Volume of work
Among the global population of seven billion, ESRD patients constitute 2.7 million, Haemodialysis (HD) patients 1.9 million, Peritoneal dialysis (PD) patients 0.27 million and Transplant patients 0.62 million. World population growth is 1.1 % and the progress of ESRD, HD and PD are 6 to 7% and Kidney transplant is 4 to 5%.
In the United States, 19 million of population are CKD patients and 8 million are with eGFR less than 60 ml/min/1.73m2. The rest are Stage 1 and stage 2 CKD patients.
Dialysis
In haemodialysis, only 20% of original kidney function can be replaced by haemodialysis machine and there are remaining toxins and complications after many years of dialysis.
There are many common and uncommon serious complications including cardio-pulmonary arrest during haemodialysis. The mortality is 50% over 5 years period of haemodialysis.
Serious complications are, pericardial tamponade, myocardial infarct, occult bleeding, septicemia, arrhythaemias, dialysis reactions, haemolysis and air embolism
Changes in age of HD population from 1996 to 2016, there is decrease in dialysis rate among younger age groups (less than 45 years), however, increase in dialysis rate among older age groups (older than 45 years as well as geriatric population). The demographic of dialysis shifts from young CKD population to older CKD population due to advanced nephrology care in paediatric practice.
Etiology of ESRD are mainly Diabetes and Hypertension. The highest incidence is Diabetes (40%) and followed by Hypertension (38%).
Mortality of dialysis the average mortality of dialysis is 50% over 5 years period of dialysis. In early 1980, mortality is 3% and increased to 7.6% annually. In 2013, the HD mortality is 12.2% and PD mortality is 9.8%. The lowest mortality of dialysis was seen in Japan of 9.8%.
Cost of dialysis is very high and in 2009, United States spend 40 billion dollars for dialysis.
Kidney transplant
By comparing with dialysis, kidney transplantation is cheaper, healthier, better quality of life and patient lives longer. The 10 years mortality of kidney transplant is 10%. Patient can only live 7 to 10 years with HD but can live up to 40 years with kidney transplant.
Kidney transplant rate increase 5.8% in 2015 compare to 2014 however kidney transplant is still under global needs of 10%. Among kidney transplants, living donors is major role and its is 41.8%.
The cost for Dialysis and kidney transplantation is the same in first year, however, later years kidney transplant is more cost effective than dialysis. The kidney transplant patients can live up to 40 years.
There are absolute contraindications and relative contraindications for kidney transplants-
Absolute contraindications are unrelated current infections, malignancy with short life span, medical conditions with expectancy less than 1 year, psychosis and active substance abuse.
Relative contraindications are chronic infections, coronary artery disease, peptic ulcer disease, cerebrovascular accidents and habitual noncompliance.
All ESRD patients, the eligibility criteria should be cleared and offer different renal replacement therapy for declined patients. Early referral is mandatory for clinically stable dialysis patients and who anticipated RRT within 12 months. Patients should be treated pre-emptively when eGFR less than 20 ml/min/1.73 m2.
New objectives for pre-transplant evaluation are identify, educate, inform, create, estimate and educate.
There are challenges of development of deceased donors, protection of live donors, combat the trafficking in human organs (THO) and human trafficking for organ removal (HTOR), improvement od Quality of Life and safety standard.
HCV positive donors
HCV positive donors can transplant to HCV positive recipients as well as HCV negative recipients. Direct acting anti-viral agents for HCV cure rate is 90% and cure rate after transplant is very high. However, complication rates and risk tolerance are need to be explored.
HV positive donors
HIV positive donors can transplant to HIV positive recipients. However, viral resistance and size of opportunity is unknown.
Paired kidney donation will improve donor availability among HLA incompatibility pair and positive cross matched pairs.
Action to maximized long term graft survival is important. In graft failure patients, returning to HD and re-transplant can increase costs. Extending graft survival reduces cost, rate of HD and re-transplantation.
Among the contributions to successful kidney transplant programs, organ procurement organization, local medical community and culture of society are important for deceased donation program. The key to success is to develop the organizations around the process of deceased donation.
Conclusion
Even though post-transplant infection, malignancy and rejections, kidney transplantation has better survival, better quality of life and better cost effectiveness compare to dialysis.
References
- Liyanage T, Ninomiya T, Jha V. 2015. “Worldwide Access to Treatment for End-Stage Kidney Disease: A Systematic Review.” Lancet; 385:1975-82.
- Coresh J. Byrd-Holt D. Astor B. Briggs J. Eggers P. Lacher D, Hostetter T. 2005. “Chronic Kidney Disease Awareness, Prevalence, and Trends among U.S. Adults”, 1999 to 2000. J Am Soc Nephrol; 16: 180-188.
- Axelrod D. Schnitzler M. Xiao H. Irish W. Tuttle-Newhall E. Chang S-H. Kasiske B. Alhamad T. Lentine K. 2018. “An economic assessment of contemporary kidney transplant practice. Am J Transplant”; 18:1168-1176.
- Reese P. Abt P. Blumberg E. Goldberg D. 2015. “Transplanting Hepatitis C–Positive Kidneys.” N Engl J Med; 373: 4: 303-305.
Author Information
Maung Maung Htay
Senior Consultant Physician
Yangon Zivita Sangga Hospital
