transplant patients are on to prevent rejection, also seem to prevent the immuno-inflammatory response of Covid.  :32

Segev’s recent study shows that vaccine response among transplant recipients is blunted, so he’s advocating for a third dose. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: People whose immune systems aren’t completely functional may have more Covid-19 worries, Elizabeth Tracey reports

People who’ve gotten organ transplants take medicines to keep their immune systems from rejecting the organ, and this unfortunately also dampens their response to Covid vaccinations, a study by Dorry Segev, a transplant surgeon at Johns Hopkins and colleagues has shown. Segev says there may be additional risks.

Segev: It is certainly possible that people who are immunocompromised who get the virus will shed it longer after their symptoms have resolved, than immunocompetent people. This is obviously dangerous in terms of the people they encounter, dangerous in terms of development of variants, and reemphasizes the fact that we need to protect immunosuppressed people as much as we possibly can, from getting exposed to this virus and getting infected with it.  :28

Segev notes that anyone taking steroids or other medicines that affect the immune response may also be at risk. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: People who’ve had organ transplants and been vaccinated against Covid-19 must exercise caution, Elizabeth Tracey reports

Most people who receive vaccines against Covid-19 produce robust antibody responses, clinical trials show. Not so for those who have gotten organ transplants, research by Dorry Segev, a transplant surgeon at Johns Hopkins and colleagues has shown.

Segev: This is really important because there are guidelines coming out that says if you have your vaccine you’re fine, you’re immune, you can go out you can hug your family members and your friends, you don’t need to worry about getting the virus. That is not true for transplant patients or probably not true for anybody who’s immunosuppressed. There are about half a million people living in the United States who’ve had an organ transplant and are immunosuppressed. And there are about 11 million other people who take immunosuppression for other  diseases like autoimmune diseases.  :32

Segev says that while more research is needed, anyone who is immunosuppressed needs to remain vigilant. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: Why do people who’ve had organ transplants not respond well to Covid vaccines? Elizabeth Tracey reports

When someone has an organ transplant, they take lots of medicines to keep their body from attacking the new organ. Dorry Segev, a transplant surgeon at Johns Hopkins, and one author of a study looking at Covid vaccine response in these organ recipients, says that’s the key to their dampened antibody production after vaccination.

Segev: To prevent rejection in transplant patients we have to block the immune system. And it turns out one of the drugs that we use to block the immune system also happens to block the ability of the immune system to respond to the vaccine very well.  :12

Segev notes that this study was confined to the first vaccine dose.

Segev: If the response to dose two is as blunted as the response to dose one, maybe fifty percent of transplant patients will have protection but it’s quite certain that the majority will still not have protection.  :14

Segev says those who’ve received organ transplants should still get vaccinated and cautions that they must be extra vigilant in avoiding potential infection. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: Transplant recipients may not respond well to Covid vaccines, Elizabeth Tracey reports

People who’ve received organ transplants don’t produce the antibody response to their first dose of an mRNA vaccine against Covid-19 seen in others, research by Dorry Segev, a transplant surgeon at Johns Hopkins, and colleagues has shown. Segev says that if the recipient was on a drug to prevent rejection called an antimetabolite, the response was even lower.

Segev: if we look at immunocompetent people, if you give them the first dose of the mRNA vaccine by two to three weeks afterwards nearly 100% of immunocompetent people will have an antibody response. What we found was in immunosuppressed transplant patients only 17% have an antibody response to dose one, and if you’re on an antimetabolite, only 8% have an immune response to dose one, and that is frightening.  :27

Segev says in the short term transplant recipients should be even more vigilant than ever regarding their exposure to Covid-19. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: As drugs are developed for Alzheimer’s disease it seems clear that there is more than one type of this form of dementia, Elizabeth Tracey reports

Even as drugs that clear amyloid, a substance that accumulates in the brains of people with Alzheimer’s disease, continue being developed and studied, experts are questioning whether amyloid is the causative agent in the disease. Constantine Lyketsos, an Alzheimer’s disease expert at Johns Hopkins, says multiple causes likely exist, something called ‘heterogeneity.’

Lyketsos: Let’s get serious about deconstructing the heterogeneity that exists around this condition that we call dementia or Alzheimer’s dementia, and start understanding the drivers of dementia. Pretty clear that amyloid itself is not a direct driver of dementia. We’ve known that for a long time. It’s presence forecasts that you might get dementia but the amount of amyloid and the amount of dementia never have been well correlated. So my idea is the deconstruction of the heterogeneity.  :31

Lyketsos says most or even all diseases are highly individual, so a single agent to treat them is unlikely. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: Are new drug trial results meaningful in Alzheimer’s disease? Elizabeth Tracey reports

A new drug that clears something called amyloid from the brain may delay progression of Alzheimer’s disease, recently released data indicate. Constantine Lyketsos, an Alzheimer’s disease expert at Johns Hopkins, says maybe.

Lyketsos: Maybe this drug is the right mechanism where amyloid reduction, which doesn’t work for any of the other drugs, might work for this drug. Because it somehow does the reduction more effectively. The phase two, we’ve seen those kinds of results a number of times, so let’s see.  :16

Lyketsos believes application may be limited.

Lyketsos: Maybe five or eight or ten percent of people with Alzheimer’s dementia are genetic overproducers of amyloid. You’d figure those were the people who would be helped by amyloid removal or reduction. First trial was put out a few months ago. Doesn’t seem to work.  :16

At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: What’s behind the use of many medicines in people with dementia? Elizabeth Tracey reports

How many medicines does an older person, and especially one with dementia, really need? A new study finds that 14% of those with dementia are taking medicines that affect the brain, and that can cause more falls and deaths. Constantine Lyketsos, an Alzheimer’s disease expert at Johns Hopkins, says this issue of too many medicines, or polypharmacy, needs more attention.

Lyketsos: There’s a huge debate about the value of statin medicines for 90 or 85 year old people without cardiovascular disease but with an elevated cholesterol if they really need to be on a statin. There’s also controversy about polypharmacy to manage blood pressure. In a much older person who has dementia, once you transition to having dementia there is a case to be made that you need a higher blood pressure to perfuse your vulnerable brain. So if you’re trying to manage the blood pressure to be lower, you might actually be causing more harm than good.  :32

Lyketsos says loved ones must advocate for those with dementia. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: How often is someone with dementia overmedicated? Elizabeth Tracey reports

Polypharmacy refers to someone taking a multitude of medicines, with a recent study demonstrating that in people with dementia, polypharmacy with drugs that affect the brain occurs in 14%. Constantine Lyketsos, an Alzheimer’s disease expert at Johns Hopkins, says that’s concerning.

Lyketsos: As a doctor taking care of people with dementia I spend more time taking them off medicines than putting them on medicine. Medicines are generally not good for people with dementia especially an accumulation of medicines. They have vulnerable brains. And medicines additively impact the brain in unpredictable ways. Make it more likely that patients will fall. You know the total number of medicines that you’re on, if you have dementia, is a direct predictor of how likely you are to fall and break a hip.  :29

Lyketsos says use of medicines in people with dementia is often attempted to control behavioral symptoms, and that does not usually meet with success. He recommends beginning with a behavioral approach instead. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: Should specialized emergency departments exist for geriatric patients? Elizabeth Tracey reports

Emergency departments are frequently chaotic places, and for older people may make the experience of being in one traumatic. A recent study suggests that specialized EDs should be constructed just for elders, with a staff expert in recognizing and managing unique problems of aging. Constantine Lyketsos, an Alzheimer’s disease expert at Johns Hopkins, has a few questions.

Lyketsos: EDs and acute care hospitals are very bad places for people with dementia. The interesting question for me would be what’s the definition of geriatric? I’m not sure that a very healthy vigorous marathon running 85 year old is the same and needs a geriatric unit whereas you might have a very frail 55 year old with severe lung disease who is more like a geriatric patient in the lay perception. Is this really about age or is it about a frailty characteristic or cognitive impairment which would justify a very different approach.  :33

Lyketsos says study of such an initiative is appropriate. At Johns Hopkins, I’m Elizabeth Tracey.