- Email: [email protected]
Introduction: Increasing Access to Renal Transplantation in the 21st Century
Advances in
Renal Replacement L!:=====:J The rap y -= ~=;i~~~i"~~n.y
Fo,nd";on
VOL 7, NO 2
APRIL 2000
FOCUSED REVIEW
Introduction: Increasing Access to Renal Transplantation in the 21st Century Joyce M. Conin
T
ransplantation increases both quality of life and patient survival in end-stage renal disease (ESRD) and should be the treatment of choice for a large percentage of patients with ESRD.l The adjusted annual incidence of ESRD between 1992 and 1996 was 7%.2 However, the number of cadaveric kidneys made available for transplantation has not changed significantly since 1993. In 1998,12,166 kidney transplants were performed in the United States of which 4,153 were from living donors. 3 However, as of February 29, 2000 there were 44,348 patients listed for kidney transplant and 2,201 patients listed for kidney-pancreas transplant. 3 To narrow the gap between organ demand and supply we need to increase the supply of organs and improve long-term graft survival to limit the need for retransplantation. Moreover, as organs are a rare resource, we need to ensure equal access to transplantation for all patients with ESRD. In this edition of Advances in Renal Replacement Therapy, MandaI et al (pp 117-130) summarize the available data on the use of a wide range of expanded criteria cadaveric donors. Early results from the use of non-heartbeating donors are encouraging with a I-year graft survival, which does not differ significantly from other cadaveric transplants. Given data to support the hypothesis that "nephron mass" is an important factor in the long-term survival of renal allografts, the use of both kid-
neys from pediatric, older, and other suboptimal donors may overcome the problem of diminished nephron mass. 4 En bloc transplantation of pediatric kidneys into adult recipients improves 1- and 5-year grafts when compared with single pediatric kidney allografts. s In addition, dual transplantation appears to improve graft survival when kidneys from other marginal donors are used. 6,7 The use of expanded criteria donors does add to the cost of transplantation because of longer hospital stays and a greater need for posttransplant dialysis. Whiting et al 8 calculated the increased cost per transplant to be appr~xi mately $20,680 to $36,011 which is less than Medicare spending for dialysis per patient year at risk. 2 The use of living unrelated donors has significantly increased the living donor pool. Despite a higher degree of HLA mismatching than in familial transplants, graft survival is excellent and does not differ significantly from one-haplotype living related transplants. 3 BeFrom the Division of Nephrology and Hypertension, Georgetown University Medical Center, Washington, DC. Address correspondence to Joyce M. Gonin, MD, Division of Nephrology and Hypertension, Georgetown University Medical Center, 3800 Reservoir Road, NW, Washington, DC 20007; e-mail: [email protected]. © 2000 by the National Kidney Foundation, Inc. 1073-4449/00/0702-0010$3.00/0 doi:10.1053/rr.2000.7467
Advances in Renal Replacement Therapy, Vol 7, No 2 (April), 2000: pp 93-94
93
94
Joyce M . Gonin
tween 1993 and 1998, transplants from living unrelated donors in the United States increased from 9.8% to 21% of all living transplants. 3 ABO incompatibility limits the potential living donor pool, and a paired kidney exchange program has been proposed as a solution. 9 In the United States there have been ethical and legal concerns about donor sharing, and it has been calculated that no more than 3% of potential transplant recipients are likely to benefit from this program.1o Overcoming the ABO barrier to transplantation will have a much greater effect on increasing the living donor pooL There have been promising results with pretransplant removal of anti-A and anti-B antibodies by double filtration plasmapheresis and with the use of A2 donors for o and B recipients. 1l,12 There are very real concerns regarding equitable access to transplantation in the United States. African Americans are less likely to be referred for transplantation than whites even after adjustment for patient preferences. 13 Gordon et al (pp 177-183 of this issue) report a significant discrepancy between physician and patient perception with regard to discussions about transplantation which is significantly influenced by socioeconomic status. A recent report that patients dialyzed at for-profit dialysis units are less likely to be referred for transplantation than patients at non-profit dialysis units cannot be dismissed. 14 Greater physician education is clearly needed as well as independent oversight of dialysis units to ensure that profit never interferes with patient care. Dr Penn's article in this issue (pp 147-156) was completed shortly before his death. His development of a transplant tumor registry contributed significantly to our long-term management of the transplant recipient. He will be greatly missed by the transplant community.
References 1. Wolfe RA, Ashby VB, Milford EL, et al: Comparison mortality in all patients on dialysis, patients on dialysis awaiting transplantation and recipients of a first cadaveric transplant. N Engl J Med 341:1725-1730, 1999 2. United States Renal Data System: Annual Data Report. Bethesda, MD, 1999 3. United Network for Organ Sharing: 1999 annual report. Available at: http://www.unos.org 4. MacKenzie HS, Azuma H, Rennke HG, et al: Renal mass as a determinant of late allograft outcome: Insights from experimental studies in rats. Kidney Int 52:538-542,1995 5. Satterthwaite R, Aswad 5, Sunga V, et al: Outcome of en bloc and single kidney transplantation from very young cadaveric donors. Transplantation 63:14051410,1997 6. Remuzzi G, Grinyo J, Ruggenenti P, et al: Early experience with dual kidney transplantation in adults using expanded donor criteria. J Am Soc Nephrol 10:2591-2598,1999 7. Lu AD, Carter ]T, Weinstein RJ, et al: Excellent outcome in recipients of dual kidney transplants: A report of the first 50 dual kidney transplants at Stanford University. Arch Surg 134:971-975, 1999 8. Whiting JW, Golconda M, Smith R, et al: Economic costs of expanded criteria donors in renal transplantation. Transplantation 65:204-207,1998 9. Ross LF, Rubin DT, Siegler M, et al: Ethics of a paired-kidney-exchange program. N Engl J Med 336: 1752-1755, 1997 10. Terasaki PI, Gjertson OW, Cecka JM: Paired kidney exchange is not a solution to ABO incompatibility. Transplantation 65:291, 1998 11. Tanabe K, Takahashi K, Sonda K, et al: Long-term results of ABO-incompatible living kidney transplantation: A single-center experience. Transplantation 65: 224-228, 1998 12. Alkhunaizi AM, de Mattos AM, Barry JM, et al: Renal transplantation across the ABO barrier using A2 kidneys. Transplantation 67:1319-1324, 1999 13. Ayanian JZ, Cleary PO, Weissman JS, et al: The effect of patient's preferences on racial differences in access to renal transplantation. N Engl J Med 341:1661-1669, 1999 14. Garg PP, Frick KD, Diener-West M, et al: Effect of the ownership of dialysis facilities on patient's survival and referral for transplantation. N Engl J Med 341:16531660,1999
Renal Replacement L!:=====:J The rap y -= ~=;i~~~i"~~n.y
Fo,nd";on
VOL 7, NO 2
APRIL 2000
FOCUSED REVIEW
Introduction: Increasing Access to Renal Transplantation in the 21st Century Joyce M. Conin
T
ransplantation increases both quality of life and patient survival in end-stage renal disease (ESRD) and should be the treatment of choice for a large percentage of patients with ESRD.l The adjusted annual incidence of ESRD between 1992 and 1996 was 7%.2 However, the number of cadaveric kidneys made available for transplantation has not changed significantly since 1993. In 1998,12,166 kidney transplants were performed in the United States of which 4,153 were from living donors. 3 However, as of February 29, 2000 there were 44,348 patients listed for kidney transplant and 2,201 patients listed for kidney-pancreas transplant. 3 To narrow the gap between organ demand and supply we need to increase the supply of organs and improve long-term graft survival to limit the need for retransplantation. Moreover, as organs are a rare resource, we need to ensure equal access to transplantation for all patients with ESRD. In this edition of Advances in Renal Replacement Therapy, MandaI et al (pp 117-130) summarize the available data on the use of a wide range of expanded criteria cadaveric donors. Early results from the use of non-heartbeating donors are encouraging with a I-year graft survival, which does not differ significantly from other cadaveric transplants. Given data to support the hypothesis that "nephron mass" is an important factor in the long-term survival of renal allografts, the use of both kid-
neys from pediatric, older, and other suboptimal donors may overcome the problem of diminished nephron mass. 4 En bloc transplantation of pediatric kidneys into adult recipients improves 1- and 5-year grafts when compared with single pediatric kidney allografts. s In addition, dual transplantation appears to improve graft survival when kidneys from other marginal donors are used. 6,7 The use of expanded criteria donors does add to the cost of transplantation because of longer hospital stays and a greater need for posttransplant dialysis. Whiting et al 8 calculated the increased cost per transplant to be appr~xi mately $20,680 to $36,011 which is less than Medicare spending for dialysis per patient year at risk. 2 The use of living unrelated donors has significantly increased the living donor pool. Despite a higher degree of HLA mismatching than in familial transplants, graft survival is excellent and does not differ significantly from one-haplotype living related transplants. 3 BeFrom the Division of Nephrology and Hypertension, Georgetown University Medical Center, Washington, DC. Address correspondence to Joyce M. Gonin, MD, Division of Nephrology and Hypertension, Georgetown University Medical Center, 3800 Reservoir Road, NW, Washington, DC 20007; e-mail: [email protected]. © 2000 by the National Kidney Foundation, Inc. 1073-4449/00/0702-0010$3.00/0 doi:10.1053/rr.2000.7467
Advances in Renal Replacement Therapy, Vol 7, No 2 (April), 2000: pp 93-94
93
94
Joyce M . Gonin
tween 1993 and 1998, transplants from living unrelated donors in the United States increased from 9.8% to 21% of all living transplants. 3 ABO incompatibility limits the potential living donor pool, and a paired kidney exchange program has been proposed as a solution. 9 In the United States there have been ethical and legal concerns about donor sharing, and it has been calculated that no more than 3% of potential transplant recipients are likely to benefit from this program.1o Overcoming the ABO barrier to transplantation will have a much greater effect on increasing the living donor pooL There have been promising results with pretransplant removal of anti-A and anti-B antibodies by double filtration plasmapheresis and with the use of A2 donors for o and B recipients. 1l,12 There are very real concerns regarding equitable access to transplantation in the United States. African Americans are less likely to be referred for transplantation than whites even after adjustment for patient preferences. 13 Gordon et al (pp 177-183 of this issue) report a significant discrepancy between physician and patient perception with regard to discussions about transplantation which is significantly influenced by socioeconomic status. A recent report that patients dialyzed at for-profit dialysis units are less likely to be referred for transplantation than patients at non-profit dialysis units cannot be dismissed. 14 Greater physician education is clearly needed as well as independent oversight of dialysis units to ensure that profit never interferes with patient care. Dr Penn's article in this issue (pp 147-156) was completed shortly before his death. His development of a transplant tumor registry contributed significantly to our long-term management of the transplant recipient. He will be greatly missed by the transplant community.
References 1. Wolfe RA, Ashby VB, Milford EL, et al: Comparison mortality in all patients on dialysis, patients on dialysis awaiting transplantation and recipients of a first cadaveric transplant. N Engl J Med 341:1725-1730, 1999 2. United States Renal Data System: Annual Data Report. Bethesda, MD, 1999 3. United Network for Organ Sharing: 1999 annual report. Available at: http://www.unos.org 4. MacKenzie HS, Azuma H, Rennke HG, et al: Renal mass as a determinant of late allograft outcome: Insights from experimental studies in rats. Kidney Int 52:538-542,1995 5. Satterthwaite R, Aswad 5, Sunga V, et al: Outcome of en bloc and single kidney transplantation from very young cadaveric donors. Transplantation 63:14051410,1997 6. Remuzzi G, Grinyo J, Ruggenenti P, et al: Early experience with dual kidney transplantation in adults using expanded donor criteria. J Am Soc Nephrol 10:2591-2598,1999 7. Lu AD, Carter ]T, Weinstein RJ, et al: Excellent outcome in recipients of dual kidney transplants: A report of the first 50 dual kidney transplants at Stanford University. Arch Surg 134:971-975, 1999 8. Whiting JW, Golconda M, Smith R, et al: Economic costs of expanded criteria donors in renal transplantation. Transplantation 65:204-207,1998 9. Ross LF, Rubin DT, Siegler M, et al: Ethics of a paired-kidney-exchange program. N Engl J Med 336: 1752-1755, 1997 10. Terasaki PI, Gjertson OW, Cecka JM: Paired kidney exchange is not a solution to ABO incompatibility. Transplantation 65:291, 1998 11. Tanabe K, Takahashi K, Sonda K, et al: Long-term results of ABO-incompatible living kidney transplantation: A single-center experience. Transplantation 65: 224-228, 1998 12. Alkhunaizi AM, de Mattos AM, Barry JM, et al: Renal transplantation across the ABO barrier using A2 kidneys. Transplantation 67:1319-1324, 1999 13. Ayanian JZ, Cleary PO, Weissman JS, et al: The effect of patient's preferences on racial differences in access to renal transplantation. N Engl J Med 341:1661-1669, 1999 14. Garg PP, Frick KD, Diener-West M, et al: Effect of the ownership of dialysis facilities on patient's survival and referral for transplantation. N Engl J Med 341:16531660,1999